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Opening Doors : A Veil Lifted

Hotel before being dropped off at MNH [Muhimbili National Hospital] for medicine rounds. I felt completely different at 1:00 p.m. than I did on Tuesday when I was late for the daladala and had to walk/run/taxi to MNH. The climate affects productivity, but folks in Dar who are moving from air-conditioned autos to air-conditioned offices are unaware.

Before I left the United States I was warned: in Tanzania, it's normal to set up a meeting and have people not show up, even after it has been reconfirmed several times. A brochure for a Tanzanian

culture/Swahili class explained that tardiness is a normal part of the culture and should not be considered rude. Still, it was difficult not to be irritated as I stood outside a building waiting in the hot sun for a couple of hours. On one of my last days in Dar, I learned that many people do not even use Swahili time (which starts with 0:00 at 6:00 a.m., when the sun rises) but identify "waking time," "eating time," and "cleaning time."

Historically, assigning time of day by task made sense. Even the modern-day lack of timeliness is understandable when one realizes how often buses break down, are full, or don't show up or traffic is simply stopped for hours. An incredible amount of effort is expended just trying to travel in Dar, never mind attempting to appear clean and presentable upon arrival.

The IDC is a leader among health-care centers in Tanzania in attempting to schedule patient visits. "Morning" is circled on nearly every appointment card, in the hope that the patient will, at least, return.

The lack of systems and infrastructure has a medical corollary as well. I was struck by how incredibly simple organizational problems hinder care. Before going on rounds at MNH, I expected the major roadblocks to health care would be a lack of technologically advanced tests and procedures. But many were available (although not all patients could afford them). The interventional radiology department, for instance, scheduled angiograms daily. But the lack of organization was the major factor impeding care; it even prevented doctors from getting timely results from routine blood tests.

Good records are key to a successful study. Left, is a log book listing patient appointments. Right, data is entered in the patients' charts by hand and is later put on a computer.

Each appointment begins with confirmation of the patient's identity and a weigh-in, since weight loss is a common symptom of TB. Above, Tanzanian medical officer Dr. Lawrence Lekashingo weighs a patient. "TB is the leading cause of death among HIV-positive patients" Lekashingo explains.

Above, clinical officer Safina Sheshe checks a patient's status and then gives him a dose of either the TB vaccine or a placebo. But neither she nor the patient knows which he's getting, because the study is doubleblind. The vaccines (and placebos) are stored in a refrigerator, at right.

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