PERSPECTIVE

Emergency medicine in a developing country:Experience from Kilimanjaro Christian MedicalCentre, Tanzania, East AfricaMegan Cox1 and John Shao2

1St George Hospital, Kogarah, New South Wales, Australia; and 2Kilimanjaro Christian Medical Centre,Moshi Tanzania, East Africa

Abstract

Tanzania in East Africa has a population of over 36 million and is one of the poorestcountries in the world. Life expectancy has declined and infant mortality rates are increas-ing. Four consultant specialist hospitals and 17 regional hospitals service the mainland.Kilimanjaro Christian Medical Centre is a major specialist teaching hospital with 500 beds,serving the entire north-west of the country. There is a small ‘casualty’ ward with threecubicles and one resuscitation room. Malaria, HIV, respiratory infections and gastroenteri-tis are the chief causes of death in children. Changing lifestyle and Western influences haveincreased diabetes and vascular disease in adults, and large numbers of trauma deaths areincreasingly encountered. Kilimanjaro Christian Medical Centre ‘Casualty’ admission dataare presented, as well as an insight into the challenges of emergency medicine in thiscountry.

Key words: emergency medicine, international emergency medicine, Tanzania.

Introduction

Increasing urbanization, changing disease patternsand rising terrorism have led many developing nationsto assess their emergency and disaster medicineresponses. Collaborations between developed and devel-oping countries exist worldwide. Emergency medicinephysicians from Australia have been involved with pro-grams in Iran, Fiji, Sri Lanka, Tonga and Papua NewGuinea.

Recently, Dr Megan Cox, an Australian emergencyphysician, had opportunities to work at Kilimanjaro

Christian Medical Centre (KCMC), a large specialistteaching hospital in Moshi, Tanzania, East Africa.Assistance establishing teaching in emergency medi-cine for final-year medical students and also developinga ‘Casualty’ was given in 2006 and 2007. This reportdetails her experience with KCMC Casualty and dis-cusses many of the challenges involved.

Tanzania

This East African country has a population of over 37million. Life expectancy figures from the World Health

Correspondence: Dr Megan Cox, Emergency Department, St George Hospital, Kensington, St Kogarah, NSW 2217, Australia. Email:drmegancox@yahoo.com.au

Megan Cox, BMed, FACEM, MIPH, Emergency Physician; John Shao, MD, PhD, Executive Director.

doi: 10.1111/j.1742-6723.2007.01012.xEmergency Medicine Australasia (2007) 19, 470–475

© 2007 The AuthorsJournal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Organization (WHO) are 47 years for men and 49 yearsfor women.1 Infant mortality rates under 5 years per1000 live births are 134 for male, and 117 for femaleindividuals.

Health facilities exist all over the country and accessmore than 80% of the population, but the general stan-dard of care is reportedly low.2 There is only 4 consult-ant specialist hospitals and 17 regional hospitals on themainland. The ratio of doctors to population is 1:40 000and nurses 8:20 000.1 The equivalent Australian figuresper 20 000 populations are 40 doctors and 200 nurses.3

Tanzania has a huge potentially reversible diseaseburden (HIV, tuberculosis, malaria and schistosomia-sis). HIV prevalence varies between 6.4% and 11.9% insome population areas.4 It is estimated that peopleliving with HIV occupy more than 50% of hospitalbeds.2

Kilimanjaro Christian Medical Centre

KCMC is the third largest hospital in Tanzaniaand is a church-owned hospital, managed inpartnership with the government. KCMC has numer-ous connections with various hospitals worldwide,involving local and expatriate staff. From the USAthere is a Harvard University-sponsored radiologyproject,5 and Duke University supports malaria andHIV research developments.6 There are several inter-national organizations involved in the ophthalmologyschool, dermatology unit, and a limb prosthesis pro-duction and training unit. Almost all of the localKCMC specialists have had some training or workexperience in European, Australian or Americanhospitals.

KCMC is the referral hospital for all north-westernTanzania, and patients are usually referred from theirregional hospital – wherever they live and whatevercondition they have. Regional centres have variable ser-vices – most have basic X-rays, sometimes ultrasoundand rudimentary laboratory facilities.

KCMC is a specialist centre and has a blood bank,more advanced laboratory facilities, CT scanning,ultrasound and an ECG machine. There is an endos-copy centre with sclerotherapy facilities. Surgicalfacilities include general, orthopaedics, urology andbasic neurosurgery. There is an eight-bed surgical ICUand a separate six-bed medical ICU, with access to asmall number of ventilators attached to portableoxygen cylinders.

The experience of an Australianemergency physician at KCMC

The medical administration and the casualty director ofKCMC had invited me (MC) to assist them in developingtheir casualty and in starting emergency medicineteaching.

I was warmly welcomed by everyone and encouragedto critique the department, educate freely, and makesuggestions on anything. I did not speak Kiswahili, sopatient contact was limited without staff translating. Allmedical and nursing staff speak English as their under-graduate education is in English, and there are fewKiswahili medical textbooks. Within 1 week, I startedtwice weekly morning education sessions with staff anddaily medical student tutorials. I was given access to thecasualty department, the statistics books and use of theeducation facilities. In both my times there I also taughtnursing students, nurses, medical assistants, medicalstudents and resident doctors informally at the bedside.I taught medical students and medical assistants for-mally at weekly lectures.

KCMC Casualty

KCMC Casualty department is an extension of the out-patient department and has been a work in progress formany years. An emergency physician and a nurse edu-cator from St Vincent’s Hospital in Sydney had visitedfor a few weeks in 2004 and helped establish some basicprotocols. There are three small rooms as the treatmentarea and one larger resuscitation room across a corridor.The three-room area had basic office equipment and asupply of bandages, basic drugs and venesection equip-ment. The resuscitation room had portable oxygen cyl-inders, an electronic BP machine and a large glasscabinet with rudimentary resuscitation equipment.

There was little educational material of any kind andno pulse oximetry or cardiac monitor. There was oneglucometer machine and one cervical collar for theentire department. A defibrillator (‘Cardio life’) had beendonated by a Japanese hospital. No one knew how to useit, and it had never been used.

The casualty was run by two senior local doctors andjunior doctors who had graduated in the past 3 yearsworking as registrars. A variable number of internswould work in the casualty every day – the majoritydoing a 4 week rotation as part of their first-year post-graduate training. Notes were written in English onpapers supplied from the medical records department.

Emergency medicine in Tanzania

471© 2007 The AuthorsJournal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Once a decision to order tests was made, the nursingstaff were responsible for taking the blood, setting upintravenous fluids and most other procedures.

Presentations and admissions throughKCMC Casualty

I was given the admission books for KCMC Casualtyand catalogued data on diagnoses recorded for 6 months(July 2005–January 2006; Fig. 1). These figures do notinclude admissions through outpatient clinics Mondayto Friday.

In 6 months 7875 patients were seen, with an averagemonthly admission rate of 46%. Major admission cat-egories for that period were medical (45%), surgical(30%) and paediatrics (17%). This high general admis-sion rate probably reflects the role of KCMC as a referral

hospital, but this might change. People who can affordthe higher fee charged for non-referred visits areincreasingly presenting there directly.

The total number of children (aged <15 years) pre-senting in the 6 month period was 1458, 18.5% of allpresentations. A comparison of paediatric and generaladmissions and presentations is presented in Figure 2.Considering that 43% of the population around the areais under the age of 15 years,7 the percentage of paediat-ric presentations is lower than expected.

Major admission categoriesThe major specialty groups for admission were medical,surgical, paediatric, and obstetric and gynaecology(Fig. 3). These statistics do not include admissions fromthe outpatient clinics or the obstetric presentations ofwomen in labour direct onto the ward.

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Figure 1. KCMC Casualty patient outcomes. ( ) Total seen at casualty; ( ) admitted; ( ) discharged; ( ) unknown. KCMC,Kilimanjaro Christian Medical Centre.

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Figure 2. Adult and paediatric presentations and admissions to KCMC for 6 months, 2005. ( ) All patients seen at casualty;( ) paediatric presentations; ( ) all admissions; ( ) paediatric admissions. KCMC, Kilimanjaro Christian Medical Centre.

M Cox and J Shao

472 © 2007 The AuthorsJournal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Figure 4 shows the continued burden of malaria butprominent ‘western’ type illness presentations of hyper-tension and diabetes. The high numbers of ‘notrecorded’ and ‘other’ diagnoses could reflect the lack ofdiagnostic tests available to the staff, the chronic insidi-ous nature of many complaints, patients leavingwithout properly being worked up, and the lack of timeto fill out the statistics.

These data correlate with a WHO report statingthat the major part of the disease burden inTanzania is still preventable and communicabledisease based. These diseases are predominantlyHIV, malaria and tuberculosis in the entire popula-tions, and diarrhoeal diseases, pneumonia and measlesin children. This report, however, also mentions theincreasing admission rate from ‘western’ diseases,

which can be identified also in these statistics fromKCMC.2

Common referrals from local hospitals that I sawwere haematemesis from schistosomiasis-inducedportal hypertension, head injuries, septic abortions andcerebrovascular accident. Wounds, fractures and dislo-cations were high due to the lack of specialist surgicaland orthopaedic services in local hospitals other thanKCMC. Anecdotally the number of fractured femurs inyoung men alone was one admission per day.

Data collection obviously needs to be improved, but Ifound it very useful in my work at KCMC for the 3months. I used these figures in consultation with seniorstaff at KCMC to decide what topics to teach to thestudents and to develop treatment protocols of thecommon presenting complaints.

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Figure 3. Admission categories for KCMC in 6 months, 2005. ( ) Medical admissions; ( ) surgical admissions; ( ) paediatricadmissions ( ) O&G admissions; ( ) ENT admissions; ( ) urological admissions. KCMC, Kilimanjaro Christian Medical Centre.

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Figure 4. Top admission diagnoses for 6 months at KCMC. HT, hypertension; GI bleed, gastrointestinal haemorrhage; GORD,gastro-oesophageal reflux disease; KCMC, Kilimanjaro Christian Medical Centre.

Emergency medicine in Tanzania

473© 2007 The AuthorsJournal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Challenges in developing emergency medicinein Tanzania

Lack of prehospital careMany patients who need critical care in the ‘goldenhour’ die due to the absence of any pre-hospital services.Road traffic victims are brought in by private transportor sometimes the police. Some of the regional hospitalshave ambulances, but these must be paid for by therecipient. The general public use buses, taxis or othervehicles.

Trauma burdenThere are many articles highlighting the rise of roadtrauma burden in the developing world.8 I saw manyaccident victims at KCMC, and the large number ofinjuries recorded in the statistics only slightly reflectsthis. While working in Tanzania, local Tanzanian mediareported an accident with 55 fatalities on a local road.9

The true burden of trauma is unable to be establishedfrom the KCMC data, as the population is unable to, anddoes not wish to, bring dead people to hospital. Statis-tics might help the government make changes to roadlaws and policing which could save many lives.

Resuscitation and stabilization of patientsThere is little comprehension of time-critical treatmentand the role of medications and intravenous fluids in theacutely unwell or injured patient. Due to the largeburden of chronic disease, this is the main focus ofteaching and management. Acute management such asanalgesia and intravenous fluids in trauma patients isoften absent or unsuccessfully administered.

Lack of equipmentThe casualty had oxygen cylinders and hand-operatedsuction, basic airway equipment and a few masks.Drugs were limited; no anaesthetics agents are routinelyavailable in the casualty, and narcotics had to beordered from pharmacy. Cervical collars, splints andother trauma equipment were often difficult to find.

Education in first aidFirst aid instruction is limited to health professionals.Cardiopulmonary resuscitation is not well understood,and the high level of HIV in the general communityhinders its usage. Medical students and nurses laughedwhen I discussed giving ‘mouth to mouth’ on strangersin Australia.

The role of the ED in a Tanzanian referral hospitalThe Anglo-American model of emergency medicineoffers advantages in developing a group of generalistacute care physicians in one area that can free up otherhospital specialists to deal with their workload. Thiswas being used at KCMC due to the expatriate emer-gency staff who have visited being from these countries.This system, however, requires duplication of acuteresources in the casualty as well as the departments.The Franco-German model promotes specialists in thepre-hospital setting and builds up individual acute unitsin each specialty. Each system has benefits and disad-vantages in the resource-poor setting.

Future challenges – internationalemergency medicine in Africa

Africa is incredibly complex in health problems such aspoverty, conflicts and a predominance of infectiousdiseases. Non-governmental organizations and healthorganizations are frequently called on to develop emer-gency services for cholera and plague outbreaks, esca-lations in violence and many other critical needs.Despite this, emergency medicine development inAfrica has been slow. There are doctors in South Africawho have established the specialty and are raising theawareness of emergency medicine as an essential healthissue in their country.10,11

Tanzania’s policy agreement with the WHO on thehealth strategies outlined developing emergency anddisaster preparedness as one of its goals.2

There are few countries with emergency systems thatare comparable or transferable to Tanzania. Kenya, theneighbouring and most similar nation in size, health andeconomy, has little literature on emergency medicine.There have been reported successful education sessionsin rural and urban Kenya, training staff in emergencycare.12

A description of emergency medicine in Ethiopia hassome similarities. International nursing and medicalstaff conducted surveys, offered basic emergency medi-cine teaching to local health staff, and trained individu-als in planning and management of EDs.13 Theinternational staff felt their most important achieve-ment was that local staff and local health officials real-ized the importance of emergency services. They alsoemphasized ongoing international support to continuethe ‘momentum’.

Australian emergency physicians and nursing staffeager to assist developing nations such as Tanzania

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474 © 2007 The AuthorsJournal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

need to consider personal issues, such as malaria pro-phylaxis, travel risks and security. They should beaware of the short- and long-term needs of the facilitythey are attending. The medical and logistical chal-lenges of working in developing countries need to bewell understood and anticipated. Careful liaison withlocal health professionals and health officials is respect-ful and critical for effective change. Education in thediffering emergency structures available and assistanceto develop a system within their health service shouldbe offered. Emphasis should be on providing a resourcethat is appropriate, sustainable and ‘owned’ by the localmedical professionals.

Acknowledgements

I would like to thank Dr Mark Swai, Director of Hospitalservices for permission to use the statistics at KCMCCasualty, and Dr John Hall, Sydney University School ofPublic Health, for encouraging me to write this article.

Competing interests

None declared.

Accepted 27 April 2007

References

1. World Health Organization. Key Health Expenditure Indicators –United Republic of Tanzania. WHO – The World Health Report.Geneva: WHO, 2006.

2. World Health Organization. Country Cooperation Strategy – Tan-zania. Millennium Development Goals: WHO. Geneva: WHO,2002–2005.

3. World Health Organization. Key Health Expenditure Indicators –Australia. WHO – The World Health Report. Geneva: WHO,2006.

4. World Health Organization. United Republic of Tanzania – HIVIndicators. WHO/UNAIDS. Geneva: WHO, 2005.

5. Harvard University. Harvard School of Public Health: AIDSInitiatives-External Collaborations and Partnerships. Boston:Harvard School of Public Health, 2006. [Cited 26 June 2006]Available from URL: http://www.eastafricafoundation.org/eaf/eaf_aboutproject/eaf_about_facilities_1.html

6. Duke University. Duke Human Vaccine Institute- Program inInternational Research. Durham: Duke University – School ofMedicine, 2006.

7. National Bureau of Statistics. Population and Housing Census.Dar es Salaam: National Bureau of Statistics, Tanzanian Govern-ment, 2002.

8. Hofman K, Primack A, Keusch G, Hrynkow S. Addressing thegrowing burden of trauma and injury in low- and middle-incomecountries. Am. J. Public Health 2005; 95: 13.

9. Ubwani Z. Road Accident Death Toll Now 55, 2006. [Cited 12June 2006] Available from URL: http://allafricacom/tanzania

10. Perrott CA. Emergency medicine in South Africa – a personalperspective. J. Emerg. Med. 2003; 25: 325–8.

11. MacFarlane C, Van Loggerenberg C, Kloeck W. InternationalEMS systems: South Africa – past, present and future. Resusci-tation 2004; 64: 145–8.

12. Doney MK, Macias DJ. Regional highlights in global emergencymedicine development. Emerg. Med. Clin. North Am. 2005; 23:31–44.

13. Bayleygne TM, Shahar A, Tsadic AW et al. An internationaltraining program to assist with establishing emergency medicinein Ethiopia. Ann. Emerg. Med. 2000; 36: 378–82.

Emergency medicine in Tanzania

475© 2007 The AuthorsJournal compilation © 2007 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine