From Doernbecher to Tanzania

Pediatric hematologist/oncologist Dr. Sue Lindemulder knows that families are families, no matter where they are in the world.

For the last three years, Dr. Lindemulder has organized and led a group of Doernbecher fellows on annual trips to Muhimbili University of Health and Allied Sciences (MUHAS) in Dar es Salaam, Tanzania, where they care for kids at children’s hospital Jengo La Watoto and work with hospital staff to develop curriculum and improve their pediatric oncology unit.

We sat down with her to learn more about the training and instruction they provide – and how it ends up making a difference in the way we care for kids right here in Portland.

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How did the relationship between Doernbecher and MUHAS develop?

Jengo La Watoto children's hospital at MUHAS
Jengo La Watoto children’s hospital at MUHAS

I was sent to Tanzania for three months when I was still in fellowship, and I ended up learning a lot and meeting a lot of people there. Over time I’ve become involved in a Masters program at MUHAS that educates and trains Tanzanian pediatricians to become hematologist/oncologists.

What kind of work do you do there?

I go back as a professor in the Masters program in Pediatric Hematology/Oncology and as a clinician to help with their unit and help manage their patients. I’ve brought senior fellows with me for three years, and Dr. Suman Malempati has also worked and taught there. With multiple providers we are able to spread out to work with students in the Masters program as well as with pediatricians, pediatric residents and others practicing on the pediatric oncology ward. We do formal education with them, we do clinical care, we do on-the-job training, give lectures – basically, whatever needs to happen.

How does their Pediatric Hematology/Oncology program differ from ours at Doernbecher and in what ways is it the same?

Their patient volume is higher – somewhere between 400 and 500 patients show up at their doors every year, and that continues to grow. They have a designated ward for children with cancer, and the facility itself is a large academic medical center like OHSU, although they don’t have the extent of support and ancillary services that we have here (for example, fewer resources in the radiology department or a lab spread over many more patients). If we do a blood count on a child at MUHAS, we might get a result the next day, or we might find out that the blood was lost and we’ll have to try again. As a result, you learn to make a lot more clinical decisions and depend a bit less on lab data. The pharmacy support is also very different – there, the nurses mix the chemo themselves!

One of the biggest differences in Hem/Onc is that there is no PICU, and there’s a single pediatric ventilator for the hospital – and it maybe works. When children get very ill, there really isn’t an alternative for support. If a kid at Doernbecher becomes extremely ill, we send them to the PICU, but the same patient in Tanzania might not make it.Ujasiri house

Another difference is that their nursing staff, though extremely dedicated, is not specifically trained in pediatric oncology as ours are in the United States. That’s something we’re working on; as we bring up the education of their physicians, we need to bring up the education of their nurses. I will say that nurses there can get an IV almost anywhere – it’s a sweaty environment, and tape doesn’t always stay on!

There are a lot of similarities between our hospitals. Tanzania is very much like Oregon, only larger. They have something called the Ujasiri House, which serves families in many of the same ways as Ronald McDonald House does here. They have a great school program at the Ujasiri House and on the unit, just like we do at Doernbecher – and these kids love school. They also have people who are Child Life equivalents – they come and color, play music or do projects with the kids.

What are some of the challenges associated with these trips?

Language is a big one. Most of the clinicians and nurses speak enough English to communicate, but if a patient comes from a village with a dialect that even local Swahili-speaking Tanzanians can’t understand, that can get tricky! I speak a bit of Swahili, so I can get the gist of a lot of things medically. Kids and families think it’s hilarious when I speak Swahili to them – they just laugh and laugh!

The kids come with much more extensive disease than we are used to seeing here due to the time and money required to get to Dar es Salaam. Patients may have first seen a medicine man, then a village provider, then gone to their district hospital, then a regional hospital and then, finally, to MUHAS. Between each visit, they return home to save up money from everyone they know for their next bus fare. Families literally strap their children to their back to get them where they need to go.

By the time they do get medical care, they are very, very ill. Once they get to Dar es Salaam, the care on the unit is mostly provided free of charge. This is huge, but a lot of families can never get there.

How do you foresee this exchange further developing?

We’ll be going back in April, and this year I hope to bring a couple of nurses with us to assist with the formal nursing staff curriculum we’re helping to develop.Hospital art MUHAS

The whole point of the Masters program is to train them in their own country, with their own resources. The flip side, though, is that in order to move their program forward, they need to visit other sites. We’re looking at bringing one of the students who just finished the program over here to do some training with me for a few months. I’d like that to be an ongoing thing.

We’re looking for grant funding, and it would be great to have some additional philanthropic support. The Kiwanis have helped, but a lot of this has been funded out of our own pockets.

How does the Tanzania experience impact Doernbecher doctors?

One of the fellows, Melinda Wu, poses with a patient in 2014
One of the fellows, Melinda Wu, poses with a patient in 2014

The trip exposes us to a degree of pathology we don’t frequently we see, which helps expand our knowledge base. It also teaches you a lot about the management of resources here and ways we can eliminate waste.

The fellows come back more comfortable, with more confidence in their ability to practice. It really reinforces what you know and it stretches what you think you know. My time in Tanzania makes me a better doctor here in Portland.

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Learn more and follow along with next spring’s Tanzanian adventure with the DCH2Tanzania blog.