Ashley Fellers
— MEDICAL SCHOOL —
University of South Carolina School of Medicine, Columbia
— GRADUATING CLASS —
2023
This year, as a current fourth-year medical student, I have had an opportunity to approach learning about medicine from different perspectives through electives. One of the most transformative experiences of my fourth year, or arguably all of medical school, has been my global health rotation. I went to Tanzania with a team of six people including medical students, physicians, and pharmacists. My institution has a longstanding contract with the Mbeya Zonal Referral Hospital in Tanzania. As students, we were able to join their home medical students and residents to complete a 1-month observership.
During this month, I rotated between internal medicine wards and the nephrology team. From them, I learned about the structure of their education system. In Tanzania, a medical degree is 5 years and is not combined with an undergraduate degree. After medical school, all graduates complete a 1-year internship. At this point, they are called registrars and can work as general practitioners, often rotating or working under various specialists. After spending time working as a registrar, a physician can apply for specialty training in a variety of fields, including internal medicine. While the structure of the education varies, the content is very similar.
Throughout this piece, I will be reflecting on a series of ethical dilemmas that speak to challenges faced by individual physicians as well as systemic issues as I understood them during my time at the hospital. While I understand the limitations of a single perspective and a brief stay, I appreciated the opportunity to learn from physicians practicing in a limited resource setting.
In the nephrology unit, there are two specialists or nephrologists. They are surrounded by a team of registrars, interns, and nurses who run an operational dialysis unit with inpatient and outpatient services available 7 days a week. They're warm and open, frequently describing themselves as a family with patients they regularly see multiple days a week. Contrasted with these warm relationships is a sharp sense of emotional burnout. Dialysis in this country costs approximately $400 U.S. dollars to begin and an additional $90 U.S. dollars for each subsequent session. For every insured patient who has fully funded dialysis 3 days per week, there are two or three patients who pay cash and can only afford to come in once or twice per month. In addition to the steep cost of insurance, there are logistical barriers such as birth certificates and government identification that are often not provided to Indigenous people living in the nomadic lifestyle such as the Maasai, barring them from ever becoming insured. The cost and logistical barriers lead to many patients being cash pay throughout their entire lives.
To understand what these costs and figures would mean to a local, I asked for salary reference points. A specialist may make approximately $900 U.S. dollars per month at a public hospital. Many physicians likely have side businesses, and their expenses would likely be $2000 U.S. dollars per month. This would be relatively standard for an upper middle-class family that sends children to private school, owns a vehicle, and saves for retirement. The physician I asked estimated that the average person in their town makes $150 U.S. dollars per month. This is relatively on par with what I could find online for income in Tanzania over the last decade. However, he stated that what he considered the bare minimum standard of living would take $300 U.S. dollars per month. This would be a family who grew their own vegetables, primarily ate rice and beans, and went to public school. Therefore, the majority of his patients will never see that standard of living and often go several days without eating. One dialysis treatment would be over half of their monthly income and could mean the difference between food or shelter for their children.
Due to the cost, some patients only come in when their symptoms are too hard to tolerate. On my first day, we visited a man in convulsions due to hyperuricemia because he struggled to gather sufficient funds for a needed dialysis session. Another man was already in a coma and passed away shortly after his catheter was placed without ever waking up. Then there was the last patient: I only saw her daughter as she came up to the nephrologists to thank them for everything they did. Her Mom was discharged home to die because her family support network could no longer afford her dialysis treatments. She died the next day. Everything in Tanzania is cash pay in advance only. There is no medical debt, but—with that—there is often no medical care. This system means that thoughts of cost and return on investment for labs, imaging, and treatment are at the forefront of everyone's mind. If a patient comes in with a certain amount of funding, which results will be the most critical for diagnosis? This created the drive to fully utilize what we had available, and I was very impressed by the physical exam skills shown by both the physicians and medical students.
On the other end of the spectrum, I encountered a private clinic patient: in our terms, a “VIP.” He had been on dialysis for several years and his children wanted him to get a kidney transplant. He had the funding and was going to be evaluated by cardiology for transplant. The difference between this scenario and one in the United States is that Tanzania has no system of national organ donation to collect from patients who may be declared brain dead or recently passed. Organs come from living donors only. This can be family; however, it is also completely expected for a relative to emerge in exchange for an unspecified sum of money. When I asked about this, I was told that—from their perspective—it was a business agreement and not their business nor the government's.
This environment creates a group of innovative and determined physicians. They often deviate from best practices when forced and adapt to what the patient can afford. They work on far fewer lab tests and imaging scans than we are accustomed to in the United States. They also work together to help as many people as possible. Insured patients cannot be charged for anything covered: if a claim is rejected, the hospital is expected to cover the loss. As a result, extra supplies may be passed around or donated. With open rooms, and longer stays, getting better is a team effort with not only your health care team but also the other patients.
I could write several more pages about my experiences and thoughts at the hospital this month. It has truly been an experience that will impact the way I practice going forward for years to come and one of the most valuable experiences of medical school. For students interested in infectious disease, rotations abroad often expose you to a variety of infectious illnesses that are not common at your home institution. It is not only about seeing infections but learning best practices and applications from the physicians who handle these infections every day. For me, it reaffirmed my desire to find a global health site and return annually as a primary care physician after residency. However, I think it has also forced me to look critically at why I am interested in global health and what impacts I have when I go to train around the world. To me, global health will always be a learning experience and can never be a situation in which I see myself as a volunteer or as someone giving back. With my plane ticket alone, I could have doubled a family's household income for a year or paid for the first month of dialysis. I could have supplied a local specialist's salary for approximately 6 weeks, a specialist who would have far more applicable skills than me. Instead, I chose to come in and learn, a decision that I will never regret but does frame the way I perceive this experience. It is one in which I am left feeling a little bit of awe and a lot of gratitude toward the physicians and patients who opened their work and convalescence, respectively, to us this month. For any students considering an international rotation, I highly recommend it. It provided a new learning environment with unique challenges and allowed for me and my classmates to learn from and befriend amazing people.
Back to the March 2023 issue of ACP IMpact