At Long Last --- An Update!

Everyone --- please forgive the length of this post ... I have been journaling at home at nights on my tiny computer but have only been able to access computers one other time besides today! There is just one computer with satellite internet access here ... and often, the electricity goes out, so when we can get to the computer, it doesn't work at all. You would not believe how gorgeous this mountain/rainforest is, but it's pretty incredible how remote we are. It's incredible there is even internet access at all! Enjoy, and until next time --- Lauren

*****

April 3, 2009

LEARNING, LEARNING

Julie and I overslept this morning until 7:15 a.m. --- but, luckily, with our work being a few meters down the hill, we didn’t have too many troubles meeting Dr. Lisingu for morning rounds. I like him a great deal --- he had been up twice in the night delivering babies, to one mother a breech set of twins, but was still gracious and gregarious. Obviously in love with teaching, he thrust two different types of fetoscopes in our hands and told us to get to work when we arrived on the maternal ward. I palpated about ten women’s abdomens checking for fetal lie and tried my best to hear for the fetal heart tones with the scopes. How I wished for my handheld ultrasound. Thank goodness a genuine smile is universally understood in any language --- hopefully that made up for my relative lack of competence with the new equipment. I was happy in that Julie and I were more active in caring for the patients --- she wrote all the progress notes as we walked along, and I got to examine the patients.

After seeing many of the doctors’ orders for chest x-rays go unfulfilled, I finally discovered why --- the almost new x-ray machine had quit working. I’m not sure if it was an electricity problem or a broken part, but it brought home the importance of securing sustainable medical devices when donating them to third world countries. Several machines, including the laundry machine and multiple pieces of infusion equipment, stand silent near the operating theater, rusted and decorated with cobwebs. In a hospital like this, it pays to think smart --- coordinating shipments of fabric scrub caps and masks that can be re-used and recycled, as opposed to disposable versions. So much is needed here though that it’s hard to know where to start.

I spent the afternoon seeing patients in the outpatient department with Dr. Lisingu. He taught me several useful Swahili phrases to use in the clinics that made the patients laugh when I tried them. I wrote all the notes, ordered labs, and performed the exams. For any patient presenting with headache and fever, we automatically ordered a “blood slide” to check for the presence of malaria and for any sick child, a white blood cell count. At Gonja, there are very limited diagnostic capabilities --- and with any sign of fever or pain, whatever antibiotic or pain medication on hand is prescribed. Getting very sick around here is a dangerous proposition.

Besides leaving Africa with a new experience and understanding under my belt, I may leave with a few extra pounds! Our cooks are overly generous in preparing rice, beans, and collard greens --- and last night, we had my favorite food so far … chipsi, or fried potato slices (sounds like home?!). Our evenings are pretty basic --- we eat dinner (usually in the dark, as the electricity is out), sit and chat while Julie knits and I work on my computer, practice yoga, heat water for our bucket baths, run away from lizards, and kill bugs (that are then promptly eaten by a swarm of ants). However, attending church services in the chapel the last two evenings has changed things up a bit --- tonight, one of the teenagers gave me a hand-written song book so that I could follow along, which certainly helped. And when I joined in their dancing toward the end of the worship, following them out in a line as the caboose, they turned to see I was dancing and started laughing, not expecting a white woman to be able to move her hips! I laughed back and told them I would see them kesho (tomorrow) … in situations like these, it never hurts to be the first and the last one to laugh at one’s self.

*****

April 2, 2009

MORNING ROUNDS

The sounds of Africa are rhythmic, harmonious, and almost … sensual. I have never heard such a combination in all my life. The nighttime as I fall asleep brings a chorus of locusts and crickets with the occasional bark of the dog in our backyard. I awake in the morning to roosters crowing, machetes chopping, cows mooing, and children laughing as they run to school. It’s as if each sound could not exist without the other, and together they form the most beautiful music.

Julie and I ate chapati again for breakfast --- we’re starting to think that it would be sacrilegious to not eat chapati for breakfast, morning, and afternoon tea. But with lots of chai tea, they slide down pretty easily. We sat in the sun studying Swahili until Dr. Mary Msema , the head doctor, walked down the ramp and smiled, “Oh, were you waiting for me?” We followed her into the outpatient department for our first morning prayer. There were just five of us, Dr. Msema, Nivo, the pharmacy clerk, Julie, and me, sitting on the shadowy benches. The three ladies began with simple worship songs, blending their voices perfectly in praise. Most every morning they gather, sometimes with a larger crowd apparently, to give thanks and ask for blessings before they begin the day’s work. Such gratitude in the face of challenged resources and constant hardship (and not to mention being the ever-gracious hosts) is, for a lack of a better description, absolutely awe-inspiring. I hid my tears as Nivo led us in the Lord’s Prayer, and Dr. Msema asked each of us to introduce ourselves to the tiny gathering.

Morning report from the night nurse was the first order of business before we made ward rounds. Her hair braided meticulously in tiny rows, the diminutive lady read her handwritten report in such low, hushed English that I had to strain to hear. She turned to us at the end and asked quietly, “Any comments?” Julie and I, of course, had none! I’m afraid the two of us made quite the stir as we followed Dr. Msema from patient to patient, ward to ward. I prompted smiles from the women and children when I cast ones their way in the maternal, female, and pediatric wards, but the men who had been busy chatting fell silent and sat on their beds watching us intently the entire time. I can only imagine what they were thinking --- whether they were wary or welcoming, stunned or supportive.

All patients in each respective section shared a common space, sleeping on old wrought iron beds with chipped paint and sagging foam mattresses with thin blankets. Malaria nets hung above each bed, and a large sheet partitioned each room from the hallway. Cobwebs and large moths hung from the ceilings, and telltale stains of water damage graced every corner. Electrical wires for lighting dangled without light bulbs on the walls, and despite the sunny day, we examined most of our patients in the relative darkness. Wooden crate inserts were used to prop the head of the bed, and portable, metal urinals rested on the floor. Family members sat attentively next to their loved ones, brushing away the occasional fly. The nurse tracked Dr. Msema with a rolling walker, carrying hand sanitizer, a couple old mercury thermometers, and our paper documentation charts in its basket. I thought my time in the federal hospitals of Brazil would prepare me for condition of this remote hospital, but I was wrong.

Gastrointestinal disorders and tropical infectious diseases were the chief complaints of the day. One woman’s abdominal incision bubbled pus two weeks after she had surgery to repair a small bowel obstruction; one gentleman sustained a blood transfusion yesterday for severe anemia following a helminth infection, and another man who was hauled in on a wooden stretcher by four men from a village nearby was started on treatment for likely malaria and typhoid. We saw a woman with an abscess following a quinine injection, a palliative care stroke patient who has been here the last six months, and a young man with a large hernia. In the pre-natal ward, the women lined up to be examined by Dr. Msema to feel the baby’s position and listen for the heartbeat with a fetoscope (a metal cone). My favorite patient, however, was a little two-year-old boy in the pediatric ward dressed in a miniature US Army jacket who was hospitalized for pneumonia. I tickled his feet and tapped his nose before he treated me to a wide smile. After examining him, I continued to play peek-a-boo with him, prompting a great deal of laughter. Dr. Msema told me it wasn’t too late to consider pediatrics!

Julie and I had the incredible opportunity to spend the first part of the afternoon in the HIV/AIDS clinic. We followed a pediatric resident who makes the trek from Moshi once a month to care for children afflicted with the disease. Mostly orphaned after their parents died from the virus, he tracks these kids’ cell counts and dispenses antiretroviral treatment, mostly donated by American philanthropic organizations. If the children fail first line treatment, they must travel to Moshi, more than four hours away, to obtain second line treatment, a feat nearly insurmountable for families in the mountains. The resident shared that while Sub-Saharan African contains 10% of the world’s population, it carries 70% of the world’s HIV/AIDS burden. Tanzania itself has an infection rate of 7%.

After a late lunch, we wandered over to the operating theater and stumbled upon a Caesarean section ready to get underway for failure to progress. We changed into white boots and walked into the sterilizing room to find Dr. Msema preparing for surgery. In Gonja Lutheran, there is essentially one operating room with its scrub station, a large anteroom with supplies, and a smaller room across the hallway for cleaning equipment. Most of the equipment is in relative disarray and/or in a state of disrepair. Julie and I each found a pair of scrubs to wear (mostly all bore the University of Iowa logo) and were rather surprised to learn that the disposable masks are bleached between cases for re-use, as well as the hair nets and plastic gloves. All the protective hats were gone after the surgery team got theirs, so Julie and I tore a disposable gown into triangles and fashioned those into hair nets. I was soon appointed as the anesthetist’s assistant, and Julie was poised to care for the baby. There is no such notion as continuous monitoring during surgery at Gonja, and so I took manual blood pressures every five minutes and recorded them on the paper record. I monitored her pulse and maintained an open airway as the section got underway.

Within minutes, the baby boy had arrived, and Julie and the nurse began rubbing his body vigorously to awaken him. I glanced up and was surprised to find him rather blue, floppy, and not making much noise. The anesthetist, who we later learned had been working at Gonja for 48 years and is the only anesthetist for the entire hospital, left me in charge of the mother while he walked over to help suction and stimulate the baby. After several long minutes of low heart rate and wet lungs, he started to maintain his own and was soon straddled in bright-colored African fabric and handed over to the mother’s family awaiting patiently next door. Julie and I exchanged several looks throughout that uncertain time as if to say, “If we were back home, he’d already have been sent with the pediatric team to a transition bed to recover … but what can we do here?” In the middle of the rainforest, the harsh reality is that we do the best we can with what we have … and, so babies with healthy starts are more likely to survive, and any born with problems don’t.
I helped the anesthetist untangle the mother from her tubing and needles and slide out the wooden plank on which her arms were outstretched. The nurses and I transferred her to the lone metal gurney and wheeled her down the hallway, outside and upward along the wooden ramp with red mud and puddles, past a curious dog and several bystanders, and into the female ward. I decided not to worry about the fact that my scrub pants only fell to my mid-calves … being a mzungu (white woman) is by far more conspicuous. (The anesthetist kindly knocked on our door tonight while Julie and I were finishing dinner to alert us to another Caesarean section --- this time the baby girl arrived and did just fine, although hauling the gurney up a dark ramp with the family and new baby trailing behind was a bit surreal.)

Each of the last two nights I have heard incredible voices singing in the chapel across the way. Nivo told me that we were very welcome to attend, so I wandered over on a footpath through the corn stalks and slipped in through the open door quietly and sat in one of the back rows. The two men and women in the front row waved for me to come forward, and I explained in rudimentary Swahili who I was and what I was doing here in the midst of their world. They grinned in response and soon were half-chanting, half-singing some of the most earthy and genuinely pure music I have ever heard. A deep bass voice resonated soundly, and the women laughed and corrected the men when they switched their stanzas. I closed my eyes and rocked back and forth --- I may not have known a word they were saying, but I understood their powerful beauty. After a closing prayer and a final song, I joined the end of the line swaying to and fro as we exited the church. One woman grabbed my hand and shook it vigorously, telling me something important. I didn’t catch any of the words except for kesho. The light bulb went on, and I said loudly, “Oh, kesho! That means tomorrow!” The group laughed, and one of the men said, “Yes, tomorrow. You are welcome to come again tomorrow.” I nodded yes, bid my good evenings, and walked the short way home, listening to their beautiful music trailing into the forest.

*****

April 1, 2009

HAPPY BIRTHDAY TO ME

Well, happy birthday to me. I’m thirty years old … thirty? From just where did that number sneak? Unlike any of my previous birthdays, I can definitely say that I didn’t have much reason or time to dwell on the fact that I marked a significant milestone. Around here in the mountains, it’s quite simply just another day. There’s food to make, patients to see, and machinery to fix. Time marches onward at its own unhurried pace.

Julie and I awoke to the sounds of morning … machetes chopping plants, roosters crowing, and a lone cow mooing in our backyard. Morning prayer apparently never happened, but in wandering the outpatient ward, we met the computer man, pharmacy assistant, and my neighbor Sister Kijuro, who introduced us to her physician husband on the wards, allowed us to use the Internet (slow but steady!), and arranged for us to ride along with the nurses to the Mhombo village for a daylong pre-natal/pediatric visit.

We were supposed to leave at ten o’clock, and by the time we finished tea and rounded up our supplies and a new mother and baby status post Caesarean and the rest of her family into the van, we finally took off at half past eleven. Enter lesson #1 --- have patience. Enter lesson #2 --- go with the flow; time is relative and imprecise. Julie and I crammed ourselves into the front after our attempts to sit in the back were met with friendly resistance from Nivo, Dr. Amini’s wife. At first, I felt slightly uncomfortable, similar to how I feel when the cooks deliver our nighttime meal directly to our home. I’m not accustomed to such consideration and rather prefer to, as a matter of respect, let others ahead of me, especially guests, those older than me, and most certainly those who gave birth just a matter of mere days ago.

Nonetheless, the unimpeded view from the front was incredible --- the narrow, red road cut through rainforests full of banana trees, palms, and bushes of morning glories and vibrant yellow flowers, somewhat of a cross between a black-eyed Susan and a daisy. Smoke gently rose from makeshift chimneys, and houses, everything from shacks to robust, plaster-covered homes of stone or wood, dotted our path. Every time we approached a bend, the driver honked the horn, and people and animals darted to the side out of harm’s way. The trees broke often enough for us to view the entire valley below ... forest covered hills yielding to fields and villages below with more mountains rising in the distance. A low-lying haze clung to the ground, blurring the edges. We slopped and slid in the mud after the heavy rains of last evening but eventually arrived in Mhombo after stopping to deliver the new mother and her family (at which point I had to relinquish the baby boy I’d been holding the entire time --- on my lap, mind you!).

Not many people were waiting at first, but soon mothers and their children were literally coming out of the forest to attend. The nurses slung a rope around a door post and attached a scale to which mothers would suspend their children via a sling or a strap on their clothing to determine their weight. Nsemba gave a lecture on meningitis with everyone gathered around outside in the courtyard breastfeeding and jostling fussy babies, and soon Julie and I were learning Swahili on the fly, recording weights, noting attendance, and deciding if and what vaccinations the children needed. I even managed to get a baby or two to smile at me, while the mothers laughed at my poor Swahili. After the babies had been seen, we cared for pre-natal patients, dispensing folic acid and iron tablets and taking blood pressures, carefully writing the records by hand.

Toward the end of the afternoon, I made friends with a couple of the teenage girls … they would peek around the doorway to take a look at me, and then grin and run away when I looked their direction. Soon, I found myself playing hide-and-seek and managed to snap a picture … they laughed when I showed them their image and soon began creating new poses for me to take. The women shied away from the camera, but the children … and the chickens … didn’t seem to mind. We piled back in the van and returned to Gonja, passing women washing clothes in mountain water, children lounging near school, and men herding cattle and arranging tomatoes for sale.
Our dinner tonight was delicious --- not only did we have rice and beans, but we enjoyed sliced cucumbers and collard greens. We mostly ate in the dark, as our electricity quit working temporarily. We were treated to singing voices from the nearby chapel, the smell of smoke, and the sound of crickets. I’m itching to explore the footpaths, sit in on the worship, and wander down to the village at the base of the hill. It will all happen in good time --- I cannot expect life to proceed on demand as it does at home … and nor should it.

*****

March 31, 2009

WELCOME HOME

Julie (my classmate with who I am traveling for this rotation) and I are sitting in the living room of what will be our home for the next few weeks just a short walk up from the Gonja Lutheran Hospital somewhere in the south Pare Mountains; we are situated near the open-air chapel and the brick kitchen families use to fix meals for their loved ones staying in the wards. At the moment, she is knitting, and I’m writing --- we’ve already planned to start yoga tomorrow evening to help while away the hours after the sun sets around a quarter to seven. The rains have been pounding ferociously, and a drop or two has fallen through the roof. We finished our simple dinner of rice, beans, and miniature bananas, and I figured out how to heat water in the hot pot for a bucket shower. Our home is simple --- three bedrooms, a tiny bathroom with a flush toilet (although we have to be careful how we operate the plastic handle lest the tank flood the house), and a fairly sizable entry room all with cement floors, creaky doors, several moths, and the lone lizard who likes to hide near my mosquito net. There is one electrical outlet in which I was able to recharge my computer. We have a kerosene heater, a cabinet with a few dishes, a handful of buckets, and a mop. I think I might catch up on a few years of sleep here.

The last twenty-four hours have been, to say the least, quite the eye-opening journey. We stepped off the plane last night to palm trees and 84 degrees sans humidity. I was thankful we had already acquired our tourist visas and stepped into the single-file “Visitors’ Only” line --- luckily, we did not have to share the story we had fabricated regarding our travels versus studies. A few stamps and a smile got us through --- no words were exchanged. Our customs experience was also pretty relaxed --- a wave of the hand and a nod toward the door, and we were done. The gentleman in front of us, however, was not quite so lucky --- he had to open his carry-on suitcase full of Kit-Kats, Milky Way bars, and licorice, among other candy. He ended up handing over the bag of Milky Way bars, and the agent tucked the bribe in his work station drawer.

We quickly found Todd, and soon we were driving down the highway toward Moshi (on the opposite side of the road from what is “normal” back home) and dodging bicyclists and people walking along the highway in virtual darkness without any warning lights. I rolled down the windows to take in the fresh air and the bright crescent moon and unfamiliar stars. When we arrived at the Uhuru Lutheran Hostel, Todd gave us each a bottle of water and showed us to our room. No international trip is complete without frying an electrical device, and I promptly ruined my mini surge strip … and stunk up our room in the process. And after battling with tucking the mosquito netting around my mattress, I passed off to sleep in no time, eight hours ahead of my life back home.

Julie and I slept in until 8 o’clock this morning and met Todd for breakfast in the conference center’s main dining room. I particularly liked the passion fruit juice and sweet jam, and the cook made us each an omelet with salsa and cheese. I tried out a few words in Swahili and was greeted with English in return --- doesn’t speak too highly of my language skills at this point! I don’t know what we would have done this morning if it hadn’t been for Todd helping us with a few errands in Moshi city center. So congested, busy, and colorful, the large city of 200,000 reminded me in many ways of Manaus and my first day in Brazil four years ago. Anything goes is apparently the rule --- people pushing carts, riding bikes, hanging out of and on top of Land Rovers and buses, carrying bags, and hauling children darted in front of and beside our vehicle without a look. The narrow, crowded stores and open-air markets lined the streets selling everything you could possibly imagine --- fresh cuts of meat, bags of rice and grain, phone cards, clothing, tools, suitcases, fruit, shoes, buckets, bread, pop, paper goods, and electronics. We stopped first at a secure bank to withdraw cash and then walked across the street to buy calling cards. We then parked next to a truck adorned with Obama’s likeness and wandered through a lively street market. I tried on some watches at a tiny store, purchasing the third one I looked at (for 3000 shillings, compared to the same one I had seen earlier in a different store for 12,000 shillings) after the first one fell apart at the wristband and the back fell out of the second one. I bought a Fanta while the young girl in the shop ran next door with 100 shillings to buy a new battery after I noticed the second hand in the watch I bought didn’t move too fast. As I began to wander away with my glass bottle, the shopkeeper waved me back and motioned at the plastic carts stacked outside the store --- apparently, one does not take pop “to go” per se but has to drink it on the spot and recycle it! We bought some bottled water at yet another store and made a last stop at a grocery store for peanut butter, lemon cookies, and laundry detergent. Throughout, Julie and I got more than a few curious looks, but a smile in their direction prompted the same in return.
The drive to Same took a little over an hour. We flew by tiny villages built along the highway and saw schoolchildren in uniforms walking to and fro their classes. Women worked the fields and carried all manner of goods on their heads --- bananas, backpacks, books, and more. Masai warriors with their cell phones and machetes blew past us on mopeds. Goats, sheep, and cattle grazed along the side of the road. So much commotion and so much color --- from the red earth to the blue sky and to the women wrapped in bright fabrics --- there was no end to what the eye could see.
Todd suggested his favorite restaurant for lunch --- the Elephant Motel. Part conference center and part hotel for safari-goers, we relaxed outdoors in the shade. A lady near us worked on her laptop plugged into a power strip hung over a tree branch. I ate tilapia and rice with coconut sauce, and Julie had something called Hungarian Goulash … none of the three of us are still quite certain about the reasoning behind its name. Soon after we were done eating, a tall man approached us from a different table. He grinned, “I apologize, but when I heard the American accent, I just had to come over and introduce myself.” Turns out Kirk, an environmental engineer currently based in Romania, is originally from Keokuk, IA, and graduated with his Master’s degree from the University of Iowa. He is here in the Same region for spring break with his son Max, a senior at Cal Poly Technical Institute. The California university donated the intellectual resources and faculty support to build a technical school in this region, and the Lutheran diocese is contributing the land and money for the project. Max and another student will return in January to live for one year and oversee the development of this school. What an unbelievably small world.

We headed to near Todd’s home and the Lutheran missionary outpost to meet our driver Martin who took us on the two-hour journey to Gonja Lutheran. Julie and I were soon jostled along a red, dirt road full of ruts, wash-outs, and stones for what turned into the two bumpiest hours of our lives as we ascended the mountain. Martin turned on the radio, and we listened to the same two or three gospel tracks the entire time. I took as many pictures of the landscape as I could as it changed from crop fields to desert brush to lush trees lining a tiny river to a rainforest of palms to rocky mountain terrain. We passed sheep herders and their livestock, tomato and cucumber stands, men fixing broken bikes and wheeling firewood, women hauling water and babies, boys chasing goats, old men lounging on stoops, old women hanging laundry to dry, and children who stopped and stared at us and then broke into smiles and waved. We even managed to shave a few feathers off an unfortunate, startled chicken that ran under our Land Rover. Every so often, Martin stopped with a grin so that I could more easily take a few pictures. So much to see and absorb --- so full of life. I learned an important lesson today --- a smile and a friendly wave speak volumes or at the very least, lessen the shock of a schoolgirl who may very well have seen the first two white women of her life.

Without much fanfare, we crested a rise and drove into a large clearing above a tree-lined village and stopped next to the hospital. Several people gathered to see who had come to stay. Julie and I climbed out and received big hugs from Sister Dora, the head nurse. Two other women approached and gave each of us flowers whose stems had been carefully wrapped in white paper. Everyone generously welcomed us, smiled, and shook our hands, and Pastor Peter wanted to know why we were only staying four weeks. Dora directed us up the hill and gave us the key to our new home. Dr. Gillian Dorner, who shares our guest house and who graduated from Iowa and completed her residency in Ventura, was away in Moshi with Dr. Amini trying to lengthen her visa stay by another three months. Dora, who will be away tomorrow and the next day on business, gave us a quick tour of the kitchen, the outpatient wards and registration area, the small pharmacy, the four doctors’ offices, the entrance to the operating theaters, the HIV clinic, the family planning room, and the rooms where expectant mothers, especially those who live far away, stay for a few days before delivering.

Dora walked us back home, and the two cooks were waiting for us with our dinner trays and big smiles. If the first twenty-four hours in Africa are any indication, I can only imagine what the next few weeks will hold.

*****

March 30, 2009

NINAJIFUNZA KISWAHILI

Ni tarehe thelathini, mwezi wa tatu.

Pole pole ninajifunza Kiswahili.

Today is the thirtieth, of the third month … slowly, I am learning Swahili.
With my tiny phrasebook, some handwritten notes from a fellow medical student, and occasional pronunciation assistance from the Danish gentleman sharing my row on the long flight from Amsterdam to Kilimanjaro, I am slowly acquiring some Swahili. Today’s accomplishment has been to recite numbers and dates and figure out the pronouns --- language baby steps. I love learning new languages, and I wish I was more adept at doing so. Knowing a few key phrases, in my experience, demonstrates interest and respect for the people and the place through which one passes, and more memorably, can be downright fun and amusing.

For instance, I remember asking to get my hair cut in Spain. I used what I had learned in Spanish class to be the word for hair (head hair, that is). The barber had a very curious look on his face in response to my question, and after a few moments to collect his thoughts, he carefully explained that he normally doesn’t cut that particular other area of body hair (If you have trouble figuring this out, let me know …), but if I wanted my head hair cut, he was happy to comply. And then there was my breakfast shake in Sao Paulo. I wanted the pineapple flavor that I saw in the menu and stated this as clearly as I could. The waiter confirmed my order repeatedly a couple of times, making sure that pineapple was what I really wanted to eat --- I nodded emphatically each time. When my green and furry avocado shake arrived, I learned quickly how close abacaxi and abacate are pronounced in Portuguese! Goodness only knows what cultural faux pas I will unleash in Tanzania with my novice Swahili, but I will be sure to pass them along.

Asanteni sana [for] somo … usiku Msema.

Thank you all very much for reading … good night.