The autoclave (steamer for sterilizing surgical instruments) is broken at Msazi Mmoja, so I spent the morning with 3 cuban doctors and the good Dr. Muhammed the medical officer (something like a physicians associate) who is in charge of the women's medical floor.

The floor is really just one large room with about 25 simple metal beds around the perimeter, each with a bedside table and a mosquito net. The patient's ages range from 18 to 70 (extremely old for here, about the oldest person I have met or seen in a hospital here). The most common diagnosis (owing in large part to the presence of one sphyngomometer) is hypertension, followed by diabetes (owing to the presence of a glucomter), also quite common is malaria, a fair number of HIV positive patients with various ill defined disease, and their was a demented patient, one with CHF, one with meningitis, and one who had had a stroke. The ward is quite challenged in terms of equipment (they lacked a thermometer, even though, right across the street, there was a pharmacy that sold thermometers for 1500 Tsh, (~$1.20 US)).

The major challnege is actually the lack of a basic format for rounding or investigating patients. We would go to each patient's bedside and one of the medical officers would tell us what the diagnosis was, but then would stop and ask what medications we thought should be given. The patient's age, vital signs, underlying health, presenting symptoms of subjective state was never forthcoming. At one obvisouly distressed pateint, who was introduced as just a known hypertensive, Dr. M (from cuba), and I asked about the physical exam, the AMO (advanced medical officer, who is actually in charge of the entire floor), thoughtfully gazed at the patient for a minute and replied, "this one is a bit weak." The Cuban just laughed (he has been here for 3 months, and is staying for two more years, so slack should be cut). No discernable thought is given to the physical exam or to what is actually happening inside the patient that may be causing their symptoms. I encountered the same lack of interest in diagnosis in Mwanza, but the good work of the Touch Foundation and others was slowly changing the S.O.P there.

Medicating is another experience entirely. The doctors here love to prescrib -steroids, antibiotics of every kind, (sometimes three at a time), quinine, artemesin, insulin, beta-blockers, chlorazepam, diazepan, eyedrops, lasix, aldactone, and lots of special clove soap and ointments, and elixers for the throat and stomach and, how could i forget, every high dose vitamin supplement you can imagine. Lab tests adn imaging get similar treatment, although there is no pathology department here, and few results are ever produced, either becuase the patient's family doesn't have the money, and the hospital doesn't do anything without money up-front (remember the ministry of health won't purchase thermometers so you can't blame them), and if tests are done it is the patient's responsibility to hold on to them, so a lot of results are lost or relative take x-rays home before we can see them, happened twice on rounds (where are the x-rays?, "at my house" -oh, sweet, i'll just pop over and take a look.

Ok, enough with the negative, the plus side is that the Cuban doctors are really dedicated to raising the standard and teaching, the economy here is stabilizing, the new minister of health is actually a physician (the first dozen or so Zanzibari minsters of health were actually illiterate, just politically appointments), and the Zanzabari medical staff I have met are all very interested in learning about medicine, they take notes on almost everything I say, and if I, or any doctor, starts to explain some pathology or show a physical finding I'll have a group of 20 nurses and AMO students around the bed in minutes, and USAID is spending a lot of money on family planning here, and the Clinton foundation is funding a comprehensive HIV/AIDS program, so the future looks a bit better.

Ok, have to run and play pool with Star and Mellisa (who was out 'till dawn last night), more to come...

Oh, and yes, after rounds I bought the floor 4 thermometers