MUSC cardiologists foster sustainability through training at advanced cardiac care center in Tanzania

Borders are disappearing due to increasing globalization of ideas, culture and technology. Health conditions found in remote locations abroad are—now more than ever—comparable to those seen in the rural United States. With these emerging phenomena, a new global health threat continues to permeate throughout the world: non-communicable diseases (NCDs).
According to the Centers for Disease Control and Prevention (CDC), more than 35 million people die from NCDs every year, totaling roughly 66 percent of the world’s deaths. Western diets and lifestyles closely mirror those now seen in many countries around the world, and as a result non-communicable disease prevalence has increased. Heart disease and stroke, cancer, diabetes, and chronic lung disease are the relatively new scourge devastating communities across the globe mostly due to high tobacco use, low physical activity, poor diets, and alcohol consumption. Genetic predisposition to cardio- and cerebrovascular disease also contribute to NCDs.

In Tanzania, President Jakaya Kikwete has not only acknowledged the increasing non-communicable disease prevalence in the country and the growing number of Tanzanians dying due to heart disease, but also laid the groundwork to build the first heart hospital in the country. The President’s goal is for Tanzania to become a center of excellence in cardiac care to battle heart disease. Two leading experts in cardiology, Eric Powers, M.D. and Peter Zwerner, M.D., saw an opportunity to use their expertise to reverse this deadly course by implementing an advanced training program at a cardiac care facility at Muhimbili National Hospital in Dar es Salaam, Tanzania—the first advanced cardiac and catheterization center in the country. The mission driving the care model at Muhimbili National Hospital is to develop skills and knowledge of the local health officials using best practices from western medicine.

Zwerner currently serves as Vice Chair of Clinical Affairs and Associate Professor of Medicine in the Department of Medicine at the Medical University of South Carolina (MUSC) and Chief Medical Officer at MUSC Physicians. Powers is Director of the Acute Coronary Syndrome Center and Professor of Medicine in the Department of Medicine at MUSC. “NCDs have become a large issue since Tanzanians are living longer and have more westernized diets,” explained Zwerner. “It is a large reason why the government wanted a heart center.” Powers remarks that previously Tanzania had to send patients to India for cardiac care, costing the country roughly 3,500 U.S. dollars per patient. “Now, they will have the training and resources to take care of patients in-country.”

Ashley Waring, a fourth year medical student and global health travel grant recipient at MUSC with interests in global medicine, recently completed a four-week clinical rotation at the advanced cardiac care center in Tanzania, working closely with local health officers, patients and her mentors, Powers and Zwerner. “Among the challenges in Tanzania, the people are not aware of the spectrum of heart disease in the country,” Powers remarked. “Ashley is developing a database at the heart hospital which they will use as a tool to measure how patients are managed and other needed quality metrics. Thanks to Ashley, that database is ready to go.”

Powers, Zwerner and Waring did not allow capacity issues—access to supplies and skill deficiencies—to compromise the progress of their project. “We saw catheterization procedures as a crucial piece of advancing cardiac care,” said Powers. “Training the trainers on how to perform cardiac catheterization procedures and other cardiac interventions is vital in sustaining the center.” Models of healthcare service provision found in some African countries are based mostly on out-of-pocket payment systems. This system, in many ways similar to first world payment schema, surprised Waring on her initial trip to Dar es Salaam. “I was taken aback by the way payment is done there,” remarked Waring. “Patients must pay up front for any medical treatment or prescription. It’s rare for the hospital to do anything unless they get paid first.”

Charged with developing a database and evaluation methodology for the center, Waring was less daunted by managing the project than she was by the difficulties securing needed resources where they are seemingly scarce. “There aren’t a lot of resources,” Waring explained. “Sometimes they can’t get the right catheters to successfully perform needed procedures. Now we have evidence that says we have patients who may die or get life-saving procedures—the data makes the case for more funding.” The overall goal of both Powers and Zwerner was to get the center off the ground and have tangible results and measurable outcomes. “Our mission was just to start this cardiac catheter program, and three heart catheterization procedures have been performed in the country,” said Powers. “We’re not as far along as we’d like to be, but we were able to intervene with heart catheterization procedures.” Newer, efficient diagnostic testing has led to a large share of this success.

Powers and Zwerner were able to introduce the Vscan Pocket Ultrasound to the population they serve in Tanzania. Intervention of the Vscan provided better diagnoses and is easily applicable in developing nations, especially in remote settings where patient information is hard to come by. Physical examinations work in tandem with the handheld ultrasound machine to minimize uncertainties and get the best available medical history on a patient. This is what happens when innovation marries appropriation—the Vscan machine is orders of magnitude cheaper than its larger counterpart and has technical feasibility in rural areas of the country. “It’s hard to make clinical diagnoses, but it’s easier to make the distinction with the machine in preoperative evaluation or if there are any congenital problems,” explained Zwerner. “If you take people to the ER with limited information, it’s hard to solve the problem.”

Waring was so taken by her experience at MUSC and with her mentors that she decided to complete her residency at the university, too. She was drawn by the mentorship she received in and out of the classroom, especially during her time in Tanzania. It was important to have access to global programs to hone skills and apply coursework in the field where resources seen in the states aren’t readily accessible (advanced screening and tests, pharmaceuticals). This underscores the case that providing global experiences for students, faculty and trainees retains talent and promotes global programs to the best and brightest across the world—essentially enhancing MUSC’s role and reputation in the global health community. “I feel like it’s growing.” Waring said of the global health presence at MUSC. “By going abroad, I learned so much about medicine and myself and working with others. You’re directly contributing to the health impact wherever you are doing your clinical, research or field work.”

Roadblocks stifle progress in capacity building and program development in low and middle income countries, both literally and figuratively. Powers, Zwerner and Waring are undoubtedly passionate about their project and are optimistic that they will make a large impact on their immediate catchment area and beyond. Their efforts serve as a model of resourcefulness and flexibility in solving problems. “Attitude is everything,” said Waring. “You just have to go back to why you’re practicing medicine and healthcare: to help people. We have to figure out how we can fix the problem and how to work with what we have. But it’s far more important to focus on the patient.”

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