Left out there - where there is an unmet surgical need.

 Dear reader,

I invite you to embark with me on my very personal journey and to delve into my reflections about health systems, hospitals, general surgery, hardship and beauty of work here in Tanzania. I will describe what I see, hear, learn and feel without prescribed limitations. Its not for every heart but mine needed to journal and share what it is going through.

I am shocked and I keep being shocked. Actually it is multiple shocks per week. The inequity of this world feels at times like a knife stabbed into my chest.

One of my earliest realisations at KCMC was the unmet surgical need of cancer patients in this region. What is an unmet need you might ask. Let me explain.

KCMC serves a population of approximately 11 million people as a tertiary referral hospital. For cancer patients it is the only facility for surgical and oncological treatment. The oncology unit has been opened only recently though and before that patient were sent to Daressalam for chemotherapy.

I think if I tell people that I work in Tanzania, and even if I tell people in Tanzania that I work at a big hospital like KCMC they think we are overwhelmed with patients. But no, that's not the case. Most of the cancer patients don't reach KCMC. They die at home, in their village, maybe at a nearby health clinic or regional hospital without seeing a surgeon and/or an oncologist. 

This week we operated on a 36 year old patient with a locally advanced colon tumour causing an intestinal obstruction that had already spread to his liver. Obviously he came to KCMC, but he came very late. The unmet surgical need includes the patient that presents very late with their condition and that can't be cured.

They have a need that is not being met by this health system. 

You might ask, as I did, why? What are the barriers?

Many, soo many barriers! 

In Global Health/Surgery they were named with the three A`s: 

Accessability, Affordability and Acceptability. (Sometimes it already feels good to name the challenges, as it is one step towards the solutions.)

So what means Accessibility? How easy is the hospital to reach? How easy is it to get an appointment at the clinic or to see a specialist? That includes transport issues - roads, busses, expenses. Housing for relatives nearby the health facility. Does the patient need a referral from another hospital to go to KCMC? How to get that referral? How long are the waiting hours for opening a file? How easy is it to open a file? Does the patient and his relative speak the language of the hospital staff? How easy is it to get the information about the surgical clinic that is happening twice a week? The list of questions representing barriers is long.

Affordability is easier to understand - patients need to pay for almost everything in a tanzanian hospital, regardless if the hospital is governmental, faith based, public-private partnership or purely private. Just the rates differ between the categories. KCMC has the standard government rates - opening a file costs 8 USD, a simple lab investigation like a full blood picture 3 USD, an ultrasound 10 USD and an operation 140 USD. The average income of a someone living in Tanzania is around 150 USD. I experience the costs for health care being one of the major hurldes to seeking health care. But without the patient paying how would the hospitals look like? How good would the quality of care be? Or how much worse would it be? Fortunately there is a growing part of the population that is health insured through their employment. At KCMC right now it is one third of the patients that do not need to pay for most investigations and interventions.

Coming to Acceptability. This last one is multifaceted and again as difficult as interesting to study and to understand. In East Africa but also in many other parts of this world traditional medicine plays a certain in some parts a very big role. Most of the patients at least from the rural parts here will have seen a traditional healer first. And we know about the importance and place of traditional medicine. Unfortunately there is no such thing as integrated traditional medicine. Entering a hospital the patient will be judged when they say they went to a traditional healer. The colonial traditions of banning traditional practices are kept high in these health care facilities until today. In general the medical system is patriarchal and very hierarchal. The patient and his or her relatives when entering the health care facility obey unconsciuously to certain rules which are i.e. not questioning the doctor or not speaking against the nurse. Noone likes to go to hospital but here hospitals are frightening places where pain and death are ubiquitous.

The integration of alternative belief systems, community structures, traditional medicine and the strengthening of personal human rights need to be pushed. 

For a future vision of a health system that offers high quality health care to everyone, affordable and in time.