Perspective
Diabetes in Tanzania
A summer project offers a glimpse at the problems that plague the Tanzanian health care system.
By Lilian Msambichaka
Help me! Someone help me please! My child is dying, please someone help me!
A woman holds her convulsing son outside a café a few steps from the Muhimbili University of Health and Allied Sciences (MUHAS) hospital in Dar es Salaam, Tanzania. The café is frequented by patients and their family members and MUHAS staff. I am there on an August afternoon to meet a family friend after my orientation at the Tanzania Diabetes Association (TDA), where I am doing a five-week project. I stand, look in the direction of the crying voice, and notice that a nurse sitting a few tables away continues to eat her lunch as if unaware of what is happening. People gather around the crying woman and her seizing son as his body jerks, his eyes roll upward, and blood-tinged foam covers his mouth. I vainly try to recall what I’ve learned about first aid for seizures. Then, people around her begin praying. When the seizure stops, the mother thanks them and explains that her son has recently sustained a head injury in a car accident and that he is going to MUHAS to be examined.
That was not how I had envisioned health care in Tanzania. I hadn’t expected to see such apathy. I had thought health care providers would rise to the call of duty and offer their services despite whatever strains they might be feeling. I was shocked and angry at the indifference of the nurse. How could she not offer to help?
To begin to understand her, to begin to understand the health care system in Tanzania, I had to look beyond this incident.
I had come to Tanzania in the summer of 2010 to do research on the prevalence and management of diabetes mellitus. As it turned out, that focus provided me with a lens through which I could see the bigger picture of this country.
My parents lived in Tanzania, so I was familiar with the country. I got interested in metabolic diseases in developing countries after hearing Antoinette Moran, M.D., an endocrinologist at the University of Minnesota, where I am a medical student, give a talk on diabetes in Uganda. Before Dr. Moran’s talk, I had no idea how prevalent diabetes was in Tanzania nor that the disease is on the rise and poses a serious problem for the future because neither society nor the health-care system is equipped to handle the management of people with chronic diseases. Like most people who consider studying or working in Africa, I was initially thinking of pursuing a project on infectious diseases such as HIV or malaria.
Dr. Moran put me in touch with the TDA. The association was formed in 1985 with the assistance of Dr. Donald McClarty, a British physician who taught medicine at Muhimbili Medical Centre and who noticed that many patients with diabetes were unaware of their condition. He also noticed many Tanzanian doctors were treating symptoms but missing the diagnosis. And many Tanzanians regarded diabetes as a disease of developed countries, rather than one that could affect them.
The TDA provides education about diabetes to the public, health care professionals, and newly diagnosed patients, and gives free insulin and glucometers to people younger than 22 years of age. During my stay, I attended diabetes education sessions at the Temeke and Amana district hospitals, and at the MUHAS diabetes clinic, all of which are government-run facilities. At the district hospitals, a dozen people gathered in small rooms for the two-hour sessions, during which educators dispelled myths about diabetes being a communicable disease or a curse. Many patients believed that people with diabetes should only eat millet with a few vegetables three times each day. Those who followed this regime got both constipated and hyperglycemic. It was refreshing to see these patients’ relief as this folklore was discounted.
The diabetes doctors who I worked with were as dedicated and hard-working as their colleagues in the United States. But they are stretched thin and paid less than most professionals in the private sector. The doctor-patient ratio in Tanzania is 1:26,000. (World Health Organization guidelines are 1:7,500. In the United States, the ratio is about 1:400.) The Tanzanian physicians see as many as 50 patients during a three- to four-hour clinic. At Amana District Hospital, a 350-bed facility, the one trained diabetes doctor is occasionally assisted by other doctors who have attended only a few seminars on working with patients who have diabetes.
As in the United States, the children with diabetes who do the best have parents who are actively involved in the management of their disease. The adults who can afford to buy medication or have some education also do better than others. Adolescents and young adults who don’t have jobs struggle the most. When they turn 22, their access to the TDA’s free supplies ends. A month’s supply of insulin costs $10 to $20; glucose strips and syringes bring the monthly treatment cost to $65, far beyond the reach of many. Unless they come from families that can afford to pay for the medications, patients frequently end up in hyperglycemic crisis and return to the pediatric clinic at MUHAS seeking free medication. One kid begged the doctor to let him stay at the clinic forever.
Half of Tanzania’s 33 million residents live below an unimaginably low poverty level. The cost of living is high, and people struggle to make ends meet. The gap between the poor and the middle class keeps growing wider. Those who have means can afford to go to a “good” hospital and get good health care; those who don’t rely on under-resourced government hospitals.
A few weeks after my encounter at the café, I was no longer angry at the nurse who stood by while the young man had the seizure, nor was I surprised that people resorted to prayer to solve their problems. I was beginning to understand what scarcity and need could do to a society. I saw that the public health care system in the country was burdened, under-resourced, and understaffed. The medical personnel were overwhelmed, which led them sometimes to the point of not caring. Prayer gave people hope and a sense of peace. It made them feel empowered when they felt the health care system and society had failed them. MM
Lilian Msambichaka is a third-year medical student at the University of Minnesota and a junior scientist in the department of medicine’s hematology office.