My fourth week marked the beginning of a very different work experience. Guy Vandenberg, a nurse and social worker by training, Steve Williams, peer educator, and I are now traveling to different district sites in the Arusha and Moshi Kilimanjaro regions to assist them with the rural health centre HIV care roll-out process. Team TZ (what we call the group of folks from UCSF who come to Tanzania to do HIV care work – originally the TZ boyz: John, Guy, Royce and Steve – and now plus me) dubbed our program the “Mentoring of Mentors Intensive,” otherwise known as MOMI.
MOMI is really what it sounds like. We are “mommying” (mothering) some of the HIV Care and Treatment Center (CTC) leaders to become better leaders and to help them train lower-level health centre staff so that the rural health centres can also provide HIV care and treatment. This sounds simple, but Tanzanian bureaucracy and politics makes it incredibly challenging. Karatu is a perfect example of this.
Our first MOMI site was Karatu Designated District Hospital. It was originally a faith-based hospital, paid for and run by the German Lutheran Church. The Lutherans decided that they wanted a nice view, so they built the hospital way up on a hill, 7 km from the actual town of Karatu. Imagine a sick person trying to walk up the 7 km hill. Not-very-smart move #1.
When we arrived, we had the mandatory meeting with the District Medical Officer (DMO) and the CTC-in-charge. The DMO was supposed to be notified at least a week in advance so that he could arrange for us to work with health centre staff. The CTC-in-charge failed to notify him, so nothing was arranged for us. And after we requested him to arrange the visits, he still did not arrange them. (We can’t arrange them on our own because we don’t know whom to contact, so we are beholden to the Tanzanian DMO or clinic administrator to do this for us.) Not-very-smart move #2.
The CTC-in-charge, Elitumaini Mziray, is the key person that we were going to groom as a mentor of the health centre staff. We found out on the day we arrived that he was going to be gone during the week. Not-very-smart move #3.
In summary, nothing was arranged or organized for us, no one knew we were coming to train them, and the key person I was going to train was gone during the time we were there. Awesome. How does one get work done in this setting?
On top of all this, the medical officer I was left to work with is a sexist buffoon who continuously referred to me as “the mzungu” (“the whitey”) instead of my name. And he even argued with me in front of a patient when I asked him to call me my proper name and that I am Asian, not white. This is not even to mention that he had a terrible bedside manner and made some flagrant medical errors. I think I picked out over a dozen instances that would have clearly constituted medical malpractice in the US.
Then, on the last day, I found out from a patient that the clinic had run out of Efavirenz for the last TWO months, a key HIV antiretroviral that many patients (particularly those with TB) have been on. Instead of telling anyone about this, the pharmacist simply failed to give the patients the drug or switched it on his own to another antiretroviral. And let me tell you, he doesn’t know squat about managing HIV. None of the clinicians there admitted to knowing about this. There was no clear plan on procuring the drug either. This is what we call a total disaster.
Can someone poke my eyes out? I’ve already pulled my hair out.
We did the best we could. Guy worked with Mama Agnes, the lovely and caring but incredibly overstretched nurse, who is a victim of her culture’s ingrained sexism. I tried to teach the medical officer some proper ways to manage cryptococcal meningitis and TB-HIV coinfection. And happily, we identified a motivated, smart young women clinical officer who was interested in becoming an HIV clinician. I taught her how to initiate patients on HIV antiretrovirals. We summed up our findings and recommendations in a dense document and presented it to Elitumaini. He made a work plan with us to tackle some of the problems. We really hope these things happen. Or the HIV-positive patients in the Karatu district are in serious trouble. At least I know that our support for them will only make a positive difference at this point – there is no other direction left to go.
Speaking of hope (a liability and an asset), I hope the next three sites are in better shape.