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.
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