Since their first year of medical school, Adam Ackerman ’14 and Peter Cooch ’14 have been traveling the world on behalf of The Microscope Exchange and the new and growing global health program at the University of Vermont College of Medicine. Their most recent trip took them to the southern African country of Zimbabwe for six weeks. Ackerman focused on surgery, while Cooch completed a rotation in pediatrics at the two teaching hospitals of the University of Zimbabwe College of Health Sciences (UZCHS).
Through The Microscope Exchange, an organization they founded to help increase the presence of diagnostic technology in the developing world, Cooch and Ackerman were also able to deliver a 70-plus pound five-headed microscope to UZCHS.
Majid Sadigh, M.D., infectious disease specialist and director of global health at clinical affiliate Danbury Hospital/Western Connecticut Health Network (WCHN), was in the country at the same time to lay the groundwork for an ongoing partnership between UVM/WCHN, and UZCHS. This will add Zimbabwe to the list of locations where medical students may complete a global health elective, which already includes Uganda, Russia, and Vietnam.
Zimbabwe poses unique challenges related to health care: It’s a country that struggled with political unrest throughout much of the early 2000s, leading to food rationing and water shortages. Although conditions have improved, resources are still limited. Acute malnutrition, HIV, and TB remain ever-present problems for many patients in the wards. The two public hospitals in the country’s capital city of Harare – the 2,000-bed Parirenyatwa Hospital, located adjacent to the university, and the 1,200-bed Harare Central Hospital, about 10 kilometers from the medical school – serve as community hospitals for the city’s three million people.
The following are excerpts from reports Cooch, Ackerman and Sadigh sent home from their time in Zimbabwe. Each entry chronicles the journey of their microscope and their reflections on clinical medicine, global health, and opportunities for the partnership:
1/24/14: Majid Sadigh, M.D.
I met with one of the translational researchers to explore the possibility of working together on HIV-related research projects in the morning, and then embarked on an afternoon excursion to medical student housing across Parirenyatwa Hospital to meet with Adam and Peter.
I was delighted to learn that both of them have been treated very well and have had a productive educational experience with great supervision by very knowledgeable and talented preceptors, residents, and interns. More importantly, I learned that medical education here is very organized and the infrastructure of clinical medicine is very close to what we have in the U.S.A. Both of them were in admiration of their peers’ medical knowledge and the people’s hospitality, warmth, and friendliness. They expressed that Harare is a safe city despite what they had previously read and heard.
1/28/14: Peter Cooch
There are at least four pediatric medical wards in the hospital that seem to have 20 to 30 patients at a given time. Each ward rotates which day they are admitting patients. There is also a four-bed PICU [Pediatric Intensive Care Unit]. Along with another six bed PICU in Harare Hospital, this is all the PICU capabilities for a country with probably five million children. I will be spending four 1.5-week blocks each in a different ward.
When on inpatient services, I generally come in with the Zimbabwean fourth-year medical students to pre-round on patients at 7 a.m. At eight, we go on walk rounds on each patient on the ward with the residents and attending. Everything is very much in the formal British tradition (I am the least best dressed by far—dress slacks and black leather shoes are the rule here). A student or resident presents each patient, and then a detailed physical exam is performed at the bedside…I have been uniformly impressed with the knowledge of the pediatricians here.
1/28/14: Adam Ackerman
I am into my second week of surgery. The experience so far has been excellent. Our day in the “theatre” is Friday, leaving the rest of the week for rounding and floor work. The surgeons are extraordinarily well read. Everyone has completely memorized Schwartz and Sabiston, two of the major surgical texts.
Without the aid of imaging or sophisticated labs, the surgeons form the most complete differentials and spend a great deal of time making a plan. Rounds are more formal than at home, and there is usually about 30 minutes of teaching at each bed. I am included in the discussions of all patients. Everyone is eager to hear about differences in management at Fletcher Allen. I try to answer to the best of my ability. I feel very comfortable with my team – they are already making fun of me all the time, which in Surgeon means you are well-liked and accepted. Despite geographical, political, and social differences, a surgeon is a surgeon.
2/1/14: Majid Sadigh, M.D.
Parirenyatwa Hospital, where Peter and Adam are currently working, is comprised of four general pediatric medical wards with 20 to 30 patients at a time each in addition to a four-bed PICU. The residents, interns, and medical students are intelligent and industrious and patient advocates. The environment at Parirenyatwa Hospital is strong and conducive to clinical learning. The University of Zimbabwe staff are courteous, humble, and helpful, and the university medical students and residents enthusiastic and receptive to new information.
The structure of medical education is similar to what we have in the U.S.A. with more time spent at the bedside, more focus on physical examination and clinical judgment, and detailed discussions of pathophysiology and relevant basic sciences on diverse clinical pathologies. Patient care and medical education are conducted under close supervision of competent and committed faculty. In addition to very well-developed clinical skills, reasonable diagnostic resources are easily accessible, rendering the emotional impact of the rotation on our students and residents manageable rather than paralyzing.
The Medical Education Partnership Initiative (MEPI) is an NIH program transforming medical education in 11 sub- Saharan African countries including Zimbabwe. This is a five-year partnership program (two million dollars/year), which started in 2010. As part of the MEPI grant in Zimbabwe, University of Cape Town, Stanford University, and the University of Colorado have a constant presence in this hospital. The presence of American and African universities in UZCHS would give UVMCOM/WCHN a broader opportunity to improve medical education and patient care cross-continentally.
2/8/14: Adam Ackerman
Pete and I have found our routine by now, the end of our third week in Zimbabwe. The alarm goes off at about six. I’m usually up a little earlier and start heating water for bathing in our two large pots. There is no hot water, and this ritual has made a big difference in our happiness for the rest of the day. We have plenty of cold running water, but this gets turned off for the weekends. There is a bush pump just outside our residence that brings water up from the ground if we are ever desperate.
Breakfast is usually Nescafe with bread and some smoked trout we found at the supermarket not too far from campus. We’ve dabbled in mango, potatoes, granola, and cereal, too. One of the surgeons told me that back in 2008, you could go to the market and there wouldn’t be a single thing on the shelves. Food is readily available in 2014, but the prices are sky high; typically much more expensive than in Burlington. The alternative to this is the local diet of porridge in the morning, and sadza (cornmeal mixed with hot water) for lunch and dinner. It will fill you up, but doesn’t increase happiness.
I’m constantly preparing for grand rounds on Thursday. It is slightly terrifying. I seem to get called on to answer questions more often than the Zimbabweans. My resident calls me “a polar bear in the Sahara,” which may have something to do with my conspicuousness during these two-hour sessions.
2/16/14: Adam Ackerman
We presented the beautiful five-headed Nikon microscope—part of the generous donation of microscope UVM made to The Microscope Exchange (TME)—to the University. The scope’s new home will be in the Department of Anatomy. It will be used for medical student and resident histology instruction. And with the digital camera capabilities, this scope can be used to teach an entire class at a time. The department members were very excited and anxious to get it up and running. Pete and I couldn’t be happier. TME was only an idea a few years ago. With the support of UVM, we literally have scopes all over the world.
2/24/14: Peter Cooch
All in all, this elective has been an incredible experience. It has opened my eyes to an entirely new aspect of global health. From the small, rural outpatient clinics I’ve spent time at in the past, we’ve now experienced the pace of major referral and teaching hospital in a developing country (several times larger than Fletcher Allen). For the first time ever, I have witnessed the toll that HIV, TB, Malaria, and acute malnutrition take on a significant percentage of the world’s children.
But rather than feeling discouraged or hopeless, I am leaving filled with hope. Zimbabwe has an incredible medical education infrastructure in place, and is actively training hundreds of dedicated and talented future providers. The staff here, from physicians to night guards, has deeply impressed me with their professionalism, knowledge, and compassion. And life-saving therapies are becoming widely available. Every patient I encountered who was eligible was screened for HIV and TB, and treatment was promptly administered, with excellent counseling and decent supportive services.
There is a huge amount that American students and residents (at least speaking from my experience in pediatrics) could learn from rotating in a Zimbabwean hospital. I am far more comfortable with the presentation and treatment of many pathologies rarely seen in the U.S. My physical exam, phlebotomy, and IV skills have all improved significantly. I have been exposed to new (or perhaps very old-fashioned) methods of rounding and note-writing—which hold some very admirable aspects that seem that have been lost in the U.S. And there are opportunities for significant potential benefits for the patients and providers in Zimbabwe from a partnership with Americans as well. We are able to provide access to current medical literature and studies, emphasize practice differences (such as hand hygiene, or surgical sterility), and hopefully even arrange opportunities for Zimbabwean providers to spend time in the U.S.
