Expert Commentary

Thoughts about ObGyn after practicing in Tanzania

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For 2 years, we’ve helped provide basic medical services to thousands of ill and injured Tanzanian women. They’ve taught us understanding and compassion and given us a sense of usefulness.


 

References

Two years ago, our family moved to Tanzania to help build a women’s health collaboration between Duke University and the Kilimanjaro Christian Medical Center (KCMC) in the town of Moshi, one of four tertiary referral centers in Tanzania that serves a population of nearly 14 million people. The goal of the collaboration was to expand the successful Duke-KCMC HIV/AIDS program that had been in operation at KCMC for 10 years to a broader women’s health service. Here is a synopsis of what we found in Tanzania and what we learned in those 2 years working alongside excellent local consultants and medical residents. (For ease of narration here, the word “we” expresses our individual and in-common experiences and thoughts.)

Welcoming party: Fire ants

Introductions. We are faculty members at Duke, in obstetrics and gynecology (Jeff) and family medicine (Sumera). In 2007, after we rented out our house for the coming 2 years, sold both cars, and packed 20 suitcases with our clothes and medical supplies, we left for Tanzania with our children in tow.

In Moshi. We arrived late at night, after the airline lost at least 30% of our baggage, to a house near the hospital that was in disrepair and infested with fire ants. There were (passing) thoughts of turning around and heading home.

Jeff had done a good deal of OB and gynecology in under-resourced settings—India and West Africa. But the work had always been brief surgical excursions, mostly to care for women who had obstetric fistula.

Now, however, broadening the Duke-KCMC HIV/AIDS to general women’s health presented great challenges and great opportunity. Yes, the Tanzanian ground was fertile for sowing seeds of collaboration in women’s health, but opportunities for federal funding for global women’s health projects, apart from HIV/AIDS, were limited. Duke’s goal was to build a research platform that cultivated awards from the National Institutes of Health, which, ultimately, are essential to the sustainability of most East-West and North-South research collaborations.

Priorities are everywhere. The fact that, every year, worldwide, more than 500,000 women die in childbirth and there are more than 6 million stillbirths and early neonatal deaths has, for a long time, eluded the conscience of the world’s major funding organizations. Devastating related problems, such as obstetric fistula, have been so neglected that some expert voices have labeled obstetric fistula “an orphan initiative.” United Nations Millennium Development Goal #5—a 75% reduction in maternal mortality by 2015—is far off target, with minimal progress made in sub-Saharan Africa.

Some interesting (often medically devastating) cases that we encountered in Tanzania

Every week at KCMC presents interesting challenges to our intellect, our surgical skills, and our resolve to press on to the next happy outcome—or tragedy. We admire our Tanzanian colleagues who confront these challenges every day of their professional lives.

  • A woman with massive labial elephantiasis with a 40-cm labial mass
  • Multiple abdominal pregnancies of advanced gestation (testing the surgical skills and resolve of anyone who dares enter the abdomen)
  • A 40 week-size molar pregnancy
  • Many cases of uterine rupture and associated complications
  • Countless women with complications of HIV infection and AIDS, in and out of pregnancy
  • More cesarean hysterectomies than we can count
  • A woman with a 18 week-size fetus in the right broad ligament, inside a huge retroperitoneal abscess that developed as a result of a botched abortion, performed in her village, that perforated the cervix.

Our strengths had been in clinical care, teaching, and program development. Based on the priority areas of the KCMC department of ObGyn and our professional experience, we chose to focus on four areas of care in expanding the Duke-KCMC program:

  • emergency OB care and neonatal resuscitation
  • OB fistula repair and recovery
  • cervical cancer screening and prevention
  • laparoscopic surgery.

In Moshi, any one of these areas could have consumed all our time. (See “Some interesting [often medically devastating] cases that we encountered in Tanzania.”)

A deficit of hands-on skills

We then determined that instruction in emergency OB care and neonatal resuscitation was needed most urgently at KCMC.

In most of sub-Saharan Africa, medical education focuses on learning theory. If we were to put medical students in Tanzania up against their US counterparts in an examination of the theoretical aspects of medicine, the Tanzanian students would perform as well or better.

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