A ‘Life-Changing’ Experience: CU programme brings Zimbabwean doctors to Colorado

By Tayler Shaw | news.cuanschutz.edu

For the first time since the COVID-19 pandemic, two doctors from Zimbabwe visited CU through the Department of Medicine’s Colorado-Zimbabwe International Exchange programme.

UNITED STATES: When Zimbabwean doctors Melinda Munemo and Tendai Mando watched surgeons in Colorado remove a failing heart from a patient and replace it with a healthy one from an organ donor, their eyes filled with awe.

“When they took out that heart, I could not believe how weak and thin the muscle was. If that patient was in Zimbabwe, they would have died in a few months; but in Colorado, that patient is alive and has years ahead of them,” Mando says.

Witnessing a heart transplant, a procedure that is typically not possible at the hospital they work at in Zimbabwe, was one of a series of firsts for Mando and Munemo as they spent three weeks at the University of Colorado Anschutz Medical Campus as part of the CU Department of Medicine’s Colorado-Zimbabwe International Exchange (CoZIE) program.

This year is the first since the COVID-19 pandemic that doctors from Zimbabwe have visited CU through the CoZIE program, which has existed since 2015 and stems from collaborations dating back to the late 1990s.

Under this bilateral exchange program, CU Department of Medicine residents and faculty visit the Department of Internal Medicine at the University of Zimbabwe College of Health Sciences (UZCHS), and UZCHS faculty and postgraduate trainees visit CU. Through this mutual exchange of doctors, both universities gain global insights and expertise that serve to elevate patient care.

For Munemo and Mando, who recently completed their senior registrar year at UZCHS, the nearly month-long trip allowed them to further explore the subspecialty of cardiology — a pressing field given the prevalence of cardiovascular health issues in Zimbabwe. They spent time shadowing CU faculty as they followed hospital rounds, observed teaching sessions of young doctors, and witnessed advanced procedures they previously had only read about in textbooks.

“I’ve gained so much from this program in every aspect — in terms of medical education, the welcoming environment, interactions with colleagues, and the culture here,” Munemo says.

Mando agreed, saying: “For me, this experience has been life changing and has imprinted in my mind that us physicians in Zimbabwe can do more so that our patients can live longer and better.”

When they were not learning from CU doctors, Mando and Munemo were living with CU faculty members like Thomas Campbell, MD, getting a taste of the day-to-day lives of Colorado doctors. Campbell, who has been involved in the CoZIE program since its origin and visited Zimbabwe more times than he can count, says it has been fantastic to see postgraduate trainees from Zimbabwe back at CU after the interruption COVID-19 caused.

“I think the greatest benefit of this program is we are working to improve health equity worldwide,” says Campbell, a professor of infectious diseases in the CU Department of Medicine. “By improving health care in other parts of the world, we improve health care for all of us. That’s really the basis for the program.”

The value of — and need for — subspecialty training 

A benefit of the CoZIE program is it offers training opportunities to Zimbabwean doctors on medical subspecialties such as infectious diseases, gastroenterology, hepatology, and cardiology.

“There are very few subspecialty training programs in Zimbabwe and, therefore, not a lot of subspecialists. Zimbabwean doctors have patients with these conditions, but they don’t have the opportunity to consult a subspecialist like we would in Colorado, so they have to be able to take care of the problems themselves,” Campbell says.

“Tendai and Melinda are interested in cardiology, but there’s not a cardiology training program in Zimbabwe. To get that type of training and certification, they would have to go out of the country.”

There is a need for cardiologists in Zimbabwe as issues like heart failure are becoming more common, Munemo explains.

“Health issues like hypertension and diabetes are on the rise in our country, following global trends. Therefore, complications have resulted from these, with heart failure and heart conditions being the top of the list,” she says.

“Being in cardiology will push me to help my country, especially in a field where there are not many subspecialist doctors. The fact that it’s one of the most common conditions in the country and there is a need are some of the reasons why I love cardiology.”

For Mando, her interest in cardiology sparked during an internship in a hospital, where she met a cardiologist who exposed her to the subspecialty.

“I’m drawn to cardiology because there are so many things you can do that will help the patient immediately,” Mando says. “I felt it was a field where I could have an impact, reduce mortality, and make a difference.”

Given that Mando and Munemo excelled as students growing up, they were encouraged to become doctors from a young age. As Munemo says: “If you do well in school, you are expected to pursue engineering or medicine.”

Both Mando and Munemo worked in the Parirenyatwa Group of Hospitals, the largest public hospital in Zimbabwe, and finished their senior registrar year in August.

“There are many things I’ve had an opportunity to get exposed to in terms of cardiology over the past year as I was doing my senior registrar, but there is still a lot that is non-existent in our country,” Mando says. “I very much looked forward to coming to CU because it meant I could get exposure to things that I otherwise would not have had any exposure to.”

Sampling the CU experience 

For their first two weeks at CU, Mando and Munemo shadowed doctors in the cardiology critical care unit and those working with heart failure patients. They followed along on hospital rounds, joined discussions and teaching sessions, and observed a variety of procedures.

“I had never gotten a chance to see a contrast echocardiogram or a pharmacological stress test, for example,” Mando says. “Now that I’ve watched these procedures, I have an understanding of how it actually works and can think of ways to transfer what I’ve learned here to improve the service we give to our patients back home.”

Munemo agreed, adding: “Oftentimes, we would read about these in books — but getting to see the procedures being done, it was amazing.”

For the third week, the doctors joined the internal medicine team, joining their hospital rounds, participating in discussions, and observing procedures.

“Many of those procedures were ones we also perform at home every day — but just watching the differences between how we do it and how CU does, it helps us to pick up certain things that we can try to adopt in Zimbabwe,” Mando says.

Munemo and Mando also offered their expertise to CU faculty and students. For instance, they each presented cases that they commonly see in Zimbabwe.

“It was a nice opportunity to give CU doctors a feel for the types of conditions we see,” Mando says, noting that she also would love to help with teaching clinical examinations. “One thing we do very well in our country is clinical examination. We don’t have fancy investigation tools at our disposal, so that means we have to be very sharp in terms of patient history taking and clinical examination so that we are able to come up with the same diagnosis without as many investigations.”

Charting differences and similarities  

Two main differences Mando and Munemo noticed between CU and the University of Zimbabwe were CU’s greater access to resources to perform advanced procedures and the different approaches to teaching future and early-career doctors.

“One of the first things I noticed is the way the teams interact. I feel there’s a lot better teamwork and communication here,” Mando says.

For instance, she noticed that during hospital rounds, CU medical teams would generally meet and develop a treatment plan for their patients before they visit the patient.

“Back home, we walk into the ward and immediately start rounds right there, in front of the patient, and we’ll discuss back and forth, telling each other the results,” Mando says. “I feel that the approach at CU is better — to discuss on their own and come to the patient with a solid plan — because there’s no confusion that way.”

Munemo describes the teaching environment at CU as welcoming and less hierarchical, allowing for more interaction between higher-level and lower-level doctors.

“It allows students to ask questions and be corrected when they’ve done something wrong,” Munemo says. “It made me want to change my teaching style, as that will make a big difference in terms of training back home.”

Mando adds: “I feel like CU’s teaching program probably encourages students to step up in terms of confidence early on in their training, which is something I think we’re failing our students on. At CU, there is a lot of positive feedback. Our teaching system is based more on negative feedback.

“It made me realize that our students probably know as much, but they don’t have as much confidence because we don’t reassure them. We don’t give them enough positive feedback.”

Although there is more limited access to certain medical technologies in Zimbabwe compared to Colorado, the managing and caring of patients between both institutions are similar.

“I’ve seen that, in terms of managing our patients, our hospital in Zimbabwe is probably not far off from where CU is, which is something that really encourages us,” Munemo says. “We do not have the big machines, we do not perform the big procedures, but in terms of medical management itself, we are doing very well as a country and as a hospital.”

The roots of CoZIE

Campbell has visited Zimbabwe more than 20 times over the past 26 years, and it was his partnerships with colleagues in Zimbabwe that planted the seeds of what would eventually become the CoZIE program.

“The connection with the University of Zimbabwe started in 1998, when I proposed some research collaborations in HIV with my colleague, Dr. Margaret Borok, at the University of Zimbabwe,” Campbell says. “What we proposed were some collaborations to improve the research capacity in Zimbabwe in the Department of Internal Medicine.”

Then, in 2010, the National Institutes of Health (NIH) released a request for applications to improve medical education in African medical schools as part of a program called the Medical Education Partnership Initiative (MEPI). As part of the application, the schools were required to have external partners, and so the University of Zimbabwe asked CU to be a partner in improving medical education.

When CU cardiologist and professor Ed Havranek, MD, saw an email in his inbox from Campbell asking if anyone would be interested in helping write the grant application, he decided to volunteer.

“We got the grant in 2010, and in November, I found myself on a plane headed to Zimbabwe having never set foot there before,” says Havranek, who is now the director of the CoZIE program.

“At the time, Zimbabwe had just experienced a hyperinflation, and the consequence was that many doctors left the country. This grant was about rebuilding health care capacity, so we came in to help teach medical students, hold conferences, and do some clinical teaching with doctors,” he adds, explaining CU faculty members visited Zimbabwe for weeks at a time to help enhance the training of physicians.

In 2015, the program ended, but faculty in Colorado and Zimbabwe recognized its value.

“That is what led to the idea for CoZIE, as a continuation of the improvement in medical education. It was established by a joint agreement between the institutions,” Campbell says. “Since that time, it has functioned to do that bi-directional exchange of doctors with the purpose of providing the opportunity for CU internal medicine residents and faculty to experience medical care in a large tertiary hospital in a metropolitan area in Harare, Zimbabwe. For Zimbabwean doctors, it proves the opportunity to come here and experience medical care in a large U.S. academic hospital.”

Planting a tree

Reflecting on how CoZIE has evolved, Havranek likens it to seeing the growth of a big oak tree.

“You have to think about this program as if you are planting a tree. You may not be around when it gets to its full height, but you planted it — that’s what you have to latch on to,” he says.

It’s this type of mentality — to take steps now that will benefit future generations — that early-career doctors like Mando and Munemo are adopting.

“As Dr. Havranek said, when you plant a tree, you may not be able to enjoy the benefits immediately, but people later on will enjoy it. That inspired me to say that I can help kickstart the process to help my country start taking small steps to invest in getting advanced medical therapies in Zimbabwe,” Munemo says. “We may not be able to see it come to fruition, but at least we can set up the foundation for the future.”

Munemo and Mando both hope to pursue fellowships in cardiology, driven by a goal to improve the level of care in Zimbabwe.

“When I saw the advanced heart failure therapies that CU is able to offer, it made me think of our patients back home who are facing end-stage heart failure. We’ve got them on the best medical therapy, and they’re still not doing well,” Mando says. “It’s easy to be complacent and think that’s all we can do. But to see a heart transplant and how much of a difference going that extra mile makes for that patient — back home, you’d have thought this was a death sentence and you’d accept that the patient is going to die within a short time. To see someone in that same state in Colorado going on to live — that’s really amazing.”

Mando explains a barrier to increasing access to advanced therapies and procedures is resources, saying: “It will be an issue of collaboration, not just amongst ourselves as professionals, but especially the hospital and the Ministry of Health and Child Care of Zimbabwe. It takes funding to make the kinds of things that are needed available.

“But if we could start with things like an electrocardiogram machine being available in the emergency department, simple things like that would make a difference. Those are the sorts of things that we can lobby for that do not require too much in terms of resources, but will go a long way,” she adds.

Reflecting on their three weeks in Colorado, Mando and Munemo express gratitude for the opportunity to learn at CU and excitement to implement the lessons they’ve gained at their home institution.

“It’s been a great and eye-opening experience,” Mando says. “I feel like I’ve matured in the three weeks that I’ve been here — not only as an individual, but I feel like there is so much more I can give and offer because of the experience I’ve had here.”