My African Life

(WARNING: Fix a large cup of coffee before you read this post! We experienced a very large storm last Tuesday that blew down power lines and flooded local areas --- our power was out for nearly a week, meaning no lights at home and no Internet. Therefore --- should you choose to read, you have a lot of reading to do! All my best from the rainforests and mountains of Tanzania, Lauren)

April 12, 2009

EASTER IN THE JUNGLE

Gillian, Julie, and I got ready for church in short order this morning and took off in the Land Rover to Nivo’s home church, a beautiful brick structure with stained glass windows perched on an outcropping overlooking the valley below. (You don’t have to go far for incredible views around here!) We were the first to arrive. We shortly found the pastor and settled down for tea, peanuts, and fried plantains. He was excited to learn that Gillian’s father attends this church’s sister congregation in Des Moines, St. John’s Lutheran Church.

Soon, families began emerging from the rainforest paths and gathered outside the main entrance, swapping greetings and smiling at the children. The women especially were dressed in their finest colors and head wraps, and the men dusted off their suits. We met Dr. Amini’s sisters and younger son, as well as the chairmen of various church committees. The service got underway at 10:30 a.m., proceeding from gospel choir music to introductions, discussion of church business, more music, the message, several rounds of offerings, and finally finished with about twenty baptisms three hours later. Julie and I spent most of the morning making faces at the toddlers around us and watching a tiny, four-and-a-half-foot man in the front row jump up and dance at every opportunity.

A small, rather hurried auction was held outside after church, and the kids were pretty curious as to what I was doing with my camera, giggling when I showed them their pictures. The four of us --- Gillian, Julie, Thomas (Dr. Amini’s son), and I
--- soon were trekking our way toward Nivo’s farm on a foot-wide red dirt path etched into the side of the mountain, cutting through backyards of people’s homes and by planted fields as we ascended the rainforest.

Dr. Amini, via the hospital Land Rover, and the four of us arrived at the same time, along with an intoxicated man who had started conversing with us on the main road. He walked into their home and sat down in Dr. Amini’s living room! Soon, he was feasting on Easter dinner --- a delicious combination of rice, beef, avocados, beans, bananas, and fried potatoes --- right along with the rest of us. We joked with this uninvited guest and carried on without a hitch, while the demented 97-year-old uncle wandered about outside. Gillian told us quietly that most folks are so laid-back, inclusive, and friendly that it’s not within their nature to tell somebody to leave, even during the middle of family celebrations.

As a token of thanks, I offered to take a family photograph, and what a production it was! We assembled the group --- Dr. Amini and Nivo, his youngest brother, wife, and son, Thomas, and Dr. Amini’s mother and the aforementioned uncle (who wore a New York Yankees baseball cap off to the side like a gangster!) --- in the living and outside overlooking the valley. The sister-in-law never looked at the camera; the mother never smiled, and Dr. Amini quickly grew anxious after three shots and said, “Enough! We have enough pictures!” To further complicate matters, a second random individual who wandered in from the road decided to stand in the outdoors family photo without asking! I took (and promptly erased) a couple of shots and “rearranged” the group without this unknown man. It was perhaps one of the most entertaining photo shoots I’ve done! Nonetheless, I look forward to printing a few and sending them back with the summer group.

I hope your holiday was as meaningful as mine. Pasaca Njema … Happy Easter, everyone!

*****

April 11, 2009

DR. AMINI COMES FOR DINNER

We discharged several patients today, all of whom were happy to make it home in time for Easter with their families. Staff and patients alike today seemed to have a lighter step and a louder tune --- excited for the holiday and anticipating its blessings. I wrote notes and kept records for Dr. Amini as he attended to patients in the outpatient clinic. He is perhaps the most dynamic and engaging Tanzanian I have met to date, a spirited man with an ever-present smile and boisterous energy. He likes to joke that his slight “abdominal swelling” is a fetus of approximately 24 weeks but “without heart tones, Dr. Gillian!” He is quite the man.

There is never an end to interesting observations here. The latest gleanings:

• Government employees are eligible for national health insurance, as well as up to five of their dependents. They contribute 3% of each month’s salary to the coverage and qualify for consultation and registration fees, common inpatient and outpatient procedures, and all surgeries saved those performed by certain specialists.

• Our anesthetist Npenda has not had a day off in four years. He suffers from diabetes, and his eyesight has begun to fail. He asks for others to confirm the medications he gives, as he is no longer able to read the fine print on the vials. It is unclear whether another anesthetist is being considered for hire.

• Belching, to any length, tone, or degree of loudness, is utterly socially acceptable. Passing jamba (gas), on the other hand, is exceedingly embarrassing and rarely heard … or smelled!

• There is no notion of patient privacy here --- families share one medical chart, and the doctor’s office is akin to a revolving door --- in the midst of one patient interview or exam, it is very common for another patient to enter with his/her lab results or questions, as well as staff who want to chat about other business.

• Various forms of contraception are available and readily used by women, often without the knowledge of their partners. Abortion, on the other hand, is illegal, punishable by fines and jail time. Despite this, an underground system of abortion providers does exist, but women run the real risk of uterine rupture or sepsis from incorrect or dirty procedures.

• Two girls were recently hospitalized for hysteria. One roamed the ward halls beating her “baby” (a rolled kanga) with an umbrella, while the mother of the other girl thinks her daughter was bewitched. Both attend the same school, and staff is trying to determine what could be the likely environmental stressor.

• Surprisingly, the four doctors here at Gonja never attended medical school, per se --- two studied to become medical officers (akin to nurse practitioner training) but have acquired extensive experience over the years and are two of the best surgeons I have ever seen. The other two, newer doctors completed what would be comparable to physician assistant training.

I spent the afternoon shooting photos in the hospital, watching the roosters fight by my front door, relaxing at home while Gillian and Julie went on a hike, and happily charging my electrical appliances after the electricity returned to the mountain. Gillian treated us to spaghetti for dinner, and Dr. Amini graced us with his presence … gifting us beer (called “Safari” beer!) and regaling us with stories of his trips to Iowa --- particularly the fat cattle, fat hogs, and fat people he saw at the Iowa State Fair last summer. He complained rather good-naturedly that his sons (ages 22 and 28) are not married and said that he asks fairly frequently (especially his first-born) when this might happen --- apparently parents are parents, no matter whether in America or in Tanzania! Sometimes, it’s reassuring to learn that no matter how far you roam, some things are, quite simply, just the same.

*****

April 10, 2009

WALKING IN THE RAIN

I can’t believe how much I am sleeping here --- but when 8:30, 9:00 p.m. rolls around, and the only light you’ve got is candlelight, the body just starts to slow down and hibernate. It’s a good thing, I suppose, as I don’t predict much sleep at all in the coming, say, four years, at the very least. The beautiful thing about heading to bed early is that I generally wake up without the alarm and get the dishes washed and the cement floor swept before I head down the hill to the canteen for breakfast. If only I could be this domestically inclined back home!

I spent a delightful ten minutes or so during ward rounds playing with my favorite little boy --- he grabbed my stethoscope and listened to my heart, his mother’s, and finally his own. I wished he wasn’t going to be discharged today. I accompanied Gillian in clinic, where we saw a young college student with a bizarre blistering rash isolated to her hands and upper lip, a mid-thirties woman with likely scarred Fallopian tubes desiring a fertility work-up, and a two-year-old boy with a severe gash in his foot after the wall of his house collapsed on him. There’s never a dull clinic at Gonja Lutheran.

The three of us ventured out for a brief afternoon stroll, meandering past the vegetable ladies at the bottom of the hill and through the local village past the quality kitenge shops and Gillian’s favorite tailor. We ran into the man Julie and I are going to hire to drive us to Mkomazi Game Reserve next weekend and greeted several folks dressed up for Good Friday. We donned our raincoats as the light drizzle gave way to soft rain and waved to the boys playing soccer near the cemetery. We climbed up an embankment when the kamikaze public transit bus hurtled by and struck up a local acquaintance as we trekked back from nearby Bombo church. (I wonder if the locals consider this rainforest as beautiful --- mostly, however, I think they associate it with a hard life, with daily survival the paramount struggle.) As per usual, children stopped in their tracks and stared, teenage boys dared one another to call out “Mzungu!” and the old folks apologized to us for having to walk. Walking here is full of purpose --- as a means to get to work, church, the market, and back to home. Hiking for pleasure is unheard of --- especially for women, and even more especially for white women in the relatively remote Pare Mountains.

For the fourth night in a row, we ate dinner by candlelight, discussing books and documentaries, our siblings and grandparents, and the notion of Tanzanian houseboys --- children that are hired out of their respective families permanently to tend to domestic chores in someone else’s home. We marveled at the fact that the OR staff doesn’t seem bothered that their supplies are in complete disarray and can never find what they need … and that they were too polite to unplug charging cell phones in the operating theater today to operate what they really needed --- oxygen machines, lights, and the like. Life on the other side of the world is just never what you would ever expect.

*****

April 9, 2009

FRUSTRATION

I have reached that point I always do when I immerse myself in a new culture in a new place. I am frustrated because I don’t understand how things work, and I can’t communicate as well as I would like to. I am a bit weary of being called “Mzungu” and feeling homebound with little to do. I wish I were more useful during morning rounds and in the clinic beyond just shadowing. I’m irritated that I have lost my sunglasses and my USB card (but grateful there was nothing important on there). I am feeling antsy that the electricity has been down for 48 hours (which means no Internet and no charging my computer) and not projected to return for days, particularly with Easter this weekend. I’m upset with myself that I feel shy today and seemingly unable to connect with the patients and apprehensive about exploring alone. I’m mad that I even am concerned with these things, especially when I come from an entirely different world of opportunity and privilege. And I really want to wear pants.

Please excuse the string of complaints --- it’s time to count my blessings. I helped deliver a baby this morning that the mother named Gillian in honor of her doctor, and I laughed when the women waiting said she looked white like us! I was able to fix the clothesline this morning after I broke it under the weight of my wet jeans. I learned how to interpret malaria, hookworm, and amoebas on slides in the laboratory. I witnessed an infant girl undergo a heel stick test for HIV in a manner that I would never experience at home. I got the small boy who has been scared of me to smile and give me a high five. I ate bananas, tomatoes, cucumbers, and pineapple for lunch, prepared by our two very enthusiastic cooks who I adore. Pastor Gray stopped by to visit and reaffirmed his invitation for us to come over for dinner and a church service. And the joyful sound of singing fills the village, radiating from choir practice across the field.

It really is an incredible life.

*****

April 8, 2009

THE FORTUITOUS HITCHHIKER

To say that I love outreach clinic days would be a bit of an understatement. Julie and I were worried that the heavy rains last night may have made the roads impassable today, but we were happy to see the driver pull up in the Land Rover as we were finishing rounds. After a bite of avocado and a cup of black tea, we drove away with Nsemba and Nivo to the tiny village of Kito, bouncing along the rocky dirt roads.

I could never tire of the drive in these mountains --- steep, forested hills dotted with small farmsteads; banana trees boasting beautiful flowers; herds of goats and cattle darting across our path. I marvel at the women that carry impressive loads of produce, chickens, books, laundry, firewood, and whatever else on their heads --- precariously balanced --- as they tote small children on their backs. The temperature sharply rose and the foliage dramatically changed as we descended the mountains … lush palm trees gave way to planted fields, shrubs, and tiny groves of trees. No matter where I looked, I saw the bluest skies, the whitest clouds, the greenest plants, and the reddest roads I have ever seen … the beauty here is utterly unreal.

At one point, Nivo, Nsemba, Julie, and I got to laughing so hard about marriage, children, and women being so complicated. Nivo especially found it funny when I told her about my mother wanting each of her daughters to have thirteen children so that we will understand how difficult we were to raise. Nsemba felt sorry for my father being the only man in the house surrounded by so much estrogen … our poor driver that had to navigate the muddy roads while we were cackling and chatting away! The fun only continued when we passed an old man hobbling along with a cane. He waved his hand and pointed in the direction we were traveling, and after a few feet, we stopped and helped our hitchhiker into the back of the vehicle. Incredibly grateful for the lift, he thanked each one of us in turn. Within a few minutes, the old man showed us what he had been carrying in his bag … hand-carved wooden people that he had engineered into torches (flashlights)! After verifying that they didn’t harbor any voodoo powers, we bought both versions that he had … for a combined total of a little less than eight dollars.

The towns we drove through in the valley were bustling with activity --- teenage boys clamored over games of pool; old men smoked cigarettes and lounged in the shade; school boys carried their books home from school. Meanwhile, women tended gardens, sewed clothes, and washed children and dishes in streams along the side of the road. Everyone biked by, hauling sugar cane, bags of rice, and one another. Children played in the dirt near chickens and trash, and diesel tractors and buses spewed thick, black smoke in the air. In the fields, flax plants were being harvested for fiber and sunflowers for oil. Near the edges of many towns, large sheets of rice dried in the sun. And as before, folks’ reactions to us varied --- from looks of disbelief and shouts of “Mzungu!” to wide smiles and waves.
After two hours or so, we finally arrived in Kito, a collection of no more than ten stick and mud homes. A small group of women and their children were already waiting for us. We unpacked our vaccines and suspended the scale from a nearby tree. Julie and I took our toilet paper and headed out back to the outhouse, stepping on corncobs, ducking the clothes line, and walking past hogs and chickens. These toilets were by far the most difficult to understand how to use --- with no doors and no obvious target to aim, we gingerly stepped back on the wooden planks and were quite thankful to not fall in. Around these parts, toilet paper is worth its weight in gold.

I spent a few minutes outside as the mothers weighed their children under the tree and took a few pictures, showing each photo to the kids who laughed in disbelief. Once they caught on to what I was doing, several more children joined the group and began to strike poses … I can already tell I am going to miss the children.
Within forty-five minutes, we were done with clinic and back on the road home, stopping once in a fairly large town for passion fruit juice, coconuts, and kerosene, while our driver fetched rice for Nivo’s Easter dinner. We arrived home to no electricity for the second night, and it sounds like it may be a few days before it comes back on --- the heavy rains last night knocked over trees and power lines … and such is life in Africa.

*****

April 7, 2009

THE FLOOD

After witnessing four Caesarean sections here at Gonja, Julie and I finally took part in our first natural delivery … with little fanfare and little equipment, one of the slightest women I have ever seen gave birth to a nearly four kilogram baby girl in absolute silence. She was soon draped in beautiful, colorful cloth and nestled in her mother’s arms. Later on, after morning rounds and in the midst of outpatient clinic with Dr. Amini, I was surprised when one of the new mother’s relatives asked him if both patients could be discharged to home today. I have come to appreciate the African women I have met here (Warning: enter broad generalizations.) as gracious, hard-working, and stoic --- no complaints or questions. I will never understand how they are able to manage all that they do.

I am continually surprised/ amused/shocked by what I learn and observe here, such as:

• Blood donation for transfusions is often given by family members of said patient; the blood is only tested for HIV. At KCMC in Moshi, the donated blood products are screened for many other transmissible diseases.

• Delivering a child at Gonja is free and paid for by the government, while most other surgeries cost around 50K shillings (around $40 total).

• We witnessed two teenage girls have “hysteria” spells during rounds, a type of psychosomatic disorder where they become so emotionally distraught they faint or appear to be having seizures. Gillian shared that this is a common reaction for girls when they face stress at home, school, or with relationships.

• Gonja is unable to provide pap smear screening for cervical cancer; women have to travel to Moshi (four hours away) if they want this performed. It makes me feel that the HPV vaccine is really needed here in Tanzania … and not necessarily back home.

• We cared for one woman who just had her third consecutive spontaneous abortion relatively late in her pregnancy --- locally, she really has no option for determining the cause, and I’m afraid she will internalize the problem as her fault alone.

• During the night shift, two nurses only work and are responsible for the management of regularly 35+ patients. It becomes perfectly understandable if a patient misses a medication or two, especially when the records are all hand-kept.

• Anything can be turned into an IV pole, including curtain rods!

I learned this afternoon what “the rainy season” really means … around 4:30 or so, gray clouds rolled in and clung to the mountains, shedding a drop or two. No sooner had Pastor Gray stopped by to introduce himself (and invite us on a hike and to his home and church) than began a sheer downpour, lightning, and thunder to the point of appearing as black as night. We lit candles and opened the door to enjoy the rapidly fading daylight, only to find the road next to our home a tiny river. Pastor Gray was anxious to get home and see his wife and children, and we sent him on his way with Julie’s raincoat. The three of us read and ate dinner by candlelight, whiling away the hours discussing relationships, Tanzanian culture, and our futures in medicine. It really was a lovely way to spend an evening.

*****

April 6, 2009

CUTTING NEEDLES

We were quite the large team this morning for rounds --- Dr. Mary, Gillian, Dr. Amini at first, a nurse, Sister Kajiro, Sister Dora, Julie, a new doctor, and me. We visited with a young man who sustained a head laceration during a fight --- Gillian laughed that no matter where the altercation takes place, the story is always the same … someone always “jumps” the person minding his/her own business! A strong handful of our patients are HIV positive, and the rest are automatically screened as part of their work-up. Even for a disease that has had a stronghold on Sub-Saharan Africa for the past thirty years, it still carries such a stigma that it is neither written in the patient’s chart nor discussed during rounds. We learned that neither electricity nor broken or missing parts were to blame for the X-ray machine not functioning --- turns out it is a matter of purchasing developer to reveal the images. When this purchase will be made or by who is not entirely clear, as the chain of command in the hospital, especially for assessing inventory, orders, and delivery, is about as clear as mud.

The real drama came in observing how the new doctor interacted with the rest of the team; supposedly paid the highest government salary of anyone at the hospital, he is quite frequently gone, attending conferences, funerals, and the like. He contributed very little insight on rounds and was frequently not familiar with his patients’ histories. And when he asked to borrow my stethoscope to listen to someone’s lungs, he inserted the ear tips backwards.

I spent the afternoon in the OR, expecting a fairly straightforward appendectomy and Caesarean section. Much to my surprise, I did not find what I had anticipated … a pelvic exam for bleeding in an older woman, two circumcisions on twin 5-year-old boys, and a laceration repair following a pig bite. I scrubbed in for the C-section with Gillian, alongside our scrub nurse who was preoccupied throughout essentially the entire procedure. When the two of us returned from lunch, the patient was in the room, but no supplies had been arranged, and Mary was nowhere to be found. When the case started, Gillian didn’t have a scalpel to cut the skin, and when she asked Mary how she was to cut, she suggested she use the scissors!

For whatever reason, Gonja has a wealth of cutting needles that often cause bleeding just as one tries to stop bleeding elsewhere. This OR does not have cautery (heat used to seal vessels), so major loss of blood is always a concern. (I hear we have units of blood somewhere in the hospital, but I’ve yet to find them and frankly, am not entirely sure how they stay fresh.) During the section, we had numerous sutures break, wrong supplies opened, the electricity flicker on and off, and Mary unable to anticipate what would be needed next. Despite our surgical troubles, the baby did just fine. I’m incredibly surprised by the lack of newborn exams that are performed and the unhurriedness when it comes to neonatal resuscitation --- there seems to be a fatalistic attitude that what is supposed to happen will happen in life and death.

I chopped onions and tomatoes for a quick salsa to mix with our beans and corn for dinner tonight --- so delicious! Ingia, bless her heart, also made us chipsi. I am excited that the tiny village market right down the hill from the hospital has plentiful tomatoes --- we do have to be careful about washing them in bleach, however, to kill typhoid and other GI bugs that I’d rather not experience. After dinner, we all of a sudden heard intermittent wailing coming from the direction of the hospital. We thought someone had died at first, but then we noticed the stretcher heading inside … a new admission that awaits us in the morning.

*****

April 5, 2009

HOW NOT TO FLASH THE NATIVES ON A PIKI-PIKI

I woke up at 6:00 a.m. to make sure I had plenty of time to get ready before the piki-pikis (motorcycles) arrived at 7:00 a.m. to take us to church seven kilometers away. I relaxed in the sun on the couch until Gillian heard the motors, and she and I picked our way down the mud path to meet them. I hopped on and hung on to my driver’s coat, but no sooner had we reached the edge of the hospital grounds, he stopped, grinned, and wrapped my arms around his waist. After a few moments, I understood why --- as we zipped along over ruts and around rocks, hitting a chicken and nearly a cow, I was grateful for the stronger hold. I waved to the children walking along the side of the road and did my best to make sure I didn’t flash the entire neighborhood. I already made enough of a scene in my skirt and hiking boots.

I waited quietly inside a pastor’s home in Ntenga, waiting for Nivo, Julie, and Gillian to arrive. The pastor’s wife served us chapati, bananas, and hard boiled eggs, and soon thereafter, we walked up a short path to the church, marveling at the incredible view of the valley below. We greeted the church officials and soon were eating a second breakfast in their administrative office. Once most of the parishioners had arrived, we got in line behind one of the choirs and danced our way into the church and our seats of honor on the stage. I don’t believe I have ever seen so much color --- everyone was dressed in their Sunday best, and strips of fabric and ribbon hung above, carefully tied to string stretched the length and breadth of the church.

The animated pastors led us through a passionate service, punctuated every so often with fervent prayers and rhythmic singing from one of the three church choirs. We heard church business reports and honored a newlywed couple. Julie and I even managed to make it through our introductions to the congregation --- in Swahili, no less! When I told them I was studying medicine and a little bit of Swahili, they laughed, and the head pastor welcomed us home in Tanzania on behalf of the church.
Every week, as I understand, the church collects offerings, but as part of their fundraising drive before Easter, the Ntenga pastors were hosting several more rounds of giving, as well as an auction. The first of five or so rounds involved gifts of money --- small ones at first, followed by progressively larger gifts. For many families, by the time we reached the second round, they donated small bags of onions, bottles of milk, or sacks of tomatoes from their farms. Gillian reminded us to give our donation with the right hand (also always used for greetings and eating); the left hand is considered dirty and unfit.

I have never experienced a more soul-filled and lively worship --- folks would break into song, nodding their heads and tapping their feet in unison. Children danced in the aisles, and shouts of thanks filled the air. For a people with so little material wealth, their faith and dedication are rich beyond measure.

Before the last round of offerings, a small group of ladies rearranged our chairs to the very front of the congregation and invited us forward so that we could witness the retreat and entrance of each of the choirs. In turn, different groups of parishioners came forward with their final tokens, handing them over with smiles and several handshakes. As part of the last group, we headed outside and danced our way back in with our final set of shillings … to several good-hearted whistles!

After church finished, we gathered immediately outside for the auction --- the old, withered auctioneer with a gap smile led the way, holding up sweet potatoes, sugar cane, milk, tomatoes, eggs, and spinach for sale, while the church secretary carefully recorded the prices. We picked up a few avocados and were gifted several bananas. I fell in love with a little girl in a red and black head wrap who played with Nivo and Gillian throughout the auction … and took no less than forty or so pictures of her!

We ate lunch at the church before beginning our long trek home. Several people stopped to greet us and walked with us a short while, including this curious old man in a dirty suit and cane. We finally met Dr. Amini at Nivo’s and his home away from Gonja, enjoying Cokes and peanuts and meeting his mother, 97-year-old uncle, brother, sister-in-law, couple goats, and a cat before hiking on trails cutting through rainforests and the backyards of people’s homes on our way back to the hospital.

And of all things, I even managed to place a phone call home --- no one picked up at the house, and Mom didn’t answer her cell phone. I did, however, reach Dad feeding cattle, and we were both impressed with how high quality the call sounded … he was curious to know if I had seen any giraffes or lions yet --- not yet, but soon, very soon!

*****

April 4, 2009

DR. GILLIAN ARRIVES

Today was, in many respects, a very lazy Saturday. I was the note-taker during morning rounds and then spent a lovely half hour on e-mail updating my blog before the power blinked off --- followed by three hours of hiding away in the pharmacy (where the computer is located) waiting in vain for the electricity to return. The technician came in at one point and said there was a breaker issue and that it would take only five minutes more for it to be fixed --- an hour-and-a-half later I gave up and met Julie for lunch. I did, however, manage to study a great deal of Swahili during those three hours. I washed my laundry (drying my socks on the rock in front of our house), napped, attended church choir practice, and did yoga with Julie. Not too shabby.

There are several aspects of medicine around Gonja that are fascinating to me, and I wonder if I lived here long enough if I would ever fully understand them. Whether they are quirks of culture or of economic necessity, it’s hard to tell. For instance,

• Fathers are not allowed in the labor and delivery rooms or in the operating theaters for Caesarean sections. Dr. Lisungu told me this may change in the future, but for now, “It is so.”

• Patients are maintained on normal saline fluids for twenty-four hours after surgery, followed by black tea for 24 hours, after which the diet is advanced to porridge. There is no dining service to speak of in the hospital, and families prepare all the meals for their loved ones in the smoke house just a few feet from where I live.

• Equipment in and around the hospital appears to be in a constant state of repair --- vehicles, sterilizing machines, and toilets, you name it. Yesterday, one of the men’s toilets on the second floor was plugged and spewing water everywhere in the hallway. We sidestepped the water and continued with our work. Today, one of the women’s toilets actively flooded, but no one seemed in a rush to address it.

• There are so many patients to be seen on morning rounds and during the outpatient clinic that taking the time to perform a physical exam --- any portion thereof --- falls by the wayside.

• Everything possible is re-used at Gonja, including the sterile papers surrounding gloves that are turned into clean papers to wrap medications dispensed at the tiny pharmacy.

• Surgeries are regularly delayed when the electricity fails, and there is not enough power to sterilize the operating equipment we need … and apparently, it is not that unusual for Caesarean sections to take place at night by head lamp if the need arises.

• The anesthetist, who I absolutely adore, leads a prayer before each and every surgery.

• So many patients here have high blood pressure, and rather than being on constant monitoring and treatment, they more often are treated episodically for seven days and then return to clinic.

• Honey dressings are often applied to wounds, so that, as Dr. Msemo explains while she laughs, “The bacteria then eat the honey and not the person!”

• Interestingly enough, the hospital features a palliative care unit that is run by a pastor who also chairs the board for the hospital and oversees a local parish. End-of-life issues are as challenging here as at home --- the wife of a stroke patient has been attending to her husband daily for six months, mashing bananas and milk together and feeding him via a nasogastric tube, hoping for a miracle to occur that very well may never happen.

Medicine is often practiced here by touch and intuition. And even with so many limitations, Gonja is still able to provide much and is the lifeblood of this part of the rainforest.

The big excitement of the day woke Julie and me from our naps --- Dr. Gillian Dorner returned from Moshi! A graduate of Iowa, she did family practice residency in California, and is halfway through her six-month stay here. She filled in our understanding of so many things --- who to ask for more water and toilet paper, who to ask to arrange a local hike and a trip to Mkomazi National Park next weekend, and where to buy kitenge (large pieces of colorful cloth) and tangas (cloths that contain messages). She advised that we could wander down to the village by ourselves as long as we inform someone where we are --- I can’t wait to head down there and look at the fabric! Apparently, there is an excellent seamstress in the village, and I’m going to have him make me a skirt at the very least. She showed us one of her favorite tangas that she purchased in Arusha --- a blue swath of fabric with a map of Africa, Obama’s likeness, and the words, “Hongera (Congratulations) Obama!” I am most certainly going to be keeping my eye out for this one! And perhaps the greatest news of all … Julie and I are going to accompany Gillian and Nivo tomorrow to a daylong church service and auction! I can scarcely wait --- we are riding tiki-tikis (small motorcycles) to the church, will eat lunch there, take part in the auction, and walk back the 45 minutes home. I’m going to be wearing my hiking boots with my skirt --- not necessarily the best fashion statement, but again, I don’t think many folks will notice my shoes!