Tanzania

It is really hard to tie off this sequence of blog posts about Tanzania and call them “finished,” because in so many ways I feel like I could never truly be finished describing the depth, colour, vivacity and meaning of my time in Moshi. Beyond any of the medical and NGO experiences I had, Moshi provided me with unparalleled opportunities for cultural immersion and enriching personal experiences. I made the greatest Tanzanian and international friends, buckled down and attempted to learn as much Swahili as I could, tried as many street foods and local flavours as possible, explored all the nooks and crannies of Moshi’s central market, and sweated it out on the dance floor every weekend to Tanzania’s biggest hits.

I drank Savannah cider or local Kilimanjaro beer while gazing at our phenomenal sunset views of Mt. Kilimanjaro…

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…from Haria Hotel’s rooftop terrace or the bar that pops up every evening at Moshi’s abandoned railway station. On these soft, warm evenings, I learned local Tanzanian card games from my friends that brought everyone, from the bar staff to passing tourists to our Maasai night guards, together for a laugh.

I wandered with the best of friends to the rice fields and forests that lie on the outskirts of Moshi, for a hefty dose of mind-blowing green…

 

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Moshi

…and spent weekends venturing further afield to steep myself in the Kilimanjaro region’s astounding natural splendour:

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Chemka Hot Springs
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Ndoro Waterfalls in Marangu

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Another weekend involved a trip to Materuni to see how the famous Tanzanian coffee is made…

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… which was downright hilarious and offered us another amazing trek to a nearby waterfall:

 

If you’re thinking what I’m thinking, I also never expected Tanzania to be so green! Isn’t it wild?!?

Yet another day trip led me to Lake Chala, a crazy-blue crater lake that spans the border between Tanzania and Kenya:

 

That particular day also inspired a re-enactment of the Lion King, which is somewhat of a right of passage for Mzungu in Tanzania/Kenya:

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We couldn’t resist!

On other days rich with even more personal meaning, I got to meet the sweet newborn baby daughter of Team Vista’s in-country manager – Ronnie – and spend time on the lentil farm Team Vista is building from the ground up to support their projects ❤ :

 

Bigger overnight trips took me to the bustling and uber-colourful markets of Arusha…

 

….and the white sand beaches and exotic towns of Zanzibar:

 

Zanzibar: Need I say more??

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The fishing village of Nungyi, Zanzibar

With all this beauty practically on my doorstep, it is hard to pick any favourite moments or sites from Tanzania. My experience on safari, however, was pretty tough to beat:

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First views upon entering Ngorongoro Crater on safari!

 

I even conducted some hippos to poke their heads out of the water for a photo…

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…and am now a self-proclaimed hippo-whisperer because it totally worked:

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This experience meant camping on the very edge of Ngorongoro Crater…

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… and waking up to views like THIS…

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…in the Serengeti, before soaking up all of its spectacular wildlife on mind-blowing game drives:

 

Nope, it just doesn’t get any better than this!! 🙂

Finally, I spent my last two nights in Tanzania in Dar Es Salaam, the country’s largest city, visiting Mama Wandoa – the country manager for Sleeping Children Around the World‘s (SCAW) projects in Tanzania. I visited a SCAW bed kit distribution during my stay in Chennai, India earlier this year, and wrote about that experience and the amazing aims and impacts of this organization in a previous post.

As in Chennai, my contact with SCAW in Dar Es Salaam was hugely heartening and inspiring. A feisty and courageous one-woman-show at age 79, Mama Wandoa single-handedly coordinates the creation and distribution of 5000 bedkits to needy Tanzanian children every year and, having heard that I was a friend of the organization and keen to learn more about her work, warmly invited me to stay with her for two nights before I left for the UK. As her guest, I accompanied Mama to visit a District Educational Authority, where I learned about how the government allocates SCAW certain districts to work in, and how those districts select schools through which teachers, parents and social workers can help select the most disadvantaged children and orchestrate bed kit distributions to those particular students. For all of these processes that occur through official government channels, Mama acts as both the friendly human face of the organization and the passionate driving force that starts the ball rolling and sees it through. Mama also took me with her to Dar Es Salaam’s largest market (an experience in and of itself!) where we shopped for the 1500 pencils and 1500 pens that would be included as part of the school supplies each child receives in a SCAW bed kit.

With Mama, I was poignantly reminded of the value of long-term and deeply-invested local partnerships in conducting good quality international NGO work. I was also able to meet several of the staff Mama Wandoa employs to create the bedkits, including the cottage workers who sew school uniform shirts for all 5000 children. When the bedkits are locally produced in this way, money is channeled directly into the local economy and this,  through a ripple-effect, impacts local communities in broad and often-under-recognized ways. As I witnessed through Mama and the way in which she treats all of her staff and local partners, this includes a very extensive and compassionate family-like support system. This Tanzanian SCAW family was beautiful to behold and feel a part of, and after just two days I already felt right at home on Mama’s couch, predicting the outcomes of South African soap operas together over an evening meal of sweet milky tea and sausages with other SCAW staff/volunteers. Hugging Mama goodbye at the airport before I boarded my plane back to the UK, I felt in her embrace all the warmth and community and treasured, meaningful friendship I had experienced in Tanzania – from her and from so so many other beautiful people. Because of all of them, I already can’t wait to be back ❤

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With Mama Wandoa at Julius Nyerere International Airport. Asante sana, Tanzania!

Young Women’s Empowerment – Part II

(Continued from my previous post):

In many ways, as I became more and more actively involved in Team Vista’s Young Women’s Empowerment sessions, the themes we discussed and explored began to overlap with the work I was doing in Community Health at KCMC. One such theme was women’s sexual and reproductive health. In one initial session, I was able to sit down on the floor with the girls – shoulder to shoulder for open and equal sharing – and talk about sex. A quick assessment of where the girls were with this topic told me that we needed to start right at the beginning, with what sex is and why it happens. I soon realized that, while human reproduction is covered in biology classes at Msasani, what was missing for these girls – and the reason why the addition of the Team Vista curriculum is so vitally important – is the essential human element that is undeniably present in sexual interactions. The girls had been told that sex makes babies, biologically speaking, but not that sex can have emotional and psychosocial impacts on their relationships that cover the whole spectrum , from deep comfort and connection to trauma. Likewise, they had been shown condoms and other methods of contraception, from a scientific standpoint, but without any discussion of how “safe sex” can also refer to sex that feels emotionally and personally safe. Two of my favourite activities from that particular lesson were having the girls create a chart on the board of when having sex is and is not okay, based on what they had learned, and giving the girls a chance to write down and anonymously submit confidential questions about sex. There was a lot of vulnerability and uncertainty expressed that day around this topic, but I do hope that sharing those questions in an atmosphere of trust and connection helped the girls go away with not just new knowledge about sex, but also different attitudes.

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The session that followed, on consent, rape and bodily autonomy, was much more difficult. It was extremely hard to drive home these definitions and to describe and enforce to the girls how pressure and coercion to have sex can present itself in many forms, but is NEVER okay. This was definitely an instance in which we worked fully in collaboration with Amina, the local teacher leading the group, to ensure that more difficult concepts could be made linguistically and culturally accessible to all of the girls.

The partnership with Amina also meant that she has been able to carry on the sessions and continue developing the curriculum now that all of the foreign volunteers are no longer there. Phoebe, having trained herself out of job and allowing Amina to take over fully, has successfully ensured the sustainability of this project and its ability to have a locally-driven and culturally-relevant impact. Huzzah!

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Phoebe, doing her thing!

The following week, we centred the discussion around the consequences of teen/early pregnancy: one of the main reasons girls drop out of school early in Khaloleni. Phoebe, through some phenomenal research, was able to share with the girls a set of statistics that drove home the real-life consequences of unplanned pregnancies during school. This included not only impacts to their own health, education and financial situation, but also – and so powerfully – statistics on the impacts of teen pregnancy on a girl’s child and also on the behaviours and life outcomes of her younger sister. Early pregnancy is a community-level issue, and the reach of its impacts should not be underestimated. I loved seeing the girls wrap their minds around the statistics and grab on to this fact, and come to see the role each and every one of them can play in changing those statistics.

TEEN PREGNANCY: LIFE OUTCOMES ON A TEEN MOTHER, HER CHILD AND SIBLINGS

Research indicates that teen pregnancy and motherhood can have detrimental socio economic and psychological outcomes for the teen mother, her child, and her young siblings.

a) A teen mother is more likely to:

  • drop out of school
  • have no or low qualifications
  • be unemployed or low-paid
  • live in poor housing conditions
  • suffer from depression which may result in suicide
  • live on welfare

b) The child of a teen mother is more likely to:

  • live in poverty
  • grow up without a father
  • become a victim of neglect or abuse
  • do less well at school
  • become involved in crime
  • abuse drugs and alcohol
  • eventually become a teenage parent and begin the cycle all over again

c) The younger sibling of a teen mother is more likely to:

  • accept sexual initiation and marriage at a younger age
  • place less importance on education and employment

~ Taken from a UNICEF document on teen pregnancy

Phoebe and Hayley had also found some concrete data specific to Tanzania, which brought the message even closer to home. We finished the session by asking all of the girls to write down their personal goals that they hope to achieve before they would consider pregnancy, and letting them get creative by role-playing the impact of early pregnancy on the life of a school girl. As always, it was so fascinating for us to stop talking and start listening, as the girls’ ideas about their own futures and the gender-related pressures and inequalities in their society unfolded in front of us. It was all too scary to see how easily they could act out a situation of forced sex that led to early pregnancy, but simultaneously immensely hopeful to read about the pre-pregnancy aspirations these girls hold to. One girl wrote:

“I want to be a pilot or a doctor. Before I have kids I want to have a career and also to get advice on how to be a good mother to my children and my family. I want to be a role model in my society or Tanzania in general.”

I love how she recognized the importance of maturing before starting a family – of gathering the advice and skills necessary to provide care and be a role model. I truly hope that all of these things come true for her, and for all of our beautiful Empowerment Group girls.

For the final two sessions I was part of before I left Moshi, the mood was a fair bit lighter.  For the first, Pendo – a cook from the Haria Hotel restaurant and a super active member of her community, church and choir – came to speak to the girls as an example of a fierce and empowered woman from their own Tanzanian society. Through her stories about dealing with boys, maintaining dignity and self-respect, and navigating life as a young Tanzanian woman, Pendo had all of the girls absolutely roaring with laugher and – as I saw it – relating 100% to her story. If my year of travels has taught me anything, it is that sharing stories in this manner is one of the strongest social forces we have for inspiring change and empowerment – and sitting in on this session was a colossal privilege.

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The girls with Pendo!

For my final week, we worked on stress management; exploring what stress is, how it is caused, and how the girls can work to cope with it. If you know me, you’ll know that I myself am the kind of girl who can let stress get the best of her – especially academic stress – so it felt truly perfect for me to get down on the floor with the girls in this session and speak heart-to-heart about this common reality. I particularly loved having the chance to talk about the ways in which writing, dance, and other artistic endeavours (ike this blog!) allow me to navigate stress and anxiety. We led the girls through yoga practice, a guided meditation (surprisingly successful, for such a rambunctious group of girls!), and finished as we had finished every single session so far: dancing our hearts out to Tanzanian pop music, hugging, singing, and laughing. I always loved to think that however much or little the girls took away from the actual content of each lesson, the pure joy and camaraderie in ‘getting down’ with a group of loving and supportive peers and mentors must have shaped these girls in at least some small way. It sure as anything shaped me.

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Guided meditation.
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My joy!

Team Vista’s Young Women’s Empowerment Group

This year has involved a lot of definitions; often of words I already knew, felt I knew the meaning of, and already used frequently. One such example is the word “vulnerable.” So many times in medical school and in global health, we use the word ‘vulnerable’ to describe populations and individuals we see as being disadvantaged, marginalized, or underserved. As such, I had come to largely accept and expect the use of this word in medical spheres. That is, until I embarked on this explorative year and delved into the world of medical humanities: the field that promotes the power of words and language to capture the ambiguous-by-nature human and patient experiences. It was through that process that I realized: if you tell me a patient is ‘vulnerable,’ you give them quite a hefty label that is heavy with meaning, connotation and assumption, and yet I could walk away with no real, concrete or specific information about that person and their individual story.

I had a very similar experience when I began to explore the concept of “empowerment” – an idea that lay at the very foundation of this scholarship project and that I probably said at least 20 times in my scholarship interview alone, when speaking about community health and health education. It’s a great word, “empowerment,” but what does it mean? If I tell you someone is “empowered,” what am I saying about them? In my mind, I eventually realized, empowerment was an exceptionally vague concept. It was an image of confidence, informed decision making, and an internal sense of our ability to take control of external circumstances: it was a kind of power, but broadly reaching and ill-defined. It could be seen in both a person’s emotional/psychological state as well as in their actions and interactions with the outside world. It could mean different things to different people, and not all empowered people – in my mind – would look, feel, or act the same. In fact, I was flabbergasted to realize that I wasn’t even sure if I could identify empowerment, as one single, uniform concept, if it smacked me in the face.

But then, it kind of did smack me in the face. When the original plans I had made for my arrival in Tanzania totally fell apart (thanks to a rather interesting turn of events that had me spending my first morning in Tanzania at the local high-security prison… don’t ask), I checked into the nearest friendly-seeming hostel, Haria Hotel, to try and regroup. Spoiler alert – checking into the Haria Hotel was probably the best decision of this entire year. Staying at Haria Hotel allowed me to meet some of the greatest human beings I have ever known, and to get involved in the work that the NGO that owns the Hostel – Team Vista (TV) – does for Moshi’s more vulnerable and underserved (pardon the ambiguous vocabulary) communities. The centre point and highlight of that experience for me was working with TV’s Young Women’s Empowerment Group at Msasani Secondary School. This weekly group was precisely where I came to be smacked in the face by the true definition of “empowerment.”

I was lucky to have this face-smacking experience occur under the invaluable guidance and mentorship of two super dear friends and spectacular role models: Phoebe, Team Vista’s in-country manager and an expert in the role of gender in international development, and Hayley, a volunteer with Team Vista, a teacher and an advocate for the role of sport in development. Through their hugely successful partnership, these two phenomenal women were able to work together with a local school teacher to channel their knowledge on development, gender and education into a meaningful and engaging curriculum for secondary school girls. The 25 girls they taught were students that the school principal had identified as struggling academically or at particularly high risk of dropping out of school for a variety of academic, cultural and social reasons (such as early pregnancy). The curriculum, then, spanned all sorts of crucial gender-related topics relevant to Tanzanian school girls: women’s rights, sexual health, bodily autonomy and consent, consequences of teen pregnancy, power and relationships, time management and coping with a heavy academic workload, managing stress and engaging in mindfulness, sport and relaxation.

Team Vista works in Moshi’s poorest urban district, Khaloleni, and I was shocked on my first visit to realize that this area – plagued by a far lower standard of living and development that the rest of the city – was just walking distance from the part of Moshi where I had thus far been blissfuly enjoying running water and paved roads. This shock was just settling in when we arrived at the secondary school, pulling up just as the school’s headmaster began *whipping* a group of 6 students with lashes to their buttocks for engaging in romantic relationships, in front of the entire school. The lovely local school teacher, Amina, who collaborates with Team Vista in running theses sessions, greeted us with a huge smile nonetheless. I couldn’t believe that this type of punishment was just the norm! I suppose it was a kind of baptism by fire to this school environment and the attitudes it holds towards power structures, relationships and human sexuality.

Once all 25 girls had come in from watching the whipping and the Women’s Empowerment Group was underway, I was totally awed to sit amongst the girls (aged 13 to 16) and learn with them about the aims of this group and what empowerment even means. When asked to suggest definitions, some of the girls came forward with “learning how to control yourself,” “gaining knowledge and confidence,” and “making decisions.” With further group discussion facilitated by Phoebe, Hayley and Amina, we came to agree that empowerment, for the purposes of this group, meant gaining both the knowledge and the confidence that allow us to make informed decisions about our own lives. Internally, I oggled that I had been throwing the word around in a public health context for 6 months already without ever solidifying a definition. Perhaps even more shockingly, I realized I had never in my life needed the concept of empowerment explained to me or defined for me because of the whopping privileges I have had that make knowledge, power, and confidence such a normal part of my life. Excistenqcial crisis? Yep!

The class discussion then went on to focus more specifically on women’s rights: why women need rights, what those rights are, and how we can make choices that best align with, protect and promote those rights. My favourite parts (and this remained true throughout the next 8 weeks I spent taking part in these sessions) was getting the chance to see and hear the girl’s ideas and perspectives on these issues. When we asked what women’s rights should be, the girls told us “to love,” “to an education,” and “to make decisions,” and it was heartwarming to realize that they knew these truths to be true. It was saddening, however, to ask them why women in Tanzania need rights and hear, “because women face discrimination,” “because of female genital mutilation,” and “because of arranged or forced child marriage.” The violation of women’s rights in these practices seemed common place to these girls as they brought them up, and I was heartbroken to reflect that evening on how culturally acceptable human right’s abuses can still be in so many parts of the world. While this heartbreak drove home for me that we – women and men everywhere – have definitely got work to do, I was already incredibly inspired – in that first session alone – to see this very work underway. Hayley and Phoebe artfully worked a huge variety of engaging teaching tools, approaches and activities into the curriculum in order to get the really big and pivotal ideas, attitudes, beliefs and feelings of female empowerment across. I knew from the get-go that I was extremely lucky to be a student in this setting, and that only more good things were to come. Other topics we covered in these sessions will follow in my next post!!

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Lessons Learned at KCMC

While the 10 weeks I spent at Kilimanjaro Christian Medical Centre were indeed largely focused on learning about disability/rehabilitation care and community health intiatives, my overall learning experience in this hospital was actually incredibly broad. As one of the largest referral hospitals for Tanzania’s northern zone, the central teaching hospital for Kilimanjaro Christian Medical University College and a medical research hub, this hospital truly never sleeps, and is always buzzing with ongoing care, teaching, research, discussion and collaboration. As a newbie to Tanzania and Moshi, arriving at the hospital for my first time was simultaneously overwhelming and a strange kind of homecoming; that vibrant, audible atmosphere of shared academic energy and excitement was music to my ears. (*nerd alert!*)

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Welcome to KCMC!

In hindsight, I am incredibly happy with the choices I made to split my time between the Department of Rehabilitation and the Department of Community Health. When I was first making the decision, however, I stressed endlessly over the fact that I would be missing out on learning opportunities in so many other fields by choosing not to be attached to any of the hospital’s 22 other departments. A few things, however, really helped to ease my academic FOMO:

Firstly, KCMC is a giant teaching hospital where students from all over the world come to observe, get involved, do electives and conduct research. Getting to know many of them in and around the Moshi social scene and at the hospital gave me glimpses, through their stories, into what was happening in other departments and a chance to compare notes and broaden my understandings of the services the hospital provides.

Secondly, and more significantly, I religiously attended the weekly Clinical Conference held in the hospital library every Wednesday morning at 8am. Each week a different department hosted the conference, bringing forward the most noteworthy current happenings of their departments and allowing all staff and students to learn, share ideas and questions, construct solutions and congratulate successes. (Nerd alert!) — It was AWESOME. So, I thought I would finish off this final post on my time at KCMC with a few snippets of what I learned in the conferences that had me on such an academic high every Wednesday and allowed me even greater exposure to Tanzania’s healthcare realities.

Pediatrics

The very first Clinical Conference (CC) I attended at KCMC was hosted by the Department of Paediatrics, and included a discussion on a recent and fatal case of pediatric Anthrax that had presented to the department. I’ll admit – at the time of the clinical conference I had absolutely no clue what Anthrax was, but I had a fairly good idea that it was not something I would see often in the UK or Canada. In the journal I’m reading through for notes to include in this blog post, I’ve written in the margin: SOOO INTERESTING!! And I still think it is! Anthrax is a zoonotic bacterial infection (i.e. it is transmitted to humans through contacts with animals) that is most prevalent in hot, wet regions like Asia and Africa. It can be transmitted through skin, ingestion, or inhalation. The disease manifests as a range of flu-like and general symptoms, as well as painful swelling of the face, black coal-like lesions (very distinctive), and eventually severe hypotension (low blood pressure) that leads to death. As part of the conference presentation, the department head also went back through case notes on the six cases of paediatric anthrax the hospital had seen in the past seven years. She used the compilation of these examples to ignite a self-reflective discussion on how effectively KCMC admits and isolates infectious disease cases, identifies and treats Anthrax, and addresses public health and prevention concerns – especially amongst Tanzanian tribes like the Maasai, who have particularly high and frequent contact with animals that can carry Anthrax. All of this discussion transpired on what was only my third day at KCMC, and was a totally riveting crash course in a fascinating component of tropical medicine. Anthrax, like Leprosy, is a disease I would certainly not have engaged with had I not embarked upon this international gap year, and one that does not often cross our global health radar in the western media. I am constantly fascinated and humbled to discover just how much about the global burden of disease I have been ignorant of up to this point.

General Surgery

Like paediatrics, General Surgery was a department I would have loved to have observed in if I’d had the time/ability to be in more than one place at one time, so I was overjoyed to get this chance to listen to their presentation and join the discussion on general hernia repairs – one of the most frequent general surgery operations performed at KCMC. Inguinal hernias, as I learned, are one of the WHO’s global surgical priorities, and doctors and scientists around the world (including at KCMC) are actively engaged in clinical research to determine the best possible methods for accomplishing good quality repairs in low-resource settings. A spectacular piece of literature discussed at the conference showed that mesquito netting (often donated in large quantities to developing countries) could be successfully used as a cheap and effective alternative for surgical mesh in hernia repairs. This talk of innovative problem solving in global surgery left me positively BUZZING.

Anaestheisa

After everything I had learned and experienced in Myanmar with Interplast, the international need for Anaestheisa services – like the need for global surgery – had become a cause that was very close to my heart. As a result, I had begun following the NGO Lifebox (which strives to improve access to safe surgical and anaesthetic care worldwide) really closely in the months that followed, and started to dream of getting involved in their work. As somewhat of a dream come true, the clinical conference hosted by the Department of Anaesthesia allowed me to meet and learn from Dr. Emma Joynes, an anaesthetic trainee from the UK working at KCMC as one of Lifebox’s quality improvement and education fellows. Huzzah!! It was such a privilege to hear her talk about striving for  safer anaesthesia in the specific KCMC context, through the implementation of pulse oximeters and surgical checklists. We watched Lifebox’s acclaimed documentary, “The Checklist Effect,” (WATCH THE TRAILER HERE) and engaged in a discussion thereafter that left me inspired beyond comparison by this field and this work. It was truly a morning I won’t forget.

Opthalmology

Having learned previously in my education that 90% of the worlds’ blind or visually impaired live in developing/low-income countries, and that 80% of conditions which cause visual impairment can be prevented or cured, I had originally hoped that this global scholarship year might include a glimpse (pardon the pun?) into global ophthalmology care in a preventative/public health context. As my year came together and other opportunities arose, it turned out that this was not to be – but I’ve treasured every chance I’ve had to learn and engage with the topic nonetheless.

This particular clinical conference centred on Retinopathy of Prematurity (ROP; damage to the retinas of the eyes caused by the interruption of normal intrauterine development when a child is born premature), which is an interesting intersection between ophthalmology and maternal/child public health as well as obstetrics, gynaecology and neonatology. I loved this multidisciplinary aspect of the discussion, and how I was able to draw on what I was learning in community health about the ways in which premature births are prevented and managed. ROP was actually thought to have a fairly low prevalence in Sub-Saharan Africa, until better data collection revealed that Africa is in fact entering a third global epidemic of ROP – thanks to higher birth rates, higher rates of prematures births, varying quality of neonatal care, and low screening coverage. 9% of babies born premature at KCMC develop ROP. This is almost 5x the prevalence of developed countries, and is likely an underestimation because so many premature babies here die before they can be screened.

From a public health standpoint, screening for ROP is vital because the condition is initially painless, so won’t cause symptoms that alert communities and physicians to its development, and because early treatment is crucial to the prevention of blindness later in life. With an indirect opthalmoscope, any healthcare professional can be trained to carry out screening and referrals. Therefore, as with so many important issues I’ve come across this year, awareness and education lie central to the efforts for prevention, detection and effective treatment of Retinopathy of Prematurity. To this end, KCMC is currently designing and rolling out a brand new screening protocol, and I’m totally smitten with this commitment to ongoing research and service improvement. Yes yes yes!!

Rehabilitation & Community Health

In a cool coincidence, the final two Clinical Conferences I attended at KCMC were directly related to the work of the two departments I had spent my time in, and reminded me once again of the reasons why I valued those experiences so much. The first was hosted by TATCOT, KCMC’s wheelchair and seating services. The wheelchair technicians leading the conference reviewed the WHO’s most recent definitions of what makes a wheelchair or seating aid “appropriate” for low-resource settings (read more here), and critically appraised how the services at KCMC do (and don’t) match up to those global guidelines. It is estimated that 20 – 25 million people who require wheelchairs globally do not have access to them, and – in Africa – only 2% of people who need wheelchairs have one. I was grateful, during this conference, to realize how much my time in the Occupational Therapy/Rehabilitation Department had stretched my mind in regards to these needs, and to have the awareness that wheelchairs are not just about meeting a phsical/medical condition, but also – and extremely importantly – about meeting a patient’s unique environmental and functional needs. Wheelchairs are about mobility, support, protection and independence, and an “appropriate” wheelchair will, even in the most challenging and poorest of settings, meet all of these needs.

The challenges at KCMC include the fact that we currently use imported chairs that function well inside the hospital, but become useless in rural, Tanzania-specific settings. There is also no local knowledge about how to repair imported chairs, and no spare parts available locally. Thus, the goal at TATCOT that was presented to the rest of the hospital and met with great enthusiasm (for it is clearly a colossal/universal area of need) is to begin the design and construction of locally made, strong, durable and easily reparable wheelchairs to be used inside and outside of the hospital. Though still in its early stages, this project struck a real chord with me in terms of both its relevance to the staggering rehabilitation needs I had already witnessed, and its capacity to provide the type sustainable, locally-derived and organically-driven community health initiatives I have come to believe so strongly in.

When the Community Health Department presented the following week, they presented data on patient satisfaction that had been collected from 5 different outpatient departments at the hospital, reflecting – yet again – a wonderful focus on the healthcare experiences of individual patients and the way this shapes health beliefs, as well as a spectacular drive to learn and improve based on that feedback. I was heartbroken to leave KCMC, and the Community Health Department in particular, on my last day, and I am (sorry for the cliches!) forever changed by both the depth and astounding breadth of learning experiences I had there. These posts don’t even begin to do that learning justice.

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A selfie with two of my favourite community health nurses on my last day!

 

Early Childhood Nutrition

The third and final of the main themes I explored during my six weeks attached to the Department of Community Health at KCMC was the crucial importance of nutrition during the first 1000 days of a child’s life. More than a year ago, when I was first planning this scholarship project, I looked to the WHO’s Facts for Life to guide and inform my exploration of public health. Of the 14 key factors pertaining to childhood wellbeing identified in the FFL list, two relate directly to this theme: breastfeeding, and nutrition and growth. Because the Facts for Life were so central to my aims with this project, I leaped at this opportunity to dive into them in this context, and was rewarded approximately ONE BILLION fold. These particular projects turned out to be the richest and most rewarding of my entire KCMC experience.

In the Hospital

I was really fortunate to arrive at the CHD at a time when a new early childhood nutrition initiative was just kicking off, and the enthusiasm for the project was buzzing. My supervisor, Sr. Mayo, had just returned from a week-long training session in Mwanza, Tanzania, on the use of the Ministry of Health’s new “Siku Elfu Moja” (literally, “1000 Days”) education materials. The materials came in bright orange backpacks (easily transportable and transferable!) brimming with tape recorders, posters, stickers, games, pamphlets and flashcards that, when unloaded in any part of the hospital or broader community, could engage families in learning about essential nutrition for children from conception (day 1) to age two (day 1000). Because these kits were brand new, I got to be around when Sr. Mayo distributed them to other nurses and community health workers and held sessions to ensure their proper use – and I learned SO much through this process.

The materials used culturally-relevant symbols for a society that still relies substantially on sustenance farming within families, comparing pregnancy to the planting of a seed and further stages of growth to the budding and blossoming of a plant when discussing appropriate feeding at different stages of a child’s life. At each stage, the information provided went way beyond the basics of nutritional information about appropriate food groups and portions (which was taught through interactive games and music), and delved into more complex cultural and societal issues surrounding the topic, like the tendency of Tanzanian men not to accompany their partners to pre-natal appointments or support them in adhering to pre-natal nutritional supplements. To this end, the educational materials included role play prompts that help women to recognize and respond to three different attitudes in their partners: the lion/”simba” (angry and confrontational when asked to be involved in pregnancy nutrition), the donkey/”punda” (stubborn and disinterested), and the giraffe/”twiga” (understanding and engaged). The role-play encouraged women to think through what their home and community support systems currently looked like in a nutritional context, and what communication techniques they could use to encourage the men in their lives to play an active role. Personally, I loved the very Tanzanian safari animal references almost as much as I loved the lively and encouraging discussions they sparked about gender equality in promoting health. Over the next six weeks, I often got to witness the kits being put to use for health education in the waiting rooms of the antenatal and vaccination clinics — and I loved it!!

In the Community

The second part of my involvement in early childhood nutrition was even more deeply engaging, and one of my favourite things I have accomplished this year. Together with a group of six medical students from KCMUCo (Kilimanjaro Christian Medical University College), I was able to conduct a nutrition status assessment for the Institute of Public Health, taking a “snapshot” of nutrition-related beliefs, behaviours, and outcomes in Machame Mashariki Ward, Hai District, Kilimanjaro.

In preparation for the fieldwork portion of this project, I joined the KCMUCo class of 3rd year medical students (I LOVED getting to be amongst a peer group so similar and yet so different from the 3rd year class I had come from in St Andrews!) for a week of lectures on health promotion strategies used in Tanzania; data collection, processing and interpretation; and different techniques used for the assessment of an individuals’ and communities’ nutritional statuses. Through the lectures and my own research, I also used this opportunity to learn as much as possible about childhood nutrition, optimal breastfeeding practices, complimentary feeding and malnutrition: how it occurs, and how the pathway to undernourishment can be interrupted and reversed. This learning was simultaneously fascinating and universally relevant – definitely something to take away with me for future forays into public health!

Following this intense week of preparation, my team spent another week out “in the field,” assessing the early childhood nutrition of this community using a 189-variable questionnaire (for the mothers) and a series of anthropometric measurements (for the children) recognized as the WHO standard. The coolest thing about the opportunity to do this fieldwork was getting the chance to visit really rural Tanzanian communities and get a first-hand understanding of what access to healthcare – and access to many determinants of health, like good nutrition –  is like for people living in these locations.

On our first day, for example, after driving two hours from Moshi on roads so bumpy it was impossible to stay in our seats, we still had to trek uphill by foot on an even bumpier, impassable road to arrive at the health clinic where mothers and babies go for care, and where we would set up for our research. My journey there begged the question – how do mothers in labour get to this clinic?? Beyond its remote location, the health centre only has one doctor, and is only open on certain days each week, which could also be a pretty big hindrance to healthcare access.

Having started the day meeting with one of the village’s leaders, we had permission to set up in the clinic, using one room for completing surveys and one room for taking measurements. On the first day, I partnered with a beautiful and unbelievably kind Zanzibari student, Sabrina, to fill out the questionnaires with the mamas. The surveys included questions about the child’s characteristics, the mother’s socioeconomic and educational situation/background, food security at the household level, breast feeding beliefs and practices, and a 24-hour dietary recall. While most surveys were conducted in Swahili, working through them with my partner was a great chance for me to assess and reflect on the different attitudes different women greeted the research with. Some were highly chatty and really keen to receive feedback and education on their beliefs and feeding habits as we went along, while others were much more reserved and less open to new ideas. I did wonder if our research would be impacted by using women from the clinic for our sample, because this meant that we were assessing the health beliefs of only women who had already made the effort to get to the health centre, attend the antenatal clinic, and seek out opportunities for the health of their children. Would this mean that the attitudes towards health and levels of healthcare education we witnessed were disproportionately positive compared to other mothers in the community?

The rest of our fieldwork that week was carried out in a different village in the same region, this one even more difficult to get to thanks to heavy rains and fallen trees that meant we had to walk the final hour of our journey, passing through lush greenery and banana trees with rogue chickens squaking at our feet. Again, in order to do ethically and culturally responsible research, we had to ensure that the village leader was on board with what we were doing. This was especially important in this particular village, where there was no health centre we could use to find subjects, and mothers with children under 5 instead had to be aware of our presence and voluntarily come to us. We had worried that this would cause great difficulty, and tried to get our numbers up with a few door to door home visits, before being unbelievably surprised to have FOURTY women lined up at the community centre we were setting up in, filling it to brimming with colour and noise. For the sake of the research, we were ecstatic! We were left wondering, however, whether this huge turnout was a reflection of a keen and positive attitude amongst the mothers towards healthcare, medical professionals and research, or of the significant power and control of the village leader over women in the community that meant they felt pressured or forced to go. The forces at play in this definitely could have also contributed to some volunteer bias for our research, and really helped expose me to some of the difficulties inherent in conducting community-based assessments.

On that second day of data collection, I was involved in taking anthropometric measurements for all of the mothers and children. This meant taking the mother’s weight and height, the child’s weight and hight/length, as well as the child’s head circumference, Mid-Upper-Arm Circumference (MUAC), and Haemoglobin. This opportunity for patient contact as well as the total overload of cute babies left me positively GLOWING, and it was fascinating to go home that night and plug the numbers from those measurements into the WHO calculator to more formally assess the nutrition status of these children in terms of their being wasted, stunted, underweight or anaemic.

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One of the bands we used for measuring upper-arm circumference in children.

Every day of that fieldwork week ended with several evening hours working with my group to enter, clean and analyze our data on computers – which was hard work, but also incredibly satisfying. I was reminded yet again of how privileged I am to have been raised in an environment where using computers is second nature to me, and my typing and excel skills allow me the power to do and learn so much.

The final component of this project was to assemble a formal written report (a document I am very proud to have collaborated on!), present it to other medical students and staff at KCMUCo, and take that data in accessible poster formats back to the leaders of the villages we visited, explain it to them, and give them the educational tools to bring this information to their communities and use it to inspire change in nutritional beliefs and practices. We were also able to compare the data from this particular region with national figures for Tanzania. The summarization, analysis, comparison, presentation and dissemination of the knowledge we acquired through this research was undoubtably the most inspiring part, because it came with the realization of what this information means and how it can be used to inform and empower real communities to protect and promote the health of their children. If I wasn’t worried about this blog post getting way too long, I’d summarize and recap all of our findings here… but I will refrain. One particularly interesting and notable finding, however, was the negative correlation we found between a mother’s education level and the likelihood of her child being anaemic. This means that the more education a mother has (ie. to the secondary level instead of leaving after primary school), the less likely it is that her child will be anaemic. As in so much of public health and preventative medicine, education really is the first step in promoting lifelong health!!

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My team with the village leader.

This project was totally enthralling for so many reasons, from the exploration of rural Tanzanian communities to the partnership and friendships I formed with a phenomenal group of my international medical student peers. Above all, maybe, I felt it was a project that so perfectly suited my current skill set and allowed me a chance to contribute meaningfully to work that I believe in and that lies so central to the very reason I set out on this scholarship year. It was work that allowed me genuine and immersive community involvement, with both research and health education/health promotion related impacts. It was also a glimpse into what medical students at my precise level are doing in other parts of the world, and the ways in which we can all be inspired to connect with the communities we aim to serve one day during our education. The only shortfall of this project – in my eyes – was that the experience was over way too soon!

Maternal & Child Health in Kilimanjaro, Tanzania

The second major theme woven through my weeks with the Community Health Department is, as I have learned, also the very foundation of community and public health: the care of mothers and children. Pregnancy and childbirth, as the places where life begins, are the absolute earliest possible opportunities we have to educate about, advocate for, and promote lifelong health. When communities are empowered to engage with awareness and healthcare initiatives surrounding maternal health, it is the very definition of “upstream” medicine. The care of mothers in pregnancy and child birth, then, bears not only extreme relevance to my aims with this scholarship but also, on a MUCH larger scale, to the healthy future of emerging generations all over the world.

At KCMC, my engagement with maternal and child health involved working in three different projects:

Antenatal Care

The first of these projects was a weekly clinical experience at KCMC’s Antenatal Clinic. Working alongside Tanzanian medical students and midwives on a Tuesday morning, I had the opportunity to greet the pregnant or post-partum women arriving at this clinic, take their weight and blood pressure, weigh their babies with the antenatal nurses, and practice my Swahili with greetings and easy conversation about how ridiculously hot it must be to pregnant in this tropical climate or how ridiculously adorable their fresh-out-of-the-womb babies were. More than anything, I loved the human-ness of this experience: the palpable buzz of energy that accompanies mothers and mothers-to-be who will do just about anything – walk just about any distance in just about any temperatures or amount of rainfall – to fight for the health of their children. This love and energy is, from my treasured observations in this room, a cornerstone and driving force in these public health services. Each new mother arrived with a hand-sewn hammock/bag that their baby could sit in and be hung from the weighing scale, and these bags – something I have seen in no other healthcare setting before – were made in the entire vibrant rainbow of local Tanzanian fabric, and served as another totally beautiful marker of the home-grown love for these children.

After these initial checks, pregnant mothers received regular checkups: ultrasounds, laboratory tests, vitamin and medication adjustments, diet and lifestyle education, and an opportunity to express questions and concerns. Newborns also received check ups, assessing their growth and general health, looking for any early red flags of ill-health or developmental delays and, when on schedule, receiving the WHO-recommended sequence of childhood vaccinations. Nervous first time parents were given education on the side-effects of vaccinations – like fever and general un-wellness – to ensure that parents are not scared off of the vaccination program and continue to return for the long-term health of their babies. This small clinic was a total hive of protective and preventative healthcare activity every week, and I loved it!

Maternal and Child Health Monitoring

Another of my weekly assignments in the department was to collect data on maternal and newborn health outcomes from the various relevant hospital departments, and compile it with incoming data reports from all over the Kilimanjaro Region. Even though data collection might sound like a little bit of a dull grind, I got a total rush (nerd alert!) from seeing all the numbers come together each week and watching as the “big picture” of such a crucial area of health unfolded in front of me. In order to develop this picture I started every Thursday morning, armed with a notebook and pen for some old-school data collection, by heading to the Neonatal Unit and NICU. Entering this unit is like leaping headfirst into a kaleidoscope. Benches line its narrow corridor, and these benches are filled shoulder to shoulder with the backbone of Tanzanian society: the mamas. Sharing a few bare-bones mattresses in a corner by night, mamas with babies in this tiny unit stay here 24/7 for the time of their child’s admission, so that they can always be on hand to breastfeed. They sit by day, exhausted, crowded, and traumatized to tears by the illnesses of their babies, but dressed nevertheless in an incredible and optimistic array of stunning Kanga and Kitenge – the local fabric that makes Tanzanian women living works of art. From these seats, they hand-pump their breast milk into tiny frail mouths or small metal dishes. It’s really quite a sight to see and I, personally, could never get enough of these beautiful, stoic mamas and the gorgeous, delicate bundles they held. Unfortunately, my job on this unit was much less beautiful and optimistic: recording the week’s admissions and deaths. It was by looking through these records to extract my data that I was reminded of why all these women were here: prematurity, labour complications, birth asyphyxia, gastroschisis, pneumonia… a whole host of complications that, despite the presence of this supportive rainbow of mamas bursting with nurturing milk and nurturing love, were very often incompatible with life.

I’d carry on from the Neonatal Unit to visit the two Pediatric Wards, where children were being admitted and dying from a whole host of terrible illnesses: pneumonia, sepsis, acute and watery diarrhea, meningitis, necrotizing fasciitis, hypovolaemic shock and anaemia secondary to sickle cell anaemia, HIV and AIDs, malnutrition, snake bites. Many of these conditions I had never seen before, and all of them I would love to never see again in a child.

I’d finish this process with a visit to the Labour and Delivery ward, slipping into a pair of crocs amidst the sounds of screaming women, screaming babies and – I seriously love you, Tanzania – the soaring voices of an African gospel choir CD that is played on repeat.  After locating the week’s birthing records, I’d  take down the numbers: babies born, babies lost, mothers deceased, hearts broken. It was both an exceptional privilege and an agonizing reality check to make these rounds, moving in and out of the different departments and learning about the heavy and horrendous problems they face for mothers and children in those first delicate years of life. I was always welcomed warmly by the charge nurses I began to form relationships with and encouraged to learn from and reflect on this data: what it means about clinical care in this region and how it can be used to inform improvements. Because records at KCMC are not computerized, all of this data collection had to be done by hand until the final step – a report submitted to the hospital director and municipal public health officer – which made it both laborious and prone to the errors of hurried handwriting. It was yet another good reminder from this year of the challenges of conducting medical practice and medical research in low resource settings, but also of the grit and resilience that people working in those systems exemplify when they get the job done regardless. No room for laziness here!

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One of the lush central courtyards of the hospital I’d pass by on data collection days!

Technology & Totos

Toto is Swahili for child, and Toto Health is an amazing NGO working in Tanzania that uses innovative mobile phone technology to bring pregnancy and early childhood health education information to the mothers  who need it. In my third and final project pertaining to this maternal health theme, I worked my way through the Labour and Delivery and Obstetric Wards with my supervisor and helped women get set up with this program on their smartphones, which are as popular and heavily-used in Tanzania as anywhere else in the world. We helped them input the relevant medical information about their pregnancy or their new baby, and watched as they began receiving tailored text messages about how to protect and promote their health and the healthy development of their child.  Even in her 60’s, Sister Mayo (my supervisor) is seriously keen to dive in and learn about newly-available technologies that can expand the access of her patients to healthcare information; and I am endlessly inspired by that attitude. Throughout Tanzania and East Africa mobile phones are increasingly being used for vital information sharing – from weather updates for farmers to vaccination reminders for mamas – and joining this innovation revolution for mothers and babies is a tremendous stride forward in public health. As I said at the beginning of this post, mothers sit at both the core and the very foundation of community health, and the more empowered they are to access and use healthcare information, the healthier their children and the future of their entire community will be.

Community-Level Sexual and Reproductive Health Services at KCMC

What I’ve written in my last two posts about my time with the Community Health Department at KCMC included some of the really varied topics I was exposed to during my time there, from antibiotic resistance to diabetic health education, to environmental health and community rehabilitation. It was fascinating for me to get the exposure to this variety, and see just how broad a range of issues “Community Health” encompasses. During my 6 weeks with this department, however, three main themes emerged that transcended almost everything else I did and, I came to realize, really form the foundations of community/public health in Tanzania and what it aims to achieve.

The first of these is Sexual and Reproductive Health. KCMC, like many hospitals and health centres in Tanzania, has a dedicated Reproductive Health Centre (RHC) that is distinct and separate from the main hospital – with the aim of removing the fear and “something is wrong with me” mentalities of visiting the actual hospital. The two main projects I was involved in at the RHC were HIV testing and the Cervical Cancer screening program.

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The Reproductive Health Centre

The idea was that I would learn some of the clinical skills required in healthcare screening programs and collect and manage data from these activities. While that did all happen, what REALLY and most-notably took place in that small centre were deep, life-altering, fully-immersive cultural and personal experiences in which I was unbelievably privileged to have the story of each visiting woman laid bare in front of me. I still get goosebumps thinking back on the courage of these women and the stories of pain and vulnerability I bore witness to. More than anything I learned about HIV or cervical cancer, I learned intimately here about the impacts sexual and reproductive health have on the lives and narratives of real, beautiful, individual people.

Cervical Cancer Screening

Thanks to public health campaigns throughout the Kilimanjaro region, the women I met here were voluntarily presenting for screening. This awareness and motivation to attend screening is still, however, the greatest challenge of the program – according to the doctor I was working with. I don’t know about you, but I didn’t realize until this year that not only is cervical cancer the third most common cancer worldwide, but 80% of cervical cancer cases occur in the developing world. Can you believe it is the leading cause of cancer death in developing countries, causing 190,000 deaths per year? Initially, I couldn’t.

I was also surprised to learn that it is relatively straightforward to screen for, using acetic acid (vinegar)! The vinegar, when applied to the cervix, will cause colour changes if pre-cancerous cells are present. KCMC is currently investigating whether this visual test alone is as effective for detection as the visual test combined with a more expensive and laborious Pap smear. While I found this process all so scientifically interesting, I really struggled to participate at the beginning. The tests themselves were very traumatic to watch at times, and I still break out into a cold sweat thinking back to a few of the experiences I had.

Firstly, standards of confidentiality are very different in Tanzania (and, by and large, many of the other countries I have visited this year) to those we exercise is Canada and the U.K. Appropriate doors and curtains for privacy are not always used and, as a woman lies on the table completely undressed from the waste down with her legs in stirrups, doctors and staff of both genders move in and out without introduction or, seemingly, much consideration for the very sensitive conversations happening in that room. I am not trying to say that I know better, nor that Tanzanian culture (generally very open, inclusive, and communal) should necessarily conform to western medical standards. What did impact me heavily in these situations, however, was the noticable fear, shame, vulnerability and isolation I saw in the eyes of the women undergoing screening in these conditions. Coming from a very conservative culture, where many of them had walked in covered up completely from head to toe – and even the most liberally-dressed wouldn’t feel comfortable showing their knees – this rapid transition to nakedness in front of strangers was understandably challenging. I felt it both very difficult, and also guilt-inducing, to add to that crowd of strangers with my presence.

Further, I have learned through this experience and through discussion with others since then that, in Muslim cultures, there can be a concern about the purity of women when objects like the speculum are inserted into their vaginas. Again, culture and religion, and concepts of modesty and purity, were thrown into contrast with medical best interests – exposure, examination, insertion. This cultural and personal fear was compounded for these women with shock, as the cold speculums were inserted, and often a great deal of physical pain. Female Genital Mutilation is still practiced in Tanzania and the Kilimanjaro region, and this alteration of the female genitalia left some women – to my horror and heartbreak – biting down on cloth and gripping my hands to stop from crying out in pain. This extreme physical pain, caused by a risky and damaging cultural practice, got to me the most. After my first experience with this, I walked out of the room – seeing stars – sat down on the clinic’s front steps, and promptly fainted. Bearing witness to this unnecessary and deeply intimate pain affected me viscerally.

All in all, I think cervical cancer screening is vitally important in empowering women to get informed about their bodies and take ownership of their health. I think the work KCMC is doing to this end is fantastic, and I am proud that each and everyone of these women showed up, despite the fear, and made the decision to get their answers. Still, I walked away feeling “not quite right” about the process, and hope to continue reflecting on how respect for patients, their cultural and religious beliefs, and their comfort can continually be integrated into this process in settings like Tanzania and all over the world.


HIV Testing

When women present themselves for cervical cancer screening at KCMC they are also required to undergo an HIV test, because HIV is a significant risk factor for cervical cancer. This is done using finger prick blood samples with two separate tests, and only if the results of the two tests differ is the test confirmed with a full blood draw and lab test. This system is great, I think, in – by removing the use of big needles – creating a less-stressful and more community-based atmosphere that puts patients at ease. Still, there was FEAR. There was heart-wrenching panic in so many of these women’s faces and voices, which also meant that sharing moments of intense relief when the results came back negative were some of the absolute richest of my experiences.

There were also stories. My job in that room was to collect the epidemiological data about the screening, and that I did. I also collected, through the staggering privilege of just being present, a collection of personal narratives that cut straight to my heart. Sr. Mayo, the community health nurse I was working with, summed it up to me: “the biggest HIV problem for these women is our men. Men are not faithful here, and we are not happy with them.” Apparently, men do not accompany their partners to this screening because they know that if they do, they must also get tested. There is, according the RHC staff and CHD nurses, huge resistance to seeking HIV testing and treatment amongst Tanzanian men. This became pretty evident to me as I recorded the sex ratios of the patients who came to see us :I saw approximately 100 women and just 2 men over 6 weeks.

Sr. Mayo, a total hero of narrative medicine, let these panicked, hurting women talk their hearts out – sometimes for hours – giving them a true safe haven to tell their stories and explain to us the reasons they had come to be so desperately afraid that they had contracted HIV. It was through this process that I heard stories of women forced to have sex with men they didn’t know, and women forced to have sex with men in their own families. I met women whose husbands had many wives who had already died of HIV/AIDS, and whose husbands were cheating, employing prostitutes, and taking new wives. I met a woman who already had 6 female children, but continues to be abused by her husband – showing me her bruises – until she bears him a son. I met women from Moshi’s prison who were not given a moment’s privacy to share their fears; to maintain their dignity. I met a woman married to an HIV+ man who did not tell her until after their wedding that he was HIV positive, and refused to use condoms. I saw women who had been brutally beaten and mistreated and abandoned, and women terrified of using birth control because their partners won’t allow it. Story after story, these days made me ache.

Interestingly, the government’s manual/school resource for the prevention of both HIV and early pregnancy is called “The Training Manual on Abstinence and Being Faithful.” As I read through the manual in between patients, I realized that – at all levels – promiscuity, infidelity and the behaviour/position of men in Tanzanian culture were being regarded as the key causes of HIV transmission. Further, it was indeed abstinence, faithfulness, and the adjustment of cultural norms and societal treatment of women that were being advocated for as solutions to HIV instead of, as I had assumed, a focus on condom use and safe sexual practices. A whole chapter of the manual is devoted to culture – and to the specific rituals, rites and practices in different Tanzanian cultures that promote or challenge women’s rights and the concepts of abstinence and faithfulness. It discusses male dominancy and power dynamics in traditional relationships, polygamy and the practice of having multiple sexual partners, transactional sex in conditions of poverty, drug and alcohol abuse, and the imbalanced requirement of women to preserve their virginity before marriage when men are not required to – among other cultural practices.

The term “social vaccine” was introduced to me at one point this year, at the time referring to maternal education levels as being a protective “vaccine” against childhood malaria. While I strongly believe that physical/medical measures, such as vaccinations and condoms, are vital in preventing disease transmission, this experience with HIV testing was a great opportunity to think about what cultural and social factors play into the spread of HIV and other infectious diseases and have the potential to, to an extent, “vaccinate” against them. Medicine is, after all, about people – and people are bound together by culture arguably much more strongly than they are bound by biology. When it comes to a disease like HIV, spread by intimate human contact, it is important to remember that culture and society are what govern our ideas and beliefs about he we interact and come into contact with others: the two are undeniably linked. More food for thought from this year, for sure!

It was also interesting to note that this clinic was specifically called an “adolescent/youth friendly” reproductive health centre. From literature I read inside the clinic, I learned that there is currently a big push ongoing in Tanzania to encourage young people to recognize their reproductive health rights and the utilize the services available to them. Health services are striving to be more welcoming for youth and adolescents, and to increase the provision of psychosocial services to care for the specific emotional needs of youth seeking reproductive healthcare.

While that all sounds great, I have to report that I did not see anyone under the age of 20 (with the VAST majority of patients falling between 25-40) during my 6 weeks at the clinic – and I do wonder what that means in terms of the successes of improved adolescent access. In a study recently carried out in several Tanzanian regions, over 80% of adolescent respondents identified “too embarrassing” and “not enough privacy” (!!!) as reasons for not attending reproductive health services. Also, while 82% of respondents said that they had heard about HIV/AIDS prevention strategies, 58% of girls and 73% of boys responding to that same survey reported not knowing how to use a condom — at all. These numbers, I think, highlight two of the concerns I have already mentioned from my time in the clinic, in an adolescent-specific context. The first of those concerns relates to inadequate privacy affecting patient comfort, and the second pertains to the suggestion of potentially inappropriate HIV prevention strategies: especially for young people, it is hard to think encouraging abstinence would be as effective as encouraging condoms and safe sex, for example. Yet again, I am no expert here, but I am certainly taking these lessons away with me and doing my best not to forget my feelings and impressions during these interactions.

HIV Care

Finally, it was important to me – after spending so much time at the RHC – to learn about what happens next for the patients who test positive for HIV.

Adult patients, I learned, are referred to the HIV Care and Treatment Clinic, and children and families are sent to the amazing Child Centred Family Care Clinic (CCFCC). The theory behind the CCFCC is that, because family is the core unit of Tanzanian society, treating families as a whole instead of individual patients is the best way to provide holistic, integrated, timely and effective multidisciplinary treatment. Culturally appropriate care? You betcha.

I loved every single moment I spent in this clinic, learning about the challenges and triumphs in long-term HIV management and how the disease impacts families and communities. It was heartening to see that a disease that carries such a significant burden and stigma, and causes so much fear and psychological trauma (as I witnessed first-hand during testing), is being treated at KCMC with such sensitivity, compassion and collaboration. I won’t be forgetting any of the doctors or families I met in this clinic any sooner than I’ll be forgetting every brave woman who came into the RHC for screening. Reproductive and sexual health impacts absolutely everyone, and requires hospitals to have a whole arsenal full of culturally-appropriate approaches to facilitate and encourage communities to engage with their services.