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Teaching Residents in Tanzania – An Immensely Rewarding Experience

If you were to travel to the Kilimanjaro Christian Medical Center in Moshi, Tanzania, you would find yourself in the shadow of snowcapped, Mt. Kilimanjaro. At dawn, you would walk through dense vegetation on a rocky and rutted red dirt path to the guarded gate of the doctors’ compound and into a small, spare reading room inside a huge hospital complex known as KCMC. The compound includes a 630-bed public hospital with 1852 students and 1300 staff, a medical school, a research institute and allied health schools. The hospital treats 1000 patients daily. Some travel great distances. Many are terribly ill. 

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Some with diseases unfamiliar to you, and others with common diseases so advanced that their imaging manifestations are no longer familiar. By 7 a.m. you are sitting at a PACS alongside a second-year resident discussing these images… 

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​​​​​​​Undifferentiated adenoca from unknown primary?

Followed by these…

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Invasive Klebsiella?

Up next…

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Phacomatoses like NF1 or the rare schwannomatosis?  Or leptomeningeal mets due to a hematologic malignancy?

...and many more similarly interesting and challenging studies throughout the day.    

KCMC was opened in March 1971 by the Good Samaritan Foundation and is now a referral hospital for over 15 million people in northern Tanzania. The KCMC radiology residency is one of two, in a country with about 150 radiologists. That’s approximately one radiologist per 400,000 Tanzanians. Upon graduation, the current class of 12 trainees will increase the country’s radiologists by 8%. kcmc2

Tanzania is a place where teaching and working provides the opportunity to impact the professional trajectory of the residents, and the practice of medicine in east Africa, on a scale rare in the US.

My involvement began about a year ago when I happened to be sharing a reading room at Johns Hopkins with Ryan England, a young navy-pilot-turned-radiologist. Ryan was on the phone recruiting a neuroradiologist to teach the KCMC residency. It had lost accreditation and was poised to reconvene with a class of first year residents on the condition that overseas radiologists would supplement the program with daily lectures. I had recently retired from a hospital where I taught Yale radiology residents. I missed it. “Could you use a body imager?” I asked.

Within weeks, I was teaching KCMC’s eight bright and eager new first years, along with equally endearing residents from Zambia—both via Zoom. I was impressed by their fund of knowledge and insightful questions, but it was their uncommonly gracious thank you’s that stood apart and made me want to join the Tanzania team organized by RAD-AID International, a humanitarian organization whose mission is to improve health of under-resourced communities here and abroad by providing radiology services, training and education. In short order, I was working with Dr. Arlene Richardson, the RAD-AID Tanzania program director and a Rad Partners MSK radiologist in Chicago, to recruit lecturers and to moderate the morning conferences given by a remarkable cadre of academic and private practice radiologists scattered across the US and Canada. My involvement increased such that I now serve as associate program director for RAD-AID Tanzania.​​​

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From Zoom to Mt. Kilimanjaro

I wanted to get a deeper sense of the challenges of being a resident at KCMC, the community they serve, and the pathology they encounter. So, as COVID began to wane I accepted the invitation of KCMC’s Program Director, Dr. Adnan Sadiq, to spend several weeks on site. I booked a flight. I thought this would help me enrich the relationship and tailor the support RAD-AID was providing—as well as to answer questions posed by those who had volunteered to serve as our faculty. 

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The experience was eye-opening and extremely rewarding—a 12 out of 10. There were far more opportunities to contribute and learn at KCMC than I could explore during a single visit. 

But I left believing that my objectives had been accomplished. I had contributed to the residents’ education, lightened Adnan’s demanding workload for a time, and personally learned a lot from the varied and challenging pathology. Ultimately, working alongside residents and getting a sense of their environment, opportunities, challenges, and personal obligations was profoundly fulfilling and has made it easier to teach and motivate from afar.​​​​​

 
​​​​​​A deeper look at the journey 


After 26 hours of travel, including an 8-hour layover in Doha, Qatar, I landed in Moshi on a Wednesday at 9 a.m. A couple was waiting with a sign that said “Welcome Dr. Wruble. They drove me the 45 minutes to Moshi, stopping along the way to negotiate the purchase of avocados, mangos and papayas from one of many roadside vendors.

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KCMC is on a large campus with infrastructure to host visitors. There was a designated doctors’ compound which was spare but not spartan. I was the only one in a three-bedroom, two-bathroom, single-story house, surrounded by a garden and flowering trees that were populated by monkeys.

Electricity is expensive there, and pre-paid. Operating the water heater is especially expensive and quickly depletes the supply. To conserve, you turn on an electric water heater with the flick of a switch and wait about an hour for tepid water with which to shower. It’s best not to forget to flick the switch to off, lest you deplete the electricity, which means no lights, no internet or internet-based WhatsApp calls home, as I did.

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The KCMC staff is welcoming and warm, hardworking and dedicated. Facilities are clean but bear the wear of traffic. The hospital is long on patients, but short on private patient rooms and the latest equipment. Patients tend to present late, often after the failure of treatment by local healers. Their imaging offers a glimpse of the natural history of late-stage disease. Some diseases and scenarios are unique to the region. For example, I encountered a paraplegic, amputee fisherman who had survived a hippopotamus attack—an epidemic related to rising lake-water levels due to climate change. More common are spinal cord injuries of patients who have fallen from trees while picking fruit to feed their families or to sell in support of their families.
 
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The Radiology Department Chief, Dr. Adnan Sadiq, is gracious, supportive, and easy to work with. As the sole interpreter of cross-sectional imaging, he is literally always on-call and appreciated the brief respite that I and other volunteers provide. 

We quickly established a full but workable routine. Before 7:00 a.m. I began reading out the on-call residents. At eight, we paused readout, and I presented an interactive conference on body imaging. From nine until noon, I read out the CT’s and MRI’s with residents. At 1:00 p.m. I presented an interactive neuroradiology conference to residents as I visited during their “neuro block.” We broke at two for lunch, followed by a Zoom conference led by a US lecturer, ending before 5 p.m.

​​​​​​​During unscheduled time I worked in Adnan’s office, reviewing interesting cases, fielding residents’ and clinicians’ questions and preparing the next day’s teaching. On several evenings I went to dinner with Adnan or some residents, and ex-pat physicians who had made the improvement of healthcare for Tanzanians their life’s work. One case involved a physician selling his home and other assets in Ireland to finance these efforts. These physicians were most impressive. I met expat neurologists Dr. William Howlett and Dr. Marieke Dekker when they came to review difficult cases. Their combined 50 years of experience treating climbers who became ill on Kilimanjaro are captured in a recent publication “Mountain Neurology,” and a presentation at the local international high school (with 400+ student of 77 nationalities), to which I was invited. The largest free-standing mountain in the world, Kilimanjaro is challenging. At 20,000 feet, the air is thin and climbers risk mountain sickness, pulmonary and cerebral edema. Because it is not a “technical” climb, however, it attracts people who would not attempt other mountains.

The Ngorongoro Crater

One weekend, I travelled to the extraordinary Ngorongoro volcanic crater, a UNESCO heritage site, where an estimated twenty-five thousand animals live and roam. There, the locally owned Pamoja Lodge provided farm-to-table dining and serve coffee that is grown, harvested and roasted on the premises. Rooms and dining tables are adorned with the petals of indigenous fuchsia flowers. Maasai warriors leap and sing to welcome arriving guests. An unexpected visit from a baboon occurred when a parking lot fender bender required briefly opening our car window. Instantly, a large baboon leapt through and settled beside me but thankfully left without attempting further familiarity.

On the 4-5 hour drive from Moshi, we visited Tanzania’s only rabbi, in Arusha, whose ancestors came from Zanzibar by way of Yemen and Ethiopia to procure and trade animal horns that could be made into a ritual instrument, a shofar. The rabbi, his wife and children live on an unmarked gated property in a home beside a synagogue with holy texts donated by a Canadian congregation. This community burgeoned to 5000 largely European Jews during WWII, but as political and financial opportunities changed, it waned to 300 nationwide.bus-1A well-traveled friend told me not to leave without a stop in Zanzibar, an island off the coast and short flight from Dar es Salaam. This is important advice that I pass along to any of you who might visit. There, Matemwe Lodge overlooks a shallow coral fringed lagoon on the quiet northeast coast. It is breathtaking. I also stopped at a spice plantation co-op where I bought spices for friends and family and visited historic Stone Town, including the Old Slave Market and the Freddie Mercy Museum.

In every respect, the trip was most rewarding. I gained tremendous respect and affection for the residents and a greater understanding of the opportunities and challenges of training at KCMC, which I will use to tailor my teaching. I tried to share my excitement about radiology, its challenge and breadth, the pivotal role it plays in patient care, and the opportunity it provides to make a difference in so many lives.

 
For physicians who wish to visit, I would share the following:
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  • Bring an electric adapter with many outlets and charge it during the day.
  • Bring ear plugs and a white noise maker; the sleeping quarters can be noisy with open windows.
  • Some people have trouble sleeping above 2500ft, as I did. Perhaps acetazolamide would help.
  • Getting a visa on site at JRO airport was easy and pretty quick.
  • I was not asked for a record of yellow fever vaccination at any time.
  • Getting a rapid COVID test at Dar es Salaam airport was required, but difficult. Have $10 cash on hand.
  • I had no trouble eating salads and fruit which were fresh, healthy, delicious, and inexpensive. Drink bottled water.

A brief note about the history of radiology in Tanzania


Radiology is relatively new to Tanzania. The program at KCMC was developed by Dr. Helmut Diefenthal, a German-American WWII survivor, and his wife, a radiographer. They worked tirelessly in Tanzania between 1988 and 2014 as self-supported missionaries of the Lutheran church with the ambitious goal of expanding and improving radiological services in Tanzania. They returned to the US when Dr. Diefenthal was 90 in 2014, and in 2019 he died at age of 95.

The radiology residency and other KCMC residencies were de-credentialed within the last few years, apparently because of insufficient faculty support and didactic instruction. The program began anew in the spring of 2021, with the support of RAD-AID and volunteer lecturers from the US and Canada who have provided exceptional one-hour conferences each day.

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Author Jill Wruble, DO

vRad Radiologist and Associate Program Director for RAD-AID Tanzania.

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