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Opening Doors : A Veil Lifted

Food for patients consisted of bottled water and large containers of ugali (similar to grits) provided by family members and stored under patients' beds. Rounds started when the attending physicians showed up and were conducted in English. Patients, therefore, were none the wiser when the attending said, for instance, "No, this is not the correct management. This patient should have test X conducted and should have been started on drug Y when he was admitted four days ago." Patient rights are something in the distant future for Tanzania, and malpractice is a nonissue.

But I was extremely impressed by the knowledge of the attendings, the capabilities of the students and residents in conducting physical exams, and the general care provided for the patients.

May 14, 2004
I've always wanted to start a clinic in a small town in an underserved country, train local folks to run it, and create a self-sustaining operation. But now I wonder what it will take. Would one year be enough to get a clinic going? Could you do it if you had young children?

My first night in Tanzania, I ate dinner with 10 visiting Italian health professionals. One doctor explained that he had opted to volunteer with a health-services division for two years rather than complete Italy's two-year military service. He and his wife, also a health professional, had spent six months in Ethiopia before their funding was diverted to the army for a peacekeeping mission there. Now, with their 7-year-old and 3-year-old children, they are ready to return to Africa for a few years. "Are you crazy?" I thought. "Two years here with two kids?" But by the end of my six weeks in Tanzania, I had reconsidered.

A veil was lifted from my eyes in Dar. I now believe that instead of my previously envisioned twoweek- a-year commitment to international health, my career will be deeply entwined in such work.

Upon my return to DMS, I began drafting classmates to volunteer in my still-hypothetical clinic. A future orthopaedic surgeon, two pediatricians, a plastic surgeon, two internists, and one emergency room physician have already signed up. I envision a hospital that functions without foreign physicians but capitalizes on different specialists-in-residence. Visiting physicians would give lectures, attend rounds, and help train young, local physicians. Surgeons would operate and teach common procedures. My Dartmouth classmates are the most community- minded and motivated people

At left, this patient's TB test was negative, so she has come in just for a check-up. Then she sits and waits outside another office, above, to receive her travel allotment. Getting to appointments is very hard for patients in the study, so if they show up they are reimbursed for travel—the equivalent of cab fare, about $2.00.

Then it's another patient's turn to get his travel reimbursement. Above, nursing officer Esther Kayichile watches him sign the register indicating that he has received his payment. Besides cabs, the other transportation option is a local bus known as the "daladala," which costs about 20¢. Below left, another patient gets her vaccination site checked; the scar is barely visible. All of the patients in this feature gave permission for their photo to be taken, although some asked that their face not be pictured. AIDS still carries a major stigma in Tanzanian society. The diagnosis can be "frightening," notes Dr. Lisa Adams, a DMS faculty member and the director of the DarDar pediatric program. She says the typical HIV-positive mother is torn between "the burden of not being able to confide in anyone in her family" and "wanting to do the right thing for her children."

Dr. Johnson Lyimo, right, talks with a patient. He is among the Tanzanian faculty who have come to DMS as a Fogarty Fellow to earn a master of public health degree. Dr. Charles Wira, a DMS physiologist, admires "the determination and sacrifice these [Fogarty Fellows] are willing to make" in order "to improve the quality of the lives of their countrymen." Wira was codirector of a DarDar immunology course.

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