January 28th (our last clinical day) and ethical dilemmas in global health

 

Robert “Cole” Pueringer here. I am a physician in the group. I practice Medical Toxicology/Addiction Medicine and Internal Medicine in Duluth, MN.

1/28/26

Maureen, Yusra, Manny, and I went on a palliative visit on 1/28. We were accompanied by Dr Nixon (equivalent to a CNP or PA in the US), who runs the palliative program, and two Community Health Workers (CHWs). We took a two-wheel drive minivan along an unpaved, rocky, fractured, and at times muddy road. We bottomed out a few times, and I honestly can’t believe we made it there and back. 

After a nearly hour-long drive, we started by visiting a dispensary in Image (owned by the ELC) to pick up a local community health worker. Reportedly, nearly every small village has its own community health worker (CHW), whose job is to keep a pulse on who in the city/village is struggling and help connect them to resources, transportation, food, etc. A dispensary is the lowest level of healthcare in Tanzania. After touring the dispensary, we departed to see our first patient.

Our first patient was a relatively wealthy 80-year-old woman who was bedbound. Dr Nixon told us that the patient was paralyzed from the waist down because of hypertension. Clinically, this makes no sense. Upon examination, she was not paralyzed. She could move her legs/feet/toes, but was emaciated, and her muscles atrophied. She had full sensation in her lower extremities, but was profoundly weak. Reportedly, these symptoms came on gradually 3-5 years ago, and she has remained bedbound since. She has received an unclear amount/intensity of physical therapy. 

Hypertension does not cause lower extremity paresis; a variety of etiologies can. If the correct diagnosis had been made several years ago, she might not be bedbound. I also have no idea if the patient could potentially walk again (or regain some function) if she engaged in a consistent/intensive physical therapy program. That said, I’m not sure that interjecting is our role as Americans/learners here for a single palliative visit. Do we markedly alter the treatment plan and start a workup when we won’t be here to act on it?

We also saw a 76-year-old woman who had poorly controlled Diabetes Type 2 (DM2) and hypertension, and had a necrotic/dead right lower leg from an infection that had started in her toes several years ago (gangrene). Without intervention, namely a below-the-knee amputation (BKA), she will die from a systemic infection that originates from the primary gangrenous right lower leg, likely within weeks to months. You can think of her dead lower leg as a petri dish/food medium for growing all types of bacteria, which could then lead to a systemic infection, septic shock, and death. A picture is located below – warning to squeamish viewers. To complicate things, she is extremely poor. She lives with and is supported by her daughter (a farmer), who has an infant of her own. They live in a 3-room mud hut, with dirt floors, no electricity, tin roofs, and minimal light. Finances are the primary barrier to getting the right BKA; they have 30,000 TZS in savings for the surgery, which is about 12 USD (100,000. They will need about 500,000–1,000,000 TZS to cover the BKA, transportation, and aftercare, which will be completed in Iringa, about an hour’s drive away. At this point, they are relying on money from the patient’s uncle and the daughter’s entire savings to pay for the surgery and perioperative care.

This poses an ethical dilemma. Do I and others in the group help pay for the surgery? There is no question she will die without the surgery, which would cost about 200-300$ USD.

Factors/Questions to consider…

- Her age and comorbidities: 

o She is a physically inactive/bedbound 76-year-old with poorly controlled DM2 and hypertension, both of which contributed to her immune system’s inability to control the infection. The same variables will impair wound healing. Given their financial constraints, closely monitoring and controlling her blood glucose and blood pressure will prove challenging. Even in the best-case scenario, she may only have a few more years to live. I have concerns about whether the wound from her BKA could heal.

- Family situation, finances, family well-being:

o The surgery will deplete her daughter of their savings and require the daughter to contribute time to help her mother with therapy, transportation, and other activities of daily living. This is money/time that could be spent on herself and the infant.

- Justice

o If we decide to contribute money, is it fair to the other palliative patients we see throughout the day, or others in the community or hospital? The amount we would contribute could help many adults and children in the village; 200-300 USD is a significant sum in Tanzania.

o If we contribute the money, it will require the daughter to also drain their life savings. Do we pay for the entire surgery and perioperative period?

o What if the patient was 40 years old, a mother of two, and otherwise healthy? What if she had mental illness or addiction-related comorbidities instead of her physical comorbidities?

Ultimately, I’m not sure what the best answer is. Herein lie the ethical dilemmas of global health.

Last week, on a palliative visit in Moshii through KCMC led by sister Anna, Yusra, and I saw a 40-year-old mother of 2 with a similar injury and dire prognosis without a BKA. She was otherwise healthy and without comorbidities. In her case, the question of whether or not to help was much easier.

Images below: 2 kittens that have made a home of our front porch, sunrise in Ilula, and a gangrenous foot.

Day 13

 Ilula, Tanzania

Today is the day before our last full day in Ilula. I am writing after a long but fulfilling day—one that began with a heart failure presentation at morning report and ended with a quiet walk through town.

I was nervous about the presentation this morning. The audience included both our visiting group and our Tanzanian hosts—hospital leadership, staff, and students training as clinical officers and nurses. As the day went on, a few comments and brief conversations reassured me that the topic had landed well. Nothing dramatic, just enough to let me exhale and carry on with the day.

Later in the evening, during my walk through town, I ran into two first-year clinical officer students. They were already in conversation with Dr. Randy and recognized me from the morning report. They told me they had assumed I was Tanzanian and were surprised by my American accent. That comment stayed with me. Earlier in the week, people had spoken to me in Swahili, only to realize I didn’t understand. This moment felt different—less awkward, more grounding.

The two students shared parts of their stories with me. They said they were “proud” of me, which caught me off guard. They talked about how they had hoped to become radiologists or dentists but enrolled in clinical officer training because of family expectations. There was no bitterness in how they spoke—just honesty. When we parted, I realized how easily that brief exchange had turned into a meaningful one. I felt honored to have listened, and quietly hopeful that the conversation may have stirred something for them, as it did for me.

Throughout the week, I made a conscious effort to be clinically present, and it has been rewarding. I learned through inpatient ward rounds with Dr. Joseph, the medical officer in charge, alongside Drs. Randy, Cole, John, Solveig, and Yusra. I scrubbed in on a cesarean section, performed bedside ultrasounds to guide clinical care, and learned about toxidromes through teaching with Dr. Cole. These moments, taken together, shaped my experience more than I anticipated.

During my walk that evening, it became clear how attached I have grown to Ilula. As our time here draws to a close, a quiet sadness has set in. I will miss the familiar streets—usually loud, but softer tonight. I will miss the children calling out “hello” and “how are you,” eager to practice their English. I will miss the constant hum of motorcycles, the honking of bajajis, the repeated “you are welcome” offered throughout the hospital day, the smell of earth mixed with fresh air after the afternoon rain, and even the Sunday church and choir.

It feels like a bittersweet moment—one I am not quite ready to leave behind.

Yours,

Tawa

Meet Ken Temba, Optometrist

 

Ken is a clinical officer (like a physician’s assistant in the US) who went back to school to become an optometrist. After 3 years of coursework, he is in his final year – an internship or field work. He will be able to test refraction, make the glasses, and refer patients with other eye related problems to an ophthalmologist.

At the end of 2026, he will seek approval to be licensed as an optometrist and begin serving patients in an Eye Department at Ilula Lutheran Hospital. He will be the only optometrist in Ilula, with a catchment area of about 100,000 people.

The hospital has identified three rooms for his practice – a waiting room/showroom, a room for examination, and a room for fitting the ordered lenses into the selected frames. I had a chance to see these rooms in action during a visit to Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania.

In addition to seeing patients at Ilula Hospital, Ken wants to begin a mobile clinic, taking his refraction equipment into nearby towns and villages that have no access to an optometrist. Ilula Lutheran Hospital will be making a request to Global Health Ministries to provide start-up funding and equipment for the new Eye Department.

Day 11 - Flex day

Hello everyone,

It's Manny coming through with the last input of the first cycle of posts. Today is Saturday, January 24, 2026, and day 11 in Tanzania (my day 7). I am excited for the day, not only because I finally gave my talk on toxic alcohols yesterday at the medical conference, but because of all the opportunities to do things without the pressure of having to. Some background of me, I am a first-year pharmacy resident at Woodwinds Hospital in Minnesota, and got my PharmD degree from Rutgers University in New Jersey.

 Our morning started with a typical breakfast from our amazing cook, which included sweet yams, eggs, bananas, meat pies, and more! This was a refreshing meal after a cool shower. Although I have the luxury of having the second room in the guest house to myself, I still struggle with getting hot water haha. 

The first journey of the day took us to the lab in Ilula where Emmanuel, the head of department, showed us his facility as well as new testing he is able to do. He was very excited to tell us about his Genesight machine. At the lab, we also had the opportunity to look at peripheral blood smears provided by Randy and learned of the 7 infectious diseases discoverable on peripheral smears. 

After leaving the lab, we took a walk over to Ilula Orphanage Program (IOP), where we were warmly welcomed and greeted by all the children in song and dance. This day we learned about how the program started, how sponsorship occurs, and how the facilities are run. Although this was a short tour, it was very informative and inspiring, as some of the graduates go on to do great things.

From the IOP, a few of us continued the journey on foot to the Ilula health center. This is a government-run facility that has an outpatient department as well as a maternity ward. We went to meet up with an old friend, Adilly, and go on a tour of the place. This day I learned that I actually may like hiking and that Air Force 1’s are NOT the shoes for it 🤣.

At the end of the IOP tour, our group was cut in half again, down to ⅓ , with the others headed back to Ilula with bajaji’s. This quest was for Yusra’s water bottle. It has been two days since Yusra has had happiness, and retrieving this water bottle might have been the highlight of her day. On the way to Adilly’s, we heard some thunder and saw dark clouds and we ended up in a Bajaji. At first, we were doubtful of the pending downpour, but as I like to say, the locals know best. A few moments later, we had a downpour of rain, which Cole, Yusra, Adilly, and I enjoyed from the front porch of the house. I thought this was much needed for Adilly’s home garden, which has avocados, mangoes, guava, beans, papaya, and more! 

During the rain, Adilly called what we THOUGHT was a bajaji, but shortly after the rain and a short walk, we met a hospital ambulance on the side of the road. So Cole, Yusra, and I took a bumpy, tight, ambulance ride home to Ilula hospital just in time for lunch (I definitely went airborne a couple of times lol). After lunch was chill time, where we sat together and shared stories from the day.

The last and final journey took us downtown to find a place to find a cool drink. This place was called the “Peace garden,” and we got local beer, soda, and their famous ginger drink. After hearing medical stories from everyone the midnight crew (Dr. Cole, Yusra, Tawa, and myself) went on our typical walk. Our walk lasted about an hour and we talked about THC and CBD. We must’ve dove too deep into the conversation because we ended up deep in the village/farmland with no way out. We ended up needing the help of a local to get back home and needed flashlights because of how dark it had gotten. That experience kind of summarizes the culture here of kindness and helpfulness.

Saturday was a great day.

Yours,

Manny

Ilula Minnesota International Healthcare Conference Day 2

 Thursday and Friday were devoted to presenting our 11th annual Ilula Minnesota International HealthCare Conference.  Starting in 2014, Shoulder to Shoulder has presented the annual conference for our colleagues in Tanzania.  All our presenters did a great job and all the healthcare professional teams that attended gave positive feedback and will return to their hospitals with knowledge and skills in quality improvement to implement based on what they learned. We are in the process of compiling the feedback from the evolutions, but the initial informal feedback has been overwhelmingly positive, both from attendees and presenters.

Our first course was presented in January 2014 with 30 attendees.  Based on extremely positive feedback from the initial conference, our partners in Tanzania encouraged us to significantly expand the conference to offer this educational experience to a much larger audience of caregivers.  As a result, we expanded the conference to include all 26 Southern Zone Lutheran Hospitals and the program has grown to include 130 healthcare professionals.   From each hospital we invite one doctor, one nurse, one pharmacist, and one administrator. 

Our conference is based on 5 principles:

1. Lifelong Learning.  We believe all professionals should contribute to a culture of learning and continuously learn to improve our practice.  

 2. Interprofessional teamwork.  We include nursing, pharmacy, administrators, and physicians in both the attendance and presentations.  We emphasize teamwork throughout the conference.  We each bring unique knowledge and skills to share; specifically Tanzanian presenters emphasize tropical medicine and HIV, American presenters emphasize the growing global problem of chronic and non-communicable diseases.

3. Mutual Respect.  We emphasize the ability for all our participants to teach and learn from each other, in spite of our differences in practice setting, culture, and socioeconomic situation.  We include local leaders in planning the conference and select topics based on feedback from participants.  Presentations are delivered by both US and Tanzanian professionals.  The program is based on a foundation of a longstanding and ongoing relationship. The second day of the conference was clinical talks delivered entirely by Tanzanian health professionals. 

4. Continuous improvement.  Learning should drive improvement in practice.  This year we devoted the entire first day to learning about quality improvement. Cole, Maureen and Theresa did an outstanding job presenting on quality improvement  

5. Sustainable Impact.  We believe that education and improvement are some of the most valuable ways to promote a sustainable positive impact on the health of our partners’ communities.

Our conference is accredited by the Education Department at the Fairview to provide participants with educational credits for participation in this program.

Funding for the course is provided through generous contributions from several foundations and individuals including Global Health Ministries, The Peter J King Family Foundation, and Fairview Health System. We could always use additional financial support to continue this conference in the future.You can donate to the conference fund through Shoulder to Shoulder. All funds raised go entirely to hosting the conference, and support for local Tanzanian staff to attend, including meals, travel and lodging expenses.  We want to thank all our donors for their generous support. I would also like to thank fellow Course Directors Dr. Mufwimi Saga and Fr Manfred Mjengwa, Shoulder to Shoulder founders Randy Hurley and Gary Moody, Ken Olson, Shana Steinbeck and all the presenters for all their hard work and critical contributions.  Special  thanks to Cindy Wilke for helping to plan for the conference  

We believe that fostering leaning through the conference principles is one of the important ways we can improve the health of the population in and around Ilula. Overall the conference was a great chance to learn together, build relationships, and plan together to improve healthcare in Tanzania.

Day 9

Day 9 brought us to Iringa for the eleventh Ilula–Minnesota International Healthcare Conference. Dr. John Kvascicka facilitated the conference, and I had the opportunity to present alongside Cole and my mom, Teresa. 

This year, 140 healthcare leaders attended from 26 hospitals across Tanzania. Each hospital sent an interprofessional team of physicians, nurses, clinical officers, pharmacists, administrators and other hospital leaders.

The conference began in 2015 with 30 participants. The growth of the conference is a direct reflection of the thoughtful relationships that have been built over time and a shared commitment to lifelong learning.

This year’s focus centered on quality improvement. While we covered many topics, one core theme was: Change does not happen overnight; it happens one step at a time, one day at a time, one problem at a time. In Swahili, the message was captured as, “Kidogo kidogo, kidogo kinakuwa kikubwa.” Which means little by little, a little becomes a lot.

For me personally, having the opportunity to co-lead the conference with my mom was certainly unforgettable. 

Day 9 reinforced a simple truth - that improvement begins with the belief that tomorrow will be better than today. I am inspired by the Tanzanian leaders’ commitment and excited to see them bring these new quality improvement tools back to their teams, positively impacting the lives of patients and staff.

- Maureen

Day 8 - Illula

 Hello! I’m Teresa, a supply chain administrator traveling with the Global Health Ministries administrative consulting team alongside Maureen, Cole, and Cindy.

We began the morning with the hospital’s procurement officer, who walked us through their entire supply chain process, from ordering and receiving to storage, distribution, and inventory tracking. We talked about supply shortages, prioritization, and the daily choices required when resources are limited. While their workflow may look a little different from what we’re used to in the U. S., there are so many similarities between the responsibilities we share and the problems many hospitals face worldwide.  

From there, we toured the operating rooms. The team shared their case flow, instrument reprocessing practices, and vision for incorporating orthopedics in the future.

Later in the day, we toured and showed in the Reproductive and Child Health clinic. As a mother of three, this part stuck with me. I watched mothers arrive with infants and young children, observed counseling and exams, and toured the birthing suites and NICU. The care was steady, thoughtful, and deeply respectful. I found myself thinking of the quiet strength of the women in those rooms, recognizing many had traveled long distances to receive care.

Throughout this entire trip, we have been met with genuine warmth from the Illula community. While walking through town, we passed a local choir practicing. They smiled, waved us over, and invited us inside to listen. The video below captures the spirit of the community here beautifully.

Today was a reminder of the impact of supply chain and why I do what I do. Supply chain decisions don’t live in storerooms or spreadsheets alone. They reach operating rooms, clinics, mothers and children – all across the world. I am grateful for this experience, and I will be taking many lessons learned back to my supply chain team in the US.

- Teresa