Visit to Ocean Road Cancer Center, Dar es Salaam, Tanzania

The group consisted of Randy Hurley, Kitsada, Tara, Emily and me. Randy is a hematologist-oncologist with Health Partners; Kitsada is a resident in Internal Medicine at the U of M who will be starting a fellowship at the University of Iowa in a few months in Oncology; Tara is a labor and delivery room nurse at St. John’s NE in Maplewood and Emily is an OR nurse at the VA Medical Center.

Randy had previously made an appointment for our visit with the cancer center’s director. The director was not in, so the assistant director gave us a tour. He showed us the nuclear medicine department where they are able to do bone scans. From there he took us to the radiology department which is equipped to do simple x-rays, but ct scans must be done across town at a larger medical center. He then took us to the radiation therapy department where they have two cobalt machines and another unit which is very old. The physician in the radiation therapy department told us that sixty percent of their patients are cervical cancer patients and estimated that they treat about 1500 cervical patients a year. This number does not account for the women who are diagnosed in outlying hospitals who live in remote villages and never make it into town to receive treatment.

We were then shown the outpatient chemotherapy clinic. The clinic was equipped with hoods for mixing and nurses were dressed in gowns, masks and gloves to mix and administer the chemotherapy. Three physicians were seated behind a table writing orders. Patients were not taken to an exam area to undergo a physical exam, the physicians simply wrote, “Patient seen,“ in the chart and orders were written.

Next we saw the inpatient wards which included a very crowded pediatric ward. I believe that they had over 20 beds, many of which had two patients in each bed! A pediatric oncologist, from Ireland, Trish Scanlan, answered our questions. She has been at the cancer center for about 2 ½ years. They see a lot of Burkett’s lymphoma, some neuroblastoma, Wilm’s tumors and a small number of leukemics. Dr. Scanlan was very enthused about the chemotherapy nurse whom they have on staff. She rechecks doses, mixes and administers all of the chemo and serves as a great role model for the other nurses on the pediatric unit. Trish told us that the whole country has a total of 8-10 pathologists and that it can take up to 2 months to get a confirmation back on a tissue sample. We then visited the men’s ward and women’s ward. I believe that the most common diagnoses on the men’s ward are Karposi’s and lymphoma. The ward was filled with very emaciated men, obviously suffering from HIV.

The women’s ward had curtains up for privacy. A list of the 10 most common diagnoses seen in women with cancer was posted:

1. Cervical cancer
2. Breast cancer
3. Karposi’s sarcoma (seen exclusively in patients with HIV)
4. Esophageal
5. Endometrial
6. Ovarian
7. Leukemia
8. Squamous cell carcinoma of the tongue
9. Choriocarcinoma
10. Anorectal cancer

Another list was posted with the major nursing duties. I wish I had taken a picture of this. They were listed in order of priority and cleaning was listed above assessing the patient! From there we divided up in groups. Tara, Emily and I went to the cervical screening clinic and Randy and Kitsada went to the chemotherapy clinic. The screening clinic consisted of three nurses one of whom had to abruptly leave for her niece’s funeral. Visual inspections ONLY were done. The one nurse, Beatrice, did the exams and another nurse did the intake. Beatrice has a four year degree from the Aga Khan Nursing School in Dar and an additional 2 year degree/certificate in public health nursing. Beatrice would have the patient step up onto the exam table after she had wiped it off with alcohol and proceed to dip the speculum in a tiny cup of water (for lubrication) and shove the speculum into the patient’s vagina. Each of the women was in a significant amount of discomfort during the exam. She rarely said anything to the woman during the exam regarding what she observed. We were allowed to observe the exam including looking at the tissue through the colposcope. First she would coat the cervix with .3% acetic acid, wait a few minutes, visualize the cervix, then coat it with Lugol’s solution, then revisualize the cervix. Neither pap smears nor biopsies were ever done, no matter if there were aceto-white changes present or not. (I guess the rationale is why do them if you only have 8-10 pathologists in the country. Nobody ever mentioned whether or not they have cytotechnologists.) The women were then instructed to wait for instructions from the intake nurse – for follow-up instructions or prescriptions in the event of signs of bacterial or yeast infections. At one point during the exams, the intake nurse came back to where we were standing, took a close look at the earrings I was wearing and said to me, “I have holes in my ears also. You give your earrings to me!” Later she did the same to Emily. Then the two women proceeded to grill us on our personal lives – whether we were married, if we had children, asking Tara and Emily why they weren’t married yet or have children. I told her that I was not leaving Tanzania that evening as the other two were set to; that I plan to stay a total of six months. She responded, “You come to Tanzania for 6 months, with no plan what to do!?” I responded that I was there to volunteer, that I am there to work without pay. Did she have something she would like me to assist with? She misunderstood me and responded, “Oh you want job; you want to make money.” When I corrected her, her response was, “Oh you must be married to a very wealthy man!” Soon she said that she was done seeing patients.

The three of us then went outside to get a bottle of cold soda. While we stood there, a woman approached Tara with what appeared to be a script/receipt for chemotherapy. She was speaking another language (Swahili?) the receipt stated Adriamycin---83,000 Tanzanian schillings (TSH) (about $78.00 and another drug, the dose being 8mg, iv stat for 300 TSH (less than $3). (Dr. Hurley later told us that the second drug was zofran. She obviously wanted us to give her the money for her medications. My initial thought was, “okay, so we give her the money; what is there to stop a mass stampede on us to pay for everybody’s meds.” My next thought was, “so I give her the money, what happens when she needs the next course of chemo?” Later, Dr Hurley told us that they presently have a shortage of Adriamycin and the staff was sending patients out to purchase their own chemotherapy and bring it back to them for administration. I now wish that I had given her what limited amount of schillings I had, because hopefully by the time her next course was due, the clinic would provide what she needed.

Dr. Hurley and Kit met up with us about 45 minutes later and shared what they had observed.
Among others, they had seen a patient with ovarian cancer who was receiving Cisplatin and Taxol and another with cervical cancer who was receiving cisplatin in addition to radiation therapy, (not too unlike what our patients would receive in the states.) They do not have some of the newer drugs and if they do, the government requires that patients pay for the newer meds because they are so much more expensive.