James Strickler Clinical Elective in Global Health Alum
Current Title and Organization/Affiliation (as of June 2025)
Family Medicine Resident Physician (PGY-1) at Mountain Area Health Education Center in Hendersonville, NC.
What was your most significant/meaningful global health experience at Dartmouth, and how did this experience prepare you, professionally and/or personally, for what you are doing now?
My most meaningful global health experience was a month on the Infectious Disease wards and in the Emergency Department at the Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania. There, I saw illnesses we never or rarely encounter in the U.S., such as disseminated TB or AIDS related infections.
I worked side by side with Tanzanian-trained clinicians, which taught me a lot about differences in system resources and training curricula. Not only did I gain medical knowledge, but I also gained experience working with limited resources. I relied much more heavily on my physical exam skills in Tanzania, where the decision to pursue imaging can be complicated by machine malfunction or unavailability. As a current resident working in a community hospital rather than a large academic center, I spend a lot of time reflecting on my time in Tanzania and on the different ways we make our healthcare systems more or less accessible and patient-centered.
What are your thoughts on the future of global health equity education and/or practice?
The future of global health equity currently feels quite threatened by funding cuts to institutions such as USAID and NIH, as well as by trends that push us to become more disconnected from one another. However, as someone training to be a rural family medicine doctor, I believe more than ever in the importance of a well-trained workforce and well-designed infrastructure across the country to ensure the health of populations from birth to death. As I continue residency and career planning, I know I will find like-minded healthcare professionals who believe in making primary care available to all as one of the many important pathways towards global health equity.
Personal Reflection
Muhimbili University of Health and Allied Sciences (MUHAS)
Dar es Salaam, Tanzania
Winter 2025
I was incredibly lucky to spend four weeks at the Muhimbili University of Health and Allied Sciences (MUHAS) in Dar es Salaam, Tanzania.
I arrived in Dar on Sunday afternoon after a multi-day journey. During the 20-minute trip from the airport, I got my first glimpse of Dar es Salaam and Tanzania. I watched from the front passenger seat (on the right!) as people walked by the road, tending to their everyday tasks and jobs, from construction to small shops to walking alongside kids. It was a warm day (and would stay that way!), and so when I arrived at the apartment my fellow Dartmouth students and I were renting, my winter coat found its way to the back of my closet.
Soon after, I started my two-week rotation on the infectious disease service. The wards are divided between male and female wards. Many patients share the same large room, which was different from what I was used to in the US, where patients are often in their own rooms, but without access to an open window. At MUHAS, a nice breeze flows throughout the wards, helping with the temperature control and infection risk mitigation. Many mornings started with some formal teaching, such as case presentations or Mortality & Morbidity conferences. Afterwards, we would go to the wards and pre-round on our patients. Every day, we rounded on the patients in both English and Kiswahili. I took some beginner Kiswahili classes in college and was glad to be able to use the many greetings I had learn years ago. I was very lucky to spend time with Tanzanian medical students, who graciously translated the patients’ histories and questions into English for me. After rounds, we transcribed our notes into paper records. What an added responsibility to make sure your handwriting is legible when you can’t rely on autocorrect!
We saw many patients with HIV who had progressed to AIDS, sometimes due to not being on treatment and sometimes due to treatment resistance. It was my first time seeing patients with conditions such as cryptococcal meningitis. It was incredible to watch somebody progress from having a severely altered mental status to being able to answer questions about how they were doing on rounds. It was also difficult to see young patients with such a high burden of disease. Although my Kiswahili was good enough for simple greetings and a basic physical exam, I regretted not knowing enough to have a meaningful conversation with patients about their experiences of their illness. During this time, I also learned how patients pay for care. Patients sometimes have private insurance but are often uninsured. When they are uninsured, they (and often their families) must deposit funds to pay for services before diagnostic testing or treatment can proceed. This also means that patients' financial status is often discussed during rounds when deciding on treatment.
I spent my last two weeks at MUHAS in the emergency department (ED). The ED was established in 2010 as the first full-capacity emergency department in Tanzania. This rotation was quite different from my sub-internship experience at large US academic medical centers. In the morning, we would round on every patient still in the emergency room, which was an opportunity for students to be tested on their knowledge of diagnostic criteria, testing modalities, and treatment. I appreciated the chance to discuss patients and potentially observe interesting physical exam findings during rounds, rather than the brief sign-out I am used to at change of shift in the US. I also participated in a mock code, which included a thoughtful debrief with everyone in the room.
As with the wards, patients often share a room, supervised by a ward attendant. Because MUHAS is a tertiary center, many patients come in as transfers from outside hospitals (sometimes from very far away!) already diagnosed, so we saw fewer undifferentiated patients. Just like in the US, when a new patient came into a room, I would often help place them on the monitor and get vitals. Unfortunately, there are often equipment glitches in the ED, and there are only a limited number of monitors, so several patients are often attached to the same monitor. There were a few scenarios in which one patient’s SpO2 was displayed on the same screen as another patient’s heart rhythm. This was a creative way to solve the problem of not having enough monitors for each patient, but it required a lot of vigilance! In the ER, the consequences of the financial system were also more noticeable. Sometimes it felt like a long time before a patient could access treatment because they couldn't collect enough funds for a deposit.
Many patients in the ER had some form of advanced cancer, often hepatocellular carcinoma and cervical cancer. In the US, we are often told that the HPV vaccine is on track to eradicate cervical cancer. In Tanzania, where access to the HPV vaccine has been more difficult than in the US, it was devastating to see so much ‘avoidable’ cancer. I felt a renewed sense of commitment to advocating for immunizations as life-saving interventions both in the US and abroad, and for better, cheaper access to medications and interventions.
I also spent some time in the pediatric ED during my last week. On the same day, I saw two very sick children with congenital heart disease, an 8-year-old with tetralogy of Fallot and a newborn with transposition of the great vessels. These patients were very sick and were transferred to the cardiac institute for management. I struggled the days after not having an electronic medical record to follow what had happened to them, a luxury I have gotten used to in the United States.
I spent a lot of time with MUHAS students discussing differences in emergency care between the United States and Tanzania, including centralized emergency services, financing, the role of primary care, the management of infectious diseases in the emergency setting, and training pathways. Students at MUHAS come from all over the country to study in Dar. They live in dorms close to the campus and spend a lot of time with their cohort and in the hospital. Many of them do not go home often, even for holidays, but were very generous in sharing stories and information about the regions they come from.
When not at the hospital, I was lucky to explore both Dar es Salaam and other parts of Tanzania. What a treat (and a welcome change from rural New Hampshire) to have vendors lining the street selling lychees, mangoes, jackfruit, and mysterious fruits. In Dar, some of our new friends took us on a tour of Kariakoo market, a bustling place where one can find food, clothing, kitenge fabric, tools, and anything you could possibly think of. The public transit enthusiast in me was thrilled when we took a dala dala (small bus) back towards campus.
Similarly, we had an amazing time exploring Tanzania. We rode a beautiful train from Dar to Morogoro, Tanzania, before taking a safari trip inside Mikumi National Park. We were incredibly lucky to see lion cubs and baby elephants, as well as countless beautiful birds! We also hiked in Udzungwa National Park, which hosts several primate species and the beautiful 170m tall Sanje waterfall. In Dar, I loved exploring the National Museum, which hosts a wonderful exhibit on human evolution. I also loved visiting the Village Museum, which was created to showcase different indigenous ways of life from Tanzania’s many tribes. Tanzania is one of many countries with a legacy of colonialism and a history of exploitation, and I enjoyed witnessing the many ways in which the people who live here fiercely protect their culture, care about their language, and want to improve the lives of their community.
My time at MUHAS coincided with the announcement that the US would withdraw from the WHO and stop funding USAID projects, which will likely have a major effect on the global health landscape. However, I left Tanzania with a renewed commitment to global health justice. A world where all of us have access to the best preventive, primary, and specialized care is one that is worth fighting for – together!
Thank you to the MUHAS staff, faculty, and patients for welcoming me to Tanzania and providing me with such a wonderful learning environment. I am deeply thankful to the Geisel Center for Global Health Equity for the opportunity, and even more thankful for my Tanzanian student peers, who generously shared not only medical knowledge and translated patient histories, but also their own stories, dance moves, and helpful tips on what to order from the cafeteria.
Asante sana! (Thank you very much!)
Photos and article by: Dr. Constance Fontanet, MED’25
