Dr. Cuff on one of the training sessions for FAME staff.

Dr. Cuff training FAME staff: looking on is FAME’s Dr. Ken (middle) and Dr. Gabriel (right).

Few people get to have a post-retirement career, let alone one as rewarding and challenging as the one I was given when I signed up to volunteer at FAME for 13 months in 2010-2011. I have watched and sometimes participated in seismic shifts as FAME matured from a simple Clinic to an established Hospital. In 12 short years, FAME has opened a free-standing and well-equipped lab; an in-patient hospital; routine surgeries; a rapidly growing Reproductive and Child Health program; a free-standing maternity center; on-site housing for staff and volunteers; and even a cafe for residents and visitors.

The following is a true story and one that gets at who, what and where FAME is. It is the story of Lazarus (not his real name, but an obvious choice, as the story reveals). Lazarus came to us when we were at a clinic housed in a single building. Lazarus looked like any ordinary patient with his shuka (traditional Maasai Blanket) over his head. 

One day a volunteer doctor/legend at FAME, Dr. Duane, brought Lazarus to see me in the lab. Dr. Duane wanted me to do a test on Lazarus. As I waited for a hint about what sort of test, Lazarus removed the shuka from his head and revealed a growth almost as large as his head, growing out of his neck. It was an anthrax tumor. We did some sampling and found that there did not appear to be active anthrax present. The doctor removed the tumor and, since we did not yet have an inpatient ward, sent the patient to a nearby guest house so he could come back daily for a while to make sure everything was ok and to have dressing changes. 

Three days went by and no word from Lazarus. Concerned that something awful had happened, reception called the number on record for Lazarus. We were told the patient had died, but nobody seemed upset at FAME for the death. The doctor was quite beside himself. The next day as the doctor entered the clinic, there was Lazarus sitting on a chair, waiting to see him!

When shown the number that was called to see how he was progressing, Lazarus said he did not recognize the number. No excuse was ever given for the three-day disappearance. One wrong number; one successfully recovering patient; one doctor trying to roll with the punches - a snapshot of FAME: who, what and where FAME is.

“FAME is a community that cares deeply for its patients; it is a place where extraordinary things can and do happen with surprising regularity; it is located in a place where ongoing or even frequent contact with patients can be quite a challenge.”

— Dr. Cuff

PS. A few years later, reception tracked down Lazarus at the doctor's request. Lazarus responded by coming to the clinic and strolling in with their neck exposed, accompanied by his new wife for a delightful reunion.

David.

David and his mother.

At FAME’s Outpatient Department (OPD), we meet 4-year-old David* and his mother. David has been suffering from ear pain for the last month. He had been playing with his friends when he came home with his ear hurting. 

“David came home from the playground complaining of ear pain. I didn't think much of it and put it down to tiredness or having jumped around too much, but by the following morning, his ear was swollen and he complained of increased pain. I asked him if he had any idea why his ear hurt and he said no. So I took him to a local clinic.” - David’s Mother. 

The doctor at the clinic gave him some ear drops and painkillers and sent him home. However, after a week, there was no improvement, so she took him back. The doctor said there was nothing further he could do as he didn't understand what was causing the problem. 

Determined to get help for her child, David’s mother decided to try another clinic slightly farther from home. This time, the doctor examined David and said he thought he had a foreign body inside his ear canal. Surprised, the mother asked David if something could be inside his ear. 

“I have a small seed in my ear. My friend put it there.”

— David

The doctor attempted to remove the seed but said it was impossible because of swelling. He asked her to return when the swelling went down and sent them home with different ear drops, tablets and an ointment. 

David's ear became infected and started oozing pus in just over a week. His mother took him back to the doctor and said the medicines he gave them were not working. One look at David’s ear and the doctor said he needed to see an ear specialist urgently and recommended FAME.

“The doctor said I should bring him to FAME, an excellent hospital with qualified doctors who may be able to handle David’s situation. He said that he had referred many of his patients to FAME and they all had good things to say. So we took a bus to FAME, 50 miles from home.”

— David's Mother

Once at FAME, they saw a doctor at OPD. The doctor struggled to inspect David’s ear because David was irritable and uncooperative, making removal difficult and risking injuries. The doctor admitted him to FAME’s inpatient ward, put him on IV antibiotics and pain medication and planned to inspect the ear under sedation.

“I wish he had told us about the seed in the ear in the beginning. We would not have wasted valuable time and his condition would not have worsened.” - David’s Mother. 

The next day the FAME staff performed an otoscopy (procedure to examine the ear) under anesthesia. The ear was found to be enlarged and containing necrotic tissue.

“The infection was much worse and the ear more fragile than we thought, with no sign of the foreign object. We feared an increased risk of eardrum damage if the foreign body was close to it and knew multiple attempts at removal would lead to serious complications. We determined that this complex case warrants a referral to an ear, nose and throat (ENT) specialist in Arusha. Foreign objects in the ear, nose and throat are a common problem we often encounter in pediatric patients, though not exclusively. Most of these objects can be removed in our outpatient clinic, but prompt recognition and management are required to minimize complications. David’s case had been ongoing for over a month, making the removal of the object quite complicated. This is why we decided to exercise caution and have an ENT specialist look at it”

— Dr. Ken Karanja

Cases like David’s are one of the reasons that over the next five years, FAME is committed to building a dedicated pediatric team that will be trained and equipped to handle screening, assessment and referral of more complex cases involving newborns, children and adolescents.  FAME’s investment in reproductive, maternal, and child health, along with outcomes for newborns generally and in our Special Care Nursery, has established its reputation as an institution committed to the well-being of newborns and children and has built a trusting relationship with the families that we work with. In David’s case, Dr. Ken counseled David’s mother extensively about the safest option, which was referring David to an ENT. FAME’s doctors work in close collaboration with other doctors and medical centers throughout Tanzania and have a deep knowledge of the options available.  Even when FAME is not the best-equipped institution for handling a case, our team takes a holistic and collaborative approach to patient-centered care, ensuring the patient feels well-cared for and receives the most appropriate treatment possible.

*While the patient’s name has been changed to protect privacy, permission was secured to share his photos and story with FAME supporters and to raise awareness of available medical care at FAME Medical.

Dr. Zetes during a training session.

The FAME doctors at Dr. Zetes training. Joining them is Dr. Michael Rubenstein (left).

Dr. Zetes explaining a point.

Dr. Zetes just finished two weeks of volunteering at FAME. A seasoned pediatrician with over 30 years of experience in California, Dr. Zetes has been involved with FAME since 2017. Her good friend, Nurse Barb Dehn (OB/GYN, FAME board member/long-term volunteer), introduced her. Dr. Zetes and Nurse Barb worked together in the same community.

“I always thought of volunteering in another country, but I was raising three kids and working in a  very busy private practice, so it was overwhelming to think about it. When Nurse Barb returned from FAME, I was thinking of winding down my career, my three children were grown and had moved out of the house and I thought I can do this!” 

Dr. Zetes and Nurse Barb came to FAME in 2017, 2018 and 2019, staying two to three weeks each time. In March 2020, they had planned to return to FAME, but the pandemic hit and all travel was suspended. September 2022 is the first time she has been back since the pandemic.

Dr. Zetes joined the FAME board a few months before she retired. Since then, she has been passionate about FAME and is impressed with the work that the FAME team does.

“At FAME, everyone works together despite having limited resources available to save lives. FAME provides an amazing service to people without or with limited access to quality healthcare.”

— Dr. Zetes

Dr. Zetes has experienced FAME’s transformation through the years. For example, FAME had a Maternal and Newborn Health program but no maternity center when she first visited. Today, FAME has a 24-bed Maternity Center with a Level 2 Nursery, operating room and four delivery rooms.  

“It is a big change! The maternity center even has the nasal C-pap machine, which is being utilized perfectly and babies who would otherwise have not survived are leaving fine and healthy.”

Dr. Zetes is impressed with how much the FAME staff care and will go the extra mile to provide the best care to its patients. She mentioned when a premature baby did not attend their scheduled check-up. The staff was worried as it is imperative that the baby undergoes frequent checkups and that their progress is monitored. The nurses called the mother and to their delight, the baby had been to FAME, but on this visit, he came under his name and not his mother’s, which he used when he was born. The mother was happy to talk to the nurse and was grateful for the staff's concern even after her discharge from FAME. 

“In the US, with all the availability of and easy access to advanced technology, the medical staff may not necessarily go the extra mile to ensure that the care provided is patient-centered. What is best for the patient should be the goal, not what is easiest for the doctor or nurse.”

— Dr. Zetes

Dr. Zetes also has some advice for anyone interested in volunteering at FAME.

“My biggest advice to volunteers is once you get to FAME, sit back, listen and see how the team is handling things, as they may not have the equipment you are used to back home. Over time, you create a relationship and build trust and your suggestions will be well received and the team will seek your input into cases.”

Dr. Zetes explains that volunteer doctors learn so much from the FAME doctors, and this exchange of information is priceless. The FAME team has local experience and is knowledgeable in handling situations better than a western trained doctor in this environment. At FAME, you also encounter diseases you may not have experienced back home.

“Before I came to FAME, I had never seen rabies, anthrax, or gonococcal conjunctivitis (GC).”

— Dr. Zetes

Education and capacity building are significant components of FAME’s volunteer program and volunteers often lead training and seminars for the FAME team. 

“I was not a professor, I was a doctor in private practice, so I was a little nervous about giving a PowerPoint presentation and being up in front of the crowd. I like it now, as the people at FAME are warm, welcoming and not critical. It was great fun to share the knowledge I have gathered over the years. I did not have to do a massive research project to give a presentation; I could speak from my experience. It was beneficial to have worked with the team for a while, so I knew what kind of information they could benefit from.”

Asked to describe FAME in one word, Dr. Zetes says, “Impressive!” 

“When you come to FAME, you are impressed by the annual budget and what FAME can accomplish with that little money. FAME is saving lives. The donations go directly to the patient’s care. It feels good to know FAME is meticulous about how they spend the money donated.”

— Dr.Zetes

Mary, holding her newborn daughter in FAME’s maternity ward.

Mary* is 36 years old and has just given birth to a little girl. This is her fifth child and her fourth pregnancy. Her first child was delivered by an emergency cesarean section (C-section), which was not a very good experience for her. Her last three pregnancies have been vaginal birth after cesarean (VBAC), including a twin pregnancy here at FAME.

“I wanted a vaginal delivery because of the C-section’s downtime. It took half a year for me to recover from the operation completely. I couldn’t work. I stayed home, lying down to rest between simple house chores. My husband does not make much money, so I have to work for our family to live comfortably. That C-section turned our lives upside down and sadly stole our joy as first-time parents.”

— Mary

Mary’s story is not unique. For a long time, medical professionals have told women that once they’ve had one C-section, they had to have the operation with every other pregnancy.

“My husband and I always wanted to have a big family, and thus I wanted to try a vaginal delivery despite already having had a C-section. I couldn't have had many kids if the operation had been my experience every time. It was just too painful.” - Mary.

At FAME, the purpose of any obstetric intervention is not only to reduce morbidity and mortality of the mother and baby but also to increase maternal satisfaction while ensuring patient safety. When Mary walked through our doors, we were ready to help. 

Dr. Anne Ghati

Dr. Anne Ghati, FAME’s Assistant Medical officer, explains the approach that FAME takes towards TOLAC and VBAC.

“At FAME, trial of labor after cesarean (TOLAC) has a 70-75% success rate and reduces maternal morbidity by allowing women to have a vaginal birth after a cesarean (VBAC) which is associated with fewer complications than repeat elective C-sections. When successful, VBAC causes a decrease in maternal morbidity and risk of complications in future pregnancies.”

— Dr. Anne Ghati

However, not all pregnant women are eligible for TOLAC. When they get to FAME, they are first screened and their past and present obstetric and reproductive history is recorded.

“The ideal candidates for TOLAC are patients with a high likelihood of VBAC and a very low likelihood of intrapartum uterine rupture. Some risk factors, such as gestational diabetes and estimated fetal weight of more than 8 lbs 13 oz, are just some of the impending factors. A C-section scar less than 18 months after a previous delivery also disqualifies the woman as it presents a higher risk of uterine rupture. Same as having undergone a classical cesarean delivery, which is a midline uterine incision in the contractile portion of the uterus.” - Dr. Anne

“I was appropriately counseled regarding delivery options. The risks and benefits of elective repeat cesarean delivery versus trial of labor were clearly explained. I didn’t know there were benefits to TOLAC, other than less pain and faster recovery until I attended FAME’s antenatal classes.”

— Mary

FAME can perform TOLAC as it is equipped to handle any emergencies that could arise. Extensive maternal education for its staff, the availability of fetal monitoring tools, and proper monitoring during labor ensure the safety of mothers and newborns. Nurses and doctors are trained to check for the signs of uterine ruptures, such as acute pain and repetitive or prolonged fetal heart rate deceleration, which are both potential risks with TOLAC. 

“As a doctor, I recommend TOLAC as it usually presents fewer complications. However, screening of the women is required to rule out possible risk factors. High C-section rates increase maternal and neonatal morbidity, and VBAC has been a good way to counter this.”

— Dr. Anne Ghati

For women like Mary, avoiding surgical recovery in the postpartum period is the biggest motivator for TOLAC. FAME continues to invest in these procedures so that we can help other women like Mary deliver vaginally despite a history of C-sections, improving maternal and newborn outcomes and meeting the needs of our patients.

*While the patient’s name has been changed to protect privacy, permission was secured to share her photos and story with FAME supporters and to raise awareness of available medical care at FAME Medical.

As part of FAME’s critical investment in maternal health services, it provides education and capacity-building opportunities to its team. FAME’s reproductive health program currently employs 21 nurse-midwives, seven medical doctors, and a staff of technicians. Continuing education for FAME’s medical team keeps them updated on the latest advances in care and treatment, enhances practices and protocols and improves patient care.

Last week, FAME hosted a four-day obstetrics training course for its nurses and doctors, to equip them with skills to effectively manage obstetrics emergencies, which are life-threatening for pregnant women and their babies. The course, Advanced Life Support on Obstetrics (ALSO), was led by Professor Mlay Pendo, OB/GYN, and assisted by Dr. Elibariki, both from Kilimanjaro Christian Medical Center (KCMC) in Moshi. 

ALSO is designed to equip the entire maternity care team, including physicians, nurse midwives, registered nurses, and other members of the maternity care team, with skills to effectively manage obstetric emergencies and improve outcomes for women and newborns.

Nine nurses and three doctors from FAME took part in the training. FAME also invited its neighbor health centers to participate: Kambi ya Simba Health Center, Rift Valley Hospital, Karatu Lutheran Hospital, Rhotia Health Center and the district-designated hospital, Karatu Health Center. They all sent a representative to the course.

Some of the topics covered in training included: the management of active third-stage labor, pre-eclampsia and eclampsia, resuscitation of newborns and vacuum extraction, among others. 

After completing the course, the attendees reported a significant increase in their comfort level in managing obstetric emergencies and a greater intention to continue improving maternal care.

“The training was excellent. I did an obstetrics course in 2016 and again in 2018, but this one was completely different! So much new information and updates in obstetrics in the last couple of years! I’ve updated my knowledge and skills, and I’m thankful to FAME for giving us this opportunity.”

— Hosiana Zephania, Registered Nurse, Ward 1 Supervisor