Background:
This summer I visited the Bugando University College of Health Sciences (BUCHS) in Mwanza, Tanzania. While it was my third trip to Tanzania, I had not previously spent time at BUCHS. In the fall of 2003 the university opened its medical school, and the inaugural class of ten students, six men and four women, finished their first academic year on August 16th , 2004. As a medical student, I hoped to talk with my Tanzanian peers about their experiences as future health care professionals.

Two goals directed my activities. First, I wanted to learn about medical education in Tanzania: secondary education, the medical school application process, the medical curriculum, post-graduate training, specialization, job placement, continuing education. Because I hope to return to Tanzania again during my education and as part of my medical practice, it is important to me to understand the training Tanzanian doctors receive and the structures governing their education and career opportunities. As a part of this, I was curious about how the curriculum is structured, and who decides - whether community members or students themselves have a say in shaping future doctors.

My second goal was to initiate what I hoped might become an ongoing discussion about the role of doctors in Tanzania and the relationship the medical students hope to have with the communities around them. I saw this conversation as an opportunity to explore together various possible ways of practicing medicine, and the extent to which the goals and needs of physicians correspond with the goals and needs of the communities they serve. Loss of trained health professionals to more affluent nations is a grave problem in many countries, including Tanzania, and I was interested in seeing how students view this problem in relation to their futures.

Preparation for the workshops:
In order to explore these topics, I designed a series of five workshops, each to take about an hour. The workshops were titled You, Bugando and Medical Education in Tanzania, Leadership and Service, Community, and The Future (see attached). In preparing for these discussions, I read most of the book Just and Lasting Change by Charles and Daniel Taylor. This remarkable work outlines a well-tested method for bringing empowering communities to assess and meet their own needs with the help of outside experts and government officials. I also investigated the community-based medicine program at Moi University in Kenya, a much-acclaimed curriculum that is part of the Towards Unity for Health network.

My initial contact at BUCHS was Liz Mach, a woman with whom I worked on both of my previous trips to Tanzania. She is an American Maryknoll lay missioner who serves as head of development of the medical school at BUCHS. She helped me get an appointment to see the school's Principal, Dr. Charles Shija, who then graciously granted permission for me to talk with the medical students.

Talking with students:
Ms. Mach introduced me to the students one morning before class. They suggested I visit them when they returned to the adjacent dormitory during a free period that afternoon; at the agreed time I spent about half an hour describing my project and asking any students who would be willing to join me in going through the workshops, at their convenience.

Because of the medical students' busy schedules, we met for a total of two 2-hour sessions, covering the first two workshops in our first meeting and the final three in the second, a week later. At the second gathering I brought soda and cookies to thank the students and entice them to attend. Eight of the ten medical students came to both sessions. In the first we became acquainted, discussing our respective backgrounds and what had moved us to pursue medicine as a career. In our discussions, the medical students also seemed eager to hear about the similarities and differences between their experiences and mine. They also helped me meet my first goal of learning about the process of becoming a doctor in Tanzania, detailed below.

In the second session, we had a more free-flowing discussion on the broader issues of leadership, service and community. This session took a different direction from that which I originally anticipated, but was nonetheless lively and provocative. The students remarked that while they had thought about many of the issues that came before, they had not had a forum to talk about them with their peers, and they hoped to continue such explorations with each other in the future.

Medical education at BUCHS and in Tanzania:
The Tanzanian government provides primary education (Standards I-VII) to all, generally starting at age 7 or 8. Children fortunate enough to pass a national exam at the end of Standard VII and who also have the financial resources for school fees may attend four years of high school, Forms I-IV. If they complete these four years and pass another general exam, students can qualify to attend two additional years of secondary education, Forms V and VI. Those interested in medicine must take biology, chemistry, physics, and math classes during these years. After Form VI, most of the medical students at BUCHS sent applications to a number of institutions, including more than one of the four medical schools in Tanzania as well as accounting, computer, engineering, general studies or other programs and universities. Unlike the American system, there is no bachelor's degree before pursuing an M.D., and so while high school students are able to pursue a wider variety of classes during Forms I-IV (geography, history, Swahili, English, etc.), the formal educational backgrounds of most of the students are almost identical.

The national medical school accreditation committee requires that all medical schools in Tanzania provide a wide range of courses. In its first year, BUCHS only offered those required courses, although Ms. Mach informed me that the administration is planning a course in Patient-Centered Care that will span more than one curriculum year. The current curriculum is as follows:

• Year 1: anatomy (including neurosciences, histology, embryology), biochemistry/ behavioral sciences (including medical sociology), biostatistics, physiology, development studies I
• Year 2: microbiology and immunology, parasitology, entomology, clinical physiology, development studies II, introduction to clinical methods/pathology, epidemiology, research methodology, nutrition field, clinical methods
• Year 3: clinical pharmacology, disease management I and II
• Year 4: community medicine, pediatrics, OB/GYN, elective, medical ethics and forensics
• Year 5: surgery, internal medicine, psychiatry, surgical subspecialties (anesthesiology, ophthalmology, critical care, etc.), medical ethics and forensics

The students expressed strong positive feelings about the quality and approachability of their professors, and during our short time together they could not come up with courses they felt were lacking from the curriculum. They spend about five hours per day in lecture and an additional five studying; the newly opened library has restricted hours, so many rest in the afternoon and study in the dorm at night. Most of their time is spent studying alone, although most do study together some of the time. While they would enjoy more patient contact, they already feel extremely busy with their current obligations.

(The medical school at Moi University in Kenya, one of the Towards Unity For Health-affiliated programs, has a similar list of classes, including community medicine. While BUCHS is not part of the TUFH network, it . . .)

The ten medical students live in a wing of Bugando Hospital that has been remodeled as a dormitory. While there are no formal extracurricular organizations, on any given night most of the students meet at 6pm to play basketball on a court at the hospital site. On the weekends, many try to make trips to downtown Mwanza, a half-hour walk or ten-minute bus ride away.

Life after medical school:
Medical graduates complete a one-year internship at one of the four major hospitals in Tanzania (Bugando, Muhimbili, Mbeya, and Kilimanjaro Christian Medical Center), and then are eligible for placement at a hospital or clinic. Almost all of the medical students who participated in the discussions receive government assistance in financing their education. Because of this, those students will be required to practice within the country for five years after graduation, at a site of the government's choosing. After fulfilling this obligation, doctors have a few options. Continuing medical education opportunities include certificates, diplomas, and Master's degrees in various specializations, depending on one's grades in given areas during medical school. If a doctor elects to continue working in the public sector, the government decides where to place her/him. The students expressed concern over the policy to move government physicians to new sites every 5-7 years, because it prevents one from developing a long-standing relationship with the community. Alternatively, a physician can leave the country to practice elsewhere, or work in the more lucrative private sector, which usually means staying in urban areas.

Major findings of the discussion sessions:
In the first discussion session we introduced ourselves, explored our respective reasons for pursuing medicine and potential problems and doubts, and discussed the process of medical education in Tanzania (see above).

Motivations for entering a career in medicine were very similar to what I have come across among my peers here in Wisconsin. Almost all of the students who shared their inspirations with the group expressed a long-standing desire to help people, stemming from either a personal connection with someone who they had seen fall ill, or a more general awareness of the health care needs of most of the Tanzanian population. A couple of students have explicit ties to churches that both provide financial support and have played a role in encouraging the student to become a physician. Several have family members who work in health care and so were encouraged to also enter the field.

All the students were aware of serious drawbacks of being a physician in Tanzania. In addition to the difficult studies, exposure to diseases, and long working hours, inadequate compensation stood out as the biggest problem. While government hospitals are desperate for more trained health professionals, the salaries they offer barely cover the cost of living. If one hoped to have a family, one would need to find additional funds, most likely through splitting one's time between public and private practice. Bigger cities offer more amenities, but the hours are longer and patients tend to be less grateful, the students said. In rural areas, money goes farther and so a salaried employee can survive more comfortably, while patients are more gracious; however, poor communication and transportation networks are isolating, and city placement feels "inevitable."

In the second session, we discussed leadership, service, and doctors' relationships with thee communities they serve. I was surprised by how much parts of this discussion resembled similarly themed LOCUS meetings in Madison. The BUCHS students described qualities of leadership: being a representative of the community, respected and but also respectful; one who follows the same processes and rules laid out by the people as a group, rather than existing above them; one who may be chosen to respond to the expressed needs and concerns of a group; and one who sets an example by one's work ethic and commitment. They suggested that the education and prestige associated with health professionals can cause doctors to abuse their power as community leaders, which may take the form of corruption, laziness, or a loss of humility. Many also forget that their practice is a service to those in need, rather than a means of earning money from patients who can afford it.

The students saw significant overlap between service and leadership, as a good leader's actions will be governed by the needs of the community s/he serves. It is where these priorities come from - one's own views, or the community's - that determines whether one is truly a public servant. At the same time, the students admitted that they know their current enthusiasm and altruism will undoubtedly fade after a few years' practice under harsh conditions with poor compensation. Burnout, one said, is waiting just around the corner.

Next we talked about the details of doctors' relationships with their communities. Government policies, limited resources, and a shortage of trained health care workers make these relationships extremely difficult to sustain. First, public doctors receive a new placement every 5-7 years, and so do not stay in the same communities for long enough to get to know their families of patients well. Second, the health system structure and limited number of physicians mean that any given doctor is responsible for far more patients than that with which s/he can build a meaningful relationship - in some areas, a doctor may have a cachement area of a quarter million or more people. Villages or collections of villages have a Clinical Officer, who has received a year or two of education. For several COs, there is one Assistant Medical Officer, a slightly higher post. Each of the 120 districts in Tanzania has a District Medical Officer, a physician, who is responsible for communicating with each of the districts AMOs. In theory, the DMOs are supposed to travel around to each of his/her wards, checking in with AMOs and personally treating difficult cases. A number of issues intervene, however. Transportation is difficult, due to poor or absent roads, lack of vehicles, or both; communication between AMOs and DMOs may be limited; there are often too many patients to see; and according to our discussion, DMOs often put in less than maximal effort. Lack of medical supplies also limits treatment options for those difficult cases DMOs are supposed to treat, and AMO clinics usually only have a handful of drugs. The link between health care providers and government officers should make public health measures easier to enact - for example, establishing new sources of water after linking contaminated streams with a cholera outbreak - but the same shortages of supplies and trained providers make this potentially helpful relationship irrelevant.

One student offered a comment that perhaps one day in the future, when she is practicing, she will keep the discussions we had in mind and strive to be more thoughtful in her relationships with her patients. However, despite the students' excitement about helping people, in our discussion of the future the students conveyed a sense of disempowerment. For at least five years after they graduate, they do not have control over their careers as the government will place them where it best sees fit. While several of the students feel a strong commitment to public service in their home communities or at least within Tanzania, they all expressed concern over losing their ideals after a few years of working in the field. They may have good intentions now, but when the limitations are on such a large scale, what can they do to actually make a difference? A few said they will do what they need to do support their families and protect their own happiness.

Discussion:
The eight BUCHS students explained that they have been thinking long and hard about these issues for many years. They expressed relief at having a chance to talk over these important topics with each other, as each had been pondering the path s/he would take but had not had the opportunity to share their concerns with others. The formal curriculum offers no opportunities for such discussion, and indeed the students barely had time for the few hours I took of them. The similarities between their intentions, their commitment to public service, and their self-conscious idealism and those of UW medical students was striking; the situations we find ourselves in respectively are profoundly different, and in my view are the source of the differences we will experience in our future careers.

I inquired as to the possibility of their continuing these discussions in my absence, and asked whether any professional societies exist that might allow organizing or at least official commentary on the woes of the medical system they find so disempowering. It seems that there are no national medical societies, although many Tanzanian midwives have organized; this stands out to me as one possible avenue for further exploration. I corresponded with the BUCHS students during the fall semester and to my disappointment most replied that they had not had a chance to return to the topics we discussed over the summer. However, all were enthusiastic about the possibility of continuing these discussions, with each other as well as with me or other US medical students, in the future.

Conclusion:
I went to Tanzania to learn more about medical education there and with hopes of starting a discussion about servant leadership. My original questions about the match between education and community needs came to little - from examining the medical side, there seems to be a thorough and wide variety of courses taught that cover the medical needs of the community. Instead, other problems with the health system loomed as greater obstacles to public health and, not surprisingly, the medical students are deeply aware of each of these. While they experience many demands on their time, and - like American medical students - their time will only become more limited, it seems to me that there is a need for more discussion of these ideas and, further, organization. The shortages - of supplies, trained doctors, opportunities, education, resources - loom large, and change, if it comes, will be slow. Still, their enthusiasm indicates an untapped resource if there could be support, as LOCUS provides for us, for maintaining the commitment to service despite the many forces that threaten it.

Acknowledgements:
Many thanks to Zorba Paster and the Compassion in Action Scholarship; and to LOCUS, for its financial and moral support.

Spending of funds: $1600 LOCUS stipend, $1000 Compassion in Action scholarship Plane ticket: $1265.30 Visa: $50 Train and bus tickets: $62.60 Internet: $5 Sodas: $5 (other refreshments provided free by medical school) Film and picture development: $10 Time: 160 hours over May and July on research, workshop development, planning and interviewing medical students, interviewing head of development, writing report: $1204.10 = $7.53/hour

January 10, 2005

Graduation Requirements Progress Chart
If you complete the requirements outlined below, you will graduate as a LOCUS fellow.

A indicates the item has been completed.

Completed	When	What	On-line
	Year 1: Beginning of Semester 2	New Project Report	Submit Report
	Year 2: Beginning of Semester 1	Project Update	Submit Update
	Year 2: Beginning of Semester 2	Project Update	Submit Update
	Year 3: Beginning of third year	Project Update	Submit Update
	Year 4: August of fourth year	2-3 page final summary of project that includes a reflective evaluation of the project process	N/A
	Ongoing	Participate in program evaluation (written and/or focus group)	View Options
	By the end of fourth year	Select poster, presentation, paper, creative option or your own idea	View Options

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