Return to Tanzania - 2011

Out Of Africa

I continue to try to digest this experience. In my last post I forgot to sum up our experience teaching at the school for assistant medical officers. For me it was the highlight of the month. By our third and final day of instructing them I was impressed at the basic knowledge they had managed to acquire. They asked very good questions and were so hungry for the answers that we spent much more time than planned working with them. Remember, in rural Tanzania there is little to do and these students live at the school. When they are not in class they are in the hospital observing and caring for patients trying, pretty much on their own, to figure it all out. They will not be doctors. They are way down on the totem pole but will be expected to function as doctors where no one else is available. They know that and are remarkably willing to accept that responsibility.

Early last week I had a conversation with Robert about the apparent lack of responsibility and initiative among the hospital staff. He observed that there are many words for the courses of action dictated by others but there did not seem to be a word in Swahili for internal obligation. So I set out to find whether that was true and it was Jasper who taught me the word “dharmia.” He said it was the word I was looking for. So, during my final session with the students I asked if they had ever heard that word. Everyone shook their heads in the affirmative and one girl said it meant “aim.” When I made a gesture of pointing a gun everyone laughed.  “No”, she said, ‘it means what you are going to do.”  So I asked where that aim was coming from. Was it because someone told you or because you just know you need to do it? She pointed to her chest and everyone agreed that the obligation came from there. I had found my word and, more importantly, I had discovered that the concept of personal responsibility was alive and well in these students. 

My final message to them was that they needed to take the concept of dharmia and put that first in their decisions in caring for patients. If you do that, I said, the right things will happen and you will make the system better. I truly believe that. These people are being trained in large numbers and if they can always be counted upon to do the right things according to their consciences it will be contagious. I also mentioned to Jasper that he should select a few of the best of this group and keep them at the hospital to run the wards. He said that it would be bureaucratic mountain to climb but he would try.

I am really anxious for our ATSU students to experience this environment. It's not only because they will encounter things that they will probably never see at home such as malaria, leprosy, bone and bowel TB, malnutrition and a host of internal catastrophes. They will  also learn what it is to deal with these problems with such limited resources that often all there is to work with is one's hands and heart. I hope I can make the foreign rotation idea work.  

The bus ride from Mbeya to Dar was even worse than anticipated. The bus broke down twice and the ten hour trip turned into almost fourteen. I would chronicle the absurdities of the journey for you but I really don’t want to re-live it. Grace and I are in Dar es Salaam now having treated ourselves to a nice hotel, some good meals and last minute shopping and a wonderful view of the harbor. The adventure is almost over. I have my boarding pass and tomorrow I fly out of Africa to meet Marcia in Paris to celebrate our anniversary. She’s been there for a few weeks working on yet another book. Our son, Ara, is joining us with his girlfriend, Iris, as his birthday is the same day. Iris is a Parisian and is there from the US visiting her family. She’s a really neat person and it will be great having someone with us who speaks French.

That’s it for this year. Will I be back? When I discussed it with Jasper he said I would have to listen to my own dharmia. He must have been thinking “Gotcha!”

Working My Way Back

Date 7/17   Posted 7/19

I left Sumbawanga this morning with mixed feelings. I was glad the time was up. I miss my home, my family and my life. I don’t think I am one of those people who are cut out for long term missionary work. Yet there is such a satisfaction in doing what no one else can or will do and watching the positive results; usually positive, except in the instances I have reported. Grace, Robert and I literally took over the hospital. Medical rounds have never been there with western intention and thoroughness and I have never had the extra eyes, ears and hands to facilitate my work.

We helped a lot of people and more importantly set an example to which the staff there can aspire. Did they all get it? Of course not, but if just a few can set change into motion the difficult and frustrating work will have been well worth it. Yes, there were more horror stories but I’ll spare you any further descriptions.

Robert is still there and will be for several months. Not only did we leave but his girlfriend, Marjon, will soon return to Holland. I’m a little worried about him being there alone. He takes his work very seriously and does not deal well with frustration. I’ve asked Jasper to keep an eye on him and try to smooth his way.

Speaking of Jasper, yes, we are still friends. He did go far out of his way to make things right after his return. I understand now that he was caught in a bureaucratic bind and it would have been unwise for him not to attend the conference. Those sort of administrative meetings there tend to be called on short notice and his boss really wanted him there. Jasper is eventually going to decide if he wants to be an effective medical director and surgeon or an administrator. Right now he has one foot in each camp and cannot deliver the kind of care of which he is capable.

Tonight Grace and I are in Mbeya courtesy of a 180 mile hospital Landcrusier ride on a road you don’t even want to think about. We're wondering if we will decide to return to Tanzania. I believe she has had a really good first experience in the third world, understands the need, and has found that she can be effective. We’ve talked about bringing some of our students next year and perhaps other physicians and surgeons. This could grow to be something big. As for me, I’m not getting any younger and am feeling a bit burned out right now.  But the human mind has a wonderful capacity for allowing us to forget discomfort or pain so I expect that by January, when life has again become routine and it’s time to start planning the trip again, I’ll probably be on board. So many good writers have described the way this continent really gets into peoples’ psyches and draws them in. It’s so true.

We’ll kick around Mbeya tomorrow visiting the markets and I’ll try to again photograph the enormous outdoor Sunday mass down the street from the hotel. Later I’ll seek out the little orphan girl, Prisca, that I met during my first visit. Then it’s the bus ride from hell to Dar es Salaam

The Positive Stuff

Since we returned from the weekend it has been non-stop excitement around here for Grace and me in our respective departments. She is fighting a constant battle to get tests done and medication administered properly. It is a quixotic task to be sure and she’s giving it her very best.  Today she and Robert discovered a man in the far reaches of a medical ward who had been misdiagnosed and desperately needed surgery for, you guessed it, an intestinal perforation. Their alertness enabled me to get him operated early and he should do well. I’ve had some interesting and less desperate cases to do which have worked out well and have left some happy people in my wake.

The highlight of the week has been our teaching program. There is a school here for assistant medical officers. Those are individuals who are third down in the hierarchy. There are physicians, medical officers who are equivalent to our PA’s (not really) and then the assistant medical officers or AMO’s. They are the ones who are sent out to the dreadful little dispensaries in remote villages and are all there is between life and death literally for millions. They have 20 months of training over two years. We encounter them in groups on hospital rounds and they are very attentive. Their English is spotty; some better than others and the better ones will ask questions, often good ones, and share the answers with their fellows in Swahili. I’m amazed at what some of these kids know. They are putting together concepts in much the same way, albeit much simpler, ways that our medical students do at home with infinitely less resources. Their books are in English which makes it so hard for them. I don’t know what language their regular lecturers use.

Last week we set up a schedule to go to their classrooms and give formal presentations. We started yesterday spending two hours. Grace and Robert covered basic neurological and chest evaluation and I spent time showing them how to evaluate the abdomen to diagnose peritonitis and obstruction. The emphasis was on making the diagnoses early and getting the patient to the right place. We went back today and I covered basics of wound closure and burn treatment. I haven’t decided yet what I’m going to talk about tomorrow.

So that’s the news for now. There are just two more days of work here for us before we leave on Saturday. We’ll be in Mbeya and then a decompression day in Dar es Salaam before heading out of Africa. There will be time then to sort all this out and try to make some sense of it. I’ll post some final comments as I travel.

 

Chemistry 101

Remember in high school when we learned the periodic table and covered those low level elements sodium, potassium and chloride? Simple stuff really and those of us who went on to the biosciences came to appreciate the role these elements play in maintaining us as organisms. For about a hundred years medical practitioners have understood that their delicate balance is crucial in determining how our cells behave. We know that our kidneys can do a reasonably good job in making sure we retain enough sodium and chloride. They do not do so well with potassium and when there is a significant loss it needs to be replaced. This knowledge has not yet reached Sumbawanga or, I’m told, any hospitals outside the capital. So begins a sad story.

I saw a young man named Giles yesterday who had been ill for about a week. He had gone through the usual routine of traditional healers and incompetent medical officers and finally came to my attention. I got him on the operating table as soon as possible and found the expected typhoid-caused intestinal perforation which we closed and drained in the prescribed fashion. This type of operation which would be a rare and ominous event in our world is a three or four times a week here so as to be just about routine. The crucial issue is how long they have been sick and how much intestinal fluid, which is potassium rich, has been lost. In this case the loss was substantial, about two liters which we drained from his abdomen. The operation was uneventful, except that we had to close the abdomen by cell phone light because the electricity went out. That was an inconvenience but did not contribute to the result. The outcome was that the boy had a cardiac arrest and died as he was coming out of anesthesia. He arrested because his potassium level was so low that the transmission of electrical impulses in the heart was disturbed. That’s what happens when there is no way to replace the loss. This situation doubtlessly played a role in the other two deaths I have reported in very ill peritonitis patients. The tragedy here is that the concept has not been grasped by the medical community here. For four years I have been pleading with them to acquire some potassium compounds for replacement. They are not expensive but the powers that be simply cannot grasp the need to have them on hand. They also refuse to acknowledge the need to expand the availability of IV solutions beyond the very basics. “After all”, they say, “fluid is fluid, right?” Tell that to Giles’s family. He was fourteen years old.

A Great Weekend And Back To Work

I´m looking out over Lake Tanganyika after a wonderful two and a half days.  Somewhat sadly we must leave what I am now convinced is my favorite spot on the planet.  Chris and Louise Horsfall continue to provide world class hospitality at a most remote, unlikely and uniquely beautiful place. The Lakeshore Lodge is located on the eastern shore of the lake near the town - really a fishing village, Kipili.  As African towns go Kipili is among the poorest, giving no hint of the special piece of paradise that lies a few kilometers down a narrow ribbon of jagged rocks that passes for a road. On day one we journeyed to the Katavi wildlife park for the always delightful encounter with the usual suspects - giraffe, hippos, crocodiles, impala, lots of elephants, warthogs, water buffalo and zebra.

 Day two included an eight kilometer round trip kayak expedition to a small island for snorkeling in perfectly clear fresh water among thousands of beautiful cichlids and other fish. It was rather like being in a huge aquarium. The rest of the time has been about lounging around at the Tahiti-esque main lodge gazing at Congo way off at the horizon and listening to the small waves lapping on the beach.  All this, of course, complimented by a bountiful selection of wines, beer and hard stuff to bring each of us to the proper level of mellow. Ive written about the physical aspects of Lakeshore before and I would refer you to the posts of July 14, 2008 and July 15, 2009 for a more detailed description.

Now we pack up to return to Sumbawanga for what promises to be a fast paced week. I scheduled  a bunch of cases so we can fnish the visit with a flurry of activity.   Hopefully the anesthetic agents will have arrived and we can get the kiddie hernias done as some others that have been waiting around. Things have got to look better after such a delightful respite.                                    

Follow Up

I finally found a working wireless connection, sort of, and I may be able to squeeze out enough band width to get this posted even if it looks weird. This is the folow up to that dreadfully depressing post I made the other day. Yes the boy, Edward, died but we all did our best and must move on. Several successful surgeries since have made life easier. I will post again some time next week if possible.

I’m back at the hotel. It’s about 6PM and I’m feeling badly about the rant that I posted this morning. Oh it’s all true and maybe even worse. But what’s the point? It is what it is and I’m here to do the best I can with what I’ve got. A good friend whom I respect got me started on the saying “All you can do is all you can and all you can do is enough.” I’ve got to stay in that space. Yes, the kid’s still alive and I’m sitting here sucking down my second half liter lager and tomorrow will be another day.

So why be here at all? I think I owe you a visual. We’re six degrees below the equator at about 6000 feet. It’s the middle of winter and the weather is glorious, delightfully warmed by the sun in the daytime and chilled in the evening to a perfect October New England night – except it’s different. The air has a sharpness and tingle to it that I’ve never experienced anywhere else. There are exotic wild flowers, some of them huge, growing everywhere and when the sun rises behind a mysterious mist each one is a lightshow of its own. Somewhere around three in the afternoon the light abruptly changes into a golden glow reminiscent of Provence but, again, different. It has a special radiance to it and any object that is backlit develops a surreal aura. The clouds kicked up from the dusty streets create a path of sunbeams that seem almost like a painting. I’m still trying to figure out how to capture that with a camera. The people here are among the warmest, most gentle and childlike I have met anywhere. This is not true for all of Africa or even Tanzania but this area, for all its cell phones, internet, etc. still remains aside and apart and mostly uncorrupted by the modern world. We are still stared at by the children which is fun and the adults are so anxious to communicate, practice their English and teach us their language. Other than that unpleasantness in the bus station the other day I have never encountered a negative vibe from anyone. It is a non-confrontational society which can be frustrating at times but certainly makes one feel comfortable and safe. Things will change soon. For years I have been writing about the need for a paved road between Sumbawanga and the outside world. It is happening now.

It will change the character of the town and take away the innocence of the people but the tradeoffs are necessary in regard to quality of life. Matching funds have come from the USA and other countries to finally do the job. Crews from China and the UK are already on sight and work will begin in September. The chief of the UK company is staying at our hotel. His name is Nigel and he is a portly man in his 60’s who has already shared with us that this is to be his last project. He needs to do one more before retiring because he has taken such a beating in the stock market. I know he was into serious business when they rolled a huge safe into his room. His local payroll will be all cash. I asked him if we need to worry about bandits coming in with AK-47’s and he assured me that at first contact he will help roll the safe into their truck. On other fronts our Dutch internist, Robert, has been joined by his girlfriend, Marjon. She is a lovely lady of perhaps 55 who seems to suit him perfectly. Robert has been traveling the world for the last four years working with various organizations for six months at a time. He’s hard to figure out. He seems to have unlimited funds stemming from a furniture company that he sold in Holland. He went to medical school at age 42 and has been traveling since finishing his training. He is compulsive about patient care and carries on constantly about the conditions here. Grace and I have both had occasion to tell him to quit whining and just get on with it. He accepts it good naturedly. Jasper should be back at work in the next day or two. I plan to have a few words with him about abandoning me with no organization. But in the end he will apologize obsequiously and go about setting things right which is all I really want.

Tomorrow will be about getting some fairly minor cases done – if the proper anesthetic material arrives from another town – and working on the program for the students. We’re looking forward to next weekend at the Lodge at Lake Tanganyika and day at Katavi wildlife preserve but there’s much to do before then.

This is Marcia, Dr. Skip's wife. Internet service is down in Sumwabanga so he may not be able to post for a while. Thank you for all your supportive comments. We appreciate them.

This is Marcia, Skip's wife. He called this AM to say the internet is down in Sumwabanga and he doesn't think he'll be able to post for a little while. I've read your comments and he will find them so supportive. Thank you so much. Knowing others care is encouraging. We appreciate you.

It Just Gets Worse

I had originally prepared a post for today though somewhat grim still had the upbeat sort of attitude that I have managed to maintain during my visits here. The last 24 hours has taken the wind out of my sails and left me thoroughly discouraged.

A young boy, horribly sick was brought to the hospital the night before last. He had peritonitis but his blood count was so low and he was so dehydrated that we postponed surgery until the morning so we could resuscitate him. He had been treated by a local witch doctor (I am no longer going to use the polite term - traditional healer) for ten days and it is only the strength of youth that permitted him to survive this long.

At surgery we found a hole in his stomach about the size of a quarter and the medically trained among you can imagine what the inside of his abdomen looked like. We got through the surgery with the anesthesiologist pushing us to finish because he was RUNNING OUT OF ETHER AND THERE WAS NO MORE TO BE HAD! The patient was literally awake as I was closing the skin. There had not been time to adequately irrigate the abdomen so the job was incomplete. I did manage to place drains appropriately.

Overnight the nurses had let his IV lines dry up so he did not get the needed fluids and blood. The dressings were soaked and unchanged and antibiotic administration had been incomplete. In the morning he was a mess. I spent the morning starting new lines and cleaning up but it does not appear that he is going to make it.

This incident is representative of the problems here. There is simply not the will to do things right nor the capacity to teach people to change. The bottom line is that no one except Grace or me cares whether the patient lives or dies so there is no support to our efforts. Oh, and speaking of Grace, she did a fabulous job 1st assisting in a very difficult situation.

To compound the situation my local counterpart, Dr. Nduasinde, left us on day one for a "few days" and has not returned nor do we know when he will. He was supposed to be my interpreter and was to have pre-scheduled cases. He has done neither. I have considered him a friend but now am quite suspicious of his motives.

I will persevere for the week and then go to the lake for a long weekend. Things have to get better.

Another Day, Another Frustration

You would think that after all the time I’ve spent here that I would get used to bad outcomes that are beyond my control. Not so. It still hurts to lose a patient that you know would have survived under better circumstances. The first case I operated was doing well until she suddenly deteriorated and died over an eight hour period. She had had peritonitis and that means she was depleted of protein and potassium, among other things and there was simply no means available to replace them. I’m not talking about sophisticated stuff here but rather items that have been routinely available in hospitals since the 1960’s. The hardest part of this volunteer business is not the travel, food, accommodations, etc, but the sheer frustration of not being able to your best and the oblivious local attitude as to why. OK, enough whining.

I mentioned the weird dinner with the regional commissioner. We were invited to meet him at a new hotel and restaurant across the road from the new slaughterhouse of which the locals are very proud. The party was Daniel, the Commissioner, Grace and me, Jasper, Dr. Kabuma and Elizabeth, the regional Director of Education. When we got there the tables were outside on a very cool night and when they asked for our drink order which was mostly beer they had to send someone back to town for it which took about 45 minutes. When we finished our beer we were informed that there was no food so we had to get into the cars and drive back to our hotel for dinner. Total elapsed time about 2 ½ hours and we had not yet eaten. So tired that I could hardly stay awake I was relieved when the evening finally ended. I felt kind of cheated because I was really looking forward to a conversation with Daniel so I told him that I want to meet one on one before I leave. I’m sure it will happen.

I saw some interesting cases today in the office. First was another of those giant keloids on a lady’s ear. We’ll remove that one on Monday. There also was a woman with one of the largest goiters I’ve ever seen. This will probably not be surgical. Add to that a couple of interesting hernias and it was a worthwhile day. Midway through clinic I was summoned to the operating room to consult for case underway. What was thought to be uterine fibroids turned out to be an inoperable lymphoma so I had to suggest that they just go no further and close the patient. Sad but the fact is that this lady should never been operated. A simple ultrasound, which is available, would have made the distinction. The surgery was being performed by assistant medical officers who have as much business being in the abdomen as I have piloting the space shuttle.

At dinner this evening we met Cal, a graduating dental student who is part of our Healthcare Volunteer team. He is a nice young man from San Francisco and will make an agreeable dinner companion for us, along with Nigel, a British road builder in town to finally get the highway done and, of course, Robert, our Dutch internist who is about to leave for Dar to get his girlfriend who is here to visit. Robert will be a separate subject for a post as his story unfolds.

OK, that’s it for now.  Off to bed.