Life is Rich

April 18, 2009

SOLAR POWER

Today was another happily lazy Saturday … Julie and I wandered down to the hospital around 9:00 a.m. Ward rounds had yet to start, and Dr. Amini was nowhere to be found. We stopped by the pharmacy to inquire about the Internet and found the “computer man” dusting the printer. When we asked him why the connection was down last night and whether it would resume today, he mentioned that he had shut off the entire system last evening so that all the equipment had a chance to “cool down” so that he could clean it this morning. What?! I’m curious to learn in which manual he found these instructions.

In one of my trips to the house during my daylong Internet marathon, I noticed a large, white van virtually covered with bumper stickers parked on the hospital lawn. As I approached, a young gal jumped out, shook my hand, and introduced herself as part of the SOLATA company, a team of folks from Dar Es Salaam traveling the countryside selling solar-powered contraptions. She quickly demonstrated how the tiny solar panels worked and the handy results --- illumination from a lamp and two types of handheld torches. Her teammate grabbed the flashlight model that allows one to also charge a cell phone and said, “Let me show you its strength!” He promptly hurled the torch to the ground, and I watched as it rolled to a stop several feet away near the small crowd that had gathered. I thanked them for their product presentation and chuckled to myself as I walked up the hill toward home.

Julie and I relaxed over dinner at home tonight, frying okra and chopping vegetables to top spaghetti. While I do love rice and beans, the pasta was a welcome change!

*****

April 17, 2009

LOST IN TRANSLATION

I’ve decided it’s hard to operate in a world where everyone is always nzuri (good) or salama (peaceful). It’s the appropriate response whenever someone asks you how your morning is going, how things are in your household, or more broadly, how things are in general. I told someone recently that I was nzuri tu, meaning that I was somewhat good, prompting a series of concerning questions about whether I was sick, sleeping well, or eating enough. So, as a result, I am always nzuri. I wonder just when and where genuine feelings are shared … this is not a mystery, however, that I am going to unravel before I leave the mountain.

Despite telling Sister Dora that we were interested in taking a day safari trip to Mkomazi Game Reserve this weekend last week, she informed us during morning report that despite several attempts to reach the driver, she was unable to do so. Luckily, I’ll be in the Serengeti and Ngorongoro Crater soon, but it was still frustrating. She did, however, arrange for us to go with one of the night nurses to the small Bombo market near the church. We took a quick jaunt there and bought eight small bananas, several okra, five tomatoes, five red onions, and one cucumber … all for approximately $1.25.

I returned from market and joined Dr. Amini finishing rounds. The division of labor had been set during morning report --- Jonah to the OPD and Amini to the theater for the lone case of the day, a hydrocelectomy. I had quickly decided to tag along with Dr. Amini. After running into a patient who wanted his ears checked and another who asked him to admit his sick relative to the palliative care service (someone with severe right groin ulcer status post amputation of that respective leg for cancer who subsequently developed tuberculosis), we eventually worked our way to morning tea in the canteen.

As soon as we sat down for chai, it was clear Dr. Amini had one order of business on his mind. “Tell me, Lauren,” he said as he peered at me over his wire-rimmed glasses. “Have you weighed yourself lately?”

Somewhat startled, I replied, “Uh … no, Dr. Amini, I have not.”

“Well,” he chuckled, waving his hands in the air for emphasis, “it is important that you go home at the same kilo or … (wagging his finger in the air) … a kilo or two more!”

Once I assured him that I was holding my own, compliments of the ample African dishes we have eaten, he seemed satisfied.

In a rather ironic twist, no one other than Mr. SH*T HAPPENS himself turned out to be the surgical patient. He granted me permission to take as many photographs as I wanted, including his massively swollen hydroceles (scrotal swelling due to fluid collection). I helped Apenda man the blood pressure and watched Dr. Amini skillfully … and creatively … proceed through the operation, including fashioning a drain bag from a Latex glove (nothing to waste here) and an impressive scrotal support system from a long strip of white fabric (which at first I thought I had heard Dr. Amini say was “made in Brazil” when he really was saying he was making a “man brassiere”!). True to form, the anesthesiologist disappeared somewhere in the middle to hunt for new plastic drain tubing he couldn’t find and resorted to fashioning it from existing tubing he found next door. A forty-five minute operation, from incision to closure, took three-and-a-half hours. I transferred the patient to our lone rusty transport table and hauled him up the “elevator” ramp to the men’s ward. I’m afraid that in America, this simple system would never work, for our patients are, as a general matter, too large for this table and too heavy to be rolled upward on rough concrete and mud.

Julie and I headed down to the village to buy more kitenge and ran into Nywele, Dr. Mary’s daughter, en route. A rather take-charge woman, she soon joined our shopping trip and shepherded us from one tiny, cramped store to the next, including one that offered three-piece, waxed fabrics in beautiful colors and patterns. I quickly found a kitenge (with large blue and green flowers set in a rust background) that Nywele and I took to her favorite tailor’s shop to have made into a two piece dress for me. In a space no larger than 8 x 8 feet in a quiet, cobblestone alley, Mr. Boca (Or is it Bocar?) had several projects-in-progress neatly displayed along the wall. His foot pedal machine sat near the window, his only source of light. He opened a frayed notebook and dutifully recorded my measurements and noted my payment of 12,000 shillings (around $9.50) in a second book. I was told to return on Tuesday to collect my dress.

We stopped for Cokes at the Green View Bar on the way home and were soon joined by the evangelist’s wife. Nothing more than a large, single room with plastic patio furniture, we were the only customers until the electricity returned, and the television came to life. Soon, a DVD that Julie and I have watched many times, especially with Dr. Amini and his family, played --- a famous, religious, Tanzanian show choir led by a woman named Rose. With the volume cranked to 60 or so (excruciatingly loud), the employees and a few others began dancing. Most of these music videos are very pastoral in nature --- the well-dressed choir dances in sync on the open highway, in a garden, in front of a beautiful apartment complex. However, the videos intermittently cut to other, more dramatic scenes, including a young boy being mauled by a bobcat, domestic violence between husband and wife, and an overjoyed, physically handicapped man on a beach who tosses aside his crutches, walks on his hands, and wipes his face with his deformed right leg. Clearly, there is great meaning here that I am missing entirely. I wonder just how much I have lost in translation and how much I would always lose if I stayed longer in a place that is not natively home. My hunch is a great deal.

*****

April 16, 2009

PALLIATIVE CARE IN THE JUNGLE

My chapati has been going down easier here lately. When I carefully wrap it (single-handedly with the right hand) around a fried egg, I can almost pretend that it’s a breakfast burrito. Some mornings, when I don’t have an egg, I dunk the chapati in my chai tea and drag it through brown sugar. I can almost certifiably guarantee that the latter preparation is not consistent with Tanzanian norms. We eat in shadows of the hospital canteen at 2:23 every morning --- the time that has been frozen on the tiny clock on the wall since we arrived. Upstairs on the second floor by the main wards, the time is always set at 12:30, the clock’s hands immobile. I wonder if these will ever be fixed.

For only the second time since I’ve been here, we gathered in the outpatient department for prayer and singing. Gillian and I both noticed the groundskeeper running back and forth in the hallway, looking in earnest in our direction. Gillian slipped out to see what had happened. I found her a few minutes later upstairs hovered over a three-year-old girl attempting to place a peripheral IV line. Her mother had gone to market early that morning, and her father, sweaty from running her in to the hospital, told us he found her eating Selectron, an organophosphate herbicide used on tomato crops. The little girl, crumpled weakly in a ball on the bed, frothed at the mouth, had wet lungs, and a very slow heart rate. I helped one nurse give atropine injections while Gillian and the others shaved her head in hopes of starting a scalp line. Once she had somewhat stabilized, we began rounds. Her father had to return home, and every time we stopped in to check on her, a different mother from the pediatric ward was tending to the child.

Julie arranged for us to venture out with the palliative care team in the afternoon. We ran up to the house, grabbed our things, and waited in the office. It took us a while to realize that we were waiting for a driver to arrive. Julie and I emphasized that we were happy and most certainly able to walk to nearby villages to visit patients. Then Joyce, one of the cooks and Gillian’s close friend, popped in and worried that we should eat lunch before leaving. Emdaeli, the palliative care nurse, turned to us and said, “We are afraid of you!” What she meant to say is that they were afraid for us in that we were not strong enough to make the trip by foot.

Within minutes, Julie and I carried the medication supply bags and walked toward Bombo with Emdaeli and the evangelist. For the life of me, I cannot remember his name, and it didn’t help that Emdaeli kept calling him the “Evangelist” instead of using his real name. We stopped at a store along the way, and the nurse disappeared inside to buy bags of tea and sugar (with her own money) so that she could give them to the patients’ families as gifts when we stopped to visit. As we walked, Emdaeli explained that the palliative care outreach team began its work in 2005, and they now have 339 patients on their roster. In addition, they care for hundreds of HIV orphans up until the age of eighteen, providing them with books, clothes, mattresses, and milk.

We shortly arrive in Bombo and waited on the veranda of the home of our first patient, a 90-year-old man with right-sided paralysis who suffered a stroke sixteen years prior. His wife is his full-time caretaker in perhaps one of the nicest African homes I have seen. He rested in a large bed in his living room underneath a plaid blanket and smiled when we introduced ourselves, telling his wife that his day was complete because he saw “two pretty ladies”. I held his hand while Julie took his blood pressure and listened to his lungs. He had developed a cough, and even though his lungs were still clear, I wrote for amoxicillin just in case.
Our second stop was right across the street for a 98-year-old woman with high blood pressure and diabetes who can no longer walk. Her daughter invited us in and showed us to her mother’s room. Very well-kept and clean, she could talk and was equally surprised to see two white women sitting in her bedroom. Even though her blood pressure had been taken that morning by the visiting doctor, the lady’s daughter invited us to do the same again. Emdaeli shared that while we may not be adjusting much medically, the family appreciates knowing that others care for their loved ones.

For our third home, we carefully picked our way through the jungle on a narrow path down the hill and over a stream to arrive at a small farmstead. The laundry was hung to dry, and chickens scattered in the front yard. We sat in the living room on tattered cushions; dirty dishes and clothes were strewn on the table and floor. We stayed only a short time here in order to verify that the young mother was taking her anti-retrovirals. Her children, virus-free, ran around with runny noses. I took a particular liking to the infant girl who quickly grew fond of tugging on my hair and earrings. The old man (probably the grandfather) who had greeted us with a toothless smile and a few broken English phrases disappeared and returned shortly with a safari hat and staff and wanted his picture taken. When we left, he gave us an avocado.

Emdaeli wanted to visit one more home but was worried that we were too hungry. We assured that we were happy to continue, and soon we were bouncing along the red dirt road a fair number of kilometers to the home of a new patient, a 58-year-old woman with jaw cancer. The evangelist talked to a few villagers to figure out where she lived, and a couple of children guided us down a steep embankment past stick-and-mud homes and wooden corrals of sheep and cattle until we reached our destination. The woman’s two daughters led us into a dimly lit smokehouse to a back room where their mother lay dying in a wooden bed. Wrapped in gray blanket and unable to communicate, her face was illuminated only by two rays of light piercing through the haze from a tiny window. A tiny fire was stoked in the corner to keep her warm. Her left eye was crusted over and scarred, and with her mouth agape, we could see a rampant fungal infection and her tongue cut in deep furrows. Beads of sweat popped on her forehead. The tumor had hardened under her chin, produced pockets of fluid behind her ear, and ate its way entirely through her left cheek, leaving a hole an inch-and-a-half across. We offered little more than paracetamol (acetaminophen), told the daughters to come to Gonja if they wanted stronger pain medication for their mother, and shared our prediction that she would die soon.

Needless to say, it was a pretty quiet ride home.

Gillian, Julie, Dr. Amini, Nivo, and I hiked over to Joyce’s house for dinner. I was happy to explore a different direction leading away from the hospital past small farms and over streams. Dr. Amini, of course, knew everyone along the path. Ingia and Nishighia, our cooks in the canteen, came along to help Joyce with dinner. We climbed over boulders and along a narrow, steep trail past terraced crops of beans to reach her home. She had a beautiful, almost landscaped yard with banana trees and bushes of pink flowers. We sat quietly in her living room, sipping on sodas, and talking softly by kerosene light. Joyce is by far the best cook we have encountered yet --- we feasted on pilau, chicken, beans, bananas, avocados, tomatoes, pineapple, and beef only after washing our hands with warm water poured from a pitcher by the evangelist’s wife who had also come to help Joyce. (Tableside hand washing is one ritual I will happily repeat back home!) We praised Joyce consistently throughout the meal, and she beamed from the shadows.

At the end of the meal, Gillian presented Joyce with a rust and navy blue kitenge, and Nivo and Joyce, in turn, gave Gillian a kitenge they both own as well. The giving did not stop there, however --- Nivo gave a short speech about Julie and I needing to become Tanzanian women and feeling completely welcomed, to which Gillian pulled out two kitenges for the two of us! Julie and I tried on our matching green fabrics, laughing and taking several pictures. It was by far one of the warmest evenings we’ve had.

By head lamp and flashlight, we carefully descended the hill and walked home under a canopy of bright stars. I am humbled by the overwhelming generosity of nature’s beauty here, and more importantly, by the overwhelming generosity and kind spirit of its people.

*****

April 15, 2009

SH*T HAPPENS

I dedicated my morning during rounds to taking photos of the team at work and an occasional patient or two, with their permission. When we entered the men’s ward, the gentleman I noticed yesterday (because of his baseball cap reading SH*T HAPPENS) grinned in our direction. I told Gillian quietly that I would love to get a picture of him, and she emphatically nodded her head yes. Soon, not only did I have a few pictures of him with his cap, but he wanted to take a picture with me! The three of us laughed and tried to explain to Dr. Amini the significance of wearing such a slogan. I think we mostly succeeded.

During tea time, I took pictures of the operating theater and couldn’t figure out why it was “raining” outside the windows … turns out it was hospital cleaning day on the second floor! Staff dumped buckets of water on the concrete floor, mopped for a few minutes, and pushed the water off the balcony with sweepers. I’m not sure if they use any soap, which around here is laced with antifungal and antibacterial properties, resulting in a rather funky smell that leaves one never feeling entirely clean. I wish the staff would remove the cobwebs and wasp nests in the deep recesses of the rooms, but their attention was solely dedicated to the floors.
I worked as Dr. Amini’s scribe during our busy afternoon outpatient clinic, recording patient attendance and writing their notes. I never know what to expect during these sessions. Patient presentations, treatment philosophies, and reasons for delays in seeking care are distinctly different than at home. For example:

• Today was the day for dental worries --- two children presented with additional teeth jutting from their gums overlying their permanent teeth; Dr. Amini told them to return in a few months to have them pulled. A three-year-old boy dressed in a pinstripe suit smiled broadly, revealing an entire upper set of caries. A teenage boy had a bleeding gum due to an erupting wisdom tooth, and several elderly women had raging cases of gingivitis. I cannot overemphasize how badly dentists are needed here.

• I have been surprised by the number of very serious hypertensive patients that are treated at Gonja. Today, a very pleasant teacher presented with a blood pressure 220/140. Dr. Amini wrote for just a two-week course of a beta-blocker and sent him on his way. The idea that chronic diseases are treated consistently over time is not one to which the physicians here ascribe. Instead, diabetes and high blood pressure are addressed episodically.

• A lady in her thirties from a remote village sought help for her massively swollen right thumb after medication from a local dispensary didn’t do the trick. Apparently, she initially had a small infection of the cuticle and nail bed that proceeded to frank osteomyelitis (infection of the bone) over several weeks. When she arrived in our office, her fingernail was completely disintegrated and enveloped in pus, and she had two open sores near the base of her thumb. Dr. Amini held her hand and just shook his head, ordering antibiotics and daily dressing changes.

• Several of our HIV patients presented with opportunistic infections. The virus spares no one --- young, old, man, woman, professional city person, or village farmer. Dr. Amini shared that it is common for married couples to live apart and regrettably, this can lead to infidelity and increasing HIV incidence.

• Anyone needing medical supplies, such as a woman with post-traumatic arthritis after a motor vehicle accident thirteen years ago, must travel to Dar Es Salaam or Moshi to fill their prescriptions.

• An eighteen-year-old female secondary school student arrived with her mother. She complained of chest tightness and abdominal pain. Dr. Amini waved me over when he performed her abdominal exam, and I listened to fetal heart tones and palpated a uterus of 24 weeks’ size. In a rather difficult discussion in front of her mother, Dr. Amini encouraged the family to be supportive and help her return to school after giving birth. The young woman continued to deny her pregnancy and looked exceptionally distraught.

Gillian, Julie, and I set off for Nivo and Dr. Amini’s house after work and found him happily installing his new DVD player he bought in Dar Es Salaam. He demonstrated its capabilities with a James Earl Jones-narrated movie about the Serengeti migrations, followed by music videos from the popular church swing choir in Tanzania. It’s incredible how lively conversation ceases when the television is in motion.

After we got home, Nasemba stopped by to return a dish from dinner the night before. I walked her home, and next thing I know I am sitting next to the outdoor kitchen in the nurse’s quarters watching them boil bananas, looking at the stars, and practicing my Swahili pronunciation in the dark of night. Nasemba was curious to know if we ate chapati back home and in how many different ways we eat bananas. She thanked me profusely for the kitenge we gifted her the night before and showed me how she had already had it cut and sewn by a tailor. Nasemba taught me how to wrap the kitenge on my head; I apparently was quite the spectacle and made the neighbor children laugh until they cried. It’s really hard to look like anything else besides a white woman in a head wrap. I made Julie worried after being gone for forty-five minutes to the point that both she and Gillian showed up to make sure I was still alive … how meaningful is the value of great friends!

*****

April 14, 2009

THE KUKU GIFT

I have never seen the outpatient department and the laboratory as full as they were today --- everyone was waiting until after the holiday to come in and be seen. I spent the first part of the morning with Dr. Amini and the latter portion in the lab, sadly noting three new cases of HIV. The laboratory organization --- or, rather, lack thereof --- is fascinating to me. Patients are handed a half sheet of paper with their ordered labs, wait in the lab itself until their labs are drawn, sit outside while the samples are processed, return to the lab to pay, and then knock on their doctor’s door to hand him or her the results for the final diagnosis and treatment verdicts. At one point, I looked up from the microscope to see approximately 30 or so people standing silently in the corner of the room with their papers in hand, most of who carefully watched every move I made. Patient privacy simply does not exist.

This tiny, remote hospital continues to teach and amuse me a great deal. Of note:

• Women store small bills and coins in handkerchiefs that they safety pin to the inside of their dresses and bras so their hands and backs are free to carry children, food, and water.

• The patient record system is a mystery to me --- some folks shuttle their tattered charts from place to place, while others are handled entirely by staff. Often, one chart collectively contains all members of one family, and it is not uncommon to begin writing a patient note and realize that you are accidentally recording a child’s diarrhea below his grandmother’s hypertensive entry.

• There is no dietary service or kitchen that prepares food for the patients. All tea and meals are made by the family members themselves in a large smokehouse on hospital grounds.

• Little things produce great wonder around here, including self-retracting scalpel blades and using staples, instead of sutures, to close wounds. Change advances slowly, and often, I think, is perplexing and resisted.

• The hospital groundskeeper/security guard gongs a metal pot nestled in a tree twice at 7:30 a.m. and again at noon. Gillian, Julie, and I aren’t entirely sure why, save that they may represent the opening of visiting hours.

• I am particularly enthralled by the clothing I see folks wear, namely resold pieces arriving in large shipments from the US. For instance, I’ve seen one man wear a Wendy’s baseball cap, and one of the laboratory employees is fond of wearing a cap bearing the emblem of J & K Trucking from somewhere in Oklahoma. The hat that takes the cake, however, is one worn by a rather smiley gentleman in the men’s ward --- a blue, mesh cap with SH*T HAPPENS written in red, capital letters. What?! I can’t handle it.

We were a hospital of very sick patients today. One man with suspected tuberculosis who has been here for days on end needs to be referred to Same for an echocardiogram and a chest X-ray, as we are still waiting on the developer and the technician to fix the radiological equipment that has yet to function once since we’ve been here (and no one seems to be troubled by this). A young boy was admitted for a severe burn wound to his right wrist from hot water, and a 21-year-old woman with one baby at home and another on the way sought treatment after ingesting rodent poison following an argument with her husband. An old medicine man with psychogenic tremors performed the physical exam on himself in front of the team, demanding treatment for supposed multiple ailments. However, one exceedingly slender woman had us all worried. She arrived after being treated by a local dispensary for excessive thirst and urination for the past year. Down to virtually skin and bones, her blood sugar was so high it didn’t even register, and she had dry, gangrenous ulcers on her left foot. She appeared decades older than her merely forty years.

Gillian took us kitenge shopping in the village after work to purchase as gifts for our new friends here. We picked up four pieces of beautiful fabric (measuring approximately four yards for around $3.50 apiece) and a couple small pineapples, along with matches, tea, and some hard candy. Nasemba’s grandson knocked on our door at 8:00 p.m. and escorted us over to the nurse’s quarters for dinner. We huddled over a spread of stewed bananas, rice and beans, catchumbari (sliced tomatoes and red onions), cooked greens, and kuku (chicken) by kerosene light (Being served a chicken is a gift of friendship and regarded highly --- especially for Nasemba who had her flock of chickens die recently due to a viral infection.). Nasemba’s cat curled around my feet, and her grandson, visiting for the Easter holiday, rested on the couch while we ate. We gave her a kitenge and took pictures of her and her grandson, much to his delight. The short walk home under the stars was incredible --- I didn’t necessarily recognize the constellations but nonetheless appreciated their innumerable, bright beauty, something readily missed under the modern lights of home.