Community Health in the Kilimanjaro Region

My recent set of posts about the time I spent at the Department of Occupational Therapy at KCMC tells a big chunk of my Moshi story – but not all of it. After a tough goodbye to the Occupational Therapists and OT students I had come to know so well, I started a 6-week placement with the Community Health Department/Institute of Public Health that would become another significant and marvellous chance to learn about how hospitals can promote health for individuals, families and communities far outside their walls.

What does a Community Health Department Do?

The Community Health Department (CHD) is one of twenty clinical departments at Kilimanjaro Christian Medical Centre (KCMC). I asked to be placed in this particular department because of its name alone, and the fact that – with this scholarship – I wanted to learn about exactly that: community health. What this department did exactly, and how they influence and monitor community health, was actually largely unknown to me before I started my placement. The department name certainly does leave more to the imagination than the Labour and Delivery Ward, for example.

I can now report that this department does a lot. My time with the CHD community health workers took me to nearly all other departments of the hospital for health promotion activities, as well as to communities as far as a 2-hour drive away from KCMC for outreach programs and research. Being a major medical centre for Northern Tanzania, KCMC’s responsibility to reach the broader community is absolutely massive. For example, the CHD office I reported to every morning is home to a Radio FM service that dispatches health information to 25 hospitals across the Kilimanjaro region and Northern Tanzania, giving staff in the field an opportunity to obtain expert advice and assistance in emergency situations. The Radio system also coordinates visits of experts from KCMC to hospitals and clinics throughout the region for education and assistance (in collaboration with AMREF Flying Doctors), and provides information about disease outbreaks (as in the Ebola crisis in 2014) to surrounding communities. Virtual links span directly from that office all over the country via Radio, connecting this one hospital with thousands of Tanzanians who benefit from its expertise and guidance on health issues. Needless to say, I was pretty wow-ed by this phenomenal outreach system from the get-go.

“Mission Control”

Another initial way I was able to learn about the incredibly broad expanse of endeavours undertaken by this department was at the department’s weekly Monday morning staff meetings, as well as during the daily tea break when all of the CHD staff gather around mugs of piping hot and extremely sweet black tea and peanut butter sandwiches. I loved the collaborative attitude of the department, and the eagerness with which each member of staff shared their projects and any new training they had been engaged in. For example, although I was never directly involved in it, I was fascinated to hear weekly updates on an Antibiotic Resistance project that the CHD was initiating after one of the department’s doctors attended a conference on “Antibiotic Resistance in Developing Countries,” where she had collaborated with delegates from as far as way as India and Cambodia. I felt that her attendance at this conference and excitement to share what she had taken away from it was a wonderful indication of how KCMC, and the CHD in particular, is reaching out for guidance and international input on how to make global WHO priorities – like combatting antibiotic resistance – KCMC’s priorities. This passionate young Tanzanian doctor reported weekly on her progress, designing first a point-prevelance study to look at current antibiotic use at KCMC and the surrounding community, followed by an intervention aimed at increasing adherence to global antibiotic protocols, followed by a final point-prevelance study to determine the effectiveness of her intervention. The intervention would, if proven to be effective, be extrapolated to other settings in the region — and I can’t wait to hear how it all turns out! Antibiotic misuse is a global problem that has been raised in many of the healthcare settings I’ve worked in this year, and community-level surveillance plays a significant role in efforts to address it.

Environment & Health

Another crucial part of the CHD’s surveillance work is looking at areas of the hospital that often go overlooked. By this, I mean the ‘in-between’s: the community and environment that exists in between every ward and between every treatment room. Where do patients go to the toilet between interventions? Where do families eat and wash their hands between visiting hours? Where do nursing mothers sleep between feeding times in the Neonatal ICU? Doctors, focused as they are on the actual interventions and operations, often overlook these ‘in-betweens,’ despite their indubitable impact on health. Once a fortnight, Sr. Mayo (the main Community Health Nurse I worked with during my time at CHD) did a round of these hospital areas and, while I was attached to the CHD, brought me with her. During these rounds, we collaborated with the staff in charge of waste disposal at the hospital to make sure garbage cans and recycling bins were located where they were needed and kept clean, with the correct signs in place to instruct even illiterate patients and family members about their proper use. This included bins not only on the wards, but also in waiting areas and at newsstands, canteens or mobile phone credit vendors. Waste left unaddressed in any part of the hospital, and especially in those areas in close proximity to infants or immune-compromised patients, poses a significant hygiene and health risk.

We also visited the hospital canteens, where visiting/waiting families come gather to eat fresh-flipped chapati and hearty bowls of mtori (beef and banana stew), and assessed both adherence to food hygiene standards in kitchens and the availability of soap and water for guests to wash their hands. While I believe these tasks might be out-width the job description of a community health nurse in Canada – where hospitals have dedicated food hygiene staff, cleaners and waste-management services – in Tanzania this role is really all-encompassing, and the CHD staff play a central role in monitoring and promoting health in all aspects of the hospital environment. The canteen staff all knew and loved Sr. Mayo, and greeted us with smiles and warmth as they showed off their clean counter tops. We left with our hands full of steaming hot chapati and avocados the size of my head, and I had a ridiculously enjoyable time doing these rounds. When I reflect on it now, I realize just how relevant and important these activities are: should the hospital not be the role-model for healthy practices in community settings, like where the worried and weary gather to eat, pray, sleep, read the news, top-up their mobile phone credit, and chat? Is that not the very definition of community health??

Are hygiene and sanitation standards being upheld in all parts of the hospital?? Do we, as doctors and medical students, need to acknowledge and care about this?

During this biweekly practice as well as during various other parts of my time in Tanzania, I had the chance to reflect extensively on the concept of environment and health. This meant looking around at the hospital setting, but also looking much more broadly at the external environment Tanzanians interact with every single day. I was fascinated to see just how intimately people in Tanzania live in connection with their natural environment, with 80% of the population being directly involved in agriculture (according to the FAO). Both the head of the OT department and Sr. Mayo, my supervisor in the CHD, described to me how they use small-scale farms to grow food for their families, before and after their day jobs at the hospital. Growing one’s own food, I came to realize, means that environmental conditions like weather, flooding, droughts, and pollution are not distant, outside problems, but instead become directly reflected in one of the most basic determinants of everyday health and wellbeing: the food on your table. Through Team Vista, the organization that ran my hostel in Moshi, I learned that managing a productive farm in Tanzania is remarkably difficult, and stress about whether or not it will rain or how much water is in your well – a stress I have never before had to consider in my entire life – can be intense and consuming. Team Vista, in order to generate funds for their community projects in country, run a small community farm not far from Moshi town – and let me tell you, it is a labour of love. I never knew what hard work a single crop of lentils could be!!

Daily traffic in the agricultural area near Team Vista’s farm.

Climate change and the resulting environmental conditions have a huge impact on weather patterns and seasonal wetness/dryness, and traditional farming methods and tools for predicting weather in Tanzanian are being thwarted by these recent changes. Two wonderful friends I met in Moshi were working in/studying agriculture extensively, and it was from them that I learned about the transitions, technology and tribulations being introduced to Tanzanian farms with changing climate and evolving knowledge. The human footprint on our environment has a direct and reciprocal impact on the wellbeing all humans who depend on the environment for our food — ie. all of us! — and while I had never really considered this before, now that I have learned about it I simply cannot forget it.

In other ways, on a tour through Rau forest and a “Coffee Tour” in the Materuni region, I saw how local guides – and village/community members of all ages – are experts on their local flora. Much like the concept of ethnobotany I learned about in Laos, Tanzanian culture and society encompasses and embodies local plant life in a way that more developed countries, from my experience, really do not. Being able to read, recognize and relate to our natural environment is, however, meaningful for health all over the globe, and one of my new-found goals for the next four years of medical school is to continue to explore this theme in Canada. I didn’t know until this year, for example, that the University of Alberta actually has a Children’s Environmental Health Clinic devoted to research, education and clinical care surrounding environmental health issues. It is the first facility of its kind in Canada and I’m excited to visit soon, in an effort to build on what I discovered in Tanzania and Laos this year and deepen my appreciation of the environment/community health interface.

Just a lil bit of biodiversity.