Tuesday 27 March 2012

On economics and education

I think we are all feeling the need for a break and I am glad to say that tomorrow we are driving to the coast to Fish Eagle Point, which I hope is a beautiful beach lodge, for Aaron's birthday and some much needed R&R!

We have been ill again with weird Tanzanian bugs and i had horrible pus on my tonsils so am on antibiotics.  I am also feeling a bit jaded at work so am including my latest BMJ posting for you to read.

I promise I will post some cheerier fare whilst we are away...



  

On education and economics

There are many differences between health care and medical education in Tanzania and in the UK, but the concept I find hardest to understand is “attendance or sitting allowance”.  This allowance is paid to all staff that attends courses for their health care education and it seems that staff will not attend educational events unless they are paid their attendance allowance.   The allowance can be a significant sum and the educational facility providing the training event is expected to cover the cost.
Apparently this practice originated many years ago when the WHO began running educational events and courses about HIV/AIDS and now seems to be ingrained.   I am used to a society where we seek and pay for medical education and now with the reduction of study budgets it is common practice to self-fund attendance at courses and meetings.

Now I understand that western salaries are much greater than salaries paid in Tanzania but mixing economics with education seems to be detrimental to the will to learn.  Perhaps a different form of attendance bonus allowance based on an 80% attendance in the workplace per year would be more successful, although I am not sure how it would be policed or funded.

The Tanzanian government is struggling to meet the doctors and nurses strike agreed 100% pay increases and this is due in part to the fact that within a population of 45 million there are only an estimated 800,000 tax payers.  There was another mini-strike of 2 days recently and we are awaiting a re-shuffling of the cabinet.  I don’t think there will be many willing volunteers stepping forward for the job of Health Minister!

Currently we have 4 Spanish surgeons who come each year to the RDTC, at their expense, for a 10 day period, to operate on our patients and train the dermatology residents in surgery and dermatopathology.  Last Monday was amazing as there were over 100 Albino and Xeroderma Pigmentosa patients in the department being screened for surgery.  All the patient expenses are paid for by a Spanish organization, as well as attendance allowance for the local staff, and some patients had traveled for 2 days across Tanzania thinking they had skin cancer to be told they had tinea capitis (a fungal infection of the scalp)! 

Xeroderma pigmentosa is a dreadful autosomal recessive disease where there is a defect in the gene responsible for repairing DNA following photodamage. Photo-damage begins in early childhood and is characterised by cutaneous and ocular changes such as freckles, photophobia, corneal keratitis and ulceration.  In Africa if strict photo-protection is not adhered to then malignant tumours such as squamous cell carcinomas, basal cell carcinomas, keratoacanthomas and malignant melanomas develop in children as young as 3 and 4; death from metastatic disease occurs from the teenage years.  


Peter and Mafalda trying to sort out paying out the expenses to the patients









queing up for the expenses with Peter trying to keep order!


It is very difficult to arrange for children to be operated on under general anaesthetic due to no dedicated paediatric theatre space.  It is the first place I have worked where adults are prioritized over children but perhaps this is due to economics as well.  As in many places there seems to be a two tiered system with those who can pay being fast-tracked to theatre and those who can’t waiting weeks and sometimes months.  We have watched a 4 year old girl’s scalp tumours multiply five fold whilst she has been an inpatient for 6 weeks.  I have found this the hardest part of my job watching but not being able to get her to theatre as inevitably there is an adult emergency and she is bumped off the list.  This week however she has been operated on thank goodness.  Dermatology are currently building their own wards and theatres so if dedicated anaesthetic time can be arranged, and this is a big if, we will be at last be able to operate on our patients.


Friday 9 March 2012

On the facts of life and running the Kilimanjaro Marathon (25-26 Feb 2012)

Tobias not gloating at all as he beats Aaron across the finishing line!!!!



It has been another action packed weekend - at this rate we will all need to go home for a rest!  However saying that it is great to have the time to do so much outdoor activites and to feel properly fit again.  Well I do but unfortunately Aaron has come down with man flu - or a viral infection he picked up by hugging Martina (and yes she is blonde and attractive even with flu!) who was poorly when she flew back from Sweden.

So Thursday saw me get back into tennis as I haven't played since before my knee operation.  I played against Terri Emmanuel (who runs the stables at the ISM school where we ride) as she was playing in a tennis tournament that weekend.  I was very rusty but had a tennis lesson booked for Friday afternoon after the boys had a lesson with Ron who is an ex-professional coach from the USA.  In the morning I went out for a wonderful ride with Terri across the coffee fields and on the tracks behind the school and it was brilliant to be cantering along the tracks in the sunshine.  I was in clinic by 10.45 am and am pleased to report that the intensive 2 week period of exams for our ADDV students is finally over.  There does seem to be a huge emphasis on exams in Tanzania and it has a huge impact on clinic time.  I do think that there should be more emphasis on teaching and learning and less on exams.  After the exam meeting reading the complicated computer analysis of the grades I was glad to get onto the tennis court.  Ron is a superb teacher and a few pointers on hand position and wrist flick have made a huge difference to my ability to hit the ball hard and in the right direction!  The boys enjoyed it too although Josh kept wanting to show Ron his "best throw" - wrong game Josh!

Another fabulous Friday night dinner but i had to leave Aaron languishing in bed feeling poorly and then I had to get 2 grumpy boys up early as I was off to Arusha National Park with Vicky and Catherine a Duke (medical school in the USA) research student working on projects in Tanzania.  We took a packed lunch and left at 8am and did not get home until 6pm. I have to say that much as I love my children it was exhausting, not due to the driving or the heat or the bumpy roads but because I had 10 hours of relentless questions from both Zac and Josh!

The road between Moshi and Arusha is pretty hairy due to the fact that buses/ dala dalas (mini buses extremely overcrowded), cars etc... tend to overtake at moments where visibility is nil usually up a hill or round a bend causing much knuckle biting. You can imagine that Zac and Josh fighting in the back of the landrover, sometimes with sticks was not conducive to concentrating on the road!




Arusha national park is a small but very pretty park about 90 minutes from Moshi.  The park was very very dry and dusty but the views were beautiful, particularly from the top of the caldura (volcanic crater) and over the string of alkaline lakes.  








Me and the Biblical Boys, Catherine and Vicky





We saw giraffes and zebras and warthogs and lots and lots of baboons and monkeys much to Zac and Josh's delight.  The forest in the park is well known for its colobus monkeys which are furry black and white ones with bushy tails and mime artist faces.  I wandered into the forest watching them hurl themselves elegantly, almost flying with arms outstretched high up in the canopy of trees.  









Meanwhile Zac and Josh went into the little museum filled with very old stuffed birds.  Zac came out and loudly asked me "why does that man have one blue eye and one brown eye?" and then Josh went into full whine mode saying "can we buy a stuffed bird?" and when I said no he said " but we only need a small one"...  In true Josh fashion he went on and on and on and on and on and didn't seem to think that my not wanting to cart a dead bird around Africa and then back to England was reasonable.  I tried to distract him by getting him to look at the flying colobus monkeys but as only Josh could he told me he wouldn't because I wouldn't buy him a dead bird! Clearly I am a most unreasonable and unkind mother!!!


Ooh there is a yummy louse..


We saw amazing icing sugar pink flamingos who all had their heads buried in the water until Zac and Josh came charging along shouting.  They then kindly popped their heads up to see what the racket was much to the pleasure of a photographer with an enormous zoom lens.  The boys then proceeded to get their croc shoes covered in a mixture of mud and flamingo poo which they delighted in sinking into on the lake shore.  


What was that terrible noise ? say the flamingoes



I asked them to wipe their shoes off on the grass but no Josh knew better so went down to the lake shore to rinse off his shoes.   So Zac followed and let go of one shoe which began to float off.  I then shouted "NO - Zac get your shoe" bringing the flamingo heads up to rapid attention - and fortunately for him he managed to lean out and hook his shoe with a stick!!  Never a dull moment with my boys...  


Just before Zac let go of his shoe!



I am sure there is a lion out there somewhere......



Luckily they fell asleep for a while which gave us all a respite and then Zac woke up to do great game spotting.  We saw a big bird which i think was an eagle, a dik-dick (antelope with very short legs) and more baboons.  Vicky had been to the park a couple of times before and was an excellent driver and guide.  She has 3 grown-up boys herself so is used to noisy boys but I think Zac and Josh have worked their natural contraception magic on Catherine.  So you are probably wondering about the facts of life conversation...


Catherine and I by the water.  Where are the children? Catherine is thinking "thank goodness the children are not right here!"

On the way out of the park we went to a deserted looking safari lodge for a drink.  We are not sure how they survive as there seemed many staff, no guests and only 2 drinks on offer: the ubiquitous coca cola or Safari beer.  We were so dusty and dirty that it was great to have a wash and a cold drink.  I think I was telling Vicky and Catherine how we came to be in Tanzania; the choice I gave Aaron of either having another baby or coming to Africa when Josh suddenly said "How do you get pregnant?" None of us could cope with that particular conversation so somehow I deflected it and then Zac said "You don't want to know it's disgusting"!!







Back to the ISM school for a quick pre-marathon pasta meal by the swimming pool where there was an outdoor showing of Chariots of Fire.  Aaron rose from his sick bed to eat large volumes of pasta and then the boys had another melt down as they were supposed to be showing a childrens’ flim: Puss in Boots but it wasn’t happening and by 8pm we thought the boys should be in bed as there was an early start planned for the morning.  Aaron had decided to run the half not full Kilimanjaro marathon due to his damaged knee and flu and the boys and I were to run the 5km fun run around Moshi. 




The full marathon was due to start at 6am, the half at 6.30am and the fun run at 7.15am so we all got up very early at 5.30am!  Actually we had to practically drag the boys out of bed as after 2 late nights they were pretty tired.  To add to the mix there had been torrential rain in the night and it was still raining in the morning so Aaron took the car to the school to catch the ISM bus to the start point.  We were going to go in the car with Mafalda but she decided she wanted to stay in bed at the last minute but luckily drove us there in her pyjamas.  So there we were all in the muddy stadium by 6.15am but this is Africa so first the inflatable start line fell down and then lord knows what happened but everything started very late.  Aaron set off about 7am and then we had to walk 1km to our start line and set off at 8am – so we were glad we got up so early!!!



Before the start and we are all very muddy already!




The fun run was great though and Zac and Josh even ran quite a bit with Noga and Amy until Zac ran along a kerb by the roundabout and fell over and hit his knee…  There was an incredible atmosphere as it was the 10th Kilimanjaro marathon and everywhere you looked there was a sea of orange T-shirts worn by the ISM brigade.   The Kenyans sprinted through Moshi like gazelles, lapping the half marathon participants!  I don’t know how they keep the speed up.  The weather cleared up and it was a blessing that it was overcast and cool.  Aaron came in at 2 hours 7 minutes I think and was just beaten by Tobias who has been gloating a lot….


At the end with lollipops and coca cola


Aaron and Mebrato at the finishing line.  Mebs ran in 1hr 45mins and Aaron in 2 hrs 7 mins but he was ill and had a dodgy knee...



Team ISM - can't lose this lot in all this bright orange!

Taking off over the bumps in true para olympic style

A very pleased Tobias !
We then had a great brunch at Camilla and Jeremy’s house followed by tea and swimming at Katie Burton’s house before collapsing into bed after another quiet weekend!