Earlier this year, a group of Kingston doctors travelled to Tanzania as part of a medical caravan. Facing primitive working conditions, a lack of resources and a language barrier in a country rife with poverty and illness, the experience forced the doctors to adapt their approach to medicine and realize that a difference can be made in even the most challenging circumstances.
(clockwise): Tanzanian woman working in the field; mural courtesy of Canadian students; Dr. Jaelyn Caudle entertains local children with her camera; A view of Mount Kilimanjaro
One of the first Swahili words you learn when you travel in East Africa is mzungu. It means “aimless wanderer,” but over the years it’s evolved to mean “foreigner,” and more specifically, “white foreigner.” Although it’s easy to mistake for a racist slur, it’s actually a friendly word. A vestige of a colonial mentality that lingers — although there hasn’t been an imperial presence in the region since the 1960s — the word carries a sense of respect. It also carries expectations.
In Tanzania, the locals tend to view mzungus as benevolent. They frequent their businesses, spending on food, trinkets and safari adventures. The evidence of their philanthropy is there in hospitals and schools built across the region. And while this trail of affluence and generosity leads to high expectations of the general mzungu population, few feel the weight of those expectations as acutely as the mzungu doctor does. Five Kingston-based doctors got a taste of those expectations when they visited several villages in rural Tanzania as part of a two-week medical caravan in January. Motivated by a combination of philanthropy and curiosity, these doctors were among 30 Canadians who took part in a mission that originated in the Pamoja Tunaweza Women’s Centre in Moshi, a city about the size of Kingston that sits in the shadow of Mount Kilimanjaro.
Swahili for “together we can,” Pamoja Tunaweza (an affiliated project of the Canada Africa Community Health Alliance) has been a mainstay of the Moshi community since two Kingstonians founded it in 2007. Dr. Karen Yeates, a nephrologist at Kingston General Hospital, and Carol Bisaillon opened the Centre to provide health care, shelter, education and counselling to women suffering from poverty, inequality, violence and disease. Yeates and KGH emergency physician Dr. Jennifer Carpenter have been hosting caravans to dispense free medical care and raise awareness about the Centre in nearby rural villages every January and September since 2008. The January 2011 caravan consisted of Yeates and Carpenter, the five Kingston doctors, three doctors from other cities, two Queen’s medical students and a large support team.
Despite a recent spate of well-intentioned social and economic reform, Tanzania is one of the world’s poorest countries. Nowhere is that poverty more apparent than in the rural regions, where most of the country’s poor people live. Not surprisingly, those regions are rife with health problems. Malaria is a constant threat. So is HIV. The situation is especially bleak for women, who are rarely treated as equals in Tanzania’s patriarchal culture, and often don’t receive any sort of health care. The caravan team arrived late on a Monday night, so their first impressions were suspended until morning when they toured downtown Moshi. During that inaugural tour, the group stopped regularly to take pictures: of smiling school children, of kanga-clad women carrying 50-pound banana bunches on their heads, of the scrawny chickens and goats that shared the streets with all of them.
A few unfamiliar sights and smells aside, true culture shock didn’t come until the following morning, when they arrived in Shimbwe, the site of their first mobile clinic. A tiny village with a population of a few hundred, Shimbwe is everything you’d expect from rural Africa: dirt roads, roofless buildings, women cooking meals over open fires. Shimbwe is home to a new clinic that passes for modern by Tanzanian standards. Unfortunately, it was locked when the caravan arrived, so instead they set up shop in a nearby, far more primitive clinic. With no electricity and no running water at their disposal, the doctors crowded into a foul-smelling one-room shack where, along with their translators, they spent the day dispensing medical care to several hundred villagers.
“That was our introduction to rural Tanzania,” says Dr. Cindy Lawlor, a general practitioner of oncology at the Southeast Regional Cancer Centre in Kingston. “We were on benches in a tiny room with 12 physicians and 12 translators and patients and their families. We were trying to hear them and examine them and feeling totally outside our comfort zone because we didn’t have the resources we normally have.” Lawlor has friends who had been on previous caravans and had thought she knew what to expect. “Even though you have an idea of what it will be like, I don’t think you can prepare yourself for it,” she says. “It’s one thing to understand that they don’t have the resources we have; it’s another to actually try to work in that.”
Wherever they went, the doctors were greeted by the same sight: hundreds of women and children, many of whom had walked for hours to get there, lining up patiently under the equatorial sun to see the mzungu doctors and benefit from their famed healing abilities.
While Tanzanian doctors don’t have access to the same education and technology that Canadian doctors do, most receive much better training now than they did even a decade ago. Still, the mythology surrounding the mzungu doctor is such that the locals will gladly give up a day’s pay to wait in line for a second opinion, despite the fact that the purveyor of that opinion lives at the other end of the world and knows little about tropical diseases.
The primitive clinics and unfamiliar diseases were just two of the factors that made it difficult for the doctors to live up to those lofty expectations. Another challenge was the fact that none of them spoke Swahili, which meant they had to work through translators.
“It took a long time to get used to the translators,” says Dr. Heather Murray, an emergency physician at KGH. “There were so many idiosyncrasies in the way they ask questions and communicate information. There was a huge learning curve.”
(clockwise): Medical drawings on the clinic walls in Uchira; children in Mabogini; more evidence of Canadians in Tanzania; Dr. Chris Frank examines an X-ray
Dr. Chris Frank, a geriatrician at St. Mary’s of the Lake Hospital, experienced one of those idiosyncrasies with his very first patient. “She was talking about waist pain,” he says. “I’d never heard of that before. I thought it was some bizarre neuropathic syndrome, but then my next three patients also talked about waist pain and I realized that it’s probably just back pain and the translator had a different name for it.”
Dr. Jaelyn Caudle, another KGH emergency physician, recalls several incidents when her translator had trouble describing parasites in a patient’s bowel movements. “She was trying to tell me that something was visible,” she recalls. “I asked if it was worms and she said, ‘No, they’re creatures.’ I had no idea what that meant, and then a short while ago it dawned on me that she was talking about parasites. So all of these patients probably had parasites, but I was treating them for worms and the treatment can be different. It took me five months to clue into that.”
More often, though, the doctors worried that they might never understand their patients. “You always worry that you’re missing something in the translation,” says Lawlor. “I found myself asking the same question three times to make sure I got it right. Sometimes the answers didn’t match the questions.”
The translators were especially important because the doctors needed anecdotal information to make up for a lack of scientific data. Although the caravan team tested for HIV and malaria, the doctors didn’t have easy access to X-rays, scans and the hundreds of other tests they depend on at home. The inability to test was especially difficult for emergency physicians Murray, Caudle and Pamoja Tunaweza Medical Director Dr. Jenn Carpenter. “In Canadian emergency departments, we’re so used to being able to get test results when the patient is still under our care,” says Carpenter. “On the caravan we had to send patients to town and wait for the results to return a few days later. The inability to get an immediate answer can be unsettling if you’re not used to it.”
“We were making decisions for people who have so many things wrong in their lives,” says Murray. “I was dealing with illnesses that I don’t know much about and without tests, I had no ability to verify that my decisions were right. We were practicing in a vacuum. It felt like we were guessing.”
“We were fumbling in the dark,” says Frank, “so we had to rely on physical examination and history.” Yet the cultural and language barriers turned the seemingly simple act of recording a patient’s medical history into an ordeal. “The patients weren’t used to the concept of giving a history,” says Frank. “It didn’t seem, even through the translator, that they knew how to present their stories. It probably led to a lot of miscommunication. We were forced to depend on instinct and clinical acumen.”
It made for an exhausting day. “I was surprised by the cognitive impact and how tired I was at the end of the day,” says Caudle. “I felt overwhelmed.”
“On top of that, there was the emotional impact of the lives these people are leading,” adds Murray. “It was like being hit by a train. It was boiling hot and we weren’t sleeping well and through it all we were worried because we wanted to do the right thing for our patients.”
The caravan continued through a chain of villages with exotic-sounding Bantu names: Mabogini, Uchira, Kahe and Chekorine, each one bringing a fresh assault on the doctors’ emotions. Sometimes it was the medical conditions that did it: a young girl whose face was covered in cold sores that would bleed every time she opened her mouth, a woman with a goitre on her neck, a woman with leprosy.
Still other times it was the combination of poverty and illness. Dr. Trevor Wesson, a family physician in private practice, tells the story of a five-year-old patient: “She was with her grandmother because her parents had abandoned her. I could see that she had risk factors for HIV and she also had a fever, so I recommended her for an HIV test and a malaria test. She had to have her finger pricked twice and she didn’t like it. She screamed and screamed and someone had to hold her down. Fortunately both of the tests were negative. Still, she was very sick. If she does get better, she’ll still have problems. I don’t know how often she has a meal.”
Amid that kind of despair, the doctors couldn’t help but wonder if they were doing any good at all. “Everywhere there was a tremendous amount of need,” says Murray. “We wanted to feel that we made a positive difference in this abyss of need. And we definitely did, but not with every patient, at least not that we know of. Not being able to follow up with our patients left us unsure about many of our decisions.”
The inability to follow up was, perhaps, what frustrated the doctors most. “We were all concerned about the continuity of care,” says Lawlor. “We were prescribing short-term treatments for chronic conditions and we weren’t able to follow up like we do at home.”
Despite the frustrations, the doctors learned to adjust. After that tumultuous first day in Shimbwe, they gathered to formulate a game plan. “We realized that we needed to change our thinking,” Frank says. “One of our big goals from that point on was to do no harm. Once we became clear on that, we just adapted our approach.”
Caudle, for example, became more flexible with each passing day. “Initially I was very dogmatic in my practice,” she says. “I would refuse to prescribe antibiotics to people who weren’t sick. People were leaving disappointed. Eventually I realized that they may not need the drugs now, but they’ll need them a few months from now and I wasn’t doing them any good by denying them.”
This new-found flexibility made the job easier. The turning point for Caudle came when she stopped trying to figure out what was wrong with her patients and focused on treating their symptoms instead. “I didn’t feel good about it at first because I would never do that here,” she says. “You always go for the diagnosis here. But I don’t think it’s a bad thing to treat their symptoms. That’s what they were there for, and once I realized that, I stopped feeling guilty about it.”
Every once in a while, the doctors could even allow themselves to feel that they had made a difference. They made diagnoses — of HIV, appendicitis and anemia — that saved or prolonged lives. “For every doctor that was there, I can think of several patients whose lives they changed,” says Carpenter.
Of course, some problems were too big, even for the mzungu doctors. Murray treated a woman who complained of a headache that had persisted for 20 years. “I realized that it was probably caused by the fact that she’s been walking around with 50 pounds of bananas on her head every day,” she says. If she were to stop carrying all those bananas on her head, her pain would likely go away, but it’s not that simple. African women have been carrying heavy loads that way and suffering the physical consequences for centuries, and it’s going to take more than a few well-meaning mzungus to change that.
(clockwise): Patient with leprosy; lineup at the clinic in Moshi; Dr. Cindy Lawlor and Dr. Trevor Wesson; one of the more spacious clinic rooms
And the mysterious waist pain that the doctors had heard about since they arrived? “It occurred to me that it probably comes from the way they bend,” says Lawlor. “If you watch the women working in the fields or cooking over the fire, they don’t bend at the knees like we do. They bend at the waist. No wonder they’re in pain.”
Faced with primitive working conditions, a formidable language barrier and a set of problems too big to solve during a two-week mission, the doctors’ modified approach seems wise in retrospect: They didn’t need to be saviours. It was enough simply to treat their patients. “It’s only possible to do so much for people you only see for a few minutes,” says Wesson. “We had no choice but to become realistic about what we could achieve.”
Once the caravan ended, the doctors returned to Kingston with a renewed appreciation for their families, the comforts of home, the freedoms Canadian women enjoy, and especially modern medical equipment and readily-available tests.
“They definitely changed lives,” says Carpenter. “It may not have been for every patient they saw, but the impact is much deeper than that. Tanzanian society is so interdependent that when you help one person, you also help their families and all of their dependents. Even those who didn’t get a medical cure often express an overwhelming sense of feeling valued. Receiving health care is a basic human right, and it’s as important as curative medicine, in many cases. Every patient who came now knows about the Centre, and they know that if a family member becomes sick, they can go there for free care.”
The Pamoja Tunaweza Women’s Centre now sees about 60 patients a day, many of whom come from the villages served by the caravan. “When we realized that the caravan was a building block in developing a primary-care system, we reconciled ourselves to its shortcomings and began to feel that we were part of something sustainable,” says Frank.
“I was worried that our little visits to these remote communities didn’t amount to much,” Murray says, “but I realize now that the program is on its way to becoming an institution. After the caravan leaves, people can go to the Centre for follow-up and build long-term relationships, and that’s awesome.”
Co-founder and executive director Dr. Karen Yeates says that was the vision from the beginning. “When we developed the Women’s Centre idea, the plan was to go back to the villages and give them the same consistent message that they can come to the Centre for follow-up. So we keep going back and eventually they get to know us and trust us.”
After the January caravan, the Centre’s seventh, the results are apparent and impressive. “The villages are becoming healthier,” Yeates says. Even Shimbwe. The impoverished village that kicked off the caravan may have seemed shocking to the doctors, but Yeates says it’s come a long way in four years. “It used to be the sickest village on our circuit, but it’s the least sick now,” she says. That’s because community leaders know about the Centre and organize trips there every two weeks. “They’re bringing in elderly people with hypertension and kids who have hygiene-related infections. We’re seeing them regularly and giving them information and it’s making a difference. They know how to manage their conditions now.”
Today the doctors have enough perspective to see past their frustrations and value their contributions in ways they couldn’t in January, and all five say they’re open to going back. “If you had asked me in February, I would have said no,” says Caudle, “but now I recognize the difference we made and the value the Centre provides. There’s an ocean of need, and maybe I only filled a teaspoon of it, but a teaspoon makes a difference when you’re part of something bigger.”