Return to Tanzania - 2011

The invasion of the African Killer Bees and other events of the day

In the last post I mentioned that Sunday was to be a reflective day of reading, writing and photography. Well, it didn’t turn out quite that way. The morning was as planned with hospital rounds going well and by 11 I was able to check email at the internet café.  Then I began the long trudge of about 2 miles back to the hotel, which is uphill, stopping to take pictures of children and families as I went.  Just as I reached the hotel a hospital Landcruiser with a driver and Catherine in it blew up a cloud of dust as it stopped in front of me on the dusty dirt road. I was needed at the hospital and would I please get in the truck. OK, back down the hill to see a patient suspected of needing urgent surgery. No, she didn’t but it’s a good thing they asked me to check. The nurse in charge of that particular ward is one of the few who speaks fluent English so she charmed me into seeing 2 other patients that, though they have interesting problems, were not going to get the troops out on a Sunday. All this consumed about 2 hours and we found the driver to take us back up the hill.

Arriving home I ran smack into my friend Godfrey. He is a young physician who, for the last 2 ½ years has been in charge of the other hospital in Sumbawanga. Sent there by the government after his internship his task was to modernize an old facility originally built by the Catholic Church ands raise the level of care. He has done a marvelous job of it and is now leaving to take a residency in Pediatrics. He is the leader of the group of young physicians practicing in the area, some of whom I met last year. They had flattered me then by asking my advice and now, as soon as they heard I was back in town, convened a meeting last night during which I heard all their complaints of insufficient supplies and equipment and other government inadequacies. The message I gave them was the same as last time. They need to be involved and exert their influence. As physicians they will not change the system. That will be left to others. What they must do is change the priorities of the system in regard to medical care. They can do that by making themselves heard collectively at all levels. Each will have to put aside a little bit of his personal quest to see to the common good. They do have a hard road ahead. I wished Godfrey well in his new position and his upcoming marriage and plan to keep in touch with him. He is a gifted leader who can go a long way.

By now it was after four and I figured I could still get some writing and reading time in before dinner. Entering my space I was greeted by the sound of hundreds of bees flying around the room with unknown intentions. I backed out quickly and closed the door, scurrying off to find the person in charge for the day. As I sputtered out my story he said, "Oh, the bees are back." "Back," I said. "Do they come often?" "No, just once or twice a year" he replied. With that he casually strolled down to my room with a can of "Red Cans Kill All Insects" and commenced spraying this into the air. Now I don’t know what’s in that stuff but the bees literally dropped out of the air – at least 500 of them – and died a rapid torturous death on the floor. Another fellow came along with a broom and dustpan to dispose of the remains leaving my room a lethal gas chamber. Hoping the rest of the swarm had passed I opened the windows, locked the door and left. That was four hours ago and now, after having disposed of a few residual bees myself, I think the room is safe to sleep in. Let’s hope so.

A Welcome Gentle End To The Week

Today, Saturday, has been interesting. Originally we were not going to work but attain because of electricity problems we did not complete yesterday and had to carry one case over. Yesterday I had to take the boy with the bowel obstruction back for a second look when we completed the first operation in the dark there were some things I was unable to verify. Had I waited for any missed problems to show themselves his nutritional status would have deteriorated to the point where it would have been impossible to correct anything. So I decided to take another look and fortunately found everything in order and today he continues to do rather well despite the second operation and the scant resources to manage him.

We arrived at the hospital after breakfast intending to start our case which was an 80 year old man with a huge combination hernia and hydrocele. We found one of the staff surgeons about to begin a procedure to correct abdominal adhesions from a past appendectomy that were causing pain. This was a private case on a woman who appeared well-to-do judging by the appearance of family members who were waiting around. I volunteered to scrub in. The case was exactly as expected. Surgeons reading this will understand completely. For everyone else I will say only that in the States we used to call these procedures B--- S--- laparotomies.

We then got my guy on the table and wouldn’t you know it, just after we started the lights went out. Now last night, after Piet (That is the way he spells his name) heard my horror story from the other day he went out to his truck and presented me with a small halogen headlamp that he sometimes uses when he works at night. "You need this more than I do" he said while I took it from hom gratefully. Sure enough I did nearly the whole case with it today and the procedure went flawlessly. Working with the junior surgeon (the adhesions guy) on my case too I managed to show him a better way to close skin and also new bandaging techniques. He seemed happy with it and everyone left the OR in good humor.

Unless there is an emergency that will do it for this week. Tomorrow, Sunday, I plan to take my camera around and catch pictures of children in their Sunday best. OH, and also I met a woman from a town about an hour from here who has come from Germany to start an orphanage. She had come into the internet café. Catherine and I are planning to visit her next weekend for an interview and a photo session. We’ll probably get out to Lake Tanganyika while we’re at it. Also, two medical students from Sweden are scheduled to show up some time next week. So the routine is going to change considerably

Surgery Begins

My student arrived from Oregon yesterday bringing the duffel bag full of donated suture material that I had shipped to her. The bag was almost bigger than she was and we shared the burden of dragging it down to the hospital this morning. Her name is Catherine. She is well educated and bright, seeming quiet and reserved at first. We were just sort of getting acquainted when she got into it with Piet over dinner. Not only did she hold her own but was able to back him down several times. Go girl! After that I knew I had a keeper on my hands. Having never been in surgery before she showed an ability to instinctively follow along, anticipating events enough to actually be quite helpful. Catherine also knows a bit of Swahili which is making my life eaiser. She happened along in time to share one of the most stressful and bizzare days of surgery that I have ever had.

Hospital_edit The day started simply enough, four or five patients referred for "the Professor's" opinion. (I love that - makes me feel like one of those old time European guys). We scheduled some resonable cases for the next few days and then went off to do the first of two scheduled for today. The first was an 80 year old man with a large mass attached to one testicle. It was not possible to determine pre operatively if it was benign or malignant but it was hurting him. Given the option of living without the pain and one testicle he enthusiastically chose the surgery. The anesthetist gave a super smooth spinal and the surgery went off without a hitch - almost. Near the end of the case our overhead surgical light died. It wasn't a big deal because the room was well lit from other sources and we were working at skin level when it happened. The next case was to start soon after but without the light - no way. Four hours later we finally got our light working and began the case around two thirty in the afternoon. This was a 24 year old male patient who had evidently been suffering with a partial intestinal obstruction for four years. He was almost emaciated looking with a hugely distended abdomen - not unlike the pictures you see of starving children. But this abdomen was filled with blocked gas in the intestine. Lacking any facilities for making an accurate anatomical diagnosis and going on history and physical examination and a poor quality abdominal x-ray we opened tha abdomen to find not the three foot large intestine dilated as I had expected but rather the entire 20 feet of small intestine. Normally the diameter of an ordinary household candle, these loops were the size of dryer vents, Once out of the abdomen there was no way they were going back until they were decompressed. The obstruction turned out to be a twisted loop that had been ignored for four years with the patient having spent the last month in the hospital undiagnosed. This is unacceptable by any standard. Emptying the small bowel is a difficult, dangerous process the details of which I will spare you. Midway through this process all lights in the OR went out leaving us with the window light of early dusk. We then found out that the person responsible for turning on the generator in such instances was nowhere to be found. No flashlights were available. We continued until most of the fluid and gas had been removed and then closed the intestine. Fortunately I had brought a modern bowel stapling device with me so I didn't have to waste a lot of time sewing it. We were rapidly heading toward darkness. There was one more thing that had to be attended to and that was placing a drain tube in the stomach. Otherwise the gas could re-accumulate before the intestine regained its function. The easiest way to do that is to pass a tube into the patient's nose and down to the stomach and tape it in place. These tubes cost about a buck and a half and are standard equipment in every OR and ward. Not here. The anesthesiologist seriously suggested that we send a family member out to a medical supply place to buy one. I declined and went for the other approach - a tube directly through the abdominal wall into the stomach using a baloon urinary catheter that was available. The problem now was that I could barely see under the incision to place the tube into the stomach and suture it securely. It was only because I have done this maneuver hundreds of times that I was able to pull it off, practically by Braille, without spilling stomach contents all over the abdomen which would have been a disaster. I quickly closed the deep layers of the abdomen and then in near darkness my assistant closed the skin while I fixed the stomach tube in place. Elapsed time - two and one half hours. The whole thing should have taken less than an hour and been finished before lunch.

The sad part is that I don't have any of the fluids or equipment to provide the concentrated intravenous nutrition that his patient needs and he could just starve to death before he regains intestinal function. Catherine asked me what the patient's chances were and I told her at home you could count on him walking out of the hospital. Here and now the chances are under twenty five percent.

This one case points up so much of what's wrong here. The equipment problem has gotten worse. Things like NG tubes , suction equipment and functioning, reliable lights should be available. They don't cost that much but nobody cares enough to see that they are on hand. It's easy to blame the administrative personnel but I accuse the doctors. The same physicians who let this boy languish with an obstruction all that time can't get it together to make sure they have basic equipment. There is one cardiogram machine in the hospital and it is in the office of the physician/administrator who never sees a patient. The excuse you hear over and over is "Well, this is Africa. Things will get better poli-poli (little by little.)" Well, people, poli-poli isn't cutting it. I've been away from here over a year and from what I see things have gotten worse. They've gone from an occasional power outage to four or five a day with no improvement or even deterioration of back-up capacity. The conditions in the wards are dreadful. Most even lack a place to wash your hands. Some improvement is noted in the availbility of pharmaceuticals but most of this is through donations. The medical record system is atrocious with almost no ability to trace a patient's history. Pathology services are non existant and lab and xray are rudimentary when available at all. They have allocated a fortune to build a new surgical unit which will be beautiful but how can they use it when they lack the ability to supply the unit they already have? When built it will be a showplace to display to visitng dignitaries who have no idea that it is an empty shell providing the same crappy care as the old one.

OK, enough ranting for one post. What's my role in all of this? For now I'll just continue trying to provide for one patient at a time as best I can. But before I leave I'm going to make sure someone high up who just may care knows exactly what I've seen and how I feel. Maybe that someone will get that it doesn't have to be this way.

 

Piet (and other interesting people)

I need to interrupt the continuity of this narrative to report something extraordinary. The something is called Piet. Piet is a South African. He is not the person from that country who we usually encounter as an expatriate. He is the person we read about all those years during the struggle against apartheid who was waging a desperate personal struggle against inevitable social change and stil lives in the land of his birth. We met two days ago. He is staying at my hotel and his job is building cell phone towers all over the country. Piet is evidently very good at what he does. He is a diminutive man of 55, perhaps 5 feet 6 and sports a scraggly salt and pepper beard. He drinks hard, smokes a lot, works outdoors and has the complexion of old saddle leather to prove it. He has some very specific ideas about race relations.

All his life Piet was a farmer and, from what he tells me, a modern and successful one. He married and raised his family on the land as his father and grandfather had done before him. At some point life became a war that he was bound to lose but he knew nothing else except to fight. Having been in the army he trained his wife and children in the craft of arms maintainence to the point that they were competent to resist the endless armed attack on his propery by members of the African Natioinal Congress. We in America see the ANC as heroes that were eventually successful in liberating millliions of blacks in South Africa. And rightly so. Apartheid was an immoral system that stamped out the future for millions. However, this is the first chance I have had to hear the story from someone whose only intention was to preserve his property and protect his family. Fortunately Pete and his family survived the violence but they lost their farm and were forced into the city. Hearing him tell the tragic story of being a victim of history one cannot help but sympathize. As we sat at dinner the other night Piet introduced me to a brand of African moonshine called Konyagi. It has a subtle gin flavor but mixed with water is alomost imperceptible - to taste that is. The effect on consciousness is equal or better than anything you have ever drunk, smoked or sniffed. Over a bottle of this stuff we got into the subject of race relations from an American and South African point of view.We were joined buy a young South African couple who, by the way, are absolutely magazine cover good looking, in town to build churches for the Jehovah's Witnesses. Don't let that fool you, they are by no means teetotalers. Their names are Tony and Ann and they represent the new South Africa. They are the product of a politically correct upbringing dedicated to solving South Africa's problems in a generation. Good luck. Piet is an old time Afrikaner. His second language is English. Tony and Ann are English first and offspring of the old leftists. But they too have seen their country deteriorate under the new order. Ordinarily these people would never have anything to do with each other but being trapped at a dinner table in the middle of nowhere necessitated conversation. And what a conversation it was. I took on the role of moderator.

And then it was time for bed. It was an evening well spent. Back to the medical happenings in the next post.

Settling In

The afternoon of my arrival day was spent unpacking and setting up my room/office to my liking. The Forest Way is a comfortable place consisting of 5 guest rooms, a restaurant and a bar. I take all my meals here. Breakfast is included and its the usual eggs a samoza (small, triangular deep fried meat pie) toast and coffee. Dinners are decent but variety is limited. Several kinds of tough local steak, spaghetti Bolognese (best thing on the menu) and chicken (often the one that woke me up that morning) are offered. The fish is inedible. Not much fiber and of course it is not a good idea to eat raw produce. They do cook up a mash of spinach, cucumbers and beans that is actually quite good. All cooking is done over open charcoal braziers. Unfortunately there is no longer internet service here as the owner is away for medical treatment so all communication is being done in town. More about that later. Since last year a new cell phone tower has been built nearby so that service is excellent. The town center and hospital are about a 30 minute walk over a dusty dirt road followed by a paved street lined with shops. Though I have a driver at my disposal I have resolved to walk at least one way each day lest I come home looking like a bowling pin with legs.. Only two streets in town are paved but I'm told that is about to change. Right! Remember, this is a town of about 25,000 people with a surrounding population of 250,000 more in scattered villages over an area about the size of Los Angeles county. It is located in a region (corresponding to our states) called Rukwa which is huge. Unfortunately, Rukwa is treated as an afterthought by the government and is badly underserved in every way. It is far from the center of power in Dar es Salaam and produces none of the tourist income of the northern regions nor does Rukwa produce much of anything for export. The economy here is mostly subsistence farming and produce for local trade and from what I can see the locals to a good job of it. The lack of economic output means that there is no paved highway in or out and social services, though the infrastructure is here, gets woefully inadequate funding. Add that to the usual level of corruption and the people do not get much. The road problem turns into a chicken and egg situation: There is no progress because there is no road and there is no road because there is no progress. Watching TV I see endless meetings of government organizations endlessly discussing this problem or that but little gets done. To their credit the Tanzanians have an open democracy. Every meeting of Parliament is televised and they even kicked out their prime minister earlier this year after a corruption scandal. It seems he was in cahoots with a corporation that was supposed to be buying electricity for resale. They borrowed the money, didn't buy the power in the way promised, managed to corner the market and drive up prices and everyone got screwed. Sound familiar? The methods of Enron were not lost on them. The consequences were. Speaking of electricity, I'm experiencing many more outages than last time. The power goes down for short periods several times a day. It is very disruptive. While at the intenet cafe yesterday posting to the blog I had to start over twice. What should have taken 10 minutes took an hour an a half. Power to Rukwa is obtained from neighboring Zambia and is supposedly pretty good but the distribution of it here is not adequate. All this is the result of lack of government attention and incompetent private enterprise. The internet cafe is a very iffy proposition. There are 5 ancient Compaq desktops working off a very cranky pirated Windows 2000 operating system. The network varies from very slow to passable depending on traffic. It is subject to the same power outages. They have surge supressors but no backup power so when it goes down you just sit and wait. I had originally planned to offer links in this blog to pertinent sites but limited time for posting does not permit. I'd rather use the time to put in pictures. I needed to do a little shopping at the town market where I found out that (a) mens underwear is hard to find and (b) they never heard of a sweatshirt both of which items I was seeking. After wandering through hundreds of stalls periodically lowering my belt to reveal the top of my Jockeys I managed to score 2 pair of semi-bikinis with no fly. I will not be bringing these home but they will do for now. No sweatshirt appeared so I bought a bizarre looking long sleeve tee shirt and a vest. Hey, it's cold here at night - down into the 40's. Walking by the food stalls a guy tempted me with a beautiful potato omelet that I washed down with a coke. Street food.....yeah

The Trip - Part 2

    In the last post I mentioned hiring a driver. That deserves some explanation. When a European appearing person (read: white) gets off a bus in a place like Mbeya there is a particular kind of person waiting. It is an ambitious local young man, who is nicely dressed, unintimidated and speaks reasonable English. He smells money. My fellow was named Charles and he immediately offered taxi service to my hotel. Since he had a driver of his own I was grateful for 2 sets of arms to haul the load. Remember, I’m still nursing a shoulder that is about half capacity. By the time we reached the hotel he had ascertained that I would be there all the next day and checking out the day after that. After hearing about my plans to visit the hospital and orphanage as well as a few errands he offered to be my guide with his driver. We negotiated a price that, for me needing assistance in a strange city was a bargain and for him a windfall. Promptly at nine they picked me up and we set out on a successful day. About 2 in the afternoon the missions were accomplished and he suggested I see a local attraction called the Bridge of Gold. (at a small additional fee, of course.)We drove for about an hour to a place that was absolutely breathtaking. A series of small waterfalls flowed under the largest and most beautiful natural bridge I had ever seen. It glowed golden through the mist in the late afternoon sun and I was in photo heaven. Just down the river was a huge waterfall accessible from the top but not the bottom. What a treasure I gained because I was willing to trust these 2 guys. Why? After all, they could have taken me our there, robbed me and left me in a ditch or worse. First, he had given me a receipt with his name, phone number and vehicle number after the first ride from the bus stop. Second, he seemed like a good person and I’m rarely wrong about people going on gut feelings. Third, I’m in Tanzania and crime is almost unknown here away from the big cities. You wouldn’t use someone without a reference in Kenya or South Africa. At 5am just the driver came to convey me back to the bus station. After he deposited me with my luggage near the bus I noted that the small canvas travel bag I was carrying was gone. It contained some reading material, food, water and the small digital camera I was carrying as a backup. I was upset, realized there was nothing I could do and went into damage control mode. Then I looked up and saw the car reappear in the emerging dawn. The driver got out, came over to me holding the missing bag. Wow, talk about vindicating trust. I was extremely grateful and let him know it. Shortly after Charles showed up and made sure my luggage and I got on the same bus together which, considering the confusion of thirty or so busses loading in the semi-dark, was not a done deal. Anyone going to Mbeya let me know. I’ll give you his number. The day was downhill from there. The bus was old, crowded and noisy. Would you enjoy loud, bad hip-hop in Swahili for 7 hours? The bus was configured 3 and 2 across. I was number 3 on the isle sandwiched between two very fat women and the armrest which prevented their sheer bulk from displacing me out into the aisle. I have a bruise on the left side of my abdomen from the pressure. There were no animals this time but I think I would have preferred the chicken from last year. The road was still unpaved, bumpy and full of holes but not as bad as last year at the end of the rainy season. We only had to get out of the bus once at a road washout to allow it to cross a makeshift repair.

When I arrived in Sumbawanga somewhat the worse for wear, a cab was waiting for me and the driver deposited me and my baggage there. I was finally rid of the burden. I felt like Henry Knox bringing the cannons over the mountains to General Washington from Fort Ticonderoga. (if you don't know that story look it up. It's a good one.) I was off then to settle in at the Forest Way Country Club and (thankfully) Bar.

The Trip Part 1

The trip to Sumbawanga, which, for reasons I will explain, expanded from four to five days. The first leg was ma red-eye from Phoenix to JFK. It’s amazing how many people fly in the middle of the night. Used to be you could get some sleep on those flights but no more. Oversold. US Airways was very gracious allowing me to check the extra 110 pounds or so of medical equipment for free.

So there I was with four pieces of luggage weighing more than I do taking the Airtrain between terminals that could not be farther apart. Arriving at the Emirates counter I had an hour wait for the flight to Dubai to open. Very interesting people fly Emirates. While waiting I met a real live sheik, a lady in a burka who had no compunction about telling me her whole life story and a man who owns, no kidding, an internet porn shop who does business by some subterfuge in the middle east. Emirates, too, allowed the overweight and over-number baggage for free. And what an airline it is. Emirates ranks right up there with the best along with Singapore and others like it. Even though I couldn’t wrangle an upgrade the seating, service and food were as good as any first class service I’ve had on domestic airlines. This was true for the connecting flight to Dar es Salaam making this portion of the trip pleasurable. This was good because total flight time from Phoenix to Dar with layovers was 29 hours.

I was met at the airport in Dar by a charming lady from Paraguay named Carolina. As a Healthcare Volunteer, her job was to get me through Dar and on to the bus the following day. I had her take me to a hotel at the O’Willie’s Irish Pub on the ocean. I remember having the best shepherds’ pie ever at that place and I wanted it again. I was not disappointed and the hotel there was passable for one night. At 5 in the morning my stuff was loaded into a cab by 2 guys in full Massai dress and I was off to the bus station.

The human mind has a merciful component that allows it to forget pain. For this reason I had put out of my memory just how unpleasant 2 days on an African bus can be. Though it looks small on the map of Africa, Tanzania is actually bigger than France. I took what I thought was an express to Mbeya, a distance of about 500 miles. Here "express" means they sell you a specific seat. After that all bets are off. Stopping at every town and village to take on or discharge passengers the bus is often packed with people in the aisles hanging over the seats and giving one a very cramped feeling. Still, I was able to read some and sleep. Thirteen hours later the bus pulled into a dark, dusty bus station in Mbeya. Thjs was the good leg of the trip.

I had decided to stay there an extra day, partly because I had some things I wanted to do and also because I wasn’t going to endure 2 days in a row on the bus. Last year, not knowing that Mbeya is a fairly large, cosmopolitan city, I stayed overnight at a murky inn near the bus station that had all of the charm of a Turkish prison. (Think Midnight Express.) I was scared to death and got out of their fast in the morning. On the way home, by private transportation, I got to see the city and stayed in a fairly nice place called the Golden City. It’s a hotel that caters to wealthy Muslims and is clean and safe with beautiful sculptured gardens in front. The interior is done completely, walls and floors, in shiny white tile. Alcohol is not served in the restaurant so if you want beer with your saffron flavored beef and rice you are relegated to the bar. A small, comfortable room with internet service and decent food for $25/night, what more could you ask?

My reasons for staying an extra day were to re-visit the hospital there to see an American acquaintance working in an AIDS project there and to seek out an orphanage I had visited to find a very special child. Those of you who have been to our home know that I have been displaying a photo of an adorable 3 year old that I happened on last year. In the photo she is wearing her Sunday best red dress and throwing a killer smile. I wanted to see and photograph her again but I did not know the name of the orphanage or where it was.

I went one for two. My Dr. friend had returned to the states so no contact there. When a foreign doctor shows up at a hospital he is treated with great respect and introduced all around. Among the people I met was the director of social services for the area and, from my description, he was able to tell me exactly where the orphanage was. I had hired a driver for the day and we immediately set out and found it with no trouble. The place was almost deserted with a Massai guard and a badly crippled woman overseeing the place. They told us most of the children were gone on some sort of holiday but we were welcome to look around. I talked to and photographed 3 small boys who told me there were no girls there. Disappointed, I wandered over to the grove of trees where I had seen the little girl last year and unbelievably she emerged with a companion. Her name is Priska. She has grown in a year. She was in dirty play clothes but the face was unmistakable. She immediately started laughing and flashing that smile and I had what I came for. Then off she and her companion ran laughing into the woods. I must have some kind of karma going on with this child. Don’t worry though, it is not permitted to adopt out of Tanzania.

So tomorrow's the day.

    It's been a hectic week. For a while it seems like there is all the time in the world and suddenly everything is a rush. First I found that a cache of surgical instruments that I had been squirreling away in the garage went missing. A desperate two day scramble ensued producing almost more (better too) stuff than I can carry. People and institutions have been so generous. The next challenge will be getting a 70 lb. extra suitcase past airline officials. I'll let you know how that goes.
    The details are endless. Hotel reservations en route, bus reservations. Yes you need a reservation to go from Mbeya to Sumbawanga. Otherwise you may get to share a seat with a chicken or goat. I did that last year and the chicken was fascinated with my camera strap, pecking at it and occasionally missing and leaving dimples in my shoulder.
    Packing has not been easy. One suitcase for me and two full of medical equipment. My carry one has all photography equipment and a little space for personal items and that's it. Fortunately my wardrobe is tee shirts, scrubs, jeans and a few things to keep warm. The expected weather there at 6000 feet 200 miles below the equator is 70s in the daytime and 40s at night. 
    I've been in contact with the doctors in Sumbawanga and they tell me they are gathering surgical cases from the entire district. The equipment I'm bringing will make a big difference, bringing them forward a half century in capability. I can hardly wait to see everyone's faces when we start unwrapping it all.
    So, now is the time to finish last minute packing, get some rest and get ready to set out. Are we ever completely ready for a trip like this?  Probably not but that's part of the adventure.