Last Day at Muhimbili!

Today is a national holiday in Tanzania (Labor Day). Therefore, much like we do at Doernbecher, we rounded with a smaller crew today and left the hospital a little early. I said “goodbye” to all the Watotos (children) as well as the moms and dads as best as I could. The interns were nice enough to translate for me a couple of times.

It has really been an interesting couple of weeks. I’ve seen some really good medicine during that time. It’s been challenging trying to make clinical decisions without ready access to labs, scans, or even other pediatric specialists. The team has cared for these patients with minimal lab tests and without a working CT scanner. The pediatric oncology Master’s students do their own ultrasound-guided biopsies, peripheral blood and marrow smears, and CSF cytospins.

It’s also been frustrating at times. There are children who had already been admitted to the hospital when I started last Monday and are still there without a diagnosis or treatment plan. When children have fevers, everything is empiric because the ability to get cultures is limited. And I often think these children may have all kinds of tropical infections that I would never recognize. We’ve had a few children with HIV and some type of malignancy. It’s disheartening that the children even have HIV.

But amazingly, despite the limited resources, I didn’t see a child die of infection or treatment-related toxicity in the two weeks I have been here. We sent a couple of kids with acute myeloid leukemia home without treatment as that intensity of treatment needed to cure AML is no possible here. Another child with AML who was only receiving supportive care died in the hospital.   Otherwise, all of the children with cancer are hanging in there (despite a few having tumors for which we don’t yet have diagnoses).

One day, I was casually speaking with team about the numbers and types of cancers that they see. We determined that at Mumhibili, they may only see about one-fifth to one-tenth of the pediatric cancer cases that likely occur in Tanzania. Muhimbili has the only real pediatric cancer treatment facility in the country. So, there are likely many more cases of childhood cancer that never get diagnosed.   It makes complete sense that Muhimbili sees a disproportionately high number of Wilms tumor cases, as those are the patients who are often OK even if it takes months to get to a facility where they can be treated.   The good news is that those are the patients who can often be successfully cured of their cancer. And from what I observed, they do a good job of treating those patients.   In the long run, much more infrastructure will be needed to be able to treat some of the more difficult types of cancers.

Like Sue, I’m leaving here with a new appreciation for all of the assets we have at Doernbecher that help us care for patients. I’m not sure how much benefit I provided (hopefully it was something—at least some teaching), but I can say that I certainly learned a lot. I come away from this experience with a little more confidence in my ability to assess patients and use clinical judgement rather than relying solely on tests. I expect this will make me a better pediatric oncologist when I get home.