Created by: Melanie Ma & Sabrina Bedell University of Vermont College of Medicine

May 2016

Global Women’s Health: Tanzania

PARTICIPANT’S GUIDE TO WASSO HOSPITAL

This participant’s guide was created to provide information about the Global Women’s Health elective in Tanzania at the University of Vermont College of Medicine.

The general curricular goals of this elective are to provide trainees with: (1) a broad sense of the comparative health disparities in a developing world setting, (2) an enhanced understanding of professionalism and cultural competence and (3) a sense of the importance of “capacity-building” in global health ventures, that is, making a contribution to the host institution that leaves them better than when trainees arrived.

Details of the trip may vary slightly from year-to-year. Please contact Dr. Dougherty to inquire about exact travel dates and itinerary.

INTRODUCTION

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1 Pre-Departure Requirements………………….

2 Trip Expenses…………………………………….

3 Travel Itinerary……………………………………

4 All About Wasso………………………………….

5 Who are the Maasai?……………………………

6 Wasso Hospital Guesthouse…………………..

7 Sample Daily Hospital Schedule………………

8 Hospital Duties and Responsibilities…………

9 Safari Weekend…………………………………..

10 Sample Packing List…………………………….

11 Learning Swahili…………………………………

12 Who’s Who of Wasso……………………………

13 Acknowledgements……………………………..

CONTENTS

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Pre-Departure Checklist Set up iAbroad account* Confirm passport validity during dates of travel Register with Department of State Obtain immunizations and medications Complete online training modules Complete pre-reading Meet with Dr. Dougherty close to departure date Notify OMSE of travel dates, location, and faculty supervisor

iAbroad iAbroad is a tool to research UVM-approved study abroad programs based on academic and other interests. It also guides you through the entire study abroad process, including pre-departure. *To set up your iAbroad account, email Dr. Molly Moore, Liaison for International Rotations, at molly.moore@uvmhealth.org.

Pre-departure requirements

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Immunizations/Medications Set up a travel clinic appointment ASAP. If you have the UVM Student Health Insurance Plan (SHIP), you may want to visit the Student Health Service’s travel clinic. If you do not have SHIP, you may want to visit UVMMC’s travel clinic. You can call both clinics to inquire about out-of-pocket fees under your personal insurance plan. (Note: Immunizations and medications are completely covered under Medicaid/Green Mountain Care. Coverage policies are subject to change.)

UVM Student Health Services Travel Clinic: (802) 656-3350 UVM Medical Center Travel Clinic: (802) 847-4594

Visit the CDC website for the most recent health guidelines for travel to Tanzania. The travel clinic will help you determine which vaccines and medications are necessary based on your immunization history. Make sure to bring your immunization records.

Commonly recommended vaccines and medications include: • Typhoid • Meningococcal • Hepatitis A & B • Tetanus • Yellow fever • Malaria prophylaxis (e.g. malarone) • Antibiotics for traveler’s diarrhea (e.g. ciprofloxacin)

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Online Training Modules Prior to your trip departure, complete these two online modules. Undergoing pre-departure training is both necessary and important. The knowledge gained from these modules will help you manage expectations, anticipate challenges you may encounter, and prepare you for culturally appropriate care. Upon completion of each module, you will earn a certificate that you can choose to list on your CV.

1) APGO: Clinical Care in Low-Resource Settings

This module is intended to help prepare you to work in under-resourced settings and prepare you for the clinical challenges facing the facility and the socioeconomic and cultural challenges underlying the patient’s experience.

2) Johns Hopkins/Stanford: Ethical Challenges in Short-Term Global Health Training

This module consists of a series of 10 cases that highlight ethical issues that may arise during your short-term training experiences abroad. It is intended to help increase awareness of ethical issues and identify strategies to help you navigate these issues as they arise.

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Pre-Reading List 1. Bhutta, ZA; Black, RE. Global Maternal, Newborn, and Child Health --So Near and Yet So Far. NEJM. 2013;369:2226-35.

2. Danso, KA; Opare-Addo, HS. Challenges associated with hypertensive disease during pregnancy in low income countries. International Journal of Gynecology and Obstetrics. 110 (2010);78-81.

3. Denny, L; Kuhn, L; De Souza, M; Pollack, AE; Dupree, W; Wright Jr., TC. Screen-and-Treat Approaches for Cervical Cancer Prevention in Low-Resource Settings: A Randomized Controlled Trial. JAMA. 2005;294:2173-81.

4. Denny, L. Cervical cancer prevention: New opportunities for primary and secondary prevention in the 21st century. International Journal of Gynecology and Obstetrics. 119 (2012);S80-84.

5. Duley, L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol. 2009;33:130-37.

6. FIGO Safe Motherhood and Newborn Health (SMNH) Committee. Prevention and treatment of postpartum hemorrhage in low-resource settings. International Journal of Gynecology and Obstetrics.117 (2012) 108-118.

7. Prata, N. Making family planning accessible in resource-poor settings. Phil. Trans. R. Soc. B (2009) 364:3093-99.

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8. Pathfinder International. Single-visit approach to cervical cancer prevention: clinical standards of practice and counseling guidelines.

9. Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, Brotons M, Mena M, Cosano R, Muñoz J, Bosch FX, de Sanjosé S, Castellsagué X. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Tanzania. Summary Report 2015-12-23.

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All trip expenses will be paid out-of-pocket. Costs can be quite high, but not every expense is required. If you are traveling on a budget, you can forego the safari, souvenirs, and many of the pre-departure items. Unfortunately, if you are receiving course credit for this trip, you will be ineligible to apply for a COM travel stipend.

The following table provides an itemized list of the estimated trip expenses:

Expense Item Estimated Cost (USD)Tanzanian travel visa 100USA-Tanzania roundtrip flight 900-1,500Work permit 200Roundtrip flight to/from Wasso 315Lodging in Arusha (total) 60Lodging in Wasso (total) 50-100 donation (may vary)Meals (total) 60Cell phone plan 20-30Safari (optional) 1000-1500

(all expenses including tip; total amount may vary depending on

size of party)Souvenirs (optional) 20-100 (may vary)

Trip Expenses

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The total cost of pre-departure items has not been included. It will vary depending on personal preference and individual health insurance plans. These expenses include items such as clothing, language learning resources, snacks, immunizations, and medications.

The only expenses you will cover prior to departing will be for the USA-Tanzania roundtrip flight and safari. You will pay all other expenses throughout the trip. It may be a good idea to bring around $1,000 USD in cash. This money will be used to pay Dr. Dougherty for room and board, the Tanzanian government for a travel visa at the Kilimanjaro airport, the Loliondo District office for your work permit once you reach Wasso, and personal items such as souvenirs and cell phone plans. Make sure to bring only recent USD bills (no older than 2008) to avoid complications.

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Students must fly together with the entire group. Coordinate your flight reservations with Dr. Dougherty.

The following itinerary may vary slightly from year-to-year:

TRAVEL ITINERARY

Day 1 Fly from JFK to Kilimanjaro. 1-hr cab drive to Arusha. Day 2

Stay at Arusha guesthouse. Withdraw shillings, get SIM card/phone service plan, groceries if desired (most basic necessities will be available in Wasso).

Day 28 Fly from Wasso to Kilimanjaro via Flying Medical Service. Depart for JFK.

Day 5 Fly to Wasso via Flying Medical Service (small chartered plane). Arrive for prolonged stay at Wasso Hospital guesthouse.

Safari Weekend If you choose to partake in safari, plan for a Friday-Monday trip. Check with Dr. Dougherty first to coordinate with possible hospital vacation dates.

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In Arusha Dr. Dougherty will bring the group to the bank, cell phone store, supermarket, and Blue Heron restaurant.

Use your ATM card to withdraw all of the shillings you’ll want for the rest of the trip. We each withdrew the maximum amount allowed from the ATM machine (400,000 TSH) which lasted through the end of the trip.

At the cell phone store, purchase a SIM card (2,000 TSH) and a data plan (5,000—10,000 TSH) if you have a smart phone. The strength of cell service of the various providers varies depending on location, so you may choose to switch cell phone service companies or just wait to purchase a service plan when you reach Wasso.

At the supermarket, you can get coffee (only instant coffee available in Wasso), alcohol, tonic water, and any other items you wish to bring to Wasso. Keep in mind that the selection in Wasso is much more limited.

You will visit the Western-style Blue Heron restaurant for an afternoon. Feel free to browse the gift shop.

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Source: www.vanrij.org

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Wasso is a rural village located in northern Tanzania near the Kenyan border. The land is lush, fertile, and teeming with flora and vegetation. If you wander down the main dirt road from the hospital, you will find a mix of modern concrete structures and traditional mud huts. The road leads to the town center where you will find a supermarket, office supply store, barber shop, liquor store, and various phone service stands. The supermarket carries basic necessities including peanut butter, jam, soap, liquor, bottled water, and spices.

Weather, Climate, and Geography Wasso is located at an altitude of 7,000 feet. Wet season is generally from November to May; dry season is generally from June to October. During your stay, temperatures will likely range from 50-80 F with mostly sunny skies, dry midday heat, occasional fog, and intermittent torrential downpours. Mornings and evenings can be quite chilly.

All about wasso

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Things To Do During your stay in Wasso, there are several options for how to spend your downtime. Activities include hiking Wasso Hill, exploring the nearby villages, visiting the town center, playing games with the children, reading, watching movies on your tablet/laptop, socializing with L&D staff, visiting the local disco on Friday nights, and attending the lively Friday market.

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The Maasai are an East African ethnic group that resides in southern Kenya and northern Tanzania. Many of the patients whom you will serve at Wasso Hospital belong to the Maasai tribe.

Formerly a semi-nomadic tribe subsisting on their cattle, the Maasai are now becoming increasingly dependent on farming. They have their own unique economy, language, lifestyle, and cultural practices. Some Maasai speak Swahili but many do not, especially the women.

The social organization of Maasai culture is traditionally rooted in paternalistic ideologies. Polyandry and polygamy are widely practiced. Female genital cutting is commonly performed. The roles of different members of the tribe are well defined. Maasai women are

responsible for building the homes, fetching water, collecting firewood, milking livestock, and cooking for the family unit. The

Who are the maasai?

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young Maasai men serve as warriors who providing protection. Young boys are responsible for herding livestock. The elder Maasai men act as decision-makers for the tribe. To learn more about Maasai tribal culture, visit the following:

http://www.maasai-association.org/maasai.html https://en.wikipedia.org/wiki/Maasai_people

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The Guesthouse is located just a few steps away from the hospital. There is one central building that consists of the dining hall and kitchen and a separate building that houses the guest rooms. Each guest room has its own bathroom. Room sizes vary; each will contain either a queen bed or a set of double-decker beds (bunkbeds). A mosquito net will be provided in each bedroom.

Each bathroom has running water and a Western-style toilet. The water is solar heated. The temperature of the water depends on the weather and time of day. It tends to be the hottest in the afternoon and cold in the mornings and late evenings. If there is a period of heavy rainfall, there may be sediment in the water which settles in a few days.

Triphonia is the guesthouse manager. She cooks all of the meals and handles any issues with the guest rooms.

Wasso hospital guesthouse

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Meals and Food At the beginning of your stay, notify Triphonia and Dr. Dougherty of any food allergies or preferences. Meals may consist of rice, chapati (crepe-like pancakes), cooked vegetables, potatoes, beef, papaya, bananas, citrus fruits, and occasionally chicken and eggs. Instant coffee, tea, filtered water, sugar, and powdered milk are available. Peanut butter can be purchased at the local supermarket. You may choose to bring your own non-perishable food items such as fruit snacks, protein bars, canned fish, dried fruit, instant oatmeal packets, and nuts.

Laundry You will wash your own clothes by hand. Various sizes of plastic buckets are available. Bring resealable pouches of liquid detergent and a few hangers. Liberal use of detergent may be necessary. Hang your clothes on the line and secure with clothespins, as it can often be quite windy. You may find it helpful to fashion a line out of rope in your room to hang smaller items that fly off easily in the wind.

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Cell Phone Data, Texting, and Internet Both in Arusha and Wasso, you can purchase a SIM card for cell phone data and internet access. Prior to your trip, download a texting/calling app such as WhatsApp or Facebook Messenger which will allow you to send texts and make international phone calls. You will be given a Tanzanian phone number and can reload minutes and data via daily or weekly vouchers that can be easily purchased at an extremely affordable price (500 TSH/day for a daily voucher).

Front and back of daily voucher

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End of workday varies based on daily workload.

Sample daily hospital schedule

Activity

Breakfast at guesthouse

Morning report at hospital administrative building

Morning rounds with attending physician (Dr. Mallange, Sister Phillipina, Dr. Dougherty or other covering physician)

Option A: outreach clinic; Option B: cervical cancer screening clinic, gyn consults or other hospital duties

Lunch at guesthouse

Time

0730

0800

0830

0930

1400

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Outreach/Travel/Flight Clinic One student at a time will attend outreach clinic. Meet Sospeter or Moshi the driver in front of the hospital near the outreach van around 0930-1000. Bring a daypack with exam gloves, pen, hand sanitizer, sunscreen, and snacks/lunch (notify Triphonia the night before to prepare a lunch box for you). For prenatal OB outreach clinics, bring a stethoscope, tape measure, and baby wipes in addition to the other supplies.

During pediatric clinics, you will help measure and record weights of children, prepare and give immunizations, and record new patient data in the record book. Duties may vary; ask what you can help with and be flexible.

During prenatal OB clinics, exams will be performed in an enclosed hut. For all visits,

you will help measure blood pressure, fundal heights, and fetal heart tones with a fetoscope. If Dr. Dougherty is available, you will assist with fetal ultrasounds. For first-time patients and their partners, you will also administer rapid HIV and syphilis tests. Sospeter will help the new patient fill out a health record (see scanned “kadi” document). The local clinical officer will provide education on pregnancy and family planning.

HOSPITAL Duties and Responsibilities

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Cervical Cancer Screening Clinic Women will receive a rapid HIV test/counseling prior to the clinic visit. The clinic visit includes: breast exam, speculum exam with VIA (visual inspection with acetic acid), and cryotherapy if indicated. As a student, you will be performing all aspects of this visit with assistance from an interpreter under the supervision of Dr. Dougherty. Screening results data will be collected.

Gyn Consults Ask a hospital employee to serve as a translator. It may be difficult to track someone down at times. Obtain the HPI and perform appropriate physical exams. Consult with Dr. Dougherty and order laboratory tests, prescribe medications, or refer to an outside hospital.

Operating Room Attend all surgeries possible. Ask the attending for permission to scrub. Bring your own scrubs to change into in the OR changing room. Keep a pair of designated OR shoes in the OR shoe area. After changing into scrubs, you

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will put on a cap and plastic apron, both of which are provided by the hospital. Bring your own PPE (sterile gloves, mask, eye protection, scrub brush). You will gown and glove yourself. Be aware that it will be very hot in the OR. Prepare to sweat.

Antenatal Ward Antenatal checks are performed 2-3 times per week. Ask the ward nurse permission to observe and partake in using the fetoscope to detect the fetal heart rate. During downtime, bring a fetoscope to the antenatal ward to practice.

Labor Ward During downtime, it is also helpful to visit L&D to socialize and establish relationships with the L&D midwives and nurses. You can leave your phone number for them to post on the wall and ask to be called for deliveries. Also leave your number with

individual L&D staff members with whom you become more familiar. You can participate fully in cervical checks and deliveries. Work with the staff to strike a balance between your scope of practice and their practice norms.

You may find some of their practices to vary greatly from those with which you are familiar; be mindful that you are a guest at the hospital and remain open-minded about their methods. Be inquisitive and advocate for your own participation when appropriate.

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Thursday Morning Presentations Every Thursday, a hospital staff member will present a topic. Coordinate with Dr. Dougherty to come up with your own topic. Create a powerpoint or chalkboard presentation and prepare to present your topic some time in the last few weeks before you depart.

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SAFARI WEEKEND

Prior to traveling to Tanzania, contact Fortes Safari Company (info@fortes-safaris.com) and request Abel Zacharia to be your safari guide. Abel is a fantastic driver and seasoned expert in scouting out the rarest of animals. If he is not available, another driver will be fine. Mention Dr. Dougherty (they will recognize our group) and inform them that pick up and drop off will need to be at the Wasso Hospital guesthouse. Fortes will provide you with several safari itinerary options and respective price quotes. Once you select an itinerary, you will complete the necessary paperwork. Determine who will be the designated point of contact for the reservation. Wire funds to Fortes to hold the reservation.

SAFARI WEEKEND PACKING LIST

• passport • cash for tips • bug spray • sunscreen • hat • camera plus extra

batteries and charger • binoculars • plastic bags for trash • water bottle • sunglasses • backpack • snacks for all-day game

drives • closed-toe shoes • sandals for lodge • raincoat • nice outfit for dinner at

lodge (if desired) • long pants (more

protection from Tsetse fly bites)

• 2-3 outfits (dress in layers)

• underwear • toiletries • swimsuit • clothes to be laundered

(if desired)

Email Fortes a few days before you are scheduled to go on safari. Confirm the driver’s name and cell number as well as the pick-up time and location (Wasso Hospital guesthouse). Notify Triphonia the night before you depart to prepare lunch boxes for the drive.

On Friday, your guide will meet you at the guesthouse. It will take about 3 hours to reach Klein’s Gate, the entrance to Serengeti National Park. There, your driver will help you obtain your park permit (already included in safari fee) and use the restroom if needed.

From Klein’s Gate, you will continue on a game drive for the remainder of the afternoon. You will arrive at the lodge around dinnertime.

For all-day game drives, you will depart the lodge around 0800. If you would like to depart earlier for better photography lighting, fewer crowds, and to increase your chances of seeing rare animals, you can request an earlier departure (e.g. 0600). Keep in mind that lunch boxes will not be available until 0800, so discuss lunch plans with your driver.

Restrooms on the game drives are available at the visitors’ center. On most days, you will only stop there during lunch. If you need to use the restroom at any other time, your driver will stop the car and you will go behind the safari vehicle. Use hand sanitizer and bring tissue packs and a trash bag if desired.

All meals on the trip will be provided. Place your lunch box order with the lodge front desk the night prior to following day’s game drive.

Tips per guest for duration of trip: • Lodge waitstaff

($10-$20) • Lodge

housekeeping ($10-$20)

• Safari guide ($20-$50/day)

This is a general list of things we found helpful to have on the trip. Before leaving, we visited Old Navy and Walmart and purchased the majority of our clothing/shoes that we brought with the intention of leaving most of them behind. That was a personal choice; you can certainly bring clothing that you already own and don’t mind getting dirty. All of our medical supplies were obtained from UVMMC. We each brought one large check-in suitcase and one carry-on backpack.

Personal Items • conservative clothing that allows for movement (no jeans at

hospital) • chinos or khakis • linen pants • below-the-knee skirts • long-sleeved shirts • fleece/sweatshirt for cool mornings and evenings • quick-dry clothes for exercise • footwear: shower sandals, indoor sandals, outdoor sandals,

sneakers/hiking shoes, OR shoes (garden sloggers on Amazon), casual closed-toe shoes for the hospital

• swimsuit (for swimming pool at safari lodge) • raincoat • pajamas • personal hygiene items (soap, shampoo, toothbrush/paste,

deodorant, feminine products)

Sample Packing list

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• medications (Rx, Imodium/Pepto Bismol, Aleve/Tylenol, Benadryl, anti-itch cream, Dramamine, first aid)

• sunscreen • bug spray with Deet • outlet adaptor/powerstrip (UK) • headlamp (you will be using this all throughout the cervical

cancer screening clinic; bring a family pack of spare batteries) • snacks (nuts, raisins, protein bars, candy, gum, dried fruit,

fruit snacks, canned tuna/salmon, instant oatmeal packets; you can buy some of these items in bulk at Costco)

• laundry detergent (resealable pouches on Amazon) • 2 packs of baby wipes/Clorox wipes • tissue packs • hand sanitizer (personal size and large refill bottle to share) • sunglasses • hat • Swahili book (recommended: Lonely Planet) • small pocket-sized notebook/pens/pencils • camera (optional: long lens, lens cloth, extra camera batteries

for long all-day game drives) • binoculars (optional) • laptop/tablet and charger • small daypack for day trips/hikes and outreach clinic • movies on tablet or laptop • book for leisure reading • water bottle • ATM card (in Arusha, you will want to withdraw shillings to

use in Wasso. Call ahead to alert your bank and credit card companies of your travel dates and location.)

• passport, plus a few photocopies

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Medical supplies (for 1 person unless specified) • white coat (Option A: purchase inexpensive coat on Amazon

or borrow old coat from friend to leave behind; Option B: bring UVM coat, make sure to wash well when you return.)

• scrubs (5 sets) • stethoscope • OR scrub brush packets (5) • 1-2 boxes of exam gloves • sterile gloves (20 pairs (10 sets for double gloving)) • eye protection (1 reusable frame & 10 disposable lenses,

extras of both to give to L&D nurses) • face masks (10) • N-95 mask (2) (good to have but probably will not use) • box of alcohol swabs to share

Miscellaneous (All items are optional. Many/most of these can be purchased at the dollar store.) • hangers • laundry clothespins • air freshener • rope • duct tape • scissors • jump rope • playing cards • gifts for Triphonia (cook): spices, kitchen tools and

accessories • Vermont-y gifts (t-shirt, cap, maple candy, etc.) for

miscellaneous staff you want to thank at end of trip

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Recommended language resources:

Lonely Planet Swahili Phrasebook & Dictionary ($20) Rosetta Stone: Learn Swahili ($100 for 3-month subscription) Memrise app: medical Swahili, basic Swahili (free)

The following are some helpful phrases and words that we used commonly throughout the trip:

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Learning Swahili

Greetings

habari = literally “news”, analogous to “how are you” nzuri = good sana = very safi = fine mambo = how are you poa = cool jambo = literally “problem”, analogous to “how are you” sijambo = no problem

Numbers

moja = one mbili = two tatu = three nne = four tano = five sita = six saba = seven nane = eight tisa = nine kumi = ten kumi na moja = eleven kumi na mbili = twelve ishirini = twenty

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General Terms

ndiyo = yes hapana = no hamna shida = no problem sawa = ok asante = thank you samahani = excuse me siku = day wiki = week mwezi = month kubwa = large mdogo = small pole = sorry pole pole = slowly baridi = cold joto = hot

nahitaji = I need unahitaji = you need nataka = I want ndege = plane mvua = rain ua = flower maji = water pipi = candy chipsies = french fries viazi = potatoes chapati = crepe mandazi = fried dough parachichi = avocado mkate = bread

Medical Terms

tumbo = stomach matako = butt kichwa = head homa = fever mafua = cold dawa = medicine kizunguzungu = dizzy panauma = hurts hapa = here

watoa chupi = remove underwear damu = blood sukuma = push mja mzito = pregnant fungua = open naoma = I look mtoto = baby mtoto nzuri = good child mtoto yuko sawa = the baby is ok

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Animals

mbuzi = goat ng’ombe = cow paka = cat mbwa = dog tembo = elephant twiga = giraffe simba = lion chui = leopard duma = cheetah ndege = bird punda milia = zebra

Who’s who of wasso

Dr. Mallange, Head Physician: rounds on inpatient wards, performs most surgeries

Sister Phillapina, Senior-Level Physician: rounds on inpatient wards, performs c-sections

Enoch, Hospital Administrator Abel, Safari Guide: very knowledgable and friendly, will lead you to prime viewing areas

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Triphonia, Cook and Guesthouse Manager: prepares all meals and manages guest quarters

Sospeter, Outreach Clinical Officer: coordinates outreach/travel clinic

Esther, Hospital Matron and Scrub Nurse: manages all hospital logistics

Stella (10), daughter of Esther: mature and knowledgable, very helpful and friendly, especially on town trips

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We would like to thank Dr. Anne Dougherty, the hospital and guesthouse staff at Wasso Hospital, and the community members of Wasso for their hospitality and the opportunity to provide care for the people of Wasso. We would also like to thank Whitney Thomas and Merima Ruhotina for their assistance and guidance prior to departure.

We are so grateful to have had this incredibly enriching educational and cultural experience. We hope that this guide will serve its purpose in providing useful information for future participants of the Global Women’s Health: Tanzania elective.

Asante sana.

acknowledgements

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Content by: Melanie Ma, Sabrina Bedell Design by: Melanie Ma Photos provided by: Melanie Ma, Anne Dougherty

May 2016

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