Report of my experiences with a tropical medicine expedition
for healthcare professionals in Tanzania, 2009
Arthur Dover, MD, DTMH
In my opinion, the training for healthcare providers in the areas of clinical tropical medicine and
travelers health in non-tropical countries has yet to reach an adequate standard. Each year, more
and more tourists choose travel destinations in tropical and subtropical regions, often without
immunization or malaria chemoprophylaxis. Returning travellers still succumb to malaria and other
tropical infectious diseases simply because the infections are recognized too late, if at all, by medical
professionals in American and European hospitals. Practice-oriented training program for doctors
and other travel medicine professionals is essential to the prompt, correct diagnosis and treatment of
tropical infectious diseases.
A very special two-week Tanzanian excursion lay ahead of us, which we would later come to regard
as an incredible experience. I traveled with my wife Dilma, who works as a nurse in my travel clinic in
Upon landing at Kilimanjaro International Airport, we met the other 12 travelers - medical colleagues
from Belgium, Switzerland and Germany.
Arriving at the Arusha Coffee Lodge, we met our excursion leader, Kay Schaefer (MD, PhD, MSc,
DTM&H), a consultant in Tropical Medicine and Travelers' Health in Cologne, Germany. He had
added Tanzania as a new destination for his "Tropical Medicine Expeditions" to East Africa. Since
1995 he has organized tropical medicine expeditions to Kenya and Uganda (in total 32 excursions
with over 250 participants from `round the world') for healthcare professionals. These are done in
collaboration with leading medical institutions and hospitals in East Africa. He and local experts
supervise individual on-site bedside teaching, lead laboratory exercises (hands-on microscopy of
parasites in blood, stool and urine), and give lectures. The curriculum (60 CME hours)
epidemiology, clinical manifestations, diagnosis, treatment, prevention and control of Africa's most
important tropical infectious diseases. In addition, the participants gain insight into the local
healthcare system and explore the fantastic scenery and prolific flora and fauna in East Africa during
epidemiologic field excursions.
In the colonial atmosphere of the lodge, Dr. Schaefer outlined the planned course of the trip. He
described the itinerary taking us from Arusha to Karatu in the Ngorongoro Conservation Area,
continuing on to Lake Eyasi in the East African Rift Valley and then back to Arusha. This would cover
approximately 450 miles in comfortable 4x4 extended Land-Cruisers with safe, experienced local
drivers. During the second week we were to travel by plane from Arusha to Zanzibar to visit hospitals,
clinics and field projects.
The next morning, we discussed malaria. Dr. Schaefer emphasized that malaria tropica
) is a medical emergency. Cerebral malaria can kill within a matter of hours. For this reason
alone, doctors in the US and Europe should ask each patient with a fever if he or she has visited the
tropics within the past 6 months. Later that same day we saw how life-threatening cerebral malaria
can be, in an 8-month-old boy with convulsions and a fever of 104° F, admitted to the pediatric unit at
the St. Elisabeth Hospital in Arusha (Photo 1)
. He immediately received IV dextrose solution and
diazepam. With the help of a paracetamol suppository and fanning motions, a nurse tried to reduce
the fever. Afterwards, the attending physician examined him and took a thin blood smear, explaining
"It is much more important to stabilize the life-threatening condition, before any thought can be given
to a diagnosis. Anyway, in most cases, it's malaria. Nevertheless, one should at least consider the
possibility of meningitis, and perform a lumbar puncture in case the malaria therapy with quinine
doesn't take effect." During the rainy season, the Anopheles mosquitoes breed very rapidly, and a
distinct rise in malaria cases can be seen in hospitals, above all in the pediatric wards. Malaria
is still the number one killer of children under the age of 5 years in Africa.
A most important progress in malaria control is the development and distribution of impregnated bed
nets. We visited a production facility on the outskirts of Arusha (Photo 2)
. The nets' fibers are
permeated with Permethrin, a "knock-down" repellent, creating a physical and also chemical barrier
against the mosquitoes. The French entomologist Dr. Kouchner, who works in the area, assured us
that this protection lasts for at least 5 years - even after multiple washings. The bed nets are
manufactured in several sizes and are used in different malaria control projects worldwide with great
success, according to the World Health Organization.
Father Pat Patten is priest, physician and pilot all rolled into one. Over 30 years ago this American
founded the Flying Medical Service (FMS) at the foot of nearby Mount Meru (15,000 ft). With small
planes, healthcare workers reach very remote regions, otherwise inaccessible. We visited the
headquarters of this small donation-funded organization. Two physicians from our group had the
opportunity to spend two days with an FMS team. In outlying Maasai villages they examined pregnant
women and inoculated small children.
After their return, everyone wanted to learn about their experience. "A complete and utter contrast to
our high-tech medicine in Europe. It's incredible how people can be helped with so little equipment
and medication," said Dr. Pöttgen from Frankfurt.
Along the journey toward Tarangire National Park we drove through a vast steppe landscape where
sleeping sickness is endemic. After a lecture by Dr. Chalamka on human African trypanosomiasis
Magugu Hospital, we visited the wards. On a rusty pallet lay a 30-year-old man with severe
meningoencephalitis. The day before he had been diagnosed with sleeping sickness. At his bedside,
we discussed with Dr. Chalamka the advantages and disadvantages of Melarsoprol therapy, a highly
toxic arsenic compound. He concluded by informing us that "with increasing frequency, tourists in
East African national parks are being bitten by the tsetse fly. Regarding differential diagnosis,
travellers to tropical regions returning home with a fever should be examined for malaria as well as
sleeping sickness, insofar as they have visited endemic areas. Both diseases can be detected in a
thin blood smear." In a field laboratory, we learned this important technique (Photo 3).
The day ended with a field excursion through the Lake Manyara National Park, where we ventured
into the habitat of antelopes - the main reservoir of the Trypanosomiasis rhodesiense
experienced public health expert and an entomologist from the Ministry of Health in Tanzania
explained the control measures taken in surrounding villages.
The following morning, we travelled along the edge of the magnificent Ngorongoro Crater (UNESCO
World Heritage), reaching the Endulen Mission Hospital, staffed by a Dutch physician. She described
the brucellosis cases, also known as undulant fever, which are often seen in the hospital. The
patients complain of sudden fever and enlargement of the spleen and liver. The treatment calls for
doxycycline and streptomycin. "Unfortunately, the patients, primarily the Maasai, return after a while
with the same symptoms. They seem to have difficulty making a habit of cooking (pasteurizing) their
cow's milk before drinking it, and therefore they infect themselves over and over again." As in the
other hospitals we visited, we saw patients with pneumonia, AIDS, tuberculosis, malnutrition, and
infants with diarrhea and dehydration.
As we drove across the sweeping Serengeti steppe and over to the Olduvai Gorge (the Cradle of
Mankind), I observed the tall Maasai warriors with their cattle herds or trekking great distances across
the arid plain in the heat of the day. Today the Maasai live as they have for centuries and are
apparently not interested in changing their lifestyle.
At the Meserani Snake Park in Arusha, we saw many live venomous African snakes about which Dr.
Schaefer had lectured the prior evening. Snakes usually avoid humans and retreat into hiding when
disturbed. On the other hand, the puff adder is fairly sluggish and is therefore most often a threat
when approached. Then there is the black mamba, by far the quickest and most poisonous snake in
Africa. Its neurotoxic venom paralyzes the respiratory muscles and can lead to death by suffocation
within minutes. The owner of the snake park, Dr. Berry Bale, is widely known as a snake expert. In
return for snakes taken to him by the locals, he produces and provides antivenoms and also teaches
about correct treatment following bites.
In the early evening we boarded our plane to fly from Arusha to Zanzibar. A hot and humid climate
welcomed us when we arrived. The pelting tropical rain evaporated on the asphalt runway. Dr.
Jiddawi, assistant minister for health in Zanzibar, received us in the modest arrival hall with a hearty
"Inshallah." He is, as are most Zanzibaris, a devout practicing Muslim.
The drive from the airport to our hotel north of Stone Town (another UNESCO World Heritage site)
was like an enchanted journey through the One Thousand and One Nights. Along the roadside,
merchants hawked their wares by candlelight. In their faces I recognized traces of Africa, India,
Arabia and Europe. Our bus driver informed us that most of them are in fact Zanzibaris, and that the
population has mixed with other races and peoples over the centuries. What unites them is Islam and
the Kiswahili language.
After the morning prayer, Dr. Khalfan, director of the Schistosomiasis/Elephantiasis Institute,
welcomed us in his office in Stone Town. From here he coordinates prevention and control projects
on Zanzibar. He is rightfully proud to report to us that in 2008, hardly any new cases of lymphatic
filariasis were registered on Zanzibar after mass drug administration. Zanzibar was the first area to
complete five rounds of treatment for the entire population using a combination of albendazole and
ivermectin, reducing both the prevalence and intensity of Wuchereria bancrofti.
"Factors crucial to its
success include high-level political commitment, the development of appropriate social mobilization
strategies, the involvement of communities in drug distribution, and the introduction of morbidity
management for individuals with lymphedema. Unfortunately, with Schistosomiasis
we're not that far
along yet," he commented.
During the drive to a school in Kinyasini in the northern part of Zanzibar, Dr. Khalfan explained why
this is so. "It's mainly because the schoolchildren bathe during the day in ponds and rivers. They get
infected, they are treated, and then they infect themselves all over again when they jump in the water.
It's a vicious circle."
An hour later we witnessed this phenomenon as we drove past a group of children in the midday heat
- over 90° F (32° C), with relatively high humidity - splashing or doing their wash in a creek (Photo 4)
Here they come in close contact with freshwater snails, the intermediate host for Schistosoma
hundreds of whose shells we found in the surrounding reeds. It is no surprise to learn
that infection with urinary schistosomiasis is extremely high here.
It wasn't easy to bid farewell to our colleagues. Over the course of the past two weeks, we grew
together as a family, learning from each other as well as from the course. We had covered the better
part of all major tropical infectious diseases, in a wide variety of hospitals, clinics and research
centers. On numerous excursions we gained familiarity and appreciation not only for the Tanzanian
healthcare system and its public health challenges but the land, the people and the extraordinary
flora and fauna.
(Formerly CDC, US Public Health Services), Watsonville, California, USA,
5. Verifiche oggettive: analisi dei dati 5.1 Il tema della misurazione della Follia e della classificazione dei disturbi Psichiatrici Nel ‘700, l’Illuminismo apre la strada ai metodi di ricerca scientifica in Psichiatria, come accade anche in tutti gli altri campi del sapere e del conoscere. A cominciare dalla ben nota Frenologia1 (secondo la quale le singole funzioni psichiche dipenderebbe
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