Boston University Medical Campus
International Health Program

Tanzania

The following is a summary and compilation of comments from three students
who undertook this experience.

General summary of experience:

A group of fourth BUSM students spent 4 weeks in Shirati, Tanzania (rural
village near Lake Victoria) and Kisumu, Kenya (urban city) with 15 other
medical students under the direction of Drs. Kawira and Mull. The majority
of time was spent shadowing clinicians in either the hospital or one of
the small clinics in the area, both of which presented unique infectious
disease burdens and patient settings. Students witnessed how health care
works in a very resource-poor setting and became familiar with the area’s
most common diseases (malaria, HIV, TB, and schistosomiasis) and their
treatment. They helped deliver care through a mobile clinic and helped
conduct community surveys; they interviewed patients through an interpreter
and talked one-on-one with doctors about their patients. Students take
patient histories and then present the cases to the attending physician
and then participate in the physical exam and treatment plan.

Student 1:

During our time, we had the chance to talk with all different kinds of
people and experience medical practice at many different levels. Although
it was frustrating to realize that after first year I didn’t have as many
skills to offer as I would have liked, with time I developed a modified
repertoire of skills that I could see was helpful where I was working.
With the language and cultural barrier, my interviewing skills and physical
exam skills were put to the test. I learned how to work with an interpreter
and how to begin developing a relationship with a patient with a drastically
different background from mine. Beyond that, it was challenging to see
how prevalent sickness and malnutrition were in those villages. It was
difficult to acknowledge that most of the patients that came in were very
ill and were often children under age 5 with malaria, a preventable disease.
It was encouraging to see how much the health care workers were able to
do with what seemed to me to be impossibly limited supplies and technology.
Overall, I learned a great deal about working within a language and cultural
barrier. I learned from the patients and from the health care professionals
about the different ways of practicing medicine and the illnesses and
diseases that were prevalent in the villages we worked in. It was an amazing
experience!

Student 2:

I spent one day helping to administer a (SHED-sponsored) survey that
consisted of questions about people’s health status and life challenges;
I walked around the town of Sota with a translator and interviewed people
in their homes. This was one of the most interesting parts of my experience
because I had saw how people lived and talked to them about their problems.
The biggest challenges I experienced during this trip were: 1) language
barriers, although there were quite often people around who were willing
and able to translate;and 2) my lack of clinical skills to offer. Overall,
this was an incredible first exposure to international health that exposed
me to the challenges and rewards of practicing medicine in a resource-poor
setting.

Student 3:

I came away from my experience in East Africa overwhelmed. What I had
thought of as a relatively straight forward experience (surveying conditions,
treating existing disease, and educating about prophylaxis) turned out
to be far from simple. I learned that workforce issues were equally as
burdensome on the healthcare system as many of the region’s diseases.
The student interested in a project in East Africa should understand the
flexibility one must have to work in an often times chaotic healthcare
environment. Though one may set up a specific project with a specific
mentor, conditions may often change very quickly, and the student must
be autonomous in seeing his/her project through.

Rwanda

I returned to Rwanda to work with Partners in Health (PIH), the Rwandan
Ministry of Health (MOH), and the Rwandan Treatment and Research of AIDS
Centre (TRAC) clinic to evaluate the implementations of the OpenMRS, a
free, open-source electronic medical record (EMR) system that has been
shown effective in Rwanda and other developing countries. I evaluated
the method of medical data transfer from the paper to electronic records,
work flow from start to end, medical usages of EMR, user satisfaction
of the EMR, overall budget, and areas of improvement. I also contributed
to the National EMR Rollout Strategic Plan to initially implement OpenMRS
at 4 new clinical sites, including 2 large district hospitals, for HIV
and primary care. With a technical manager at the TRAC clinic, we planned
and executed several clinical site surveys, developed goals and research
questions for evaluation, initiated equipment purchases and personnel
employment, strategized with a team over the next year’s EMR implementation
and timeline, and finally, I documented our process and implementation
plan in a report that is being integrated into a larger report document.

I shadowed 3-4 local Rwandan and US doctors in rural settings (Kapgayi
and Ruhengeri) who were participating in the first post-graduate family-medicine
program in Rwanda. I performed physical exams and learned about the diseases,
diagnostic tests and treatment options in this rural setting. I witnessed
my first baby delivery, assisted in a scrotal torsion surgery, performed
ultrasounds and pelvic exams, and learned about the high incidence of
pediatric osteomyelitis in developing countries due to malnutrition and
sepsis. I lectured for 5 hours on basic health, nutrition, Rwandan epidemiology
and socioeconomic factors, and introduction to infectious diseases (HIV,
TB, and malaria) to 12 local EMR/medical-informatics computer programmers
in a year-long training program that I co-founded in Rwanda the previous
year, reminding me how much I love to teach.

Challenges

Initially there was a misunderstanding on my role (literally due to the
word choice of how my role was explained) for the summer, so one of the
technical managers at an TRAC HIV clinic in Kigali was very uncomfortable
about my involvement. It took 1-2 days to explain my role and clarify
the misunderstanding via 2 mediators. Afterwards, it was a delicate situation,
and I had to be careful to earn his trust. Thankfully, we developed a
friendly, strong, good working relationship. Another major challenge was
how far behind schedule the project was due to funding delays and lack
of staff.

Uganda (1)

I spent the summer at the main referral hospital in Kampala, Uganda
working with a Ugandan doctor to devise a study to determine the prevalence
of protozoan infections in HIV-positive patients. Much of my time was
spent at the hospital, familiarizing myself with the specific medical
setting and the target patient population so that the study could be as
feasible as possible while still meeting the study objectives. In doing
so, I was able to attain a secondary goal of building an understanding
of tropical medicine and infectious disease and the unique challenges
faced by patients in an underserved setting.

By their very nature, international research endeavors are challenging
perhaps due to unpredictable obstacles. For instance, given the sheer
number of HIV-positive patients presenting to the ID and GI wards at Mulago
Hospital with chronic or persistent diarrhea, we did not suspect that
it would prove difficult to enroll the required number of patients. To
confirm that the laboratory testing kits were functional, I performed
a “mock run” of the study and attempted to collect fecal samples from
our target patient population, but after five days, I had only collected
three samples. The low number of eligible patients was due most significantly
to the fact that many patients were already started on antibiotics and
their diarrhea had already resolved. After this experience, we decided
to modify the protocol to include enrollment of patients from the Casualty
ward (pre-treatment registration area) and to extend the number of months
of enrollment.

I may have been overly ambitious to believe that in the space of ten
weeks, I could initiate and complete a project within the constraints
of the setting. I would have also appreciated having more to show for
my efforts, the project did move forward. I also strengthened my understanding
of conducting research in an international setting in learning to be more
flexible, devising plausible methods of stool collection, and being sensitive
to cultural nuances and unspoken rules governing interactions with attendings,
interns, and patients. More significantly, through the generosity I encountered
at the bedside of each patient, I reaffirmed the importance of committing
time and resources to such underserved populations.

Kenya

• I was able to use my epidemiological skills, while assisting
  in several data analyses. I helped analyze a data set that was evaluating
  an intervention designed to improve the quality of Antenatal Care (ANC)
  Visits.
• Also, I am currently working to finish a data analysis that
  I started while I was still working in Kisumu that will examine how
  rapid diagnostic tests (RDTs), which test for the presence of malaria
  antigens in blood samples, perform at varying parasite levels.
• While interning at the CDC/KEMRI, I had the opportunity to help
  out with the set up of the MAL55 malaria vaccine trial. Researchers
  at the CDC (and I) were busy rolling out the pre-phase trial, which
  started enrolling patients after I left. The purpose of the pre-phase
  trial is to ensure that malaria diagnosis and treatment is standardized
  across all 11 sites. I helped with the drafting of and editing of standard
  operating procedures.
• I attended and helped teach some of the modules for the training
  of clinical staff. I learned how pediatric patients with malnutrition,
  HIV, malaria are treated in Kenya. I learned the signs and symptoms
  of malaria, meningitis, pneumonia and septicemia and specifically how
  to tell them apart in a research setting.
• Once a week, I shadowed physicians at the Nyanza Provincial
  Hospital (PGH). I rounded in the pediatric ward, pediatric oncology
  ward, and the adult medicine ward.

This experience cemented the benefit of practicing both medicine and
public health.

Malawi

Mali

South Africa

Uganda (2)

Uganda (3)