In Bulongwa und Makete wurden Gottfried, Judith unsere neue Kollegin (Medizinerin und HAK Absolventin) freundlich empfangen.
Besonders die Jungen hatten die Daumen oben und Alten die Hände gefaltet. PIUMA hat ein Meeting mit ca 300 Menschen orgnisiert und die Kranken sind zu Stars in der Community geworden. Wenn es Dir schlecht geht, dann geh doch zu den Ärzten von PIUMA, das ist ein Wort hier.

Es wurde das Gerücht gestreut, dass der Bischof mich des Landes verwiesen hätte und ich nie wieder kommen würde, das erzählen manche. Dass ein Bischof diese Macht nicht hat, das weiß kaum einer.

Um so mehr Erststaunen, Erleichterung und Freude mich wieder mit dem Auto herumkurven zu sehen. Jackson meint, das wäre schon genug, um den Menschen Hoffnung zu geben und zu denken: "Wenn der Bischof nicht allmächtig ist, dann ist es niemand und es lohnt sich für Rechte zu kämpfen".

Die Alten sind gekommen und die Dorfvorsteher, die Verwaltungsbeamten und sagen wir würden alle unter ihrem Schutz stehen und es ist der Wunsch der Menschen, dass die Klinik wieder arbeiten muss. Es wird eine Petition an die Freunde und Geber in Europa geschrieben und gebeten, dass es weitergeht.

Wir haben Verhandlungen mit dem Distriktshauptmann, der möchte dass das Programm in "Partenrschaft" mit dem Disktrikt durchgeführt wird. Von PIUMA oder Menschen mit HIV/AIDS im Kommitee will keiner was wissen, vor allem seit PIUMA bei der Demonstration angekündigt hat, dass auch die Verwendung der HIV/AIDS Gelder (vor allem aus dem Global Fund) überprüft werden müsse, das macht wohl einigen Beamten hier Angst.

Wir einigen uns darauf, dass wir weiterverhandln werden.

Die cd4 Maschinen und das andere teure Laborgerät (ca. 45.000 Euro Wert) wird noch immer nicht verwendet und so nehmen die Patienten ihre Antiretroviralen (AIDS) Medikamente ohne begleitende Untersuchungen, was vor allem im Hinblick auf Nebemwirkungen langfristig problematisch erscheint. Es gibt auch keine ausreichende klinische Begutachutng und Untersuchungen.

Aber PIUMA ist "imara kama simba" - "stark wie ein Löwe" wir fürchten die T-shirts mit den PIUMA Aufdrucken sind bald alle weg, sogar die afrikanischen Mitarbeiter von Ärzten ohne Grenzen tragen sie.

Im Haus von Jackson wurde mein Satellitenfernsehen installiert und es ist die Hölle los, wegen der Fusballweltmeisterschaft, auch das steigert die Popularität von PIUMA und der Menschen, die mit HIV/AIDS leben, es ist ein Kampf Kirche gegen PIUMA geworden und die meisten Menschen in den Dörfern unterstützen die Kranken - kein Wunder bei wahrscheinlich 20% HIV positiven!

Veneranda, unsere 15 Jährige Patientin (Siehe www.highlandshope.com) ist glücklich mich zu sehen und auch sie spielt Fußball, ich mache mir ein wenig Sorgen, weil ihren cd4 Zellen zuletzt gesunken waren, aber sie sieht gut aus und ohne unsere Maschinen können wir nicht kontrollieren.

Im Hintergrund gibt es Neuigkeiten die bis ins Gesundheitsministerium und angeblich in die Präsidentenkanzlei spielen, alle hat mit HIV/AIDS und Korruption um Maschinen und Tests zu tun, ich werde später berichten, wenn das alles geklärt ist. Nur eines: Soviel kann man kann nicht kotzen wie nötig wäre, wenn man sieht wie internationale und lokal Eliten und Firmen mit dem Leben von armen und unwissenden HIV/AIDS Opfern spielen - es geht ums Geld und den Profit, den man daraus erzielen kann! Später mehr und wir drücken der neuen Tansanischen Regierung die Daumen - vor allem dem Präsidenten, dass er es schafft eine neue politische Ethik durchzusetzen.

Unsere Freunde spielen dabei eine große Rolle!

Morgen geht es wieder nach Tansania. Mit Gottfried, dem Sekretär vom EAWM (Evangelischer Arbeitskreis für Weltkirche und Mission).

Unsere Position ins klar, wir wollen weitermachen und noch mehr Patienten behandeln, PIUMA, die Selbsthilfegruppe soll ein wichtiger Partner sein und wir sind bereit mit der Regierung zusammenzuarbeiten. Es gibt mehrere Einladungen zu Gesprächen.

Lagebericht aus Bulongwa:

Die Schüler der Schulen singen Lieder die PIUMA und die Menschen, die an HIV/AIDS leiden preisen und sie solidarisieren sich mit ihnen. Sie laufen von Kirche zu Schule und zurück und singen.

Im Krankenhaus ist jemand gestorben, der PIUMA Mitglied war. Ein "Arzt" wollte die Leiche nicht freigeben, da gingen die Verwandten zum Dorfvorsteher, der bewegte sich wütend in das Krankenhaus und vorher zur Polizei, was wurde im Krankenhaus erzählt wurde und auf einmal gibt es Beschwichtigungsversuche und der Tote wird "gratis" mit dem Krankenhausauto in sein Heimantdorf gebracht.

Es gibt keinen Arzt mehr im Krankenhaus und es wird diskutiert, das Haus zu einer Krankenstation umzufunktionieren.

Wir haben sehr viele Stellungnahmen an höchste Regierungsstellen geschickt.

Wir bekommen viele Hinweise, dass wir etwas sehr positives Aufbauen können mit Hilfe der Community und mit Unterstützung der Regeirung.

Die Alten kommen ins Krankenhaus und waschen den Dieben den Kopf und wollen, dass einige derer, die ihre Macht ausgenutzt haben nun verschwinden. Das zählt noch immer viel, wenn die Alten kommen und das tun sie!

Es gibt wieder Strom und immer mehr Fusball.

Die Schule für Zahntechniker soll geschlossen werden, da die Schüler nur um ihr Geld erleichtert wurden, aber kaum unterrichtet wurden, die Lehrer kamen auch aus dem Krankenhaus und viele waren unter denen, die das Krankenhaus nur als privates Einkommensprojekt gesehen haben.

Die Schüler demonstrieren.

Alles in allem scheint die Stimmung gut zu sein, es gibt aufatmen, die Lähmung sinkt und wir hoffen alle, dass am Ende aus dem Konflikt noch besseres und größeres entsteht.

Wir werden sicher gut empfangen, ich habe mit dem Bezirkshauptmann telefoniert, es geht ihm gut und wir sollen kommen.

Wir müssen weise sein und zeigen, dass wir aufbauen wollen und dass es sich auszahlt, aufzustehen und für sein Recht zu kämpfen, stark aber ohne sich die Köpfe einzuschlagen.

Recht nicht Rache Stimmung.

Bischof Manyiewa und Vizebischf Sigalla sind angeblich gestern gekommen und haben sich erkundigt, wie es denn den Ausländern gehe und dem CTC Team und ob alle zufrieden seien...

Da fürchten sich Menschen zur Verantwortung gezogen zu werden und genau das soll passieren. Das hören wir auch aus Dar es Salaam. Dann werden wir noch mehr auf die Therapie setzen können und uns vor allem auch den abgelegenen Dörfern und den Kindern widmen.

Wir sind gespannt und werden von der Reise berichten.

Nach dem Trinidad gegen Schweden Fussball match.

Jackson schreibt aus Bulongwa, dass er es geschafft hat meine Satellitenfernsehanlage in Betrieb zu nehmen, nachdem gestern der Strom wieder aufgedreht wurde. er sagt, das Haus sei voll und immer wenn ein langhaariger Fusballer zu sehen ist, dann sagen die Menschen "Dr. Rainer..." er denkt, dass sie mich vermissen - das freut mich, weil ich weiß wer mich vermisst.

Das Krankenhaus ist in großen Schwierigkeiten und so kommt es anscheinend zum Aufstand, Jackson schreibt, dass die Alten und die Dorfvorsteher gestern gekommen sind und dem Krankanhausmanagment den Kopf gewaschen haben. Sie haben gefordert, dass Mr. Uhagile und Mr. Mcheschi (angeblich Ärzte) das Krankenhaus verlassen, dass die Kirche das Krankenhaus hergibt und es den Menschen, der Community zurückgibt. Es ist nicht das Haus der Kirche, es ist das Haus der Patienten.
Amos ein anderer "Arzt" geht in ein anderes Krankenhaus, viele Schwestern kriegen einen Job bei der Regeirung, das Haus scheint zu sterben und die Menschen auch. Die HIV/AIDS Patienten leiden und die Angehörigen solidarisieren sich - wer hätte das vor einem Jahr gedacht.

Vielleicht war und ist dieser Kampf notwendig damit ein besseres und größeres Projekt entsteht und der Kampf gegen die Krankheit und für die Menschen richtig begonnen werden kann, ohne ständig gegen eine verlogene und korrupte Kirche zu kämpfen!

Auf jeden Fall haben die Alten gefordert, dass der Strom zu den Häusern der "Feinde" des gefeuerten CTC Teams sofort wieder angeschlossen wird. Das Kraftwerk ist im Besitz des Krankenhauses. Das ist auch geschehen und nun regiert in Bulongwa, wie überall auf der Welt: König Fussball!

Meine Öffentliche Darstellung der Ereignisse am 12. April, dem Tag an dem ich aus der Klink gesperrt wurde:

Statement regarding the lock - out of Care and Treatment Clinic (CTC) Staff at Bulongwa Lutheran Hospital
Bulongwa / Makete / Iringa Region/ Tanzania

Dr. Rainer Brandl, MD, MO in Charge at Bulongwa CTC under the NACP/MoH of Tanzania

Background and history:

The Care and Treatment Clinic (CTC) at Bulongwa Lutheran Hospital (BLH) has been in place since December 2004 and is working as an approved site of the National AIDS Control Programme (NACP) under the Ministry of Health in Tanzania. The government decided to designate BLH as one of the first “quick start” sites in the country.

This decision followed the presentation and lobbying for the “HAART programme” (written down in a proposal designated as “A Comprehensive Approach to Treat HIV/AIDS due to the Invention of Modified DOT-HAART (Directly Observed Therapy with Highly Active Antiretroviral Therapy)” during a period at the end 2003 and beginning of 2004. This representation work was organized by the Evangelical Association for World Mission (EAWM) / Austria in close cooperation with local stakeholders like the Makete Development Association (MDA) and BLH Hospital management, following discussions with a number of Makete natives (In Dar Es Salaam and Makete district - including Bishop Shadrack Manyiewa of the South Central Diocese (SCD) and Hospital’s staff and officers).

The programme is legally owned and financed by EAWM and co-financed by the state-owned Austrian Development Association (ADA) a trust fund based in Lichtenstein along with many small private donors. The direct financial contribution of the local Tanzanian church to the programme turned out to be nil, though efforts to provide funding were promised during the preparation of the programme and it was stated by church officials that there were funds for HIV/AIDS work earmarked within the Evangelical Lutheran Church of Tanzania (ELCT) and the Christian Social Service Commission.

Since the very beginning of the programme and even during the planning phase there has been cooperation with MSF Spain (Doctors without Borders) which still supports the government CTC in Makete and BLH and previously did so at Ikonda Consolata RC Hospital (which is now running without MSF support).
Another fruitful direct local partnership was developed with Tanwat Company Hospital in Njombe and Ikonda Consolata RC Hospital (http://www.higlandshope.com/) and recently with a group of Canadians and McGill University in Montreal. There is also essential financial and technical support given by companies and non profit companies from Germany who are dealing with HIV/AIDS laboratory equipment and drugs (PARTEC and Action Medeor)

From the very beginning the local Lutheran Church (SCD/ELCT) turned out to be a difficult partner —almost nothing was respected of what was written down in the Memorandum of Understanding signed by the Bishop (Shadrack Manyiewa) and the BLH management (Dr. G. Mpumilwa) with EAWM as the main developer and owner of the programme.

At the time of the signing of the MoU, it was planned by EAWM to donate or hand over a self supporting and well working programme to the Hospital (BLH) after the initiating phase of three years. All the actions were intended to be carried out according to the rules of the NACP in order to facilitate future government support.

Shortly after my arrival at BLH, it was uncovered that theft and corruption and mismanagement of projects seems to be a long lasting problem at BLH and SCD/ELCT leading to management chaos as for example posts like Treasurer, Doctor in Charge and Administrator were either vacant or filled by persons who are suspects in the audit reports or untrained and inexperienced people or – equally problematic - by officers who repeatedly declared that they are not interested in the job. (e.g. the expatriate Doctor in charge, who agreed to fill the post on an interim basis for one month after the former Dr. in Charge was sacked - but remained in this post for more than a year while repeatedly protesting that he just doing the job out of a sense of professional responsibility and in favour of the bishop but not out of genuine interest).

Account Books were not kept properly at the hospital and fraud was facilitated through this neglect of normal administrative procedures. This situation was prolonged through the slow implementation of various external audits, which - in contradiction to former ELCT audits from ELCT Headquarters in Arusha - brought to fore that there is obviously a dark cloud of theft of donor monies hanging over the whole SCD.

The story was repeatedly taken up by the Tanzanian media and this brought the case up to the highest political levels of the country. Already summer 2005, the responsible bishop of SCD/ELCT in Makete gave interviews confirming the allegations of theft of 150 Million TSH at BLH.

Although the memorandum of understanding between EAWM and BLH envisaged that the financial management of the CTC should be done by BLH, the administrative chaos at the hospital made it necessary that I took on all the management of CTC finances, first by myself and later on by an Expatriate treasurer who was installed by EAWM in order to sustain the well working clinic. To me it appears that church authorities and colleagues in the hospital were interested in bringing the funds under their control in order to use them according to their own wishes instead for the intended purposes written down in the project.

Early 2006 the external audit reports done by independent auditors from Iringa (Ashvin Solanki & Company, certified public accountants in public practice registered tax & management consultants P.O.BOX 1537) and Mbeya (MOSES AB & COMPANY, certified public accountants in public practice, P.O. BOX 2412) unveiled embezzlements of about 200.000 Euro within 2003/2004 in SCD which led EAWM to the decision to cease a direct relationship with SCD and this was communicated early 2006 to the Bishop, and planned to come into effect as of the 31st March, 2006 for the Hospital and HAART programme, with an offer of technical cooperation and talks about the future of the CTC in order to ensure that the medical support of CTC patients would not be interrupted.

Neither the Bishop nor BLH management replied to the offer.

The auditor’s report about BLH is in possession of EAWM.

The incidence:

On 12th of April, 2006, in the afternoon an essential part of the CTC team partly working together for more than a year was denied access to the hospital. This was done through the use of force and without any preceding talks, warning or written statement. (A BBC freelance reporter) was physically present because of an announced community protest against the thefts in the church and witnessed the incident. His report was broadcast during the following day on BBC Kiswahili service and Focus on Africa on the English Service).

The watchmen locked the doors to the CTC and denied us access to patients (I went to my residence for 5 minutes, was body searched when I left the hospital and not allowed to enter the clinic again and the waiting patients were not attended state of the art):

Following staff were prevented by force from continuing their work:

Laboratory technician to run the cd4 counters and biochemistry testing: Barnabas Lwila
Assistant coordinator for clinic organization, prevention, outreach, social work and self helped group: Jackson Mbogela, BSc
Programme Treasurer: Erika Trojer
CTC leading Medical officer: Dr. Rainer Brandl, MD

Nurses Mauricia Msigwa as Secretary Rebecca Sanga refused to go on working without being guided by properly trained medical staff. Nurse Mary Musoma was on holidays. Later on the two nurses refused to go on working without the help of their experienced team (as they were asked to cooperate with the remnant staff and to tell the clinicians their knowledge about Antiretroviral Treatment (ART) and take over doctor’s responsibilities – which was a common practise anyhow that nurses admitted severely ill patients and making treatment decisions).

Through lack of knowledge, skills, reagents and internal quality control, patients could not get their cd4 - counts (Partec’s Cyflow and SL_3 green) and liver - function tests done. Both of the machines were working well when the trained staffs was forced to leave the clinic (The machines just came back from maintenance by the manufacturer in Dar es Salaam because both of the counters were not working for a short time due to uncommon and unusual problems documented by the manufacturer – both of the machines were exposed to laypeople as BLH management could not agree about safety procedures nor are they in place).
These laboratory investigations are essential requests to a quality HIV/AIDS treatment. Subsequently, drug prescriptions and treatment adjustments are in jeopardy again because of lack of knowledge, skills and experience in proper patient follow-up. This situation seems to have continued up to the present date, though MSF representatives told me that they are willing to support the clinic with one clinical officer in order to help prescribing the ART. I was told that at this stage MSF announced this support only to continue to the end of June. Some cd4 counts for newly registered patients are reportedly done at Ikonda Hospital (Partec’s Cyflow) and paid by 6000 TSH each, the intended funds can not be used at BLH at present. Cd4 monitoring of patients on HAART is not done according to reports from patients since (This has to be done about every 3 months according to WHO/NACP and following clinical monitoring HIV/AIDS staging).

There was no official reason given to EAWM or the CTC leading in Charges explaining the lock-out and it is not clear to us who was responsible for the decision to change the whole clinical team at the CTC from one instant to the next. There is no medical doctor at BLH who is trained by NACP and has the right to decide about prescriptions of ARVs or to lead a CTC.

Also it was not officially announced and unclear who was the official doctor in charge of Bulongwa Lutheran Hospital at this moment as the former Expatriate in Charge resigned from the post earlier. (There is only this Doctor and I who are holding a medical degree).

As an experienced HIV/AIDS medical doctor under resource limited settings and as advocate for my patients, I strongly protest a situation where it is possible at BLH for people who are not trained as medical doctors to be allowed to interfere treatment decisions that jeopardize the life of my patients.

In the evening of the same day as the lock-out took place, about 20 – 25 heavily armed policemen came by car in the same moment I was allowed by the general secretary of SCD to enter the hospital and take out my private property like my medical text books and my personal laptop. I felt that this was intended as a threat – though the leading police officers were very friendly and asked me if I feel safe. What should I fear to need protection by the police? During the next day the hospital was guided by heavily armed police and we were still not allowed to enter. I left the district on request of my mission EAWM on the day after the incidence to Dar es Salaam and later on home to Europe.

At present there are only two staffs at BLH who have been trained by the National AIDS Control Programme – but neither has been regularly participating in the clinical routine of the CTC at earlier stages and sometimes they have not been willing to take on their duties. The struggle to get clinics working and maintained by NACP trained staff and led by an MD was severely set back by locking out what was an experienced and very effective working team.

The CTC has not been working according to the regulations and guidelines of the NACP since 12th April, 2006. Though the remnant staffs of Assistant Medical Officers are obviously not acting under the statutes of BLH, they claim that the clinic is working properly; reportedly they even said this to the Minister of Health when he visited BLH at the directive of the Prime Minister. I have received contradictory information from Bulongwa CTC patients who say that laboratory monitoring is not being done in the proper way (We know as well that reagents have run out and there is no procurement system organized by BLH at this time).

NACP assessment visitors told us early this year, that they are satisfied with the performance of Bulongwa CTC and they were especially impressed by the fact that the CTC was able provide cd4 tests and biochemistry in a very short time (sometimes within one hour, but most of the time at least on the same day) while we were told that some bigger clinics sometimes took up to 14 days to provide results.

Here are some figures for the CTC up to April 2006 (the clinic treated the first HIV patient December 2004):

Registered HIV patients: about 630 (with several children)
HIV patients under ARVs: about 260
VCT done: more than 1100

(Accurate numbers can be obtained from the FUCHIA computer programme of MSF or the files of NACP/MoH provided the privacy and confidentiality of the patients is not touched)

These patients were being monitored for cd4 and liver function on a regular basis.

The equipment at the CTC laboratory is worth about 50.000 Euro and in danger of being mishandled by inexperienced staff and consequently destroyed. Lack of maintenance and proper internal quality control and lack of critical interpretation of laboratory results can lead to improper results, leading to treatment decisions that may endanger patients’ lives.

The week after the action against the clinic, I had a long talk with the Minister of Health about the situation at Bulongwa

Thereafter – on directive of the Prime Minister - the Minister of Health went to Bulongwa/BLH and it was reported that he talked to BLH staff (the hospital has no leading MD in charge as Dr. Hans Reichold has resigned), to PIUMA (the local HIV self helped group) and church as well as district authorities. The outcomes of those discussions have not yet been communicated to us officially. We have heard that efforts seem to be underway to create a new CTC in Bulongwa under the strong participation of PIUMA and there is the idea that EAWM can partner them in close cooperation with the district counsel.

Foreseeable challenges for the Bulongwa CTC:

At present the knowledge and experience about second line regimens (the drugs you have to switch to in case of resistance or long term side effects to the available single pill ARV drug combination) and expected treatment problems is very poor as most the present staff has neither been trained by NACP or participated the regular in house training nor took part in the daily routine of the CTC before they took over.

The CTC/HAART team started to think about unavoidable treatment situations and had already taken efforts to prepare for these difficulties. There is a vast experience from other countries (e.g. Thailand, which I visited – on my private pocket - end of the last year) that were using the same regimens since years and have nowadays changed away from most of the drug regimens Tanzania is currently using. This is a normal process and nothing special at all, but teams have to be prepared for these eventualities in time and these situations have to be dealt with by experienced staff. International experience suggests that for effective long term care of HIV/AIDS patients, a stable relationship between doctor and patient is absolutely essential in order to succeed in the AIDS treatment marathon.

The present remnant staff at BLH had no sense of the danger and future problems of HAART or how to deal with them as they did not attend regular trainings and group counselling were the patients were prepared for such eventualities and the CTC staff was trained on the job.

Likely this year, the issue of Stavudine (d4T) and lactacidosis, (clinical monitoring, monitoring by laboratory parameters, lactate) and lipodystrophia will be especially pressing and could become life threatening for patients who are not properly monitored.

Other issues are resistance to NVP and consequently EFZ through Prevention of Mother to Child Programmes not carried out with high quality standards (The way forward is PMTCT+ and planned treatment interruption which we already started at BLH and is now ended).
Mothers with high cd4 are susceptible to lactacidosis especially when using d4T (for PMTCT+ and planned treatment interruptions after weaning) and have to be followed by experienced staff.

These are challenging situations for the future and we had started to prepare for them with suppliers, manufacturers (like Partec in Germany and Action Medeor) and colleagues from abroad (Austria, Canada, Thailand) who are willing to help through their expertise by direct and Internet consultancy.




Dr Rainer Brandl, MD Vienna, 10th May 2006