Return to Tanzania - 2011

Wrapping Up

Our last day of work at Ndala  Hospital was the usual mix of the mundane and tragic. Two pediatric and one obstetrical death clouded the flow of things and in the surgical department we had two acute abdomens, one of which was a simple appendicitis and the other a nasty typhoid perforation. She should be all right as she came immediately without wasting time with a local healer. Making rounds on our remaining patients I realized that this is the first year I have had no post-operative deaths. Again summing up life and death cases in sports terms:

                ELSKIPO  8                  GRIM REAPER  0

That feels really good. And, you know, the equipment here isn’t even as good as Sumbawanga and the availability of  lab and x-ray even less. No, there’s still no running water in the wards and one is hard pressed to find a toilet that works. But it’s the people who care. I’m not only talking about the nuns, there are only six of them and not all work at the hospital. The rest of the personnel are trained to a varying degree but all of them seem so committed to patient care that it doesn’t even seem like the same country. The assistant medical officers function well, accept suggestions and love their jobs. It is they who really determine the level of care. Morning report at 8am weekdays is a serious meeting dedicated to continuity of care and it works. As discouraged as I felt in past years, I leave Ndala feeling there is hope for the medical system here and that people really do care about their parts in it. My hope is that the public/private/government partnership that supports this project can continue to make progress not only in Ndala but across the country. This formula seems to work. During the day we were summoned to the administrator’s office and I’m thinking to myself, “OK, that’s it. You pissed people off again and they are running us out of town.” What they did was question us for almost an hour about what we would suggest to make the hospital better. By now I have learned the niceties of a Tanzanian policy meetings and I think we did the dance really well as they wound up taking copious notes about “mutually arrived at” ideas concerning equipment, organization, record keeping and scheduling.

The night before departure was party time again. This time it was the sisters’ turn to wish us well. Over beer and that jug sangria they each made a little speech attesting that our presence was appreciated. They gave each of us a little gift – an African shirt for me and those cloth wrap around things for Grace and Stacey. We were quite touched by this unexpected gesture. I’m sure they were equally moved by our donation to their foundation which is richly deserved.

So, that’s about it. Early this morning a Landcruiser showed up for us with our driver and a sister for a chaperone and by 4:30 we were on our way back to Shinyanga to catch our plane to Dar then Arusha and to start our safari.

I’ve only been able to share a few photos of this experience in this blog. Over the next month or so I will publish an album on Facebook but be patient. I have a lot of catching up to do.

Day To Day

Posting late because of troublesome internet connectivity I continue:

 

We had a busy and somewhat routine day of surgery on Wednesday (if any day here can be called routine). There were hernias, assorted lumps and bumps, a couple of C-sections and a D&C. This was the first day where we had no catastrophic cases to deal with. Stacey continues to gain confidence in the OR and, as with any beginning 2^nd year student, has a long way to go in the understanding of surgical disease. That will come, of course, but sometimes I worry that I’m putting the cart before the horse. Oh well, the whole medical curriculum seems to be going in that direction anyway. This light day gave me an opportunity to make ward rounds with Rob, Grace and the assistant medical officers. Grace has been a gift to the medical staff here. I never stop marveling at the depth of her medical knowledge and her passion for applying it. She will be missed but since she is now hooked on this type of work I’m sure she will return.

Rob, or Robie as he is called, is a very interesting fellow. Only 27, he came here with his nurse girlfriend, Danielle, right out of internship. In Holland they go to school for six years and then intern for one prior to any specialty training. His commitment to the foundation that supports the hospital is for 2 years, one of which has passed, and he and Danielle are paid for their work. They choose to pass as married only because her life as a single young white woman living here would be unbearable as she would be fair game for every local Don Juan and Robbie would be constantly challenged. Rob does things medically that a generalist in Europe or America would not even dare think about. He’s called upon to do everything from cardioversion and treating malaria to operating on acute abdomens and bowel obstructions. His surgical technique is logical but not sophisticated and his decision making is sometimes flawed. Nevertheless he gets the job done, not always with the best results but way better than if no one had tried. I enjoyed teaching him this trip and I can’t say I didn’t learn a few things too just based on his experience. For a while I was wishing I had brought up to date disposable staplers and such with me but really, Rob was way better served by my having used the materials at hand properly. By the way, when he leaves here he plans to train in OBGYN.

On our next to last night there was a party at Rob and Danielle’s house. It is quite a house with running water, six rooms and a beautiful garden. They have a maid/cook to take care of things and actually live quite nicely with their 2 thoroughly undisciplined dogs and a very forbearing  cat. Rob, Danielle, Grace, Stacey, the 3 medical students from Holland and I sat around in the garden drinking beer and swapping outrageous stories. It was a great evening. Then it was time to go back to the convent, begin getting our things together and plan the last day of work. As we came through the door Sister Georgiana was waiting with a laundry basket insisting we fill it our clothes would be clean for the road. It’s so nice to be taken care of.

On A Roll

I’ve had two full days of surgery under difficult conditions and yet felt little if any stress. Maybe living this monastic existence is good for me. But equanimity comes at a price. I’m dreaming about food, a good steak, Roka Akor sushi and a good old Waffle House breakfast. Perhaps I’ll be able to take the lessons of simplicity with me. I know I’ll never look at water use quite the same way again and will try not to take electricity for granted. I’ve often wondered what it would be like to conduct one’s life in the nineteenth century without modern amenities. Now I’m getting some idea and strangely enough, it’s not all that bad.

Doing surgery with mid 20^th century equipment, however, is not ideal. The only reliable blood tests we have are a hemoglobin level, pregnancy determination and HIV tests. There is an old ultrasound machine that no one knows exactly how to use so the results are iffy at best. So diagnosis, as in most places in the third world, depends on old fashioned physical examination skills. What an eye opener this is for Stacey. Innately bright and a quick learner, she’s been assisting on some heavy cases. Unavoidably clumsy at first she is gaining skill quickly and I don’t have to tell her the same thing twice. She had the universal newbie experience today when she removed a clamp from an artery too soon and nearly passed out from fright as I regained control.

Wonder of wonders, all of the really sick postops – about 8 – are doing well. This is as much a testimony of genetic resilience and a strong immune system as it is to any skill I brought along. In baseball terms this is my best ERA since I joined the African League back in ’07.

Today, Wednesday, is a quiet day with no surgery scheduled though I suspect there are a couple of emergencies brewing down in the OPD. I will have to do clinic this afternoon. As my son, Ara,  is fond of saying, “If surgery is the game then clinic is the penalty box.” Tomorrow is our last day to work and we will operate dawn till dusk to get everything done.

Friday 4am we leave for Shinyanga to catch an 8:30 plane to Dar and  then to Arusha where we will actually have a real shower in  a real hotel and eat something besides rice and beans. Then into one of those pop-top vans to ride around for a few days and take animal pictures. After that home. I’ll try to post a wrap-up from here tomorrow.

Off To See The Wizard

Instead of Sunday the powers that be decided that we should visit the Archbishop of Tabora today, Saturday. OK, so after breakfast we set out with Sister Claudia and our driver on the trek. Tabora is about 50 km. from our hamlet of Ndala. We traveled in a Toyota Landcruiser which is not the vehicle you see with its cushy independent 4 wheel suspension and shocks leveled to take the bumps out of driving on the moon. No, this is a pointy nosed double transaxle affair with leaf springs that make every crack in the road seem like a Mexican speed bump. The road, of course, was even worse than expected. These were not potholes, they were kettle holes that required navigating around them even if it meant going off the road.

Tabora is a fairly large place, similar in appearance to Sumbawanga with roughly the same population. Unlike Sumbawanga the Catholic Church is very visible. The archbishop is apparently the most important man in town. Once we arrived, Sister tracked him down by cell phone and we drove to an orphanage where we had a five minute meeting under a tree exchanging cordialities. The Archbishop is a pleasant enough man who looks like a Desmond Tutu wannabe. He was not disposed to discuss anything of substance which disappointed me because I was prepared to ask why the church had not yet provided the sisters with a pump to run their well even though they are short of water. So much for that meeting.

We toured the cathedral and the grounds which were impressive. After that we were ushered into a large dining hall where we were told that the Pope once took tea. When I asked which seat he used everyone laughed. There is a sense of humor there. During a wretchedly inedible lunch came the first highlight of my day. Father Joseph, a high ranking priest there got into a discussion with me about Tanzanian politics. I follow the political situation in the country as much as I can via the internet. Father Joseph filled me in on some details that I was lacking, the most important of which is the unrest brewing among the educated young people who cannot find appropriate employment. From this group, he feels, will come significant political change or, failing that, violent revolution. The country’s entrenched paternalistic political dynasty has gone on too long. I have to agree thereby letting go of my heretofore Pollyannaish view of a happy, cheerful if somewhat impoverished population. Change must come here and we can only hope that it is rational, orderly and peaceful.

The second highlight of the day I shall call The Great Mattress Massacre. At some time during our stay at Tabora Sister Claudia decided it would  be a good time to buy some mattresses. We stopped at a mattress store (shack?) where she purchased six, count ‘em six, foam mattresses and had the storekeeper tie them to the roof of the truck. Twenty kilometers out of Tabora on the aforementioned road they got loose and were strung out along the dusty trail for about a quarter of a mile. (Sorry to mix measurements here but I’m trying to give this meaning.) All of us left the vehicle and commenced retrieving the mattresses while dodging constant vehicle and bicycle traffic. Can you imagine the sight of three rare white people, a nervous driver and a nun running all over retrieving mattresses?  At one point Grace and I sat down in the road and just started laughing hysterically. We finally re-lashed them to the top and returned very slowly to Ndala.

On the medical side: All patients are doing well. The little girl with the facial abscess is much better, the woman with the neck tumor went home, The lady with the ovarian tumor is doing nicely and the boy with the bowel perforation looks better and may make it after all. The old man with the hydrocele? I couldn’t find him today. I suspect he’s out buying new pants.

Tomorrow is Sunday and I’m planning a comprehensive photo shoot of this place in early morning light. Monday the adventure begins anew.

I Can't Believe It's Already Been A Week

Anyone who has read the book Cutting For Stone will immediately get the picture if I say that I am living in "Missing". That is a corruption of "Mission" in the hospital name in Ethiopia that is the center of the story. Ensconced in a community of a few dedicated people trying their best to do so much with so little is a humbling experience. It comes back to that old quote, "All you can do is all you can do and all you can do is enough." So many people die despite our best efforts and the only trick to this existance is being able to go to bed each night without having to doubt that your effort was the best.

   

 

 

                                                          Beautiful Downtown Ndala

 

 

Everything I did surgically this week was fairly routine until today. This day brought a young man with a bowel perforation with abscesses and obstruction who should have been operatedon days ago and will probably not  survive. Then there was a salivary gland (parotid) tumor that I mostly removed but had to leave some because I lacked the neccessary equipment to go deeper. It probably won't matter but it was distressing. Next came a difficult C-section that turned out well. That brightened the day. The giant, and I mean giant, hydrocele (If you don't know look it up) that followed was fun and attracted cameras from all over the hospital.

The last patient in the outpatient clinic as a 7 year old girl with an abscess on  the side of her face, probably dental in origen causing enough swelling to close her eye and immobilize her jaw. By then it was after 5 but I feared immediate and fatal complications if I waited until morning so I lassoed an anesthetist and got it drained. She's not out of the woods but it's a start.

The support I'm getting from the Medical Director, Rob and his 2 Dutch med students is terrific. Stacey scubbed majors with me for the first time today and I think I have her over her initial hesitancy. I mentioned to her yesterday what was required of a junior surgery house officer and she was up early to see patients so she could give me a spot-on report. She's going to be OK.

Grace is having a great time. She is medically quite astute and has really bonded with Rob caring for patients. I hang out with them when I'm not busy and they are apparently learning a great deal from each other.

That's it for the week except for emergencies. The head honcho priest, Father Chobo, showed up today to say hello. He has his heart set on taking us to Tabora on Sunday to meet the Bishop. We're talking 2 hours each way on what some people might call a road. I am not excited. Rob said he would conjure up an emergency if I want but I think I probably should go. Besides, maybe the Bishop has running water and I could ask for a shower - uh, or maybe not. He might try to count that as a conversion.

Off to our nightly dinner party with the nuns. Last night we bought beer and washed dinner down some jug sangria. These ladies know how to party.

Getting Acquainted

Awakened by the ubiquitous roosters starting at 4 AM the day got off to a rousing start. After a quick, chilly bucket bath I was out and dressed in time to witness a glorious sunrise. The nuns had breakfast waiting for us, the usual eggs bread, margarine and coffee, in a large and comfortable living/sitting room. There was time for questions. What I found out is that this 150 bed hospital is run entirely on charitable donations from Catholic sources and others. It is cleverly managed. There is no hookup to either public water supply or electricity. Power comes from six huge solar panels in a courtyard and is sufficient to provide power for most of the building except for the wee hours of the morning. Each building, and there are about 20, has an intricate system of rain collection gutters which serve to fill about 50 cisterns of 20,000 gallons each. In good years this is more than enough. This year, however, provided less than normal rainfall and they may have to resort to their well. Rainwater has advantages. It is clean on arrival, quite soft and free. The water is drawn off and routed for different purposes. Drinking water requires filtering and boiling which is scrupulously done. The rest is for washing and cleaning purposes.

Six nuns, all nurses, run the place. They are a Dutch order that established a branch here in Tanzania. All are black and each serves a different function in the hospital. They are cheerful, funny and so anxious to please that it is almost embarrassing. They were mortified by their mistake. Not knowing the nature of our relationship we were originally placed us in an outlying building rather than single rooms inside the compound. The food, typical Tanzanian fare of beef, chicken, pork, rice, potatoes and greens has been quite good.

Once in the hospital I found many of the problems I had in past years. Basic equipment and drugs are scarce, particularly adequate IV solutions. Again, it is a question of money. This is not a government hospital so people are expected to pay something. Hospital revenue needs to be balanced against expenditures and treatments are often tailored to what people can afford to pay. The church does not pour a lot of resources into this project. I’ll probably comment on this later as I learn more.

The day was spent touring the hospital, having tea at the appropriate times and afternoon clinic where I got to know Dr. Rob. He is a six foot three Dutchman completing his third year here as a prerequisite for his OBGYN residency back home. He is an affable young man who runs the medical aspect of the hospital. Making rounds and conducting clinic with him produced five surgeries for tomorrow so we are off to a good start. There was a goodbye party tonight for a departing physician so it’s late and I’ve had a little wine. Time to sign off and go to bed.

 

The Journey

Conventional wisdom warns us to be careful what we wish for. Looking forward to something new and different we certainly found it. It just wasn’t exactly what we expected. Our trip began at JFK airport boarding an Emirates Airlines 777 to Dubai and then a connecting flight to Dar es Salaam, Tanzania. I cannot say enough good things about that airline. First of all they donated our tickets through the Emirates Foundation which cares for poor children in Africa. Aside from that the service is exquisite. In scrupulously clean and beautifully appointed planes the service and comfort in coach exceeds the quality of business class on many of our domestic carriers.
  Once in Dar we overnighted at a plain but efficient hotel near the airport before boarding a prop plane for Shinyanga. As expected the airfield there was a shack and a wind sock but we were immediately met by people from our hospital who loaded us and our considerable baggage into a ubiquitous Landcruiser for the 3 hour drive to the Sisters of Charity of Saint Charles Borromeo in Ndala. When we arrived we were shown to our quarters and that’s when the so far flawless trip began to break down.

When we inquired weeks ago about our accommodations they were described as Spartan but adequate. OK, I’ve done that before. But all previous locations did include at least two of the big three – running water, electricity and flush toilets. What we were offered was generator electricity from 7-10 PM (maybe), an outdoor bucket operated privy and a room to take a cold bucket bath. Uh, not good. When I saw that others at the compound suffered no such deprivations and diplomatically let it be known that we were not happy better arrangements were hastily made. Now the toilet is still bucket operated but inside, electricity is more or less full time and the bucket bath, not so bad and saves time.  So now it’s time to coat exposed parts with repellent, crawl under the mosquito net and go to sleep

Here We Go Again

It's hard to believe that almost a year has gone by since the last trip to Tanzania. Since then I've done short stints in Haiti and Nicaragua but it's really the African experience that keeps drawing me back. If you've followed this blog or care to review past entries you'll note that my relationship with Sumbawanga has been, to say the least, up and down. During the "off sesaon" I have repeatedly tried to contact the key players there but the only one I heard back from was Daniel Njoolay, the Rukwa regional commissioner and he was excited about my possible return. Trying to reach Dr. Kabuma, the medical kahuna for the region was fruitless. He just didn't answer my emails. This is particularly curious as I keep getting repeated requests from him to be friends on Facebook. So far I have declined. Our old friend Dr. Jasper Nduasinde has been equally non-responsive which leads me to believe that he may have been posted to a different location. The other possibility is that during my four previous yearly visits I managed to make enough waves and piss off enough people that they don't want me back. Read the last two summer's blog postings and you decide.

This year will be a diffferent experience. I am due to be accompanied by Dr. Grace Stewart for her first return trip and a second year medical student named Stacey who wants desperately to be a surgeon. We may cure her of that affliction straightaway or make the disease incurable. We shall see. One thing for sure is that she will experience things that would never happen in normal training.

We are going to a place called Tabora which is smack in the middle of the country. It's a fairly large town and there are satellite clinics around it that we expect to visit. The good news is that we can fly to within 50 miles of it so no more cross country bus trips. I have documented those pretty well in the past. What we can expect medically in Tabora and its environs I have no idea. The difference between this kind of a mission and those shorter commando team projects in western hemisphere is the unknown. With those big team short trips you know exactly what you'll be doing every minute. Going to Tabora is like Forrest Gump's box of chocolates. We have no idea what we'll get. We've been given a vague idea of our accommodations and itinerary but other than when we arrive and when we leave nothing is certain. Therin lies the advanture.

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