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Tanzanian Doctor Shortage Spurs Training Innovation

September 15, 2009 at 12:00 AM EDT
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In the first installment of a three-part series on health care challenges in the east African nation of Tanzania, Ray Suarez reports on how health officials there have had to come up with new training efforts in order to meet the nation's medical needs.
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GWEN IFILL: Finally tonight, to our Global Health Unit, with the first in a three-part series about Tanzania and its efforts to address the deep medical problems afflicting that East African nation. Tonight, Ray Suarez looks at the shortage of doctors.

RAY SUAREZ: In a dusty rural hospital in northern Tanzania, a young woman requires emergency surgery. A ruptured appendix is suspected, but Jibai Mukome is alarmed when he slices into 27-year-old Rahel Rubin’s abdomen and finds a widespread toxic infection.

JIBAI MUKOME: It was life threatening because the end result is septicemia. Septicemia is a killing situation. Septicemia is the spreading of the bacteria through the bloodstream, so the end result is death, obviously.

RAY SUAREZ: This patient’s heart was failing before surgery. This impoverished hospital had only the crudest operating room tools. It’s a wonder this surgery was a success. What’s more amazing: Jibai Mukome is not a medical doctor. He’s Tanzania’s version of a physician’s assistant.

JIBAI MUKOME: It was a very difficult procedure. That’s why I’m sweating, you know? Difficult, yes, very, very difficult procedure.

RAY SUAREZ: In fact, at this crowded district hospital in Kahama, Tanzania, where patients double and even triple up on beds, there’s only one fully trained physician for a population of 800,000. He’s Dr. Leonard Subi, and he works mainly as an administrator.

DR. LEONARD SUBI: For a medical doctor like me…the districts, I’m alone. I’m alone in my district.

RAY SUAREZ: Tanzania’s terribly short of doctors to treat its more than 40 million people, and the government has been working hard to get trained medical personnel even in the smallest communities. But with Kahama’s vast population base, the hospital must make due by relying on assistant medical officers, like Jibai Mukome, to fill the gap.

DR. LEONARD SUBI: This assistant medical officers, medical officers, they are doing other work which should be done by specialists.

DR. DAVID MWAKYUSA, minister of health, Tanzania: This we call task-shifting. Someone who is not a doctor doing a job of a doctor. And that is what has kept us alive.

Medical care is a luxury

RAY SUAREZ: Tanzania's minister of health, Professor David Mwakyusa, explains how his country has struggled to meet its health care needs.

DR. DAVID MWAKYUSA: In the U.S., if you fell ill and you're taken to hospital, you are going to meet a doctor. In my country, that's a luxury. A lot of people have gone to their graves without meeting a doctor. And so we depend, we need doctors, but we really don't depend on them only.

RAY SUAREZ: Instead, Tanzania looked to its clinical workers, some with the equivalent of a seventh-grade education in the United States, and sent them back to school.

DR. DAVID MWAKYUSA: We designed a system where we've been training people to... which are less than doctors, less than pharmacists. You find a clinical officer who was actually a chemist who leave, who goes to school to a training college for three years, becomes a...or later becomes a clinical officer.

These ones, we teach them about malaria, for instance. We teach them about the common conditions, most of the common conditions where infectious diseases, you know, top 10 diseases we call them. So they become pretty proficient.

RAY SUAREZ: Despite their proficiencies, assistant medical officers, or AMOs, face daunting odds. By the time patients with little money and no transportation finally make it to a district hospital like Kahama, they're quite ill, having delayed care. Many are pregnant women in labor with complications.

AMOs do caesarean sections all day long, and many have become quite skilled at them. Still, maternal mortality rates remain grim. At least one mother a week dies in childbirth at Kahama's hospital. In Tanzania as a whole, a mother dies every hour.

Tanzania's medical deficits go well beyond the doctor shortage. There are too few nurses, too little equipment. One X-ray machine serves 800,000 people.

DR. LEONARD SUBI: We need good diagnostic equipment to make sure that we diagnose patients very fast, we give them the right treatment, OK? But...need the money. They need the money.

Addressing the shortage

RAY SUAREZ: And while money is ultimately the problem, the Tanzanian government has pledged millions to upgrade health care and graduate more medical doctors, the country is poor and salaries are stunningly low, less than $200 a month.

Dr. Alfancina Mosco Nanay left patient care to work on HIV prevention for an NGO. She's now paid 10 times more. But Dr. Nanay said a lack of support staff was also a factor.

DOCTOR: The staff are few, so the...is quite high. But if it would pay better, I'd think of going back.

RAY SUAREZ: The government hopes its plan to train more medical support staff will ease the burnout now felt by doctors in public practice.

And in the meantime, new doctors are coming online for Tanzania. An organization called the Touch Foundation was created solely to help Tanzania's doctor and health worker shortage.

DOCTOR: You have a mother with possible signs of IDS, who's coughing for three weeks.

RAY SUAREZ: Financed mostly with private and public money from the United States, Touch created a medical school at Bugando Medical Center, one of Tanzania's largest hospitals on the shores of Lake Victoria. The new school, which is also supported by Tanzania's government, now has 800 Tanzanian students and plans to double the number of doctors in the region.

The foundation hopes to capitalize on money pouring in from the global community to help with diseases like HIV, tuberculosis, and malaria by emphasizing the need for medical doctors to treat those diseases.

Lee Wells is the executive director of the Touch Foundation.

LEE WELLS: If we care about HIV-AIDS patients, if we care about malaria patients, infant mortality, all of these really crucial areas, then we ought to care about how that care is delivered.

AMOs no match for doctors' care

RAY SUAREZ: For all the successes Tanzania has had with its assistant medical officers, or AMOs, their experience can't always match the knowledge of a medical doctor, as was the case on morning rounds at Bugando. Dr. Robert Peck, a doctor on loan from Weill Cornell Medical College, discussed with his medical students the case of a malnourished baby who was sent back to the hospital after being treated by AMOs.

DR. ROBERT PECK: When you have severe malnutrition, one of the most important things is to think about the cause, to ask why. Because if we don't know why in these children with severe malnutrition, when we treat them for malnutrition, when we discharge them home, what is going to happen?

That's right. They'll develop severe malnutrition again. What often happens for AMOs is, because they're so busy, because their training is limited, they think of first things first. They think of malnutrition; they treat the malnutrition. And in this case, it didn't get better.

What other things, other than socioeconomic factors, can cause malnutrition in a child this age, severe malnutrition?

HIV, very important.

RAY SUAREZ: The baby, it's determined, likely has HIV and tuberculosis, making it tough to keep food down.

DR. ROBERT PECK: The AMO training is very good for what they do: taking care of patients on a practical day-to-day level. But they don't have the time to learn the path of physiology, to really understand the diseases as well as the medical students do, because they simply don't have as much time in their education.

RAY SUAREZ: A study released in August showed Tanzania's health worker shortages are part of a bigger problem. According to the Journal of Health Affairs, Africa has only 30 percent of the 1.16 million doctors, nurses and midwives it needs.

GWEN IFILL: Ray's next story looks at the fight against river blindness. On our Web site, newshour.pbs.org, you can watch more of Ray's interview with the health minister and learn about the nation's high maternal mortality rate.