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Making a difference in Tanzania: global perspectives on medical practice.

When Dr. Andrea Zaenglein was a medical student at Pennsylvania State University doing her dermatology rotation, she heard a presentation that changed the course of her life.

The chief of the dermatology department at Perm State at the time, Dr. Donald Lookingbill, shared his experiences working at the Regional Dermatology Training Center (RDTC) in Moshi, Tanzania. He had spent more than 6 months there and was heavily involved with establishing educational programs for skin cancer prevention in patients affected with albinism. His story resonated with her, tapping into her dual interests in dermatology and pediatrics. "He inspired me to want to give back not just locally, but globally. ... The need for dermatologic care in Tanzania really hit home," Dr. Zaenglein said in an interview.

Fast forward more than 13 years to 2010, when Dr. Zaenglein finally felt like she was at a point in her life "to do something big," she called Dr. Lookingbill and arranged to spend 3 months working at the RDTC with her husband and 5-year-old son in tow.

Describe the clinic. What were the facilities like in terms of resources?

The RDTC is a well-funded, very modern clinic by African standards. They are very fortunate to have the support of the International Foundation for Dermatology, along with other generous benefactors. It is located on the grounds of the Kilimanjaro Christian Medical Center, but is run independently of the hospital. Upon entering the two-story clinic, patients find a large, open waiting area with benches. There are 8-10 exam rooms, all with large windows in case the power goes out, which is not uncommon. There are two large surgical rooms, a dispensing pharmacy, large and small lecture rooms, an area for photography, and a pathology room with a microscope for reading histopathology slides.

The dermatology officers maintain separate male and female wards in the hospital dedicated to skin disorders. There are typically 10-12 patients on the ward at any given time, with disorders ranging from chronic leg ulcers to Kaposi's sarcoma to toxic epidermal necrolysis.

How many patients did you see on a daily basis?

Outpatient clinic was held Monday, Wednesday, and Friday, from 9 a.m. until the day was done, typically around 2 p.m. We would see approximately 80-100 or so patients a day. Friday was the most popular clinic day. It was the pediatric day, when most of the kids came in. More than 40% of the Tanzanian population is under 15 years of age, but they have no pediatric dermatologist in all of East Africa. Nor do training programs have a formal pediatric dermatology curriculum.

What were the most common conditions?

We saw many of the conditions that I see in my patients here: atopic dermatitis, impetigo, and warts. However, there were different presentations. For example, there were several children with warts in the oral mucosa. We do not see that much in the United States. Also, because of the prevalence of HIV, many of the infectious diseases are much more extensive or advanced than what we see in the United States, where HIV especially advanced HIV, is uncommon in children. Disorders that we saw commonly in Tanzania that are not common in the United States included endemic Kaposi's sarcoma and leprosy.

Did you have any unusual or puzzling cases?

Both albinism and xeroderma pigmentosum (XP) are very common in this part of East Africa. Because they are made worse by ultraviolet light exposure, patients present with extremely advanced and extensive skin cancers. The prevalence of albinism and the horrific targeting of affected individuals for their body parts are well publicized. I was surprised by the number of people with XP. One little girl with the disease arrived from hundreds of miles away from a very remote part of Tanzania. She was only 4 years old and already had incredible numbers of lentigines covering both sun-exposed and nonexposed areas, where the sun had penetrated her clothing. She had numerous squamous cell carcinomas as well as basal cell carcinomas. Her eyesight was so compromised, she was essentially blind. We were able to provide the family with education about the disorder, including the role of sunlight and the need for constant protection from the sun, but the reality is that she lives in a country that lies just south of equator, and access to care is limited. Her prognosis, and that of others like her, is very grim.

What were some of the greatest challenges to practicing medicine in Moshi?

The hardest thing about treating patients in this setting is the lack of access to medications. You could reasonably make a diagnosis, but not be able to help because the necessary medications were not available or affordable to the patient. This is especially true of pediatric formulations. In one case, a newborn baby had been exposed to varicella. Here in the United States, that child would have promptly received intravenous acyclovir. Since that wasn't available in Moshi, we simply observed the baby, hoping he would clear on his own. Luckily he did so, but many other babies aren't so fortunate.

What were some of the most rewarding aspects of the trip?

Professionally speaking, I loved seeing the patients. They were very grateful for any help I could provide, and in turn they provided innumerable diagnostic challenges. Equally rewarding was teaching the dermatology and pediatrics residents. They sincerely appreciated any time spent educating them, and they were quite eager to learn.

I can say without doubt that the residents that I met in Tanzania were on par with our residents here and are truly wonderful doctors.

On a personal level, this was a great adventure for my family and me. It was absolutely wonderful to see my son adapt to a different culture. He attended a great international school and made friends quickly with children from all over the world. We also learned that mechanics are much more sought after than doctors. My husband volunteered in the hospital workshops, fixing everything from the hospital's decaying fleet of Land Rovers to the aging and temperamental hospital generator. We saw the great migration in the Serengeti, we swam in the Indian Ocean, and I climbed Mt. Kilimanjaro. These experiences will shape my family and me for the rest of our lives.

How have you applied what you learned in Tanzania to your practice in the U.S.?

While I always have an eye out for leprosy or the rare infectious disease, mostly I use the practicality that was a necessity there in treating my patients here. The simple choice often works just fine. Also, I do not take for granted the access to care that we have here in the United States. People would have to travel days, at an exorbitant personal cost, just to see a dermatologist. I hope to continue to serve in global health, training physicians in pediatric dermatology who are working in remote parts of the world.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit the World Wide Med column at www.internalmedicinenews.com or send an e-mail to imnews@ebevier.com.

--Interview by Heidi Splete
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Title Annotation:World Wide Med
Author:Splete, Heidi
Publication:Internal Medicine News
Article Type:Interview
Geographic Code:6TANZ
Date:Dec 1, 2011
Words:1199
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