Goodbye Tanzania, Hello Ethiopia!

Three countries down! I had a great last few days in Tanzania and am already having a fantastic time here in the Ethiopian capital of Addis Ababa. Three informative interviews capped off my experience in Dar es Salaam, the first of which was on Thursday with Dr. Nema Simkoko, the National Officer for TB Control at Tanzania’s WHO Country Office. One of Dr. Simkoko’s earliest and most interesting comments revolved around the capacity-building that the WHO offers the Tanzanian Ministry of Health and Social Welfare. She made it clear that the Ministry is “in the driver’s seat” with respect to operations and infrastructure. The WHO’s (and her) role is to support their efforts by providing the policy recommendations and training for TB personnel that a national control program needs to function well. And Tanzania’s TB control program is functioning well, as less than 1% of TB-positive patients nationally are multidrug-resistant — despite Tanzania being a WHO “high-burden” country for non-resistant TB — and no cases of the often-deadly XDR-TB have yet been found. But the need to improve Tanzania’s overwhelmed laboratory network is dire, so that early diagnosis can keep those levels low and prevent XDR-TB from emerging and spreading (as it has in neighboring Kenya and Mozambique).

With Dr. Nema Simkoko, National Officer for TB Control at Tanzania’s WHO Country Office.

Next, I was fortunate enough to speak with a key representative of that all-important national laboratory network. After parting ways with Dr. Simkoko, I hopped in a Dalla Dalla to make my way from the WHO office to Muhimbili National Hospital. There, I met with Mrs. Basra Doulla, Head of Tanzania’s National Reference Laboratory (NRL). In developing countries, NRLs are generally the largest, most bio-secure, and best-equipped public labs. For TB, this means that they will likely be one of the few (or only) in-country labs capable of drug-susceptibility testing (DST) for patients’ drug-resistance status. For some Tanzanian context: 25% of the country’s newly detected TB cases are subject to DST, but that percentage is not associated with policy related to random screening as one might expect. It’s 25% because the NRL’s limited capacity forces all of Tanzania’s regional hospitals into a strict schedule which only allows them to send in newly detected case samples during just one assigned quarter per year. In other words: if you are newly diagnosed as TB-positive during one of your regional hospital’s three non-assigned quarters (and aren’t HIV positive or living near a current or former MDR patient), you will not be tested for drug-resistance.

With Mrs. Basra Doulla, Head of Tanzania’s National Reference Laboratory (NRL).

Mrs. Doulla’s comments were very informative, as she shared the details of both her current and ‘ideal world’ MDR diagnostic protocols. Among many other relevant points, she also discussed the challenges associated with training personnel in the country’s regional labs, which sit one rung below Tanzania’s NRL on the national network ladder. The critical end goal there is to give other laboratories the capacity to conduct bacterial culture (and eventually, DST) independently, but a shortage of qualified personnel and the challenges associated with training new technicians (and ensuring that training is both absorbed and retained over the long term) have severely limited the NRL’s ability to lighten its case load. Increased support for human resource development and unifying recommendations for diagnostic methodologies among various anti-TB agencies are critical steps Mrs. Doulla says the international health community must take.

I planned on having two interviews on Friday, one with a representative from the Tanzanian National Institute for Medical Research’s (NIMR) central TB laboratory. But during my visit to the NRL on Thursday, I learned that NIMR’s lab actually is the NRL and that I had been contacting someone literally down the hall from Mrs. Doulla. NIMR partners with the Ministry to operate the NRL, meaning that the appointment would have essentially been a carbon copy of Thursday’s interview. So I cancelled after explaining the situation (and getting a laugh out of Mrs. Doulla and her colleague in the process) and slept in before heading off for my interview with Dr. Jacob Kayombo, Coordinator of the Tanzanian Public Health Initiative. Funded by the Stop TB Partnership (a large international coalition of governmental, international, and non-governmental organizations broadly interested in TB control), his organization is similar to ORES (but operates in a different region) in that it uses educational programming to improve community-based management of Tanzania’s TB epidemic and care for TB-positive patients. We discussed his organization’s work and its relationship with the Stop TB Partnership in detail, but an interesting point that concluded his commentary touched on the differences between HIV/AIDS and TB control. Though TB predates HIV literally by millennia, TB control lags behind that of HIV/AIDS in terms of its definition as a social (and not just medical) emergency. Dr. Kayombo has made changing that reality in Tanzania one of his central goals.

With Dr. Jacob Kayombo, Coordinator of the Tanzanian Public Health Initiative.

I spent my final hours in Tanzania playing around on Adobe Photoshop, doing some graphic design work for Deus’ startup non-profit, The Rafiki Foundation. Rafiki, aside from being the name of the popular Lion King character, means “friend” in Swahili. “Empowering People Through International Friendship” is the foundation’s motto, and it aims to bolster community-based projects in underprivileged areas through international internship exchanges for high school and college students. It will start with exchanges between Tanzania and the US, but Deus has ambitious goals to expand the model elsewhere if pilot projects work out. He’s getting his MBA specifically to give himself the skill set needed to run the foundation, and we spent a fair bit of time over the past twelve days cleaning up the organization’s mission statement and organizational structure.

Below are the logo and business card graphics I made, attempting to connect the foundation’s friendship-centered exchange model and four project foci (environment, education, wildlife, and health) with a touch of East Africa via a stylized Baobab Tree. Also known as “upside down” trees or the “tree of life,” Baobabs are beautiful, huge, ancient (the largest ones are 3,000-plus years old!), and can be found throughout much of the drier countryside here. I’ll set up Deus and the rest of the Rafiki team with their first website and .org email addresses once I’m somewhere with faster internet. Having a great time helping out a friend as a ‘thanks for hosting me’ that’s also fun and for a good cause.

            

After saying goodbye to Deus and Philemon and thanking them for an incredible stay, I left for the airport at midnight in advance of a horrible 3:30 – 6:45 AM flight to Addis. The flight ended up being delayed until 5:30, but I eventually made it without any real trouble. I’m using http://www.couchsurfing.org for the first time ever while I’m here, and I’m already having a blast because of it. CouchSurfing is an online community with thousands of generous users around the world that offers up free couches and spare beds to travelers on a budget. I was initially hesitant about the prospect of living with strangers, but online profiles and public user-to-user reviews make it very easy to find awesome, safe people to stay with. One such person is Kume Haileysus, a 23 year-old local who speaks Amharic (Ethiopia’s official language), another Ethiopian dialect, English, French, and some German. He just finished his Masters in Teaching English as a Foreign Language and has a couple of weeks to relax before formally graduating and starting a job at a local university. I spent yesterday finalizing my Ethiopian interview schedule and cruising around Addis with Kume and two other CouchSurfers (27 and 19, from Switzerland and Germany) that he’s hosting for the next few days. We started things off by having lunch at an amazing restaurant behind a butcher’s shop for some delicious tibs and injara, small pieces of beef that you pick up with traditional soft Ethiopian flatbread and dip in a variety of sauces. We hit another great Ethiopian restaurant for dinner before finishing off the night with a visit to an awesome local jazz club, where we saw two amazing bands perform. Very excited to enjoy the rest of my time here!

Ngorongoro Crater

None of my remaining Tanzanian interviewees could meet on Monday, Tuesday, or Wednesday this week, which bought Deus and I a few days to travel around the country. Our original plan was to visit Gombe National Park, the remote reserve where Jane Goodall conducted her famous chimpanzee research, but buses to and from the nearby town of Kigoma were full by the time we checked. I would have loved to get an inside view of the reserve courtesy of Deus’ connections at the Jane Goodall Institute, but that will have to wait for another trip to Tanzania sometime down the road!

Plus: what we settled for can hardly be called a consolation prize. Deus and I traveled north to visit the renowned Ngorongoro Conservation Area, at the center of which is the Ngorongoro Crater: a huge, 100 square-mile caldera from a volcanic eruption that imploded 3.8 million years ago. Its high, completely intact caldera walls, rich soil, and large lake make it a wildlife haven. Getting into the park was more of an ordeal than we planned for; the guide we made arrangements with the night before we were to visit the crater either lied to us or didn’t know about a recent change in regulations that requires each vehicle carrying a foreigner to pay a US $200 entry fee. Obviously unwilling to pay that much, we were trying to figure out what to do when a nice, young Swiss and Italian couple offered to take me along in their car’s vacant front seat. Despite my initial “thanks but no thanks” reaction that would let me stick with Deus, he was very intent on me getting into the park after coming so far. I felt (and still feel) bad about it, but we parted ways and Deus enjoyed his day at the also awesome Lake Manyara National Park nearby.

The route into the crater began with an ascent through the fog that shrouds the rainforest on the crater’s upper rim during the dry season. Shortly after descending into the crater, we began to see tons of great wildlife: zebras, wildebeest, cape buffalo, ostriches, gazelle, hyenas, and elephants. We saw a few lions and two black rhinos from afar (the latter being VERY rare), but the highlight of the day was spotting two cheetahs—one of which was no more than 30 yards from our vehicle and eating a Thompson’s Gazelle it recently killed.

           

           

           

It was great getting to know the Italian guy, Swiss girl, and Tanzanian guide I hitched a ride with over the course of a great day in the crater. After ascending back out late in the afternoon and reuiniting with Deus, we spent the night in the nearby town of Karatu before taking the long bus ride back to Dar. I have four interviews scheduled over the next two days, which are my last two here in Tanzania before I’ll continue on to Ethiopia. I’ll also be wrapping up some graphic and web design work I’ve been doing for Deus’ startup non-profit, so I’m all set for a fun and productive end to my stay.

NGO & Ministry Interviews, Zanzibar

Tanzanian interviews got off to a great start yesterday, as I met with two very different but important TB control experts. The first was Dr. Hermengild Mayunga, Program Director at Orphan Relief Services (ORES) Tanzania—a domestic NGO that supports social services for young Tanzanians and manages major health education programs in five of the country’s largest regions. Dr. Mayunga embodies an interesting interplay between curative and preventative medicine: he began his medical career as a physician in a TB-specialized hospital but later elected to pursue a Masters in Public Health in order to spend the rest of his career tackling the social elements of his country’s health crises.

MDR-TB is a growing problem in Tanzania—one of 22 countries the WHO defines as “high-burden” for non-resistant TB that has not yet attained that unfortunate label for MDR cases—and Dr. Mayunga informed me that 90% of resistance detected nationwide is owed to patients failing to adhere to their treatment regimens. That’s where ORES comes in, with an impressive TB education program to target four important populations: TB patients, families of the affected, high school students, and village health committees (which exist, thanks to a Ministry of Health & Social Welfare initiative, essentially throughout the entire country). Their programming for patients focuses on the importance of the uninterrupted treatment, informing them that neither improving nor worsening health should be a reason to stray from their prescribed regimens. Initiatives for families, students, and health committees focus on the social burden of the disease, combat its stigmatization, teach how to care for the actively ill, and promote social assistance for families with ailing loved ones. Interestingly, Dr. Mayunga explained that the Ministry of Health & Social Welfare consciously outsourced such work to domestic NGOs like ORES because they are better equipped to organize the freer-form public programming required of preventative efforts.

With Dr. Hermengild Mayunga, Program Director at the education-oriented Orphan Relief Services (ORES) Tanzania.

A couple of hours later, I sat down to interview Dr. Sode Matiku, Coordinator of Monitoring and Evaluation for the Ministry of Health & Social Welfare’s National TB Program. Dr. Matiku’s comments relayed an invaluable overview of the strategies and systems in use throughout Tanzania, illuminating some impressive strengths and unfortunate weaknesses. First: TB control in Tanzania benefits from an incredibly well organized network of health professionals. Every one of Tanzania’s 26 regions, and every one of the 98 districts that make up those regions, each has its own TB coordinator. District coordinators report to regional coordinators, who work more directly with regional diagnostic and treatment centers as well as with the National TB Program based here in Dar.  Recent efforts to improve TB laboratories have succeeded, as Tanzanian diagnostics are relatively advanced, with a GenXpert system and liquid culture already in place. Unfortunately, the quantity of laboratories equipped for that kind of work—one—remains a serious problem. But Dr. Matiku asserted that the lack of hospital beds for MDR patients limiting treatment efforts (TB is spread by particulates released when actively ill patients cough, meaning that in order to admit patients hospitals must have negatively pressurized TB wards which prevent others from being exposed) and inability to reach the 84% of suspected TB patients who live in rural areas as the National TB program’s most pressing concerns. Dr. Matiku has kindly helped to arrange a visit to Tanzania’s National TB Reference Laboratory later in the week, where I will learn a great deal more about the country’s evolving diagnostic strategy.

With Dr. Sode Matiku, Coordinator of Monitoring and Evaluation for the Tanzanian National TB Program.

After waking up at 4:00 AM to watch the US Mens National Soccer Team go up 2-0 against a favored Mexican side only to give up four straight goals en route to a 2-4 trouncing, I hopped on  a ferry at 7:00 to begin a great day-trip to the nearby island of Zanzibar.  Recalling a bit of School of Foreign Service “Map of the Modern World” required knowledge: the current United Republic of Tanzania, and actually the name Tanzania itself, was formed in 1964 when the sovereign nations of Zanzibar and Tanganyika (today’s Tanzanian mainland) merged. The tropical scenery was absolutely gorgeous, and I spent most of my day on a postcard-quality white sand beach. I also really enjoyed the hour and a half long ferry ride to and from the island: whoever thought to put beanbag chairs on the second floor’s outdoor deck was a genius.

           

           

I made it back to Dar in time to have a delicious home cooked meal with Deus and his good friend, next-door neighbor, and fellow MBA student named Philemon. Even though I didn’t know him before this trip, I’ve actually been staying in Philemon’s place this entire time. He and Deus are very close and share almost everything, including offers of hospitality. We’ve all been having a great time this week, and I feel very fortunate to know such great guys and be shown such generosity. I’ve repeatedly told them that they’re both welcome in Washington or San Diego whenever they can get a visa and make the trip. The three of us are hoping they take me up on that soon!