Medical Missions in Tanzania: Creating a Sustainable Health Care Infrastructure
In 2006, the non-governmental organization Madaktari Africa began its mission to improve health care and create medical autonomy in Tanzania, Africa, through the training and education of local medical personnel. In more recent years, Dilantha Ellegala, MD, a neurosurgeon and the founder of Madaktari, reached out to Centra Health in Lynchburg, VA, for assistance in the creation of a cardiology program. Since then, Peter O’Brien, MD, FACC, a practicing cardiologist with Centra Health, has played an integral role in the establishment of this successful and life-changing program.
Madaktari’s focus on sustainability in building the Tanzanian health care infrastructure was what piqued the interest of O’Brien, who, prior to his time in Tanzania, had never participated in medical mission work overseas. “At that point in my career, I felt very blessed,” says O’Brien. “I was practicing in a great community for a very good health care system; I had fantastic partners and enjoyed my work, so I felt like it was time to give something back.” He was enthusiastic about embarking on his first medical mission with Madaktari, primarily because of their use of a “train forward” methodology, which focuses on investing time and knowledge into training local providers to deliver care autonomously. “Although I can’t say I knew exactly what I was getting myself into,” O’Brien jokes.
O’Brien explains that Tanzania is unique among sub-Saharan African nations, in that it is a relatively peaceful and stable democracy. Although poor, Tanzania is growing economically, partially due to the nation’s current presidential administration’s commitment to improving the well-being and health care of its populous. He also expresses special appreciation for the work of Mohamed Janabi, MD, who was a physician champion in Tanzania. “Dr. Janabi, a cardiologist and the president of Tanzania’s personal physician, was not only an extremely astute clinician and capable administrator, but also a visionary. He envisioned the creation of a center of excellence in East Africa,” he explains.
Having fully committed colleagues in every facet of the cardiovascular team is a critical part to succeeding in these medical missions. O’Brien’s first trip included partners and staff from Centra Health, as well as Eric R. Powers, MD, and Peter L. Zwerner, MD, from the Medical University of South Carolina (MUSC) in Charleston. “MUSC has been an equal partner in this effort. MUSC, Madaktari and our group have formed an incredible partnership, and we alternate taking teams over there. We are very indebted to them for the resources, teaching, support and guidance that a great academic center can provide.”
O’Brien explains that an experienced cath lab nurse, who can also scrub in on cases, is an essential member of the team. He gives special credit to Jordan Slayton, RN, whom he describes as being “vital” to the Madaktari efforts. “She has helped tremendously in educating the nursing staff and cardiovascular technicians, teaching them everything from administering drugs and circulating during cases, to prepping the table, scrubbing and handling the catheters and wires,” he says. “But in addition to being a nurse and case assistant, she is also a leader and program builder.” He notes that Erick Funke, MD, Joy Simmons, RN, Adrian VanBakel, MD, and Kayla Norton, RN, have all made important contributions as well.
Working in this new environment presented the team with several unfamiliar obstacles. According to O’Brien, it was often the small and unexpected hitches that created the biggest threats to success. One such example occurred when, after months of preparation, upon arrival the team realized that the manifold cable was not compatible with a monitor cable, which would render the team incapable of monitoring any pressures during diagnostic cardiac catheterization. Eventually, the team was able to finagle a makeshift system using arterial lines. “I felt like we were resorting to duct tape and chewing gum,” explains O’Brien. “By working through these challenges with the teams in Tanzania, we learned to be very patient, optimistic and resourceful.” That creativity and persistence paid off. In January 2014, the first ever cardiac catheterization in Tanzanian history was performed at Muhimbili National Hospital in Dar es Salaam. “It was a simple procedure, but what a thrill. I felt like we took a huge step forward that day,” he notes. Since then, a percutaneous coronary intervention program has been instituted.
An ongoing challenge faced by the team is the lack of resources, specifically what are known as “consumables,” like drapes, gowns, catheters, wires, etc. The acquisition and transport of such items remains a challenge. O’Brien and his colleagues would typically pack a suitcase full of equipment generously donated by vendors in the U.S. Other materials were mailed, but several shipments were lost in customs. Such inconsistency necessitated months of meticulous planning for each trip. While the resource acquisition process has gradually improved as the program has grown, O’Brien laments the barriers still encountered regularly.
While not all of these obstacles are typical to O’Brien’s domestic practice, there was a notable similarity between his practice in Tanzania and in Virginia: the challenges of building a program. “To build and develop a program, you have to overcome inertia and convince people to do things a different way. You have to rally stakeholders around a shared goal; you must be patient and learn from any setbacks,” he explains. “If you can remind people that it’s not about the doctors or staff, but about the patient on the table, you’ll be successful,” he adds.
In addition, there are also similarities in the benefits that follow the establishment of data registries. Chad A. Hoyt, MD, FACC, and Joyce Nicholas, PhD, collaborated with the ACC to create a streamlined version of the NCDR data form, allowing Madaktari to collect demographic clinical and outcomes data on patients. “This program, inspired by the NCDR, is still in its early stages, but we are very excited,” says O’Brien. “I told the Tanzanians that they could do something that took physicians in America decades to figure out, collect quality data on every case and use that to drive change.” The collected data will be used to track disease patterns and clinical characteristics in order to get a better grasp of the magnitude of cardiovascular disease in the region, along with facilitating feedback to improve patient safety and outcomes.
The College has also been supportive of plans to establish an ACC Chapter in the region. “I think the creation of an ACC Regional Chapter would enhance the level of professionalism among their cardiovascular specialists,” says O’Brien. “It will also make available many of the educational and quality improvement resources that we take for granted.” He believes there are mutual benefits of international chapters. “Bringing together delegates from various countries to gain a global perspective of cardiovascular disease and health care delivery is a worthwhile endeavor. Prior to my trips, I didn’t realize the extent of coronary artery disease and other non-communicable diseases in East Africa,” he says.
In order to continue its mission to build self-sustainable systems of health care. O’Brien expressed the desire to recruit more participating health care providers. Currently, Madaktari is working to launch cardiothoracic surgery and electrophysiology programs; however, all disciplines and professionals — pharmacists, nurses, interventionalists, administrators, echocardiographers, along with others — are needed.
A change in perspective has been the most prolific take-away from O’Brien’s work in Tanzania. “There is something very rejuvenating and enlightening about going to another culture, practicing, learning and teaching,” he says. “I have come to realize that many of the things that I consider to be problematic in my day-to-day practice in the U.S. are not that big of a deal. And establishing this program, which has already impacted the lives of so many Tanzanian patients, has been immensely gratifying.”
Clinical Topics: Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Coronary Artery Disease
Keywords: ACC Publications, Cardiology Magazine, Africa, Africa, Northern, Africa, Eastern, Cardiac Catheterization, Coronary Artery Disease, Electrophysiology, Percutaneous Coronary Intervention, Quality Improvement, Tanzania
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