Pilly Chillo aspired to be one of the first cardiologists in Tanzania. She knew this would not be an easy road. At the time, Pilly Chillo could only follow programmes abroad; today, she herself trains prospective cardiologists at the MUHAS Medical Centre in the capital of Dar es Salaam. Her students are very ambitious, like she was: ‘Many of them would prefer to do heart transplants. I always explain to them: In Europe, transplants are performed because they first conquered all the simple diseases.’ To brush up on her knowledge of 3D echocardiography, Chillo trained at the UMC Utrecht, at the invitation of professor of Cardiovascular Genetics Folkert Asselbergs. We meet her on her final working day in Utrecht, before returning to Tanzania. ‘This weekend I want to go and explore the city a bit’, she says. ‘I haven’t had the time yet.’ Not that she is complaining: She goes home with her head full of freshly-gained knowledge and experience, as well as a pile of notes. These will be very useful: Chillo is closely involved in the formation of the brand-new Centre of Excellence in Cardiovascular Sciences, which will be part of the – also new – training hospital.
Why did you choose cardiology? A choice that was not so obvious in a country like Tanzania.
Dr. Chillo: ‘Right, fighting infections would have been more obvious. For these, the largest budgets and best research opportunities were available. But I was young and ambitious. The fact it would be a difficult road appealed to me. What is more, back then, around 2002, it was already clear that cardiovascular diseases were on the rise, primarily as a consequence of the changing lifestyle.’

Which cardiologic afflictions are most common in Tanzania?
‘The biggest problem are rheumatic heart diseases as a result of neglected throat infections, which chiefly affect young children. The lecture I gave on this at the UMC created quite a stir. My mentor during my Internal Medicine master, who studied Cardiology in England, inspired me to go for Cardiology. However, we didn’t have any training facilities, let alone treatment facilities. Eventually, our university set up a programme in association with the University of Bergen, where I obtained my PhD, and the Medical Centre in Vellore, India, for the clinical practice part: over there, a complete surgical team did a two-year internship. In 2008, the very first heart surgery in our country took place.’

That must have been a special moment.
‘It was a milestone. The then president came down to the hospital to congratulate us. The patient was a nine-year-old girl from Zanzibar and we replaced one of her cardiac valves. The only option we used to have for these patients was to send them to India for surgery. But only a few of the thousands of children on the waiting list were eligible. I talked to scores of desperate mothers on the phone.’

What is the current situation in the Cardiology ward?
‘We have two operating theatres and in the future we’ll get out own building, specially geared to heart diseases, with hundreds of beds. Since we are the sole centre for heart conditions in the country, more and more people find their way to us. Besides, the awareness about cardiovascular diseases has strongly increased in recent years.
When it comes to cardiologic interventions, we are not fully equipped. So what we often do is simultaneously invite a group of patients who need a stent. They are then treated by a team of doctors from Australia and the US, who come to us in an act of charity. In the process, our people can be trained on the job by experts.
The problem is that we can perform cardiac valve operations, but for financing we are wholly dependent on the government. Rheumatic cardiomyopathy is chiefly found in the poorest regions, where people don’t have access to antibiotics. Only thirty percent of all Tanzanians have health insurance. Fortunately, this percentage is now slowly increasing, since the new government is working on a minimum insurance coverage for everyone.’

So you have a lot to gain by the early detection of neglected disorders.
‘We do. On paper we have a good system. With health workers in the villages, who trace disorders and proceed to send patients to a mobile health unit, where they can get level 1 medication. If necessary, they can be referred, via health centres and district hospitals, to our national hospital. But in practice we’re still missing too much. This sometimes keeps me awake at night.’

To what extent has Tanzania been affected by typically Western phenomena like stress and obesity?
’My PhD dealt with hypertension. The statistics speak volumes. In 1930, it was simply absent from our society. In the 1980s, it amounted to six percent, but only in urban areas. Nowadays, a quarter of all Tanzanians over the age of 25 suffers from hypertension. This is directly linked to the changing lifestyle. People used to cover long distances on foot. Sugar, potato chips and soft drinks were not available. By the way, salt has always been a problem. On the south coast, where a lot of fish is prepared with salt, all pregnant women have hypertension. This is also partly caused by the ethnic, genetic predisposition that makes our population oversensitive to salt. When prosperity in the cities grew, being fat turned into something fashionable, a status symbol. “If you have a car, why walk?”, that idea. Fortunately, this is slowly changing.’
What struck you most during your stay at UMC Utrecht?
‘The degree of professionalism. Doctors and nurses are very scrupulous. Everyone knows the guidelines and adheres to them. Every patient gets a precise diagnosis. Due to our limited means, we have to restrict ourselves to: “From my experience I can say that…” We have only one MRI and one CT scanner, but no specialised radiologist to interpret the results. The radiologists in Utrecht are fantastic. What I also really like is that young doctors and experienced ones closely cooperate and deliberate. Medical staff also really look at the person behind the disorder. I had the chance to attend many consultations. If people spoke Dutch, I couldn’t always understand things, but from the body language I always gathered a strong commitment of doctors to patients.’

What does it mean to you personally to lack the means to provide the best care possible?
‘In your country, patients are treated until the end. We are forced to focus on areas that have the greatest impact. My students are very ambitious: Many would prefer to do heart transplants. I always explain to them: In Europe, transplants are performed because they first conquered all the simple diseases. We should follow the same path. Let’s first make sure we detect neglected throat infections at an early stage; this will save many more lives. Okay, if one day we strike oil in our country, then we can say: now we can treat everyone for any disorder.’
Which experience you gained over here will you immediately invest in Tanzania?
‘Apart from sharing the knowledge of 3D echocardiography I gathered here, I plan to set up a new system for data collection and processing in the new hospital, like the one I saw here. If everyone starts collecting and entering information in a standard way, we can better assure quality.’

What can doctors in Europe learn from you?
‘We admire your guidelines, but they have one downside: they don’t tell you what to do if conditions are poor, or not perfect, as is always the case in our country. Perhaps this helped us improvise: what do you do if conditions aren’t perfect? How do you diagnose, based on incomplete information? I’m also thinking of prioritisation. Something we are forced to do, but which is also relevant in your context, considering your rising healthcare costs. Until which age do you still give someone a hip replacement? It’s hard to imagine this over here, but when I saw that a primary school teacher was on a list for surgery abroad, I made an extra effort to put him higher on the list. If we lose a teacher in our country, we lose a lot more than just this teacher.’

-This article was published in the Dutch magazine for cardiologists De Cardioloog, 2018.  Translation by Sjaan de Bruijn