Return to Tanzania - 2011

On The Way Home

July 29

During the last four days Ara and I had the wonderful experience of exploring northern Tanzania, specifically Arusha, Ngorogoro crater, Lake Manyara National Park and the Serengeti. Not a trip for wimps it involved many spine compressing hours in a Landcruiser over bumpy roads. Fighting off the tsetse flies that bite through several layers of clothing was not a lot of fun either. But it was worth it. The wildlife is so abundant that at times it seems like a movie. We saw and photographed what is known as “the big five” – elephant, lion, water buffalo, leopard, and rhinoceros – and also countless giraffe, antelope of various kinds and so many more. We stayed in a really cool tent camp where we heard hippos and elephants close by during the night. A baboon even tried to join us for breakfast this morning but was quickly shooed away by the management.

It was a great time to relax and think about the previous three weeks. We contacted Jasper and our patients are doing well. Diana, now called spinach girl instead of spinach lady (she is only 16) has definitely turned the corner and is on the mend. Little Johnny is home and waiting for a referral to Dar. We will follow up on that and try to make that happen. Everyone else has gone home or is close to doing so.

We are constantly mulling over what we can do to help improve the medical care at Sumbawanga. The new buildings are just a start and without the equipment and personnel to run them not much will happen. The equipment is available from several sources and we can help with that. The staffing problem will only be solved when people want to live there. I did get to meet with Daniel Njoolay, th Regional Commissioner of Rukwa while in Arusha and he assured me that the airport in Mbeya will be finished soon and the road to Sumbawanga will be paved. This will cut down the time from Dar es Salaam from 2 days to about 6 hours. Not only will it give an enhanced lifestyle and flexibility to the people of Sumbawanga but will also allow for service people to maintain more sophisticated equipment.

This is our final night in Africa. We leave Dar tomorrow on a flight to Dubai. From there I’ll go on to New York and then Phoenix by way of Minneapolis. Ara heads off to Paris for a visit with friends. It’s a long flight but, hey, after that 17 hour bus ride to Arusha it’ll be a piece of cake.

Next time we would like to bring an orthopedic and maybe a plastic surgeon as well as some medical students. It is feasible and it appears that Ara has got the “Africa bug” along with me. This continent is magical. I am so thankful for the experiences that I have had here and for the time freedom and health to be able to do it. I look forward to next year.

Thanks for reading these postings. They have not been as extensive as previously but, truth be told, we were working more and Ihad less time for writing.

Until next time………………………..

Skip and Ara

The Long Ride

Have you ever spent 17 hours on a bus? Have you ever spent 17 hours on a bus traveling on a treacherous 2 lane blacktop with blaring unintelligible music playing and driven by a manic person who spent less time than advisable watching the road? That was our day today. At 4:45 am this morning our host at the Golden City, Kissa, escorted us out to a dark, scary bus stop to wait. It was cold, very coild and as we stood there waiting to start the journey to our safari Ara remarked, "We better see King %^#&$ Kong." The good news was that we had seats right in front so we could see through the windshield. The bad news was that the seat was barely wide enough for the two of us and by the time the front of the bus was packed with people sitting on the floor we could hardly move. No reading, too jiggly for that. All we could do was be alone with our thoughts or listen to somethng on Ipods that would drown our the cacacophony around us. People here are beautiful but their one not-so-endearing trait is to shout their conversations witout regrard for others' personal space. The only real food stop was at the Al Jazeehra bus stop where I got stuck last year. We bought some stuff to eat there but mainly we survived on Attain bars, potato chips, Snickers bars and water. All things do end and now we sit at a beautiful hotel in Arusha at nearly 2am having just finished Ara's birthday dinner.

Off to bed now.  Since I have a good connection there will be more tomorrow.

On The Road Again

 

July 22

After traveling over the wretched dirt road from Sumbawanga to Mbeya I sit in the computer area of the Golden City hotel trying to do this post on an ancient computer attached to a phone modem. It is taking a long time and there definitely won’t be any pictures.

The trip to Sumbawanga was very successful. It was hard saying goodbye to Jasper and the staff. Everyone there has been so kind and gracious to us. I believe we actually did make a difference for the reasons that I explained in my last post. Having had he opportunity to be here 3 times a year apart I do see progress. It is slow, uneven and disorganized but the place is moving forward. In the hospital it’s the little things; gloves being more easily available, drains and tubes accessible and a wider variety of medications. There has been a substantial improvement in the electrical situation both on a city-wide level and the installation of effective emergency generators at the hospital. Though voltage variations still play havoc with the equipment we experienced no power outages this trip. I mentioned the two new buildings under construction and there is a real sense of excitement and anticipation among the staff. They want to make things better.

I mentioned before we left that I was excited to be working with Ara. I said that I expected to be impressed and I was not disappointed. This is the most time I’ve gotten to spend with him since he moved out to go to college 17 years ago and it has been fun getting to know him again as a grown man. As a surgeon he has the technical skill, knowledge and judgment that I would expect of someone with such superb training and these are exceptional. But most of all I was taken by his ferocious, single-minded commitment to making everything he does exactly right no matter what. This is the same quality I saw when he was a small boy building with Legos and later when he was a high school wrestler. Only the best will do. The best part is that he manages this while being and exceptionally nice and caring person. Ara is going to have a wonderful career.

So there: I’ve had my proud father moment. Thanks for your indulgence.

So now we’re on our way to Arusha – yuk! 18 hour bus trip tomorrow starting at 5am. The Regional Commissioner (Governor) of Rukwa, where Sumbawanga is located, is currently on vacation at his permanent home in Arusha. We are friends and he has asked that I call when I get there. I expect it will be a dinner invitation for Friday night and I welcome the meeting because I get a chance to hear the updates of what is going on and to put in my 2 cents also. Saturday we take to the bush in search of great wildlife pictures and get to stay in some neat lodges and tent camps. After that it’s back to Arizona via Dar es Salaam, Dubai and New York. I don’t know if I’ll have a chance to  post any more so if not I’ll tell about the safari when I return.

Starting To Wind It Down

July 20

The last two days have been spent doing routine cases and a couple of standouts such as one of the biggest breast cancers I have ever seen. The tumor itself was about the size of a softball and located in an enormous breast that showed all the characteristics of malignancy. On these findings alone I elected to perform a mastectomy, a procedure that is not done very often any more in modern countries. Nevertheless, this was the only option and it is doubtful that the woman will be able to receive the necessary chemotherapy and radiation that is needed to prolong her life. We probably bought her 1 to 2 years with the surgery.

The lady with the skull fracture died. She would have needed a simple neurosurgery procedure to possibly save her. Neither Ara nor I are neurosurgeons but we could have figured it out. Unfortunately the necessary equipment is just not here. There is a murder investigation about this lady underway.

The poor 13 year old with the botched abdominal surgery has also died. We found out this morning when we went in for rounds. It was so sad but her suffering was unimaginable. Between us we must have spent more than 24 hours working on this girl trying to save her but the odds were just too great. Ara was feeling particularly bad and began questioning whether or not we are really doing any good.

Just as we were questioning our reason for being here I received an email from one of Ara’s fellow residents who had spent a year in Kenya prior to starting practice. He’s been following our blog and a summary of what he said is as follows: There does not exist in Africa the absolute dedication to getting the job done no matter what. They will make some effort and if it doesn’t work they will let it go and move on. When they see western trained volunteers doing whatever it takes to do the job right it makes a huge impression. Spending all night working on a kid with a collapsed lung or taking 3 or 4 hours to get an IV going when everyone has failed makes an impression. The outcomes of what we do are, of course, important. But far more important is the example we set. This is what the medical personnel here will remember.

We felt much better after reading that.

And of course the bright spots appear such as our little Johnny Thomas, the boy with the kidney tumor, who, despite a collapsed lung which has been handled, continues to do well and is committed to a trip to Dar for further treatment. Spinach lady has a bit of a wound infection but appears to be turning the corner. All of the cases that are doing well remain unremarkable for just that reason.

We are working with a wonderful man named Jasper Nduasinde. He is the chief (and at times only) physician on the premises. (Read more about him in the previous post from last year bearing his name.) He has been an extraordinary help and support and has taught us a great deal about how things are done locally. He remains a steadfast government-employed doctor and really cares about his patients and improving the system. He has been a terrific host and we have enjoyed the give and take and exchange of information.

Tomorrow is out last day at the hospital. There are 2, maybe 3, surgeries scheduled and we will finish up. Wednesday, after rounds we leave for Arusha which is a 2 day bus trip through Mbeya. There we will go out on safari for a few days to the Serengeti before departing Africa. I’ll sum up my final thoughts about Sumbawanga in my last post from here tomorrow.

Coping With Frustration

July 16

We have found out that there are certain cases that are kept from us because the staff is either too embarrassed by them or they feel we should not waste our time with what they consider hopeless. One such case is a girl of 13 who had a badly botched surgery by the assistant medical officers. She had an intestinal perforation that was not adequately identified and treated originally and even though Jasper had made a great effort to re-operate and fix the damage it had not gone well. Continued leakage of intestinal contents, now through the incision, was causing the skin to become extremely irritated, inflamed and painful. Her inability to eat was depleting her nutrition making the likelihood of any healing quite small. The appearance of her abdomen was too dreadful to describe here and she had essentially been placed in a corner to await the end.

To be honest if I had been here alone I probably would have looked at this girl and concluded that it was indeed hopeless. However, to a recently trained, bright-eyed idealistic young surgeon without too many heartbreaks under his belt not to try to help was unacceptable. So after a full clinic day on Wednesday Ara and I spent about three hours in the OR seeing what we could salvage. We arranged to get all of the drainage coming from one place so it could be kept off the skin and managed to get the abdomen completely closed which it had not been before. From a technical point of view it was something of an accomplishment. It is still doubtful that she will survive because there is just no way to provide the nutrition that she needs to even begin to heal, which brings me to the point of this piece.

  As I mentioned earlier C-sections (or anything dealing with maternal and child health) take precedence in this hospital. Looking at the maternity ward with its clean floors and walls, uniform clean bedding and attentive nursing staff you would think you were in a well run if not terribly modern facility. The contrast with the abysmal conditions in the medical and surgical words and even the ICU is startling. There are probably two main reasons for this. First, maternal and child health is the key to a strong population. If one has limited resources better to expend them adding fresh, healthy members to the population than to try to save the sick and dying. Besides, great things can be accomplished in terms of mother and infant mortality rates by doing some basic things well which are neither expensive nor complicated. By contrast, improving outcomes in the medical and surgical areas requires a huge investment in equipment, training, personnel and ongoing maintenance.  Unless massive transfusions of money can be injected into third world economies such investments are just not possible. This dichotomy of priorities gives rise to the awful conditions I describe here. But, in the end the expended available resources are geared to producing the maximum number of life years.

However, things are changing. The hospital is about to complete two new buildings. One is a new surgical unit with three OR’s and amenities heretofore unavailable and, of course, a new women’s health building that is really impressive by almost any standard. Their successful operation is fully dependent on two things. One is equipment which can be had from a variety of organizations which supply used, modern serviceable equipment world-wide at minimal cost. The more difficult challenge is personnel. There are precious few well trained physicians, nurses and technicians in Tanzania.  These people want to live in places that provide the lifestyle they feel they have earned. Sumbawanga is not one of those places. There is not much to do here. There are only two paved streets and the lack of a paved road to or from anywhere makes the city unattractive. The success of the hospital, the city and everything else in southwest Tanzania is dependent on road construction and the pace is excruciatingly slow.

And so I have ranted on for 2 pages giving no news. I’ll follow up in the next post.

Back To Work

July 15

Yesterday and today were surgery days. They were not as full as we would have liked because during construction here we need to share an operating room with the assistant medical officers who do Caesarian sections. There are many of these because the level of pre-natal care here is abysmal. The AMO’s have figured out that if they get here early they can start before us and we end up waiting to use the OR. It has decreased out workload considerably. We spend the down time in the clinic seeing new patients in hope that we will be able to fit them all into the surgical schedule. Some updates: “Spinach Lady” had complications and needed to be returned to surgery. We wound up having to remove half her stomach. The operation actually went well but she is so nutritionally depleted that the outcome is in jeopardy. In the States we would have her on total intravenous nutrition but no such capacity exists here so he will have to make it on her own with simple fluid replacement. It all depends on her reserve and because she is young and strong I am hopeful. All of our other cases have gone smoothly and are doing well.

A young boy of six was presented to us last week with an enormous mass in his abdomen. Diagnostically all we had was an inadequate ultrasound exam so we went into the case not knowing for sure whether it was an enlarged spleen or a kidney tumor. Unfortunately for him and us it turned out to be kidney and presented an operation that would have been formidable in the most sophisticated of settings. The mass, called a Wilms tumor, was about the size of a regulation football trapped in the abdomen of a 40 pound person. Ara and I worked together for about 3 hours and successfully removed it. Blood transfusions were required and, at times, it appeared that he would not make it off the table. This morning he is alert, awake and smiling and tomorrow should resume taking solid food. This will probably be the signature case of the trip but in reality his future depends on his getting to Dar es Salaam for follow-up chemotherapy and radiation. Otherwise he is not likely to survive past 1-2 years. Today, after the C-sections cleared out we managed to do 3 interesting cases. The first was a woman who had been assaulted in a local village because she was suspected of being a witch. Someone took a heavy stick to her head and caused a depressed skull fracture and a skin wound so severe that a piece of her skull the size of a sliver dollar was bared to the bone. It took some fancy plastic surgery techniques to get the bone covered. We have no facility for dealing with the fracture but so far she shows no signs of brain damage. The next case was the removal of a softball size benign fatty tumor from the front of a woman’s leg. We wound up the day by removing a large testicular tumor from a middle aged man. Ara and I then decided it was “Kili Time”, named for our favorite beer, Kilimanjaro. An adequate but by now boring dinner followed 2 games of scrabble. Ara leads 4 games to 2 and all have been well played. And so here I sit, writing this post before I have to give the computer back to Ara so he can continue his French lessons. Tomorrow is a straight clinic day though we may get to do one case in the afternoon. Sitting in the office is not my favorite. As Ara put it, “Surgery is the game, clinic is the penalty box.” Spoken like a true surgeon.

Paradise Revisited

July 13

Early Saturday morning we checked on our patient from last night who will forever be known as “Spinach Lady”. There were a few concerns, most notably her persistent dehydration and anemia, but overall she was holding her own and we felt confident leaving her in Jasper’s care.

The hospital administration has been very gracious toward us and they provided a Landcruiser and a driver for the 3½ hour drive to Kapili. We only had to pay for the fuel. The drive is over a typical Tanzania road, unpaved and, even in the dry season, uneven and innards-crushing bumpy in places. The Landcruiser in Africa is not the posh vehicle sold in the US. These are older style squarish affairs built for durability not comfort.

Kapili is a non-descript small town one step up from a village. As Louise, our hostess described it, “The rest of the world is going to the moon, Kapili is going to the market.”

Lake Tanganyika is the longest lake in the world and the second deepest. Its coastline borders four countries, the longest portion being

Tanzania. Kapili is located at about the junction of the upper two thirds and be bottom third of the lake. A mile or so down the coast from there lies a most unlikely piece of paradise. Conceived, built and operated by a wonderful young South African couple, Chris and Louise Horsfall, the Lakeshore Lodge offers everything the discriminating traveler seeks in luxury, exotic accommodations. Built on 55 acres of lakefront property the lodge is currently set up to accommodate about 20-30 guests in addition to a campground up the hill which could be used by many more. The meals are wonderful with most of the food (including livestock) being raised on site. The resident chef puts it all together in delicious and surprising ways. The décor around and in the wonderful open air lodge and living quarters is done in the most simple but comfortable way giving the entire place an air of Zen beauty and harmony. After arriving we spent the afternoon lounging by the lake reading and playing Scrabble. After a sumptuous dinner we hung out at the bar with some other guests and the owners enjoying come very interesting conversation. The next day we took kayaks out to an island about 3 miles out and spent the afternoon snorkeling in the crystal clear water watching an incredible number of species of fresh water fish and lounging on the rocks. It was a great workout.

That evening some interesting people showed up. A woman physician from Chicago named Amy Lehman has taken on the project of building and operating a hospital ship to cruise the entire length of the lake to service the hundred or so villages that have no road access to the interior. As she tells it a foundation has put up seed money for to make a video that will present her project to major foundations to raise the 10 to 15 million dollars that completing and maintaining the project will require. Amy is interesting. She is a thirty six year old divorced mother, trained in surgery, heavily tattooed and an independently wealthy trust-funder. She brought with her a maritime consultant trained at the coastguard academy and a high powered video-photographer named Ron to document her every move. He also is a walking canvas. I guess it’s possible that she can pull it off but right now the whole project smacks of hubris and narcissism. It will be interesting to follow the story as it unfolds.

After a somewhat raucous night with this bunch we got a good night’s sleep and prepared for our departure after breakfast. Waking up at the lodge to the lapping of the waves surrounded by relative silence is a pleasant experience.  I write this sitting at the bar enjoying my second cup of excellent coffee awaiting the delicious communal breakfast to come. I could stay here for a long time but we need to go back. Our driver will call for us around 10:30 and take us back to the work we came here for. Tomorrow is a big surgical day.

Wasting No Time.................

July 10

Today was the kind of day that we came here for. Surgery early and we were able to shorten the time between cases considerably. The day started simply enough with the removal of a large breast mass from a woman who was breast feeding. It had appeared highly suspicious but o removal turned out to be mass of blocked milk glands. Another breast case followed which was a tennis ball sized benign mass in the breast of a 19 year old girl. I say benign only because it appeared that way based on years of experience. In reality there is no way to determine for sure if I’m right but given her age and the character of the tumor the chances are over 95 per cent that it is not malignant.

As we prepared to do three other elective cases the day changed dramatically. One of the assistant medical officers rushed over to tell us that he had a woman that had been in labor for some time and was beginning to show fetal distress. Could we do an emergency C-section? Of course. After quickly preparing the patient I began the case with Jasper assisting. Ara elected to watch and learn as this type of surgery had not been part of his training. The operation went smoothly, quick incision into the abdomen, entering the uterus and delivering a healthy boy who was crying before he left the table. As I reached in to deliver the placenta I was greeted by a wagging foot. Yes, totally unexpected twins. With mother and babies doing well we wrapped up a very satisfying case. Then the day turned considerably more somber.

We were informed that a woman had been admitted with apparent peritonitis and septic shock. She had admitted to the admitting medical officer that she had undergone an illegal abortion five days earlier. All abortions in Tanzania are illegal and are also a cultural taboo. Nevertheless back alley procedures do get done and sometimes the results are disastrous. So it appeared to be with this woman. When these types of patients arrive they are treated with indifference bordering on neglect. Jasper was reluctant to even have us see the patient, probably because he considered it beneath us to become involved in such a case. I insisted and we were escorted to the ward. What we found was a 19 year old woman who was truly close to death. Her abdomen was rigid; she barely had a blood pressure and appeared to be in septic shock, presumably from a botched abortion. Knowing that the assistant medical officer’s plan to operate on her later was a sure death sentence I insisted on moving her to the OR immediately and postpone the other cases. Reluctantly they agreed.

I decided to have Ara take the lead and be operating surgeon on this case. I would assist. After all, this is what he has been trained so well to do. When the abdomen was opened we did not find evidence of the infection and pus one would expect from a septic abortion. In fact the uterus and ovaries looked perfectly normal. What greeted us was a massive amount of dirty looking fluid that contained a large amount of food that looked like spinach. That could mean only that there was an opening in the stomach itself. Sure enough, after thoroughly inspecting the abdomen we found a huge perforated gastric ulcer that was also bleeding profusely. All that was necessary was to close the hole, patch it, wash out the abdomen and close. She might not survive but at least she now had a chance. We were able to get some blood for transfusion but we lacked any of the tools that we would have had at home to manage such a critical patient To my delight Ara had performed flawlessly and at about 8:30 at night we retired to the hotel. At dinner we discussed how close this patient had come to dying because the presumptive diagnosis was totally wrong. And even if it hadn’t been she deserved better than to have been neglected to death.

And so Friday came to an end. The weekend is free and we are going off to Kapili, about a three hour drive, to visit my friends Chris and Louise at their new resort, Lakeshore Lodge, on

Lake Tanganyika

. For background check out the blog post about them from last year.

We Arrive - Finally

July 9

We arrived in Sumbawanga on the 7^th after a very long journey that started in Phoenix and proceeded to New York, Dubaiand Dar es Saalam by air. After a night in Dar we boarded a bus and rode for 13 hours to Mbeya – a distance of about 700 miles. In the morning we made the final 200 mile leg to our destination in a Landcruiser that the hospital graciously provided with a driver. This was my third trip and by now I have learned which are the nice hotels along the way and how to handle the chaotic bus terminals. Nevertheless, a four day journey takes its toll and I was exhausted on arrival. This trip I decided that intestinal stapling instruments were the things to bring and we toted a duffle bag full of them. Many thanks to Nathan Breece of Covidian, Inc. for supplying thousands of dollars worth of these disposable instruments at no charge.  Kudos to Emirates Airlines who not only sponsored our trip – Ara’s and mine, but also waived all luggage fees to bring things over including a heavy microscope. There are not so kind words for US Airways who charged me for every ounce.

On arrival we checked into the Forest Way Inn where I have stayed on previous trips. To be truthful the place is not as good as before. It is noisier, not quite so clean and the food has gone from plain and adequate to barely tolerable. Were we staying a full month I would contemplate moving but since we will be here only two more weeks we’ll stick it out.

Dr Jasper Nduasinde, my Tanzanian counterpart, was waiting for us at the hospital yesterday morning and he did not waste any time. He first took us around town to make courtesy calls on local dignitaries. This is obligatory protocol where we sign each one’s visitor’s book and engage in small talk during which I try to make very simple sentences sound intelligent. Despite the fact that English is the official government language it would be charitable to characterize the English skills of most local officials as marginal. These visits, though extremely cordial, have awkward silences broken by inane questions. We got through them and set off for the hospital.

Sumbawanga

Regional

Hospital

is a big place. It serves and area of over 150,000 people. Each ward is a separate building and though somewhat dilapidated they are serviceable. They are placed around a central yard that serves as staging area, meeting place and portable outside laundry where patients’ families wash clothes for their loved ones. I was very impressed by the progress being made here and I will write more about that later.

I had concerns that there might not be enough work to keep us busy. That fear was unfounded as Jasper had built up a large consultation list and in our first two days, yesterday and today, we have seen over forty patients and performed several procedures. There is a full surgery schedule tomorrow.

This is the first time I have ever worked with Ara and I was so pleased with the way he took charge and displayed terrific confidence as well as an amazing command of a wide variety of medical knowledge. I’ll try not to “kvell” too much.

Off to bed now. Tomorrow’s a big day.

Leaving tomorrow

Ara and I are in New York taking in our last breath of western civilization for July. I divided my day between B&H which is the worlds most fabulous photography store and the Metropolitan Museum of Art where I was fascinated by an exhibit called "Models as Muse" which beautifully traces the history of the modeling industry from the 1940's onward. It sounds trivial, I know, but from a photographer's point of view it is quite relevant.

Meanwhile, my contacts on the ground in Tanzania have become somewhat "iffy". We will be fending for ourselves in Dar es Salaam but I know the place well enough by now that we'll be OK. I'm sure the road to Sumbawanga has not changed and we will find our own way to the bus. I'm anxious to get started and will spend the evening checking equipment and making sure all is in order.