There was a doctor volunteering at Nkoaranga hospital who developed a problem and needed surgery.  He arranged to travel to the States to get treated.  Within two days he was home and the surgery was scheduled.  A woman in Ngarenanyuki delivers a child and develops profuse bleeding, a serious but treatable complication in most places. This woman is taken to the Dispensary which cannot treat her. The untrained nurse attendant on duty assesses that patient must be taken to Nkoaranga Hospital. This new, bleeding mother waits for transport to the Hospital. The clinical officer on duty locates a vehicle, then a driver and sends it the rutted rock strewn roads to the dispensary.  Several hours pass and the patient is growing weaker.  Nkoaranga does not have an ambulance and the only vehicle that can safely travel the rocky dirt roads to this outpost of the Masai is a Land Rover.  Finally, the woman arrives at the hospital.  She is assessed and they are not able to treat her. She needs a transfusion and perhaps a D and C.  Nkoaranga can hydrate her but she must now be transferred to KCMC the nearest hospital that can do these procedures. She dies on her way to KCMC.  Dr. Mollel who is telling this story, shakes his head and asks,  how can this be that my colleague whose condition is serious and cannot be treated in Tanzania receives treatment while the woman who is treatable but poor and living remotely dies?  What good does training do if it is undeliverable?

We are on a crash course of the issues of delivering health care in the harsh and unforgiving environment.  In three days we visit the far Northern dispensary at Ngarenanyuki,  the far Southern dispensary at Velasko,and those at Leguruki, and Kikatiti.  We also visit Maangashiny Dispensary which is closed.  Each dispensary is located some distance from the hospital in underserved areas.  They are intended to provide first line treatment of malaria, typhoid and diarrheal disease ,first aid for injuries.  They also have limited nurse midwife capabilities and provide mother child clinics. HIV testing, diabetes and hypertension screenings are also available.  Each dispensary has some major issue in fulfilling these fairly simple functions.  Chief among these issues is qualified staff.  Because these areas are remote and the salaries are low, not many people are eager to serve.  In addition, only a few have any staff housing which is essential to recruiting qualified staff. Competition for trained staff is high in more desirable locations.  Much like rural U.S.  but more so.  In addition, the government has begun to inspect the facilities, particularly the laboratory test areas that test for HIV, typhoid and malaria.  Not one of the Diocese supported dispensary laboratories meets standards.  To the dismay of the people, some have been closed and others are operating without meeting standards.

We ask Dr. Mollel why we are going to Maangashiny if the dispensary is closed?  He laughs and says we will understand the challenges better if we go there.  It is around 8 kilometers from the tarmac road on a rutted path to the dispensary, shorter if you walk cross country.  We bounce along raising clouds of dust. You can count the ribs of the cattle that we see, goats are not quite so scrawny.  We pass only one green patch the entire way.  We drive past the partner parish of First United Sheboygan,  up a hill to a relatively solid looking building of painted brick and mortar, unlike the mud and stick huts that serve as homes in this area. When we park outside the clinic, a group of children magically appear.  Dr Mollel has a cheerful conversation.  He is clearly a compassionate caregiver who clearly enjoys people.  Then we turn to the hard realities of running a dispensary here.  The minimum requirements are a water supply, electricity, food for staff and housing for staff.  The nearest water is several miles away and must be hauled by buckets on donkeys.  The nearest fresh vegetable market is equally as far away.  Electricity would be possible only with a generator, (very expensive to maintain) or solar power(expensive to install), as Tanesco does not reach this far. Since schools are few and far between and fees have become almost impossible to pay due to the drought and famine, qualified staff must be recruited to live and work here from somewhere else.  This makes staff housing essential. It has become clear to us that these are interrelated issues that are not easily resolved.  Yet, there are people here who need health care.  No easy answers here.  Dr. Julius clearly is troubled by this dilemma.

The afternoon is spent at the hospital which has its own set of complexities.  We meet the management team,  the Hospital Secretary who serves as the chief administrative worker, the Treasurer (who must track expenses but also revenues from the patients, the government, from NGO’s and from church related partners such as us), and the Director of Nursing.  Patient revenue is its own story, as there seems to be very little that is charged for and no health insurance system to provide payment. To be seen by a doctor in the Outpatient clinic is 2000 TSh for the first visit and 500 for subsequent visits.  There is a one- time charge of 5000 TSH for linens if you are admitted.  Many procedures are free by government or sponsor mandate. The more questions we ask the more overwhelming it becomes.  Yet, these are dedicated people, they persevere even as they know that they are not meeting any kind of business plan or many basic standards.  On our tour, we see renovated and new facilities, an important component in recruiting and retaining qualified staff.  Dr. Mollel is Chief Medical Officer, the chief clinician,  the only MD to supervise clinical officers( a kind of physicians assistant), and runs both inpatient and outpatient medical care. He is the only MD on staff and has new contracted MD for back-up.  Because he is required to go to Dodoma for some meetings, he has been living at the hospital and on-call for 4 days.

As we tour, I ask Neema, the director of nursing what the most common reasons for admission are.  She responds that by far, malaria is the most common.  An average stay of 3-4 days is the normal stay for treatment to work. Others are typhus and minor injuries.  Pregnant mothers can deliver at the hospital without charge so for those who live near the hospital it is sometimes a good option. The government supports this option with the hope that some basic neo-natal care can be given and that the mothers receive some recommendations for nutrition and infant care at home.  All children under 5 are also to be treated without charge.  What the government pays the hospital for these services does not cover the costs but they are provided as best they can.  In talking with a nurse-midwife,  I learn that a big issue related to the drought are the number of malnourished children who are underweight at birth and fail to thrive due to the malnutrition of the mother.

There is a family atmosphere at the hospital. Patients must bring their own clothing and food.  Family members accompany them to provide this so in one room there is a small group having afternoon tea.  Outside the new pediatric unit, there is a laundry area where women are vigorously doing laundry.  When I ask about the posted visiting hours, I am told that they are only enforced for local people as some people have come some distance to be treated and it is not practical for them to leave and come back.

The tour is completed and our heads are about to explode with all the sights and sounds and information we have experienced in 3 days.  We agree to return for a follow-up visit and to tour the orphanage which is also administered by the Hospital.  After saying her farewells to us,  Neema sprints over to the orphanage to check on something.  The treasurer retreats to his office where he keeps manual records because his computer is so old it cannot take the programs needed.  The hospital secretary Jeremiah makes an impassioned plea that we tell their story well in Milwaukee and Dr. Mollel escorts us back to the Guest House before buying his bus ticket for the 12 hour trip to Dodoma.

The spirit of these workers is humbling.  They keep on going even though they know it could be so much better trusting that little by little they will be able to fulfill their calling.  The gap is wide between what could be and what is,  but the spirit is strong.  Mind the Gap!

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