Voices rise up in harmony as the Sisters and hospital staff make their way down towards morning hymns, the official start of the day at the Kilema Hospital. We were wishing we could incorporate the spirit of this “team huddle” at the start of our work day in Canada! We sit, listen to the prayers and attempt to sing the hymns in Swahili (song sheets helped). On our first day we are introduced, and the staff (in Swahili) are told to “look sharp” for the visiting Doctors. This spiritual beginning is followed daily by “morning reporti”, a meeting of doctors and nurses; the previous night’s admissions are reviewed by the busy dr. on call, and a report of any deaths. Somber silence often follows the death report, along with educational words from the head doctor on gaps in care and potential for quality improvement. Discussions follow on timeliness of investigations and empiric treatment of serious cases. Clinical officers ( who have 3 years of medical training after high school) defer to the senior doctors in most discussions. After this, the doctors disperse to do hospital rounds, attend maternity patients or hold outpatient clinics.

One morning after rounds Dr. Mlay headed off to a gyne clinic, and as always we were welcomed to attend. The morning unfolded bit by bit… We joined a group of about 40 women, mostly in their 30’s/40’s dressed in bright kitangas who had congregated in the outdoor meeting space in the maternity building. They had heard about the clinic from community announcements – for example at their churches. It turns out this clinic is part of a national advocacy program for the prevention of cervical cancer. After a ‘group visit’ talk by Dr. Mlay (in Swahili, but the gist was clear from various anatomical drawings and the introduction of the speculum, amazingly done with lots of laughter from both the presenter and the audience!) a gynecologist from KCMC in Moshi arrived with his entourage. It took about an hour to get the barebones exam room organized with the right buckets of cleaning solution, a working flashlight, and the national register ready to go. The KCMC doctor explained that this was a VIA clinic (Visual Inspection with Acid, i.e. vinegar). For many of the women, this would be their first pelvic exam- and most of them had to wait many hours for it (with grace as always…)! Most women don’t have pap smears (although it is recommended, they can only be done in Moshi). HPV vaccine is unaffordable for women here. Screening mammograms do not seem to done, and if a breast lump is detected on clinical exam, patients are sent to Moshi for a biopsy, at their own expense (some opting for no investigation). Screening and prevention is in its early days, and having the resources and availability of tests we are accustomed to is not expected here. An acceptance of fate seems inherent to daily life.

A morning at the outpatient TB clinic illustrates the ubiquitous nature of this contagious disease. Many outpatients of all ages arrive from surrounding villages for their followup clinical visit, confirmation (hopefully) of negative TB cultures, and further treatment if necessary. New cases have contact tracing completed, with family members being tested and treated, and all children under age 5 being given prophylactic treatment. Cases lost to followup are found by the patients home medical district or a home based health care worker. In the outpatient clinic, and attempts are made to segregate the contagious TB patients from vulnerable HIV patients with compromised immunity. HIV patients are to attend clinics on separate days, to avoid infection. However, newly diagnosed TB patients, being discharged from the hospital, register at the clinic before making their way home. One wonders what mode of transport they will take back to their village, crowded Dala-Dala (bus), or dangerous motorcycle? Both equally risky for all parties.