Heart of Darkness: Just Another Day in the Village

After an eventful journey from Nairobi to the Tanzanian border I settled into the sleepy village of Shirati for a much needed respite after 48 hours of travelling. It took an additional two hours over dirt roads and paths winding through various villages to finally reach our destination. Dr. Esther Kawira had a piping hot meal ready for me when I arrived. Her story is remarkable. She is a U.S. trained Family Medicine physician who married a local and settled in Tanzania 30 years ago. Twenty of those years she spent running the only hospital in the village and has since opened her own rural clinic serving the underserved population for nominal fees. It is to work with her and the individuals in the hospital that I have journeyed here.

First a little about the village of Shirati. When I was trying to research the area I could not find it on a map. I have since only seen it listed on a single map (blown up to include only this province) which belongs to the local historian. Homes are primarily mud huts with thatched roofs or made from tin. The wealthier folks can afford small brick houses. Small bumpy, dusty roads connect the farms in the surrounding area. Animals roam freely and still see people infrequently enough to stare intently at you as you pass by. Whenever I ran through the village, children would cheer and join me from each community of huts, slowly forming a flying-V entourage around me. It reminded me of the Muhammad Ali movie where the whole town in Zaire started running with him yelling, “Bomaye Bomaye” (“Kill him, Kill him” prior to the ‘Rumble in the Jungle’ against George Foreman).

Shirati’s central area is located by the hospital. It consists of the hospital compound and then a row of shops and fruit/vegetable stands across the road. Each shop contains essentially the same 10 items with an occasional oddity thrown in. These include (in no particular order): peanut butter, medium fat spread, dilute hot sauce, bread, shampoo, coffee powder, washing powder, and fluorescent orange drink concentrate. One or two shops have a rare refrigerator where you can purchase “cold drinks.” Fanta gone wild, flavors abound. Orange. Black currant. Pineapple. Passion fruit. There is also a fruit and vegetable stand and some streetside grillers of meat (what I have come to call “danger meat” but can never resist since I love street food). What you absolutely cannot find is anything dairy related. No milk. No yogurt. No cheese. I repeat, no cheese. I can survive without tv, internet, electricity, and other niceties of modern life, however, I do not know if I can survive without cheese.

Our village Gas Station

Fruit & Vegetable stand

'Danger' meat

Dr. Kawira’s new clinic is still a work in progress (no power yet) but is shiny and expansive and the patients have started flocking from near and far to see her. The pathology seen here is distinctly different from that seen in the U.S. and there are very limited resources with which to diagnose and treat many conditions. Our rapid testing at the clinic was limited to the following: HIV, syphilis, malaria (P. falciparum), hemoglobin, urinalysis, and urine pregnancy. We also had a small storeroom of medications, much of which was donated or procured from Nairobi. After a few days of training under Dr. Kawira I was set off to run the clinic on my own with a band of medical and PA students. We had a nurse to translate from Swahili (or Luo) to English. At our disposal was a stethoscope, flashlight, measuring tape, Doppler for fetal heart tones, lubricant, and gloves, but most importantly our clinical acumen. No imaging or ultrasound. No CBC or electrolyte panels.

Sota Clinic

Our Pharmacy

On my first day alone we diagnosed new cases of HIV, tuberculosis, syphilis, malaria, schistosomiasis, dysentery, CHF, and asthma. There were a few days when we diagnosed half the patients at the clinic with malaria (of the P. falciparum variety) often with varying and very different presentations. In addition to these “bread and butter” cases I saw even more interesting pathology including lymphatic filariasis, known more colloquially as ‘Elephantiasis,’ hepatocellular carcinoma secondary to chronic Hepatitis B in a young unimmunized man, and even diagnosed my first case of leprosy. Acutely ill patients could be “admitted” overnight essentially for observation and treatment at the clinic or they could be “transferred” to Shirati Hospital. Care in resource limited settings is often fraught with ethical dilemmas. A typical case follows:

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Case: 65 yo M PMH CHF (congestive heart failure) and PUD (peptic ulcer disease) presents with pitting edema to thighs, diffuse crackles bilaterally. Previously treated with Hctz, digoxin, and Lasix but lives in extreme poverty with inability to afford meds and has poor access to health care as he lives several hours away from the nearest clinic. Still has some Lasix remaining but no digoxin or Hctz.

Physical Exam

Vitals: 37C HR 120s RR 20 BP 200/100

Gen: Appears uncomfortable and short of breath.

HEENT: PERRL, EOMI, +conjunctival pallor

C/V: S1S2 present. Tachycardic to 120s. Normal rhythm. III-IV/VI holosystolic murmur loudest at the LUSB

Resp: Diffuse crackles bl; decreased air movement

Abd: Epigastric tenderness. Mild abdominal fullness. No rebound. Mild voluntary guarding. +Fluid wave.

Ext: Diffuse 3+ pitting edema to bl thighs

Ethical Dilemma: This patient would clearly benefit from admission to a hospital with aggressive management for decompensated heart failure. However, in TZ most care is fee for service and this patient is unable to afford admission to the local hospital. In fact, he is unable to afford observation overnight at your clinic or even HIV/syphilis tests. The total cost for overnight observation and IV medications and tests would amount to less than $10. What do you do?

This was a case that I had on one of the days I was running the rural stand-alone clinic by myself. This is a common example of an ethical dilemma that may arise during a global health elective. Diagnostics and therapeutics in this patient would normally be straight forward however the waters are muddied when resources are limited. Issues raised in this case include resource allocation, poverty, and access to care. Since it would cost just a few dollars to get medications, tests, and an admission the thought of pulling out a few bucks from one’s pocket immediately comes to mind. We are fierce patient advocates but must be cognizant of the downstream effects of our actions. How do you decide whom to help and whom not to help? Will treating this man for one day change the course of his disease? There are no right or wrong answers but each case is worth analyzing closely.

In our case, the man was able to afford several vials of IV Lasix (40 mg) which I administered to him prior to his discharge. I was also able to increase his oral Lasix dose and restart his digoxin and hydrochlorothiazide. The patient promised to return for admission the following week after he returned to his village and gathered more funds.