Return to Tanzania - 2011

And So It Ends

It’s hard to believe more than five weeks has passed and the time has come to tally up my cases and go home. Paradoxically the total time has gone by very quickly while the down time, and there has been more than a little, has seemed excruciatingly slow. I have experienced disturbing mood swings here ranging from exhilarated and commanding to feeling helpless and depressed.  The dark side, I’m sure, stems from watching tragedy unfold under my gaze and being powerless. Idle time intensifies the frustration which lasts until the next triumph. Fortunately the triumphs have outnumbered the tragedies but by far less than I am used to in clinical practice at home. The highs have been many. The standouts are seeing the three year old girl eating normally for the first time in her life, the woman who nearly died from intestinal obstruction laughing with her family as I removed her stitches and the pretty young woman going about for the first time in years without a shawl to hide her horrible ear keloids. Then there are the open ended cases. What will happen to the nun who lost her lower leg to melanoma? How will the young woman with the malignancy on her toes be able to walk on a foot that looks like the middle of it was bitten off? Will the man with the huge lymphoma on his neck really get to Dar es Salaam for proper treatment? The biggest question of all is have the powers that be really listened to my pleas and suggestions to bring some order to this chaos? Or, has my presence here been like sticking my finger in a bowl of water. I can stir things up and make lots of waves but when the finger is gone it’s as though nothing happened. I believe something will stick. I feel emotionally tied to this place though if you saw it you would certainly wonder why. The people have gotten under my skin and I think I have finally started to really understand who they are and how they think. Believe me when I say that there is not much in our American experience to help me relate. Being here, now for a total of ten weeks and finally being able to settle into the indigenous pace and mindset has left me connected in a way that is not always pleasurable but certainly challenging and, I believe, irrevocable. East Africa is now part of my being.

The night before I left Sumbawanga I was invited to the home of Daniel Njoolay,the Regional Administrator (Governor) for dinner. You remember that I entertained him and his wife a couple of weeks ago. This time it was him, me and Jasper sitting around his dining room table seriously discussing hospital problems and what to do about them. Jasper, unaccustomed to such meetings was sure he would lose his job over this. In Africa frankness is not common in such conversations. Circumlocution leading nowhere is the norm and that’s why so little gets done. Because of his education in Canada Daniel understands my style which is polite and certainly not blunt but gets to the heart of matters fairly quickly. I made my points carefully, surrounding each with background facts that locked it into an inescapable discussion pattern. Daniel was very frank with me explaining where the bureaucratic resistance to change is and what are the extents and limits of his own power. By the time we were half way through the second bottle of wine Jasper was giving a pretty good account of himself. He is the senior and best trained physician in town and has the respect of everyone including the politicians. We went on for over four hours and in the end had formulated a restructuring plan. We determined that the reason for a lot of the shortcomings at the hospital is that no one is running it.  The regional medical director who is responsible for all of Rukwa has his office in the hospital and he is the de facto administrator but does not function in that capacity. Daniel has decided to move him out of the hospital into the regional government office building where he belongs and replace him at the hospital with a real administrator. I suggested he get a newly minted health care MBA out of Dar or Nairobi to come in there and kick some butt and make a name for himself. I must, of course follow up this meeting with a report and I’m happy to do it because I finally feel that I have done more here than just care for one patient at a time.

Back at the hotel I packed my stuff and prepared for my morning departure. You’re already familiar with the details of my trip so we’ll skip to today.

The National Museum in Dar es Salaam is no Smithsonian. Located near the waterfront about four blocks from my hotel it is a smallish building with displays in two parts. The first is an interesting somewhat sanitized version of the country’s history before and since independence in 1967. It is mostly pictures of revered but outside Tanzania, obscure individuals who played some part of the “bloodless revolution” Looking at it closely though one gets a sense of the intensity and fervor that was involved and still lingers in the minds of Tanzanians. Forty years is a short time for nationhood and the pride is still there. The second section is the anthropological history of the country.  Because of the great geological rift that runs through it Tanzania is a great repository for fossil evidence. Someone very knowledgeable has taken very great care to reconstruct and illustrate the fossil record of humankind creating a remarkable journey through our evolution that is truly worth seeing. All in all the museum, though lame in parts, gets pretty fair marks for giving  the visitor some idea of what this country is about.

Then I went off to the Kariakoo market. This is one of those places where the guidebooks and travel mavens tell you to stay away from.  There are pickpockets, thieves, murderers and perhaps even worse just lurking there waiting for the unwitting visitor. As my 10th grade English teacher used to say, Balderdash!!  The market is a huge place built like a square stadium, Inside are hundreds of stalls each, apparently, its own individual business. It’s sort of an impoverished version of the Reading Terminal in Philadelphia or Pike Place Market in Seattle. What interested me is what they sell. In a city of nearly three million people who have access to cell phones, satellite TV and all of the associated hype what would you expect to find in a central market, electronic toys, gadgets and such? There are some but not much. Most of this building is dedicated to simple farm implements, seeds, fertilizers and garden tools. There are multiple stalls selling sewing machines, some of which are Chinese knock-offs of the ancient foot treadle Singer that my grandmother used. They sell for about 100 bucks as do the best of the Chinese bicycles. Almost all of the merchandise here is dedicated to people making their living. The place was packed and I met some of the nicest people there. I was the only white person not only in the market but in the whole neighborhood so my presence did not go unnoticed. Parking myself on the corner of a balcony I was able to get some great candid pictures and walking among the crowd people were only too glad to pose. My only detractor was a local Imam who accused me of stealing peoples’ souls with my camera. I assured him that out of respect I do not take pictures of Muslims without permission and if I have stolen any Christian or heathen souls I promised to take very good care of them. He actually laughed and was satisfied with that.

The lesson of the market is that these people are hard working and, so far, basically uncorrupted by the “I wants”. Families come to the market to buy the things they need to sustain their lives and one can see on their faces the joy of the shared experience. Maybe it’s a good thing that the guide books steer people away from the place. They really don’t need us there.

Then it was time to reclaim my suitcase and head back for the hotel. Happy hour was fun. I met some nice people here for an international financial conference. Dinner was, to use an old fashioned term, splendid. I’ll not go into details. Back in my room I finish this piece, make final preparations for my flight to join Marcia and Ara in Paris. It is our wedding anniversary and his birthday on Wednesday and we plan to celebrate.

So the Africa 2008 adventure is over. I know it has changed me in ways that will emerge slowly over the coming months. Of course I’m already planning when and how I will return and which of the many people I’ve met that I will continue to contact. When one’s world expands there is no stuffing it back into the old container. You just have to try to keep a handle on it and go where it takes you.

If you’ve been a fan of this blog thanks for reading. Go out and have your own adventure. I’ll be glad to read about it. Watch for a pictorial review on this site after I have had a chance to review and edit my photos.

Tutaonana   (until next time – Swahili)

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Just In Case You Thought This Was Easy.....

This is a post I never expected to write. In all the traveling I have done on these missions, two trips to remote Pakistan and now two to Africa, all the complicated transportation plans have been remarkably hassle free. Yesterday was payback time. Anticipating an uneventful trip to Dar I had already begun composing my philosophical review of my time here. You’ll get that later but first the nightmare.

I did get a private ride from Sumbawanga to Mbeya – sort of. The hospital supplied a Land cruiser and driver assigned to pick up supplies and seven other unidentified people. We were packed in so tightly that the bus would have seemed comfortable by comparison. No one spoke any English and the driver played very loud African music through the entire 4 ½ hour trip. Its only a hundred miles or so but the dirt road, even in good dry season condition, equals a class 2-3 off road trail in Arizona. OK, it was uncomfortable but not so bad. After buying a best class bus ticket to Dar es Salaam for the morning I checked into my usual Spartan, clean and safe hotel.

The Mbeya bus station is a scary place any time but in the cold pre-dawn hour it comes to life like throbbing organism intent on enveloping the throngs of people pouring in. A massive place, perhaps three or four acres of concrete rubble, it is surrounded like a bull ring with dozens of dilapidated buildings housing ticket offices, run down shops and what passes for food stands. Dozens, perhaps hundreds of young men scurry about grabbing peoples’ luggage and, for a fee of course, showing them where their particular bus is likely to show up. The traveler unfamiliar with the system is at their mercy. In the four times I’ve been through the place my “guide” has never failed to get me and my luggage on the right bus. Tucked away in my seat with my carry on with me and my big suitcase in the luggage boot under the bus I settle in as we pulled out heading east into the just rising sun for the 500 mile trip. I’ve got my Ipod, noise canceling headphones and even some leg room. The road is paved all the way and this is going to be a pleasant 10 or 11 hours. The bus had TV soda and bottled water on board and even a bathroom for limited use. (We still take pee breaks by the side of the road.) What the vehicle did not have was a fuel pump that was going to last the trip.

I was seated in the front row next to Omari, who looked a lot like a taller, bigger version of Richard Pryor. His English was good so we exchanged pleasantries and then hunkered down for the ride. About four hours later we noticed the bus slowing down and the driver muttering to himself in Arabic. As we wheezed into the parking area of a roadside stop called the Aljezeera restaurant and bus stop it was obvious that we were going no further without some mechanical attention. The scene and terrain were so much like the movie “Babel” it was freaky except no one got shot. During the next three hours I finished a book, ate 6 skewers of roasted beef cubes, downed a Coke and 3 bottles of water and became increasingly agitated about not getting to Dar that night. The mechanic had been sent for but still had not arrived. After the 4th hour he finally showed up and confirmed what everyone already knew, the bus needed a fuel pump or at least a filter. In true African style he had not brought parts and declared that they would send to Aringa, 50 miles back and have one sent out. I calculated the time and figured if everything went on schedule, and why should it, we would be in Dar some time around 4 am.  Enter Omari. It turned out that he is a big time business guy and president of the largest labor union in the country. He had made a call hours before and someone drove out from Dar to pick him up. He offered a ride to me and a couple whom he knew. We would be 3 people literally squashed into the back seat of a very small car. There was no room for all of our luggage. We found out that the luggage was inaccessible anyway because for safety reasons the luggage boots on the bus cannot be opened if the motor is not running and this motor was definitely not. It was time for a tough decision. Do I leave my large suitcase in the hands of the baggage gods or wait it out with the 50 or so souls camped out at the Aljezeera? I asked myself is there anything in that suitcase that justifies my sleeping on the cold hard floor of that place rather than in the bed of the deluxe room I reserved for myself at one of my three of four favorite hotels in the world. I’m outta there!

We piled into this little cracker box, my carry on with my computer and cameras safely stowed behind me and my knees pressed into the seat in front. The young woman in the middle was pressed against me so that lateral shifting was impossible. It was like being trussed up so that all I could move was my elbows. The next problem was that the car had an exhaust leak so that no matter how we adjusted the windows fumes came into the back seat producing a headache that increased with each breath. Next of course was the music. Africans cannot stand quiet. They must have every nearby TV or radio turned up to full volume. If conversation is necessary it is shouted rather than turn down the music. Such was the ambiance of the trip. Last, I noticed that my seat mate did not say anything. I found out why when she answered her cell phone with a croak that could only mean severe laryngitis. Her subsequent cough confirmed the diagnosis. I was trapped in this position for 5 ½ hours and could have not designed a more perfect version of hell. The floor of the Aljezeera began to look sort of cozy.

Pulling into Dar around 1 am we dropped off the plague ridden couple. Omari got off at his office and another guy got in to drive the car. I was feeling a little uneasy as we set out for my hotel. The driver made an illegal u-turn and we were stopped by two uniformed people carrying assault rifles. One came over to inspect me in the back seat and told me to keep quiet and everything would be all right. They proceeded to verbally work this guy over for a full 30 minutes. All the time I was thinking: Am I going to be one of those people who get in the middle of some African vendetta and get shot in a car? No, they let us go and around 1:30 I was finally safe in my hotel room enjoying a hot bath and a room service club sandwich while turning on my computer, getting on the internet and watching the Diamondbacks blow a 3 run lead in the ninth.

Oh, the suitcase? I had written it off and it’s amazing how situations work out if you become detached from them. Early this morning I had the concierge call the bus company (I’d have done it myself but my Swahili still leaves a lot to be desired) and we were informed that the bus in question, now get this, was not expected at the garage until 3pm today. That means all those people were 21 hours overdue! Stuff like that just happens here. I had planned to go to the Kariakoo market today and the National Museum.  I did both and they were great. I’ll talk about them in the final post. At 3pm I took a cab to the bus station and there it was, the big black ugly suitcase I had said goodbye to 24 hours earlier. Sometimes you just have to wonder. And by the way, there are no refunds if the bus breaks down.

There’s lots more to talk about before I leave here but I’ll save it for after happy hour and dinner.

Into The Final Week

The intensity has picked up around here. Our new students are wide eyed and eager. Susanna and Charlotte are Swedish women going to medical school in Poland. Second and third year they have, surprisingly, almost no clinical experience and none in surgery. It has been interesting watching Catherine, who has not yet been to medical school, orienting them as to operating room protocol and procedures. That girl learns so fast it\rquote s almost frightening. I'm really proud of what she has accomplished the last four weeks. I hope she chooses surgery later on because she's good at it and is definitely temperamentally suited for the field.

It's fun having a class now. Our new students have the academic background for me to explain things in medical jargon and to coax out answers to questions based on what I think they should already know. Actually, they're not bad though Charlotte as a third year is more advanced. Their English is almost southern California. They learn our language almost from birth and watch a lot of American television. Anyway, they walked into a storm of clinical activity. Surgical cases are coming at us thick and fast. It's necessary to pick and chose the cases I want to do in the limited time I have left here. We can only do three a day and I have just three days left in which to work. Tomorrow we will tackle a case of what is probably colon cancer (remember, clinical diagnosis only, no x-ray help) and a weird neck cyst about he size of a large orange that keeps recurring and who knows what emergency will show up. The new girls will alternate assisting as it seems Catherine has become the darling of the OB department and has taken to first assisting the two or three caesarian sections that happen each day.

I'm going to relate another very weird story now. About three o'clock this afternoon we were called to see an elderly man who had been hit by a falling tree several days ago. On his right side there were four fractured ribs and his collar bone was fractured and the ends collapsed and overlapping by at least two inches. Either the ribs or the collar bone fragment had pierced his chest and the lung was 80% collapsed. We took him right to the OR to reduce the fracture and apply a brace to his shoulders. He also needed a tube in his chest to re-expand the lung. Luckily, one modern chest tube with an introducer was available. As we were starting our procedure the next case, an emergency caesarian section was brought to the operating room door. While she was waiting there she delivered spontaneously and suddenly we were surrounded by people running around trying to resuscitate the baby, tend to the mother and keep the equipment going. After reducing the fracture and prior to placing the chest tube I sensed things were not going well and stopped what I was doing. Moving over to the nurse who was frantically trying to revive the infant I began external cardiac massage while the nurse administered oxygen. Now all this was going on in a room less than 20 feet square. The infant did not respond and after 15 minutes I abandoned CPR and returned to my patient placing the chest tube uneventfully. When it was all over I turned to the students and told them to remember this day because they will probably never experience anything quite so bizarre.

That case finished all that remained was to tap into the chest of the young woman with the toe amputation two days ago. It seems she had developed massive fluid around her right lung and was having a lot of trouble breathing. We had no idea of why this was happening but it was clear from the chest x-ray we managed to get by sending her over to the other hospital that something needed to be done fast. Over in the ward we simply stuck a plastic covered needle into the chest, removed the needle and left the tube. Minutes later about a quart of fluid had drained, she was breathing better and we could all go home. From the looks of the fluid we're considering TB aggravated by anesthesia and surgery. We can get the fluid tested to make sure and if we\rquote re right she\rquote ll do well with treatment.

We really hadn't expected the students to come as I had suggested that they be sent to another hospital because they were arriving so late. Jasper has arranged to go on vacation during the middle of next week. Fortunately there is a young man her, Dr. Haan, who is practicing internal medicine and pediatrics. I had met him only briefly and had mistaken him for an assistant medical officer. Fortunately not only is he a highly qualified doctor but his English is pretty fair too. He has agreed to take over responsibility for the students after Jasper and I are gone. We have a meeting tomorrow morning to arrange the details. By the middle of next week I think Charlotte and Susanna will have had enough of surgery anyway.

It's time to start arranging the details of my departure. I sent out the last batch of laundry, had a new pair of jeans altered and some dry cleaning done. Now I need to decide which clothes to take back with me and what things to leave behind. There is still more work to do here and I plan to utilize all the time remaining. I'll post my final thoughts on Tanzania from Dar es Salaam on Monday. There is a not so enjoyable two day bus trip in the meantime. Hopefully I'll get a private ride for the first half.

A Great Weekend

I haven’t written for 3 days and it’s amazing how many things happen and how many interesting people cross my path. Let’s start with the weekend.

I arranged a car and driver for the weekend to take us to Kipili which is a small village on the edge of Lake Tanganyika. It is not an easy trip but well worth the effort. The lake is the longest and second deepest in the world. It is also one of the most beautiful places I have ever seen. I took my signature sunset picture there last year and hoped to get one even better. We were invited by Chris and Louise Horsfall, a South African couple who are building a resort on the beach dedicated to the adventurous traveler who loves water sports, especially scuba diving. The location is dramatic and yet very peaceful. They have been living there for some time in a semi-open air dwelling, perfectly suited to the climate that provides visual and physical access to an environment so idyllic that once there it is difficult to leave. Their mission is to build the perfect space to share with about 40 guests in either super-deluxe or just plain beautiful accommodations. They are well on their way and expect to receive the first paying guests in September. The food for the resort will come mostly from their organic gardens. Power is self generated from solar panels leading to a huge battery array. Chris hopes to add wind power soon so that the resort will actually add power to the local grid. During the day the place is abuzz with building activity. At night the quiet is perfect, broken only by the gentle lap of waves on the beach that are the whisper kiss that only a lake can deliver.

There were other visitors there for the weekend including Tony and Ann whom I’ve mentioned before. We also met Ross and Heidi Lloyd, a young coupe from South Africa who have quit their jobs and are touring all of Africa in their Landcruiser. Just them, no guide and no set itinerary. What stories they tell.

After hanging around all day Saturday enjoying the surroundings and downing a few beers while watching cricket and rugby (yes they have full satellite TV and internet service) we had a delightful dinner on the beach. After determining the true nature of our relationship (they had only met us once briefly) they set up 2 separate tents for Catherine and me and, fears of snakes, giant lizards, spiders, etc, notwithstanding, I slept like a stone. Awakening at dawn to watch the sunlight coming from behind me reach out over the lake was awesome. Oh, and by the way, I did get a killer sunset shot.

Back in Sumbawanga Sunday evening after another 3 ½ hour kishka krunching Landcruiser ride it was time to review the week ahead and plan for the new medical students due to arrive Monday. I will need to give then my full attention as I will be leaving here on Saturday. Wow, a month goes by fast. I’ll need to enlist other physicians to provide a program for them after I’m gone. There are several options and at least one will work out. We have some interesting cases to do. It seems the word has spread among the ear keloid afflicted that we’re taking on most comers. We scheduled two more of them for the coming week. There are a bunch more interesting surgeries to do and we’ll pack the schedule with as many as possible.

Today I made a belated tour of the AIDS/HIV project going on at Rukwa Regional Hospital. Five years ago people were literally dying in the streets. The HIV infection rate was upwards of 30%. Starting in January, 2005 the CTC (Care and Treatment Center) for AIDS/HIV was started here funded by the US government. It is a carefully managed, highly accountable program. We were shown around by a well trained, carefully spoken nurse named Matilda Ulinyeusya who has made this program her life’s work. She explained that over 3000 people locally have registered for the program And over 1400 have been placed on medication. The medications, known as AVR’s, are given free, again courtesy of Uncle Sam and the program has been a huge success. Besides diagnosis and treatment there is a strong outreach program to the outlying villages, condom distribution and massive education. The result is that we now seldom see aids patients at the hospital the HIV positive rate has dropped to about 7-8% of the population which is low for sub-Saharan Africa. Most of these people have good control of their disease. This program works on a similar scale nationwide. The problem is that the US aid package, known as PEPFAR, is in danger of not being renewed for political reasons. If you want to directly save the lives of countless people Google the program, learn the facts and then climb all over your senators and congressmen. This program cannot be allowed to lapse.

Another interesting character is Paul Graham Philips, the director of Sumbawanga Agriculture and Animal Food Industries. He is a black man from Zimbabwe who’s first language is perfectly elegant English. He is working for a member of the Tanzanian parliament who owns a huge cattle ranch not far out of town. He is dealing with a group of Jordanians who stayed at our hotel last night. Unfortunately his boss got fleeced by these guys and signed a huge contract to deliver beef in unsustainable quantities at a price that will bankrupt the company. Paul’s job is to figure out a way to make it work. I mention this only because at dinner tonight we had an in depth discussion of how the nascent African agribusiness works. What I learned is that most Tanzanians have no head for anything above day to day business and are very vulnerable to being taken advantage of. There is a great need for imported talent like Paul to help realize the tremendous potential of farming here. Tanzania could be a major player in the continental food supply if they could just get past "poli-poli" and get their act together. Paul’s a very savvy guy and I’m betting he’ll find a way to pull it out.

Our three medical students arrived this evening. I met them briefly. Fortunately they are staying at another hotel. I don’t think I could handle three more 24/7 shadows. Catherine is enough. We’ll meet in the morning and I’ll plunge them into the wonders of primitive surgery. I've given them some warning as to what to expect.

Off to bed............my mosquito net beckons.

The News From Lake Rukwa

Lots has happened since my last post. When one begins to become involved in a place events seem to pile up on one another. I’ll just start writing and see how it comes out.

For openers let’s catch up on the hospital. We’ve been doing a lot of surgery. "We" means the little team I’ve put together and not me being full of myself. Some cases have been routine and others have been extraordinary. The routine ones have been hernias, hydroceles, various GYN cases, rectal problems and such. All have done well and it almost seems like home. The weird stuff that one would only see in a place like this makes the trip really interesting. For instance: Take a look at the before and afters of  this 22 year old girl who went through some ritual mutilation of her earlobes and developed keloids (out of control scars) that are the size of small oranges. Even if you’ve got a large plastic surgery practice in the states chances are you will never get to treat anything like this. Operating these was a fascinating 2 ½ hours of seat-of-the-pants decision making about skin flaps, reconstruction, etc with the goal being to come out with something resembling an ear. Also this week we have a local nun who ignored my advice last year to have her localized melanoma removed from her foot and now requires a below the knee amputation. Another one in line is a stunningly beautiful young woman who needs the middle three toes of her foot amputated because of sarcoma (soft tissue malignant tumor).  Yeah, life can be a barrel of laughs around here. And then there are the fun cases like the 75 year old guy we operated today who had lemon sized stone in his bladder. Why is it fun? Because starting tonight he no longer has to stand on his head to pee.

There is one sad and strange story I have to report. Yesterday afternoon a 3 month old child was brought in seemingly in abdominal distress. The child’s abdomen was distended more than any I have seen. It appeared about to burst. With no x-ray to help (the unit has been down for 2 months) we made a decision to operate based on what we saw feeling that something in there needed to be decompressed. When the anesthesiologist put the baby to sleep the distention was relieved and the abdomen appeared normal. Puzzled, we cancelled the surgery and placed the baby back in the pediatric ward. By morning he had died. Further questioning of the mother revealed that she had taken him to a traditional healer (read witch doctor) for a belly ache who had evidently given him an overdose of some powerful local herb. Yes, the baby had been poisoned. Welcome to Africa.

On the social side I seem to be falling in with an expanding circle of South Africans. Last night I had dinner with a couple of guys who are about to open a resort on Lake Tanganyika. Last year I visited the lake which is the longest and second deepest in the world. It is positively spectacular and a long neglected asset to the Tanzanian economy. All that is about to change. Heretofore the only place to stay was a posh fly-in-fly-out $900 a night resort that only a few could experience and added nothing to the economy. These guys, Chris and Ben, are building a low and middle end place that should attract ordinary tourists from everywhere. We had a great time talking about their plans for the lake and the upshot is that we are invited there over the weekend to sleep in a deluxe tent and get the feel of the area. I intend to do an interview and photo essay on the place and try to get it published in an American travel magazine. More on this next week.

And finally, I had dinner tonight with the regional administrator of Rukwa Province. The appointed equivalent of our state governor the honorable Daniel Njoolay (pronounced July) is the head guy for a huge territory that I have described before. We met last year and have finally gotten together again. Dinner was at Forest Way and he brought his wife who remained silent through most of dinner. . My agenda was to lobby for hospital improvement. His was to find out about Barack Obama. Neither of us was disappointed. I carefully laid out for him which deficiencies I thought could be remedied. There was no sense bothering with those that can not. Most of what I told him he already knew. One or two thins genuinely shocked him. He asked me to send him a written report which I will, being careful not to point a blaming finger at anyone in particular. I’m told that’s how one survives here. Then I described the current nature of American politics bearing in mind that Bush has been extremely popular here. It seems that one of the few things the administration has done right has been to earmark significant funds for African health care and it has been appreciated. Looking to the future I described the Obama-mania in the US that robbed Hillary of her shot and assured Daniel that the nominee would be a good choice for everyone and will probably be elected.

Over coffee the Commissioner/Governor launched into an explanation of how African politics work that I found fascinating. I can’t comment on it because it was only an hour ago and I haven’t had time to digest it all. Maybe I’ll write about it later. Feeling privileged to have had this conversation I picked up the check. After all, where else can you take a governor and his wife out to dinner for under 20 bucks?

Meanwhile, poor Catherine missed this event because she has come down with a case of what I call the Tanzanian three-step. She spent the day sitting on the can with her head in a bucket while Jasper and I took turns running back to the hotel to give her shots of anti-nausea medication. She seems better tonight and may even emerge from her room in the morning.

Well, that’s the news from Lake Rukwa where the women have perfect balance, the men have perfect teeth and all the children think white people are funny looking.

Until next time………….

Jasper

The key to my effectiveness here in Tanzania is Dr. Jasper Nduosindi. He is the senior of four or five physicians assigned by the government to staff Rukwa Regional Hospital. It is a daunting task particularly as one or more of the junior docs seems to be away at a meeting most of the time. I have not been impressed with any of them except Jasper. He has had surgical training, how much I’m not sure. Nevertheless, he has been responsible for all surgery, crossing all specialty lines, for several years. He does it all, OBGYN, urology, orthopedics and general surgery. As I’ve indicated, he has very little to work with in terms of equipment and supplies. There are almost no x-ray or laboratory diagnostic methods available. His diagnoses are always strictly clinical, arrived at by physical examination supported by experience. He must act on them every day knowing that he might be wrong. Under these circumstances the most important things he needs to avoid are exceeding his limits and getting into situations where he runs out of options.

Jasper is a bright guy. He attends postgraduate seminars often in Nairobi or Dar. He can put little new knowledge to use here because of equipment limitations. WE sit for hours sometimes talking surgery and as I describe the developments of the last 20 years he is incredulous. I brought intestinal stapling devices with me. Although they have been in use in the US for 40 years he had never heard of them. I can show him how to use them and leave my stock. It will be up to him to cajole the government into getting him some more. I’m not real hopeful about that.

We have a neat relationship. Going about the day with him I get to help set bones, treat malaria and do other things that I’ve either never done or long forgotten. He gets to assist me in surgery doing the things that I know well thereby upgrading his own technique and decision making. Where Jasper is rapidly becoming a formidable expert is in the area of repairing fistulas caused by obstetrical damage which is a huge problem here. Each year he works with a dedicated team from Nairobi that comes for two weeks to work and teach. He’s getting really good at it and may be forming a team of his own.

Doing medicine for the government doesn’t pay much here – perhaps ten to twelve thousand dollars a year. The good news is that things are very inexpensive here outside Dar and the northern tourist areas. Jasper has managed to raise a beautiful family and acquire a few houses and a sizable piece of ranch property not far from town. His wife is currently away working on a nursing administration degree in Dar. He sees himself getting out of government medicine before too long and settling down as a gentleman rancher and perhaps running a small private clinic somewhere. Those are positions in life that he will have rightfuly earned

Sumbawanga

I mentioned in a previous post that Sumbawanga is located in the southwest portion of Tanzania near the borders of Zambia and Congo. I talked about the population numbers and all that but I have never really described the city itself. The first word that comes to mind is dusty. There are only two paved streets in town and auto traffic over the dirt roads raises a continuous cloud of fine, brownish red dust that settles everywhere. Where the paved streets intersect in a "t" is the only building downtown that looks even vaguely modern and houses the elite businesses of the town. On both sides of any street are three foot open ditches, sometimes covered by slatted decking to accommodate pedestrians crossing. These ditches, thankfully, no longer convey sewage as modern septic tanks have arrived. They serve as runoff canals during the rainy season lest the whole place gets flooded. In the dry season there is no water in them and the population considers it perfectly natural to toss whatever trash they may he holding into them knowing that when the rains come the refuse will be washed away. The concept of avoiding littering is unknown. I have never seen a public trash receptacle.

OK, with that unpleasantness out of the way let’s talk about the good stuff. There is a special energy here. Everyone is hustling something. There are throngs of people everywhere fixing bicycles, making furniture, repairing cars, driving taxis, selling fruit running small shops and engaging in all the kinds of familiar commerce and some we probably don’t want to know about. All of this is occurring in buildings that look like they were built yesterday out of scrap bricks, wood and tarpaper and covered with a corrugated tin roof. The surroundings may appear squalid but the attitude is beautiful. Most people are decently dressed, some strikingly with women in beautiful native designs and men in worn but serviceable western clothes. They go about their business cheerfully greeting each and when they see me they smile effusively testing out their English while I try to answer with my nascent Swahili. Everyone seems to be trying to make something happen. Most have cell phones and delight in using them. Entrepreneurs carry some of the most creative business cards I’ve ever seen and most shops offer several separate types of goods and services. There are a few nice neighborhoods,of course, with houses built in the Euopean style. These belong to local politicians and business pople but the average living conditions are simple and primitive. All in all this is not an especially attractive place. The only tourists I’ve seen are a few South Africans on their way to Zambia. It is a far cry, however, from the cliché of a stagnant third world mud hole. Cars are everywhere. They are mostly 80’s and 90’s vintage Japanese, mostly Toyota. I have not seen an American made vehicle anywhere in Tanzania and rarely see a European one. These are all four cylinder jobs with full sedan bodies. The most remarkable thing is that they are all immaculate. Whether a taxi or private car they are always clean and polished, rarely dented and recently reupholstered with pristine if sometimes garish leather. I have not seen one junked vehicle anywhere in town. There are a lot of motorcycles, mostly dirt bikes and a very strict helmet law. And everywhere there are bicycles, the chief transportation of the masses. Bikes here are very inexpensive, imported from China by the hundreds of thousands.

Walking around town one might ask if this town is coming or going. It’s a good question and the answer is not at all obvious or certain. Rukwa province is the stepchild of the government. Being a region of subsistence farming and small local markets there is nothing here for export. There are no other saleable resources other than good year round weather. Unfortunately the way things are is that the region that does not contribute much to the economy gets largely ignored. Even electricity is unreliable as we spend at least a portion of each day without power and have just ended an 18 hour outage. Water is plentiful but there is not a purification system worth the name so all consumed water is boiled or bottled.

Whether the city is coming or going in terms of development depends almost entirely on transportation. Sumbawanga remains a very wide spot on a very bad road. From Mbeya 90 miles to the south to Mpanda 150 miles to the north the only road is a rutted, potholed, often flooded and impassable mess. Everything and everybody moving in or out of Sumbawanga uses this road. The government has been promising to pave it for years but nothing seems to happen. This may be the year however. The new Prime Minister of the country is from this area. His name is Mpinda and I had the opportunity to meet and photograph him several times last year as his previous duties brought him through town and he stayed at Forest Way. My personal feeling is that when that road is completed this area will soar. The potential for manufacturing and organized farming is tremendous. Lake Tanganyika 40 miles to the west is one of the most beautiful places on earth and is located near spectacular waterfalls and almost untouched wildlife preserves. Tourism there could be as important there as it is in the North Country around the Serengeti. It all depends on that road. After that the investment will come and Sumbawanga could become one of the most important cities in south central Africa.