Tanzania
Trip Report - Dr. Samuel Feinstein - May-July, 2008:
I'm returning to lead a surgical team in western Tanzania this summer. I'll be using this blog to keep in touch so if you want to keep up with my craziness go to the site and I'll do my best to paint an accurate picture. Now it's just four weeks to go. My trip back to Tanzania is motivated somewhat differently than last year. Then it was about fascination with the unknown, the chance to do some remarkable photography and the probability that I would be able to do some good. Now the unknown part is over - I know what to expect and am much better prepared mentally for the arduous journey with its strange sights and smells. I also know how to find accommodations in transit that provide enough security to let me close my eyes and survive the night.. The photography part has narrowed. Instead of trying to paint a hodge-podge panorama with my camera my focus will be limited. I've been given an assignment by Emirates Airline, which is sponsoring my trip, to do a piece on the children of Africa. That's still a huge subject but having been there I know where the stories are and intend to capture them. The medical part, however, has taken front position. When I left Sumbawanga and it's large, under-supplied hospital last summer I was devastated by my inability to provide even the simplest care that could have been lifesaving. Severe burns and serious infections went untreated or inadequately managed simply because the means to treat them were not there. I performed major surgery using only the barest of essential equipment and got surprisingly good but not acceptable (to me) results. I am taking a good supply of sutures and other equipment, as well as some medications with me and have been successful in getting others to donate items. However, I have no illusions about being able to solve all the problems. My focus this trip will be to provide training for the many people who, thought barely educated, make up the bulk of the hospital staff and provide care on a daily basis. This will not be easy. They are a proud group and jealously guard their positions. However, as a returning physician and not a one-time interloper, I believe I will have their trust. The main challenge right now is to get ready physically. A dumb skiing accident in March resulted in complicated shoulder surgery April 1. With intensive physical therapy the goal is to get the shoulder at least pain free if not fully functional by the time I have to leave. I'm working hard at it and it's not fun. Other tasks include stuffing as much equipment as possible into a duffel bag, getting politicians in Tanzania to grease the customs wheels for me so I don't get hung up on my way in and contacting the doctors and other personnel with whom I will be working. There's lots to do. Stay tuned.
The time to departure is beginning to move quickly. I've been in touch with the people in Tanzania which in itself is not an easy process. Without making judgments I can report that the culture of East Africa is not really amenable to modern technology. Broadband web access is surprisingly available and relatively low cost computers are becoming ubiquitous in developed areas. In spite of that there is a cultural disconnect when it comes to reliably checking and answering email. The easy going, laid back lifestyle simply refuses to generate the sense of urgency necessary for instant communication to work. Though that is probably a good thing for them it poses some challenges for me. After some phone calls to Sumbawanga I managed to confirm that my presence there is anticipated. I continue to accumulate supplies. The Ethicon corporation, a subsidiary of Johnson and Johnson, filled an order for sutures that are unavailable in Africa. The $4000 order was custom assembled for free. Kudos to them. Now I have to get it there. Fortunately I can ship some of it to one of our team members to hand- carry. I cannot ship anything. Even if it got there unmolested it would take weeks to negotiate it out of customs. I also have an assortment of disposable surgical staplers donated by the Autosuture company. These, also worth thousands, will need to be hand carried. Using such devices advances the level of intestinal surgery by 75 years. Meanwhile I am faithfully attending my physical therapy sessions 3 times a week and working the shoulder at home. It won't be fully functional by the time I leave but if the present level of progress continues I should be able to do what needs to be done with minimal discomfort. Now it's about paying attention to the details of being away for 6 weeks. Getting bills paid, arranging home maintenance, arranging coverage for business obligations, assembling a meager travel wardrobe and a generous photographic toolbox, updating immunizations and the list just goes on. Yeah, I am beginning to get excited about this.
It's been a hectic week. For a while it seems like there is all the time in the world and suddenly everything is a rush. First I found that a cache of surgical instruments that I had been squirreling away in the garage went missing. A desperate two day scramble ensued producing almost more (better too) stuff than I can carry. People and institutions have been so generous. The next challenge will be getting a 70 lb. extra suitcase past airline officials. I'll let you know how that goes. The details are endless. Hotel reservations en route, bus reservations. Yes you need a reservation to go from Mbeya to Sumbawanga. Otherwise you may get to share a seat with a chicken or goat. I did that last year and the chicken was fascinated with my camera strap, pecking at it and occasionally missing and leaving dimples in my shoulder. Packing has not been easy. One suitcase for me and two full of medical equipment. My carry one has all photography equipment and a little space for personal items and that's it. Fortunately my wardrobe is tee shirts, scrubs, jeans and a few things to keep warm. The expected weather there at 6000 feet 200 miles below the equator is 70s in the daytime and 40s at night. I've been in contact with the doctors in Sumbawanga and they tell me they are gathering surgical cases from the entire district. The equipment I'm bringing will make a big difference, bringing them forward a half century in capability. I can hardly wait to see everyone's faces when we start unwrapping it all. So, now is the time to finish last minute packing, get some rest and get ready to set out. Are we ever completely ready for a trip like this? Probably not but that's part of the adventure.
The trip to Sumbawanga, which, for reasons I will explain, expanded from four to five days. The first leg was ma red-eye from Phoenix to JFK. It’s amazing how many people fly in the middle of the night. Used to be you could get some sleep on those flights but no more. Oversold. US Airways was very gracious allowing me to check the extra 110 pounds or so of medical equipment for free. So there I was with four pieces of luggage weighing more than I do taking the Airtrain between terminals that could not be farther apart. Arriving at the Emirates counter I had an hour wait for the flight to Dubai to open. Very interesting people fly Emirates. While waiting I met a real live sheik, a lady in a burka who had no compunction about telling me her whole life story and a man who owns, no kidding, an internet porn shop who does business by some subterfuge in the middle east. Emirates, too, allowed the overweight and over-number baggage for free. And what an airline it is. Emirates ranks right up there with the best along with Singapore and others like it. Even though I couldn’t wrangle an upgrade the seating, service and food were as good as any first class service I’ve had on domestic airlines. This was true for the connecting flight to Dar es Salaam making this portion of the trip pleasurable. This was good because total flight time from Phoenix to Dar with layovers was 29 hours. I was met at the airport in Dar by a charming lady from Paraguay named Carolina. As a Healthcare Volunteer, her job was to get me through Dar and on to the bus the following day. I had her take me to a hotel at the O’Willie’s Irish Pub on the ocean. I remember having the best shepherds’ pie ever at that place and I wanted it again. I was not disappointed and the hotel there was passable for one night. At 5 in the morning my stuff was loaded into a cab by 2 guys in full Massai dress and I was off to the bus station. The human mind has a merciful component that allows it to forget pain. For this reason I had put out of my memory just how unpleasant 2 days on an African bus can be. Though it looks small on the map of Africa, Tanzania is actually bigger than France. I took what I thought was an express to Mbeya, a distance of about 500 miles. Here "express" means they sell you a specific seat. After that all bets are off. Stopping at every town and village to take on or discharge passengers the bus is often packed with people in the aisles hanging over the seats and giving one a very cramped feeling. Still, I was able to read some and sleep. Thirteen hours later the bus pulled into a dark, dusty bus station in Mbeya. Thjs was the good leg of the trip. I had decided to stay there an extra day, partly because I had some things I wanted to do and also because I wasn’t going to endure 2 days in a row on the bus. Last year, not knowing that Mbeya is a fairly large, cosmopolitan city, I stayed overnight at a murky inn near the bus station that had all of the charm of a Turkish prison. (Think Midnight Express.) I was scared to death and got out of their fast in the morning. On the way home, by private transportation, I got to see the city and stayed in a fairly nice place called the Golden City. It’s a hotel that caters to wealthy Muslims and is clean and safe with beautiful sculptured gardens in front. The interior is done completely, walls and floors, in shiny white tile. Alcohol is not served in the restaurant so if you want beer with your saffron flavored beef and rice you are relegated to the bar. A small, comfortable room with internet service and decent food for $25/night, what more could you ask? My reasons for staying an extra day were to re-visit the hospital there to see an American acquaintance working in an AIDS project there and to seek out an orphanage I had visited to find a very special child. Those of you who have been to our home know that I have been displaying a photo of an adorable 3 year old that I happened on last year. In the photo she is wearing her Sunday best red dress and throwing a killer smile. I wanted to see and photograph her again but I did not know the name of the orphanage or where it was. I went one for two. My Dr. friend had returned to the states so no contact there. When a foreign doctor shows up at a hospital he is treated with great respect and introduced all around. Among the people I met was the director of social services for the area and, from my description, he was able to tell me exactly where the orphanage was. I had hired a driver for the day and we immediately set out and found it with no trouble. The place was almost deserted with a Massai guard and a badly crippled woman overseeing the place. They told us most of the children were gone on some sort of holiday but we were welcome to look around. I talked to and photographed 3 small boys who told me there were no girls there. Disappointed, I wandered over to the grove of trees where I had seen the little girl last year and unbelievably she emerged with a companion. Her name is Priska. She has grown in a year. She was in dirty play clothes but the face was unmistakable. She immediately started laughing and flashing that smile and I had what I came for. Then off she and her companion ran laughing into the woods. I must have some kind of karma going on with this child. Don’t worry though, it is not permitted to adopt out of Tanzania.
In the last post I mentioned hiring a driver. That deserves some explanation. When a European appearing person (read: white) gets off a bus in a place like Mbeya there is a particular kind of person waiting. It is an ambitious local young man, who is nicely dressed, unintimidated and speaks reasonable English. He smells money. My fellow was named Charles and he immediately offered taxi service to my hotel. Since he had a driver of his own I was grateful for 2 sets of arms to haul the load. Remember, I’m still nursing a shoulder that is about half capacity. By the time we reached the hotel he had ascertained that I would be there all the next day and checking out the day after that. After hearing about my plans to visit the hospital and orphanage as well as a few errands he offered to be my guide with his driver. We negotiated a price that, for me needing assistance in a strange city was a bargain and for him a windfall. Promptly at nine they picked me up and we set out on a successful day. About 2 in the afternoon the missions were accomplished and he suggested I see a local attraction called the Bridge of Gold. (at a small additional fee, of course.)We drove for about an hour to a place that was absolutely breathtaking. A series of small waterfalls flowed under the largest and most beautiful natural bridge I had ever seen. It glowed golden through the mist in the late afternoon sun and I was in photo heaven. Just down the river was a huge waterfall accessible from the top but not the bottom. What a treasure I gained because I was willing to trust these 2 guys. Why? After all, they could have taken me our there, robbed me and left me in a ditch or worse. First, he had given me a receipt with his name, phone number and vehicle number after the first ride from the bus stop. Second, he seemed like a good person and I’m rarely wrong about people going on gut feelings. Third, I’m in Tanzania and crime is almost unknown here away from the big cities. You wouldn’t use someone without a reference in Kenya or South Africa. At 5am just the driver came to convey me back to the bus station. After he deposited me with my luggage near the bus I noted that the small canvas travel bag I was carrying was gone. It contained some reading material, food, water and the small digital camera I was carrying as a backup. I was upset, realized there was nothing I could do and went into damage control mode. Then I looked up and saw the car reappear in the emerging dawn. The driver got out, came over to me holding the missing bag. Wow, talk about vindicating trust. I was extremely grateful and let him know it. Shortly after Charles showed up and made sure my luggage and I got on the same bus together which, considering the confusion of thirty or so busses loading in the semi-dark, was not a done deal. Anyone going to Mbeya let me know. I’ll give you his number. The day was downhill from there. The bus was old, crowded and noisy. Would you enjoy loud, bad hip-hop in Swahili for 7 hours? The bus was configured 3 and 2 across. I was number 3 on the isle sandwiched between two very fat women and the armrest which prevented their sheer bulk from displacing me out into the aisle. I have a bruise on the left side of my abdomen from the pressure. There were no animals this time but I think I would have preferred the chicken from last year. The road was still unpaved, bumpy and full of holes but not as bad as last year at the end of the rainy season. We only had to get out of the bus once at a road washout to allow it to cross a makeshift repair. When I arrived in Sumbawanga somewhat the worse for wear, a cab was waiting for me and the driver deposited me and my baggage there. I was finally rid of the burden. I felt like Henry Knox bringing the cannons over the mountains to General Washington from Fort Ticonderoga. (if you don't know that story look it up. It's a good one.) I was off then to settle in at the Forest Way Country Club and (thankfully) Bar.
Specifically: The afternoon of my arrival day was spent unpacking and setting up my room/office to my liking. The Forest Way is a comfortable place consisting of 5 guest rooms, a restaurant and a bar. I take all my meals here. Breakfast is included and its the usual eggs a samoza (small, triangular deep fried meat pie) toast and coffee. Dinners are decent but variety is limited. Several kinds of tough local steak, spaghetti Bolognese (best thing on the menu) and chicken (often the one that woke me up that morning) are offered. The fish is inedible. Not much fiber and of course it is not a good idea to eat raw produce. They do cook up a mash of spinach, cucumbers and beans that is actually quite good. All cooking is done over open charcoal braziers. Unfortunately there is no longer internet service here as the owner is away for medical treatment so all communication is being done in town. More about that later. Since last year a new cell phone tower has been built nearby so that service is excellent. The town center and hospital are about a 30 minute walk over a dusty dirt road followed by a paved street lined with shops. Though I have a driver at my disposal I have resolved to walk at least one way each day lest I come home looking like a bowling pin with legs.. Only two streets in town are paved but I'm told that is about to change. Right! Remember, this is a town of about 25,000 people with a surrounding population of 250,000 more in scattered villages over an area about the size of Los Angeles county. It is located in a region (corresponding to our states) called Rukwa which is huge. Unfortunately, Rukwa is treated as an afterthought by the government and is badly underserved in every way. It is far from the center of power in Dar es Salaam and produces none of the tourist income of the northern regions nor does Rukwa produce much of anything for export. The economy here is mostly subsistence farming and produce for local trade and from what I can see the locals to a good job of it. The lack of economic output means that there is no paved highway in or out and social services, though the infrastructure is here, gets woefully inadequate funding. Add that to the usual level of corruption and the people do not get much. The road problem turns into a chicken and egg situation: There is no progress because there is no road and there is no road because there is no progress. Watching TV I see endless meetings of government organizations endlessly discussing this problem or that but little gets done. To their credit the Tanzanians have an open democracy. Every meeting of Parliament is televised and they even kicked out their prime minister earlier this year after a corruption scandal. It seems he was in cahoots with a corporation that was supposed to be buying electricity for resale. They borrowed the money, didn't buy the power in the way promised, managed to corner the market and drive up prices and everyone got screwed. Sound familiar? The methods of Enron were not lost on them. The consequences were. Speaking of electricity, I'm experiencing many more outages than last time. The power goes down for short periods several times a day. It is very disruptive. While at the intenet cafe yesterday posting to the blog I had to start over twice. What should have taken 10 minutes took an hour an a half. Power to Rukwa is obtained from neighboring Zambia and is supposedly pretty good but the distribution of it here is not adequate. All this is the result of lack of government attention and incompetent private enterprise. The internet cafe is a very iffy proposition. There are 5 ancient Compaq desktops working off a very cranky pirated Windows 2000 operating system. The network varies from very slow to passable depending on traffic. It is subject to the same power outages. They have surge supressors but no backup power so when it goes down you just sit and wait. I had originally planned to offer links in this blog to pertinent sites but limited time for posting does not permit. I'd rather use the time to put in pictures. I needed to do a little shopping at the town market where I found out that (a) mens underwear is hard to find and (b) they never heard of a sweatshirt both of which items I was seeking. After wandering through hundreds of stalls periodically lowering my belt to reveal the top of my Jockeys I managed to score 2 pair of semi-bikinis with no fly. I will not be bringing these home but they will do for now. No sweatshirt appeared so I bought a bizarre looking long sleeve tee shirt and a vest. Hey, it's cold here at night - down into the 40's. Walking by the food stalls a guy tempted me with a beautiful potato omelet that I washed down with a coke. Street food.....yeah
My student arrived from Oregon yesterday bringing the duffel bag full of donated suture material that I had shipped to her. The bag was almost bigger than she was and we shared the burden of dragging it down to the hospital this morning. Her name is Catherine. She is well educated and bright, seeming quiet and reserved at first. We were just sort of getting acquainted when she got into it with Piet over dinner. Not only did she hold her own but was able to back him down several times. Go girl! After that I knew I had a keeper on my hands. Having never been in surgery before she showed an ability to instinctively follow along, anticipating events enough to actually be quite helpful. Catherine also knows a bit of Swahili which is making my life eaiser. She happened along in time to share one of the most stressful and bizzare days of surgery that I have ever had. Hospital_edit The day started simply enough, four or five patients referred for "the Professor's" opinion. (I love that - makes me feel like one of those old time European guys). We scheduled some resonable cases for the next few days and then went off to do the first of two scheduled for today. The first was an 80 year old man with a large mass attached to one testicle. It was not possible to determine pre operatively if it was benign or malignant but it was hurting him. Given the option of living without the pain and one testicle he enthusiastically chose the surgery. The anesthetist gave a super smooth spinal and the surgery went off without a hitch - almost. Near the end of the case our overhead surgical light died. It wasn't a big deal because the room was well lit from other sources and we were working at skin level when it happened. The next case was to start soon after but without the light - no way. Four hours later we finally got our light working and began the case around two thirty in the afternoon. This was a 24 year old male patient who had evidently been suffering with a partial intestinal obstruction for four years. He was almost emaciated looking with a hugely distended abdomen - not unlike the pictures you see of starving children. But this abdomen was filled with blocked gas in the intestine. Lacking any facilities for making an accurate anatomical diagnosis and going on history and physical examination and a poor quality abdominal x-ray we opened tha abdomen to find not the three foot large intestine dilated as I had expected but rather the entire 20 feet of small intestine. Normally the diameter of an ordinary household candle, these loops were the size of dryer vents, Once out of the abdomen there was no way they were going back until they were decompressed. The obstruction turned out to be a twisted loop that had been ignored for four years with the patient having spent the last month in the hospital undiagnosed. This is unacceptable by any standard. Emptying the small bowel is a difficult, dangerous process the details of which I will spare you. Midway through this process all lights in the OR went out leaving us with the window light of early dusk. We then found out that the person responsible for turning on the generator in such instances was nowhere to be found. No flashlights were available. We continued until most of the fluid and gas had been removed and then closed the intestine. Fortunately I had brought a modern bowel stapling device with me so I didn't have to waste a lot of time sewing it. We were rapidly heading toward darkness. There was one more thing that had to be attended to and that was placing a drain tube in the stomach. Otherwise the gas could re-accumulate before the intestine regained its function. The easiest way to do that is to pass a tube into the patient's nose and down to the stomach and tape it in place. These tubes cost about a buck and a half and are standard equipment in every OR and ward. Not here. The anesthesiologist seriously suggested that we send a family member out to a medical supply place to buy one. I declined and went for the other approach - a tube directly through the abdominal wall into the stomach using a baloon urinary catheter that was available. The problem now was that I could barely see under the incision to place the tube into the stomach and suture it securely. It was only because I have done this maneuver hundreds of times that I was able to pull it off, practically by Braille, without spilling stomach contents all over the abdomen which would have been a disaster. I quickly closed the deep layers of the abdomen and then in near darkness my assistant closed the skin while I fixed the stomach tube in place. Elapsed time - two and one half hours. The whole thing should have taken less than an hour and been finished before lunch. The sad part is that I don't have any of the fluids or equipment to provide the concentrated intravenous nutrition that his patient needs and he could just starve to death before he regains intestinal function. Catherine asked me what the patient's chances were and I told her at home you could count on him walking out of the hospital. Here and now the chances are under twenty five percent. This one case points up so much of what's wrong here. The equipment problem has gotten worse. Things like NG tubes , suction equipment and functioning, reliable lights should be available. They don't cost that much but nobody cares enough to see that they are on hand. It's easy to blame the administrative personnel but I accuse the doctors. The same physicians who let this boy languish with an obstruction all that time can't get it together to make sure they have basic equipment. There is one cardiogram machine in the hospital and it is in the office of the physician/administrator who never sees a patient. The excuse you hear over and over is "Well, this is Africa. Things will get better poli-poli (little by little.)" Well, people, poli-poli isn't cutting it. I've been away from here over a year and from what I see things have gotten worse. They've gone from an occasional power outage to four or five a day with no improvement or even deterioration of back-up capacity. The conditions in the wards are dreadful. Most even lack a place to wash your hands. Some improvement is noted in the availbility of pharmaceuticals but most of this is through donations. The medical record system is atrocious with almost no ability to trace a patient's history. Pathology services are non existant and lab and xray are rudimentary when available at all. They have allocated a fortune to build a new surgical unit which will be beautiful but how can they use it when they lack the ability to supply the unit they already have? When built it will be a showplace to display to visitng dignitaries who have no idea that it is an empty shell providing the same crappy care as the old one. OK, enough ranting for one post. What's my role in all of this? For now I'll just continue trying to provide for one patient at a time as best I can. But before I leave I'm going to make sure someone high up who just may care knows exactly what I've seen and how I feel. Maybe that someone will get that it doesn't have to be this way.
Today, Saturday, has been interesting. Originally we were not going to work but attain because of electricity problems we did not complete yesterday and had to carry one case over. Yesterday I had to take the boy with the bowel obstruction back for a second look when we completed the first operation in the dark there were some things I was unable to verify. Had I waited for any missed problems to show themselves his nutritional status would have deteriorated to the point where it would have been impossible to correct anything. So I decided to take another look and fortunately found everything in order and today he continues to do rather well despite the second operation and the scant resources to manage him. We arrived at the hospital after breakfast intending to start our case which was an 80 year old man with a huge combination hernia and hydrocele. We found one of the staff surgeons about to begin a procedure to correct abdominal adhesions from a past appendectomy that were causing pain. This was a private case on a woman who appeared well-to-do judging by the appearance of family members who were waiting around. I volunteered to scrub in. The case was exactly as expected. Surgeons reading this will understand completely. For everyone else I will say only that in the States we used to call these procedures B--- S--- laparotomies. We then got my guy on the table and wouldn’t you know it, just after we started the lights went out. Now last night, after Piet (That is the way he spells his name) heard my horror story from the other day he went out to his truck and presented me with a small halogen headlamp that he sometimes uses when he works at night. "You need this more than I do" he said while I took it from hom gratefully. Sure enough I did nearly the whole case with it today and the procedure went flawlessly. Working with the junior surgeon (the adhesions guy) on my case too I managed to show him a better way to close skin and also new bandaging techniques. He seemed happy with it and everyone left the OR in good humor. Unless there is an emergency that will do it for this week. Tomorrow, Sunday, I plan to take my camera around and catch pictures of children in their Sunday best. OH, and also I met a woman from a town about an hour from here who has come from Germany to start an orphanage. She had come into the internet café. Catherine and I are planning to visit her next weekend for an interview and a photo session. We’ll probably get out to Lake Tanganyika while we’re at it. Also, two medical students from Sweden are scheduled to show up some time next week. So the routine is going to change considerably
In the last post I mentioned that Sunday was to be a reflective day of reading, writing and photography. Well, it didn’t turn out quite that way. The morning was as planned with hospital rounds going well and by 11 I was able to check email at the internet café. Then I began the long trudge of about 2 miles back to the hotel, which is uphill, stopping to take pictures of children and families as I went. Just as I reached the hotel a hospital Landcruiser with a driver and Catherine in it blew up a cloud of dust as it stopped in front of me on the dusty dirt road. I was needed at the hospital and would I please get in the truck. OK, back down the hill to see a patient suspected of needing urgent surgery. No, she didn’t but it’s a good thing they asked me to check. The nurse in charge of that particular ward is one of the few who speaks fluent English so she charmed me into seeing 2 other patients that, though they have interesting problems, were not going to get the troops out on a Sunday. All this consumed about 2 hours and we found the driver to take us back up the hill. Arriving home I ran smack into my friend Godfrey. He is a young physician who, for the last 2 ½ years has been in charge of the other hospital in Sumbawanga. Sent there by the government after his internship his task was to modernize an old facility originally built by the Catholic Church ands raise the level of care. He has done a marvelous job of it and is now leaving to take a residency in Pediatrics. He is the leader of the group of young physicians practicing in the area, some of whom I met last year. They had flattered me then by asking my advice and now, as soon as they heard I was back in town, convened a meeting last night during which I heard all their complaints of insufficient supplies and equipment and other government inadequacies. The message I gave them was the same as last time. They need to be involved and exert their influence. As physicians they will not change the system. That will be left to others. What they must do is change the priorities of the system in regard to medical care. They can do that by making themselves heard collectively at all levels. Each will have to put aside a little bit of his personal quest to see to the common good. They do have a hard road ahead. I wished Godfrey well in his new position and his upcoming marriage and plan to keep in touch with him. He is a gifted leader who can go a long way. By now it was after four and I figured I could still get some writing and reading time in before dinner. Entering my space I was greeted by the sound of hundreds of bees flying around the room with unknown intentions. I backed out quickly and closed the door, scurrying off to find the person in charge for the day. As I sputtered out my story he said, "Oh, the bees are back." "Back," I said. "Do they come often?" "No, just once or twice a year" he replied. With that he casually strolled down to my room with a can of "Red Cans Kill All Insects" and commenced spraying this into the air. Now I don’t know what’s in that stuff but the bees literally dropped out of the air – at least 500 of them – and died a rapid torturous death on the floor. Another fellow came along with a broom and dustpan to dispose of the remains leaving my room a lethal gas chamber. Hoping the rest of the swarm had passed I opened the windows, locked the door and left. That was four hours ago and now, after having disposed of a few residual bees myself, I think the room is safe to sleep in. Let’s hope so.
I mentioned in a previous post that Sumbawanga is located in the southwest portion of Tanzania near the borders of Zambia and Congo. I talked about the population numbers and all that but I have never really described the city itself. The first word that comes to mind is dusty. There are only two paved streets in town and auto traffic over the dirt roads raises a continuous cloud of fine, brownish red dust that settles everywhere. Where the paved streets intersect in a "t" is the only building downtown that looks even vaguely modern and houses the elite businesses of the town. On both sides of any street are three foot open ditches, sometimes covered by slatted decking to accommodate pedestrians crossing. These ditches, thankfully, no longer convey sewage as modern septic tanks have arrived. They serve as runoff canals during the rainy season lest the whole place gets flooded. In the dry season there is no water in them and the population considers it perfectly natural to toss whatever trash they may he holding into them knowing that when the rains come the refuse will be washed away. The concept of avoiding littering is unknown. I have never seen a public trash receptacle. OK, with that unpleasantness out of the way let’s talk about the good stuff. There is a special energy here. Everyone is hustling something. There are throngs of people everywhere fixing bicycles, making furniture, repairing cars, driving taxis, selling fruit running small shops and engaging in all the kinds of familiar commerce and some we probably don’t want to know about. All of this is occurring in buildings that look like they were built yesterday out of scrap bricks, wood and tarpaper and covered with a corrugated tin roof. The surroundings may appear squalid but the attitude is beautiful. Most people are decently dressed, some strikingly with women in beautiful native designs and men in worn but serviceable western clothes. They go about their business cheerfully greeting each and when they see me they smile effusively testing out their English while I try to answer with my nascent Swahili. Everyone seems to be trying to make something happen. Most have cell phones and delight in using them. Entrepreneurs carry some of the most creative business cards I’ve ever seen and most shops offer several separate types of goods and services. There are a few nice neighborhoods,of course, with houses built in the Euopean style. These belong to local politicians and business pople but the average living conditions are simple and primitive. All in all this is not an especially attractive place. The only tourists I’ve seen are a few South Africans on their way to Zambia. It is a far cry, however, from the cliché of a stagnant third world mud hole. Cars are everywhere. They are mostly 80’s and 90’s vintage Japanese, mostly Toyota. I have not seen an American made vehicle anywhere in Tanzania and rarely see a European one. These are all four cylinder jobs with full sedan bodies. The most remarkable thing is that they are all immaculate. Whether a taxi or private car they are always clean and polished, rarely dented and recently reupholstered with pristine if sometimes garish leather. I have not seen one junked vehicle anywhere in town. There are a lot of motorcycles, mostly dirt bikes and a very strict helmet law. And everywhere there are bicycles, the chief transportation of the masses. Bikes here are very inexpensive, imported from China by the hundreds of thousands. Walking around town one might ask if this town is coming or going. It’s a good question and the answer is not at all obvious or certain. Rukwa province is the stepchild of the government. Being a region of subsistence farming and small local markets there is nothing here for export. There are no other saleable resources other than good year round weather. Unfortunately the way things are is that the region that does not contribute much to the economy gets largely ignored. Even electricity is unreliable as we spend at least a portion of each day without power and have just ended an 18 hour outage. Water is plentiful but there is not a purification system worth the name so all consumed water is boiled or bottled. Whether the city is coming or going in terms of development depends almost entirely on transportation. Sumbawanga remains a very wide spot on a very bad road. From Mbeya 90 miles to the south to Mpanda 150 miles to the north the only road is a rutted, potholed, often flooded and impassable mess. Everything and everybody moving in or out of Sumbawanga uses this road. The government has been promising to pave it for years but nothing seems to happen. This may be the year however. The new Prime Minister of the country is from this area. His name is Mpinda and I had the opportunity to meet and photograph him several times last year as his previous duties brought him through town and he stayed at Forest Way. My personal feeling is that when that road is completed this area will soar. The potential for manufacturing and organized farming is tremendous. Lake Tanganyika 40 miles to the west is one of the most beautiful places on earth and is located near spectacular waterfalls and almost untouched wildlife preserves. Tourism there could be as important there as it is in the North Country around the Serengeti. It all depends on that road. After that the investment will come and Sumbawanga could become one of the most important cities in south central Africa.
The key to my effectiveness here in Tanzania is Dr. Jasper Nduosindi. He is the senior of four or five physicians assigned by the government to staff Rukwa Regional Hospital. It is a daunting task particularly as one or more of the junior docs seems to be away at a meeting most of the time. I have not been impressed with any of them except Jasper. He has had surgical training, how much I’m not sure. Nevertheless, he has been responsible for all surgery, crossing all specialty lines, for several years. He does it all, OBGYN, urology, orthopedics and general surgery. As I’ve indicated, he has very little to work with in terms of equipment and supplies. There are almost no x-ray or laboratory diagnostic methods available. His diagnoses are always strictly clinical, arrived at by physical examination supported by experience. He must act on them every day knowing that he might be wrong. Under these circumstances the most important things he needs to avoid are exceeding his limits and getting into situations where he runs out of options. Jasper is a bright guy. He attends postgraduate seminars often in Nairobi or Dar. He can put little new knowledge to use here because of equipment limitations. WE sit for hours sometimes talking surgery and as I describe the developments of the last 20 years he is incredulous. I brought intestinal stapling devices with me. Although they have been in use in the US for 40 years he had never heard of them. I can show him how to use them and leave my stock. It will be up to him to cajole the government into getting him some more. I’m not real hopeful about that. We have a neat relationship. Going about the day with him I get to help set bones, treat malaria and do other things that I’ve either never done or long forgotten. He gets to assist me in surgery doing the things that I know well thereby upgrading his own technique and decision making. Where Jasper is rapidly becoming a formidable expert is in the area of repairing fistulas caused by obstetrical damage which is a huge problem here. Each year he works with a dedicated team from Nairobi that comes for two weeks to work and teach. He’s getting really good at it and may be forming a team of his own. Doing medicine for the government doesn’t pay much here – perhaps ten to twelve thousand dollars a year. The good news is that things are very inexpensive here outside Dar and the northern tourist areas. Jasper has managed to raise a beautiful family and acquire a few houses and a sizable piece of ranch property not far from town. His wife is currently away working on a nursing administration degree in Dar. He sees himself getting out of government medicine before too long and settling down as a gentleman rancher and perhaps running a small private clinic somewhere. Those are positions in life that he will have rightfuly earned
Lots has happened since my last post. When one begins to become involved in a place events seem to pile up on one another. I’ll just start writing and see how it comes out. For openers let’s catch up on the hospital. We’ve been doing a lot of surgery. "We" means the little team I’ve put together and not me being full of myself. Some cases have been routine and others have been extraordinary. The routine ones have been hernias, hydroceles, various GYN cases, rectal problems and such. All have done well and it almost seems like home. The weird stuff that one would only see in a place like this makes the trip really interesting. For instance: Take a look at the before and afters of this 22 year old girl who went through some ritual mutilation of her earlobes and developed keloids (out of control scars) that are the size of small oranges. Even if you’ve got a large plastic surgery practice in the states chances are you will never get to treat anything like this. Operating these was a fascinating 2 ½ hours of seat-of-the-pants decision making about skin flaps, reconstruction, etc with the goal being to come out with something resembling an ear. Also this week we have a local nun who ignored my advice last year to have her localized melanoma removed from her foot and now requires a below the knee amputation. Another one in line is a stunningly beautiful young woman who needs the middle three toes of her foot amputated because of sarcoma (soft tissue malignant tumor). Yeah, life can be a barrel of laughs around here. And then there are the fun cases like the 75 year old guy we operated today who had lemon sized stone in his bladder. Why is it fun? Because starting tonight he no longer has to stand on his head to pee. There is one sad and strange story I have to report. Yesterday afternoon a 3 month old child was brought in seemingly in abdominal distress. The child’s abdomen was distended more than any I have seen. It appeared about to burst. With no x-ray to help (the unit has been down for 2 months) we made a decision to operate based on what we saw feeling that something in there needed to be decompressed. When the anesthesiologist put the baby to sleep the distention was relieved and the abdomen appeared normal. Puzzled, we cancelled the surgery and placed the baby back in the pediatric ward. By morning he had died. Further questioning of the mother revealed that she had taken him to a traditional healer (read witch doctor) for a belly ache who had evidently given him an overdose of some powerful local herb. Yes, the baby had been poisoned. Welcome to Africa. On the social side I seem to be falling in with an expanding circle of South Africans. Last night I had dinner with a couple of guys who are about to open a resort on Lake Tanganyika. Last year I visited the lake which is the longest and second deepest in the world. It is positively spectacular and a long neglected asset to the Tanzanian economy. All that is about to change. Heretofore the only place to stay was a posh fly-in-fly-out $900 a night resort that only a few could experience and added nothing to the economy. These guys, Chris and Ben, are building a low and middle end place that should attract ordinary tourists from everywhere. We had a great time talking about their plans for the lake and the upshot is that we are invited there over the weekend to sleep in a deluxe tent and get the feel of the area. I intend to do an interview and photo essay on the place and try to get it published in an American travel magazine. More on this next week. And finally, I had dinner tonight with the regional administrator of Rukwa Province. The appointed equivalent of our state governor the honorable Daniel Njoolay (pronounced July) is the head guy for a huge territory that I have described before. We met last year and have finally gotten together again. Dinner was at Forest Way and he brought his wife who remained silent through most of dinner. . My agenda was to lobby for hospital improvement. His was to find out about Barack Obama. Neither of us was disappointed. I carefully laid out for him which deficiencies I thought could be remedied. There was no sense bothering with those that can not. Most of what I told him he already knew. One or two thins genuinely shocked him. He asked me to send him a written report which I will, being careful not to point a blaming finger at anyone in particular. I’m told that’s how one survives here. Then I described the current nature of American politics bearing in mind that Bush has been extremely popular here. It seems that one of the few things the administration has done right has been to earmark significant funds for African health care and it has been appreciated. Looking to the future I described the Obama-mania in the US that robbed Hillary of her shot and assured Daniel that the nominee would be a good choice for everyone and will probably be elected. Over coffee the Commissioner/Governor launched into an explanation of how African politics work that I found fascinating. I can’t comment on it because it was only an hour ago and I haven’t had time to digest it all. Maybe I’ll write about it later. Feeling privileged to have had this conversation I picked up the check. After all, where else can you take a governor and his wife out to dinner for under 20 bucks? Meanwhile, poor Catherine missed this event because she has come down with a case of what I call the Tanzanian three-step. She spent the day sitting on the can with her head in a bucket while Jasper and I took turns running back to the hotel to give her shots of anti-nausea medication. She seems better tonight and may even emerge from her room in the morning. Well, that’s the news from Lake Rukwa where the women have perfect balance, the men have perfect teeth and all the children think white people are funny looking. Until next time………….
I haven’t written for 3 days and it’s amazing how many things happen and how many interesting people cross my path. Let’s start with the weekend. I arranged a car and driver for the weekend to take us to Kipili which is a small village on the edge of Lake Tanganyika. It is not an easy trip but well worth the effort. The lake is the longest and second deepest in the world. It is also one of the most beautiful places I have ever seen. I took my signature sunset picture there last year and hoped to get one even better. We were invited by Chris and Louise Horsfall, a South African couple who are building a resort on the beach dedicated to the adventurous traveler who loves water sports, especially scuba diving. The location is dramatic and yet very peaceful. They have been living there for some time in a semi-open air dwelling, perfectly suited to the climate that provides visual and physical access to an environment so idyllic that once there it is difficult to leave. Their mission is to build the perfect space to share with about 40 guests in either super-deluxe or just plain beautiful accommodations. They are well on their way and expect to receive the first paying guests in September. The food for the resort will come mostly from their organic gardens. Power is self generated from solar panels leading to a huge battery array. Chris hopes to add wind power soon so that the resort will actually add power to the local grid. During the day the place is abuzz with building activity. At night the quiet is perfect, broken only by the gentle lap of waves on the beach that are the whisper kiss that only a lake can deliver. There were other visitors there for the weekend including Tony and Ann whom I’ve mentioned before. We also met Ross and Heidi Lloyd, a young coupe from South Africa who have quit their jobs and are touring all of Africa in their Landcruiser. Just them, no guide and no set itinerary. What stories they tell. After hanging around all day Saturday enjoying the surroundings and downing a few beers while watching cricket and rugby (yes they have full satellite TV and internet service) we had a delightful dinner on the beach. After determining the true nature of our relationship (they had only met us once briefly) they set up 2 separate tents for Catherine and me and, fears of snakes, giant lizards, spiders, etc, notwithstanding, I slept like a stone. Awakening at dawn to watch the sunlight coming from behind me reach out over the lake was awesome. Oh, and by the way, I did get a killer sunset shot. Back in Sumbawanga Sunday evening after another 3 ½ hour kishka krunching Landcruiser ride it was time to review the week ahead and plan for the new medical students due to arrive Monday. I will need to give then my full attention as I will be leaving here on Saturday. Wow, a month goes by fast. I’ll need to enlist other physicians to provide a program for them after I’m gone. There are several options and at least one will work out. We have some interesting cases to do. It seems the word has spread among the ear keloid afflicted that we’re taking on most comers. We scheduled two more of them for the coming week. There are a bunch more interesting surgeries to do and we’ll pack the schedule with as many as possible. Today I made a belated tour of the AIDS/HIV project going on at Rukwa Regional Hospital. Five years ago people were literally dying in the streets. The HIV infection rate was upwards of 30%. Starting in January, 2005 the CTC (Care and Treatment Center) for AIDS/HIV was started here funded by the US government. It is a carefully managed, highly accountable program. We were shown around by a well trained, carefully spoken nurse named Matilda Ulinyeusya who has made this program her life’s work. She explained that over 3000 people locally have registered for the program And over 1400 have been placed on medication. The medications, known as AVR’s, are given free, again courtesy of Uncle Sam and the program has been a huge success. Besides diagnosis and treatment there is a strong outreach program to the outlying villages, condom distribution and massive education. The result is that we now seldom see aids patients at the hospital the HIV positive rate has dropped to about 7-8% of the population which is low for sub-Saharan Africa. Most of these people have good control of their disease. This program works on a similar scale nationwide. The problem is that the US aid package, known as PEPFAR, is in danger of not being renewed for political reasons. If you want to directly save the lives of countless people Google the program, learn the facts and then climb all over your senators and congressmen. This program cannot be allowed to lapse. Another interesting character is Paul Graham Philips, the director of Sumbawanga Agriculture and Animal Food Industries. He is a black man from Zimbabwe who’s first language is perfectly elegant English. He is working for a member of the Tanzanian parliament who owns a huge cattle ranch not far out of town. He is dealing with a group of Jordanians who stayed at our hotel last night. Unfortunately his boss got fleeced by these guys and signed a huge contract to deliver beef in unsustainable quantities at a price that will bankrupt the company. Paul’s job is to figure out a way to make it work. I mention this only because at dinner tonight we had an in depth discussion of how the nascent African agribusiness works. What I learned is that most Tanzanians have no head for anything above day to day business and are very vulnerable to being taken advantage of. There is a great need for imported talent like Paul to help realize the tremendous potential of farming here. Tanzania could be a major player in the continental food supply if they could just get past "poli-poli" and get their act together. Paul’s a very savvy guy and I’m betting he’ll find a way to pull it out. Our three medical students arrived this evening. I met them briefly. Fortunately they are staying at another hotel. I don’t think I could handle three more 24/7 shadows. Catherine is enough. We’ll meet in the morning and I’ll plunge them into the wonders of primitive surgery. I've given them some warning as to what to expect. Off to bed............my mosquito net beckons.
The intensity has picked up around here. Our new students are wide eyed and eager. Susanna and Charlotte are Swedish women going to medical school in Poland. Second and third year they have, surprisingly, almost no clinical experience and none in surgery. It has been interesting watching Catherine, who has not yet been to medical school, orienting them as to operating room protocol and procedures. That girl learns so fast it\rquote s almost frightening. I'm really proud of what she has accomplished the last four weeks. I hope she chooses surgery later on because she's good at it and is definitely temperamentally suited for the field. It's fun having a class now. Our new students have the academic background for me to explain things in medical jargon and to coax out answers to questions based on what I think they should already know. Actually, they're not bad though Charlotte as a third year is more advanced. Their English is almost southern California. They learn our language almost from birth and watch a lot of American television. Anyway, they walked into a storm of clinical activity. Surgical cases are coming at us thick and fast. It's necessary to pick and chose the cases I want to do in the limited time I have left here. We can only do three a day and I have just three days left in which to work. Tomorrow we will tackle a case of what is probably colon cancer (remember, clinical diagnosis only, no x-ray help) and a weird neck cyst about he size of a large orange that keeps recurring and who knows what emergency will show up. The new girls will alternate assisting as it seems Catherine has become the darling of the OB department and has taken to first assisting the two or three caesarian sections that happen each day. I'm going to relate another very weird story now. About three o'clock this afternoon we were called to see an elderly man who had been hit by a falling tree several days ago. On his right side there were four fractured ribs and his collar bone was fractured and the ends collapsed and overlapping by at least two inches. Either the ribs or the collar bone fragment had pierced his chest and the lung was 80% collapsed. We took him right to the OR to reduce the fracture and apply a brace to his shoulders. He also needed a tube in his chest to re-expand the lung. Luckily, one modern chest tube with an introducer was available. As we were starting our procedure the next case, an emergency caesarian section was brought to the operating room door. While she was waiting there she delivered spontaneously and suddenly we were surrounded by people running around trying to resuscitate the baby, tend to the mother and keep the equipment going. After reducing the fracture and prior to placing the chest tube I sensed things were not going well and stopped what I was doing. Moving over to the nurse who was frantically trying to revive the infant I began external cardiac massage while the nurse administered oxygen. Now all this was going on in a room less than 20 feet square. The infant did not respond and after 15 minutes I abandoned CPR and returned to my patient placing the chest tube uneventfully. When it was all over I turned to the students and told them to remember this day because they will probably never experience anything quite so bizarre. That case finished all that remained was to tap into the chest of the young woman with the toe amputation two days ago. It seems she had developed massive fluid around her right lung and was having a lot of trouble breathing. We had no idea of why this was happening but it was clear from the chest x-ray we managed to get by sending her over to the other hospital that something needed to be done fast. Over in the ward we simply stuck a plastic covered needle into the chest, removed the needle and left the tube. Minutes later about a quart of fluid had drained, she was breathing better and we could all go home. From the looks of the fluid we're considering TB aggravated by anesthesia and surgery. We can get the fluid tested to make sure and if we\rquote re right she\rquote ll do well with treatment. We really hadn't expected the students to come as I had suggested that they be sent to another hospital because they were arriving so late. Jasper has arranged to go on vacation during the middle of next week. Fortunately there is a young man her, Dr. Haan, who is practicing internal medicine and pediatrics. I had met him only briefly and had mistaken him for an assistant medical officer. Fortunately not only is he a highly qualified doctor but his English is pretty fair too. He has agreed to take over responsibility for the students after Jasper and I are gone. We have a meeting tomorrow morning to arrange the details. By the middle of next week I think Charlotte and Susanna will have had enough of surgery anyway. It's time to start arranging the details of my departure. I sent out the last batch of laundry, had a new pair of jeans altered and some dry cleaning done. Now I need to decide which clothes to take back with me and what things to leave behind. There is still more work to do here and I plan to utilize all the time remaining. I'll post my final thoughts on Tanzania from Dar es Salaam on Monday. There is a not so enjoyable two day bus trip in the meantime. Hopefully I'll get a private ride for the first half.
This is a post I never expected to write. In all the traveling I have done on these missions, two trips to remote Pakistan and now two to Africa, all the complicated transportation plans have been remarkably hassle free. Yesterday was payback time. Anticipating an uneventful trip to Dar I had already begun composing my philosophical review of my time here. You’ll get that later but first the nightmare. I did get a private ride from Sumbawanga to Mbeya – sort of. The hospital supplied a Land cruiser and driver assigned to pick up supplies and seven other unidentified people. We were packed in so tightly that the bus would have seemed comfortable by comparison. No one spoke any English and the driver played very loud African music through the entire 4 ½ hour trip. Its only a hundred miles or so but the dirt road, even in good dry season condition, equals a class 2-3 off road trail in Arizona. OK, it was uncomfortable but not so bad. After buying a best class bus ticket to Dar es Salaam for the morning I checked into my usual Spartan, clean and safe hotel. The Mbeya bus station : Dozens, perhaps hundreds of young men scurry about grabbing peoples’ luggage and, for a fee of course, showing them where their particular bus is likely to show up. The traveler unfamiliar with the system is at their mercy. In the four times I’ve been through the place my “guide” has never failed to get me and my luggage on the right bus. Tucked away in my seat with my carry on with me and my big suitcase in the luggage boot under the bus I settle in as we pulled out heading east into the just rising sun for the 500 mile trip. I’ve got my Ipod, noise canceling headphones and even some leg room. The road is paved all the way and this is going to be a pleasant 10 or 11 hours. The bus had TV soda and bottled water on board and even a bathroom for limited use. (We still take pee breaks by the side of the road.) What the vehicle did not have was a fuel pump that was going to last the trip. I was seated in the front row next to Omari, who looked a lot like a taller, bigger version of Richard Pryor. His English was good so we exchanged pleasantries and then hunkered down for the ride. About four hours later we noticed the bus slowing down and the driver muttering to himself in Arabic. As we wheezed into the parking area of a roadside stop called the Aljezeera restaurant and bus stop it was obvious that we were going no further without some mechanical attention. The scene and terrain were so much like the movie “Babel” it was freaky except no one got shot. During the next three hours I finished a book, ate 6 skewers of roasted beef cubes, downed a Coke and 3 bottles of water and became increasingly agitated about not getting to Dar that night. The mechanic had been sent for but still had not arrived. After the 4th hour he finally showed up and confirmed what everyone already knew, the bus needed a fuel pump or at least a filter. In true African style he had not brought parts and declared that they would send to Aringa, 50 miles back and have one sent out. I calculated the time and figured if everything went on schedule, and why should it, we would be in Dar some time around 4 am. Enter Omari. It turned out that he is a big time business guy and president of the largest labor union in the country. He had made a call hours before and someone drove out from Dar to pick him up. He offered a ride to me and a couple whom he knew. We would be 3 people literally squashed into the back seat of a very small car. There was no room for all of our luggage. We found out that the luggage was inaccessible anyway because for safety reasons the luggage boots on the bus cannot be opened if the motor is not running and this motor was definitely not. It was time for a tough decision. Do I leave my large suitcase in the hands of the baggage gods or wait it out with the 50 or so souls camped out at the Aljezeera? I asked myself is there anything in that suitcase that justifies my sleeping on the cold hard floor of that place rather than in the bed of the deluxe room I reserved for myself at one of my three of four favorite hotels in the world. I’m outta there! We piled into this little cracker box, my carry on with my computer and cameras safely stowed behind me and my knees pressed into the seat in front. The young woman in the middle was pressed against me so that lateral shifting was impossible. It was like being trussed up so that all I could move was my elbows. The next problem was that the car had an exhaust leak so that no matter how we adjusted the windows fumes came into the back seat producing a headache that increased with each breath. Next of course was the music. Africans cannot stand quiet. They must have every nearby TV or radio turned up to full volume. If conversation is necessary it is shouted rather than turn down the music. Such was the ambiance of the trip. Last, I noticed that my seat mate did not say anything. I found out why when she answered her cell phone with a croak that could only mean severe laryngitis. Her subsequent cough confirmed the diagnosis. I was trapped in this position for 5 ½ hours and could have not designed a more perfect version of hell. The floor of the Aljezeera began to look sort of cozy. Pulling into Dar around 1 am we dropped off the plague ridden couple. Omari got off at his office and another guy got in to drive the car. I was feeling a little uneasy as we set out for my hotel. The driver made an illegal u-turn and we were stopped by two uniformed people carrying assault rifles. One came over to inspect me in the back seat and told me to keep quiet and everything would be all right. They proceeded to verbally work this guy over for a full 30 minutes. All the time I was thinking: Am I going to be one of those people who get in the middle of some African vendetta and get shot in a car? No, they let us go and around 1:30 I was finally safe in my hotel room enjoying a hot bath and a room service club sandwich while turning on my computer, getting on the internet and watching the Diamondbacks blow a 3 run lead in the ninth. Oh, the suitcase? I had written it off and it’s amazing how situations work out if you become detached from them. Early this morning I had the concierge call the bus company (I’d have done it myself but my Swahili still leaves a lot to be desired) and we were informed that the bus in question, now get this, was not expected at the garage until 3pm today. That means all those people were 21 hours overdue! Stuff like that just happens here. I had planned to go to the Kariakoo market today and the National Museum. I did both and they were great. I’ll talk about them in the final post. At 3pm I took a cab to the bus station and there it was, the big black ugly suitcase I had said goodbye to 24 hours earlier. Sometimes you just have to wonder. And by the way, there are no refunds if the bus breaks down. There’s lots more to talk about before I leave here but I’ll save it for after happy hour and dinner.
It’s hard to believe more than five weeks has passed and the time has come to tally up my cases and go home. Paradoxically the total time has gone by very quickly while the down time, and there has been more than a little, has seemed excruciatingly slow. I have experienced disturbing mood swings here ranging from exhilarated and commanding to feeling helpless and depressed. The dark side, I’m sure, stems from watching tragedy unfold under my gaze and being powerless. Idle time intensifies the frustration which lasts until the next triumph. Fortunately the triumphs have outnumbered the tragedies but by far less than I am used to in clinical practice at home. The highs have been many. The standouts are seeing the three year old girl eating normally for the first time in her life, the woman who nearly died from intestinal obstruction laughing with her family as I removed her stitches and the pretty young woman going about for the first time in years without a shawl to hide her horrible ear keloids. Then there are the open ended cases. What will happen to the nun who lost her lower leg to melanoma? How will the young woman with the malignancy on her toes be able to walk on a foot that looks like the middle of it was bitten off? Will the man with the huge lymphoma on his neck really get to Dar es Salaam for proper treatment? The biggest question of all is have the powers that be really listened to my pleas and suggestions to bring some order to this chaos? Or, has my presence here been like sticking my finger in a bowl of water. I can stir things up and make lots of waves but when the finger is gone it’s as though nothing happened. I believe something will stick. I feel emotionally tied to this place though if you saw it you would certainly wonder why. The people have gotten under my skin and I think I have finally started to really understand who they are and how they think. Believe me when I say that there is not much in our American experience to help me relate. Being here, now for a total of ten weeks and finally being able to settle into the indigenous pace and mindset has left me connected in a way that is not always pleasurable but certainly challenging and, I believe, irrevocable. East Africa is now part of my being. The night before I left Sumbawanga I was invited to the home of Daniel Njoolay,the Regional Administrator (Governor) for dinner. You remember that I entertained him and his wife a couple of weeks ago. This time it was him, me and Jasper sitting around his dining room table seriously discussing hospital problems and what to do about them. Jasper, unaccustomed to such meetings was sure he would lose his job over this. In Africa frankness is not common in such conversations. Circumlocution leading nowhere is the norm and that’s why so little gets done. Because of his education in Canada Daniel understands my style which is polite and certainly not blunt but gets to the heart of matters fairly quickly. I made my points carefully, surrounding each with background facts that locked it into an inescapable discussion pattern. Daniel was very frank with me explaining where the bureaucratic resistance to change is and what are the extents and limits of his own power. By the time we were half way through the second bottle of wine Jasper was giving a pretty good account of himself. He is the senior and best trained physician in town and has the respect of everyone including the politicians. We went on for over four hours and in the end had formulated a restructuring plan. We determined that the reason for a lot of the shortcomings at the hospital is that no one is running it. The regional medical director who is responsible for all of Rukwa has his office in the hospital and he is the de facto administrator but does not function in that capacity. Daniel has decided to move him out of the hospital into the regional government office building where he belongs and replace him at the hospital with a real administrator. I suggested he get a newly minted health care MBA out of Dar or Nairobi to come in there and kick some butt and make a name for himself. I must, of course follow up this meeting with a report and I’m happy to do it because I finally feel that I have done more here than just care for one patient at a time. Back at the hotel I packed my stuff and prepared for my morning departure. You’re already familiar with the details of my trip so we’ll skip to today. The National Museum in Dar es Salaam is no Smithsonian. Located near the waterfront about four blocks from my hotel it is a smallish building with displays in two parts. The first is an interesting somewhat sanitized version of the country’s history before and since independence in 1967. It is mostly pictures of revered but outside Tanzania, obscure individuals who played some part of the “bloodless revolution” Looking at it closely though one gets a sense of the intensity and fervor that was involved and still lingers in the minds of Tanzanians. Forty years is a short time for nationhood and the pride is still there. The second section is the anthropological history of the country. Because of the great geological rift that runs through it Tanzania is a great repository for fossil evidence. Someone very knowledgeable has taken very great care to reconstruct and illustrate the fossil record of humankind creating a remarkable journey through our evolution that is truly worth seeing. All in all the museum, though lame in parts, gets pretty fair marks for giving the visitor some idea of what this country is about. Then I went off to the Kariakoo market. This is one of those places where the guidebooks and travel mavens tell you to stay away from. There are pickpockets, thieves, murderers and perhaps even worse just lurking there waiting for the unwitting visitor. As my 10th grade English teacher used to say, Balderdash!! The market is a huge place built like a square stadium, Inside are hundreds of stalls each, apparently, its own individual business. It’s sort of an impoverished version of the Reading Terminal in Philadelphia or Pike Place Market in Seattle. What interested me is what they sell. In a city of nearly three million people who have access to cell phones, satellite TV and all of the associated hype what would you expect to find in a central market, electronic toys, gadgets and such? There are some but not much. Most of this building is dedicated to simple farm implements, seeds, fertilizers and garden tools. There are multiple stalls selling sewing machines, some of which are Chinese knock-offs of the ancient foot treadle Singer that my grandmother used. They sell for about 100 bucks as do the best of the Chinese bicycles. Almost all of the merchandise here is dedicated to people making their living. The place was packed and I met some of the nicest people there. I was the only white person not only in the market but in the whole neighborhood so my presence did not go unnoticed. Parking myself on the corner of a balcony I was able to get some great candid pictures and walking among the crowd people were only too glad to pose. My only detractor was a local Imam who accused me of stealing peoples’ souls with my camera. I assured him that out of respect I do not take pictures of Muslims without permission and if I have stolen any Christian or heathen souls I promised to take very good care of them. He actually laughed and was satisfied with that. The lesson of the market is that these people are hard working and, so far, basically uncorrupted by the “I wants”. Families come to the market to buy the things they need to sustain their lives and one can see on their faces the joy of the shared experience. Maybe it’s a good thing that the guide books steer people away from the place. They really don’t need us there. Then it was time to reclaim my suitcase and head back for the hotel. Happy hour was fun. I met some nice people here for an international financial conference. Dinner was, to use an old fashioned term, splendid. I’ll not go into details. Back in my room I finish this piece, make final preparations for my flight to join Marcia and Ara in Paris. It is our wedding anniversary and his birthday on Wednesday and we plan to celebrate. So the Africa 2008 adventure is over. I know it has changed me in ways that will emerge slowly over the coming months. Of course I’m already planning when and how I will return and which of the many people I’ve met that I will continue to contact. When one’s world expands there is no stuffing it back into the old container. You just have to try to keep a handle on it and go where it takes you. If you’ve been a fan of this blog thanks for reading. Go out and have your own adventure. I’ll be glad to read about it. Watch for a pictorial review on this site after I have had a chance to review and edit my photos. Tutaonana (until next time – Swahili) Skip Apply now
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Trip Report - Dr. Samuel Feinstein - May-July, 2008:
I'm returning to lead a surgical team in western Tanzania this summer. I'll be using this blog to keep in touch so if you want to keep up with my craziness go to the site and I'll do my best to paint an accurate picture. Now it's just four weeks to go. My trip back to Tanzania is motivated somewhat differently than last year. Then it was about fascination with the unknown, the chance to do some remarkable photography and the probability that I would be able to do some good. Now the unknown part is over - I know what to expect and am much better prepared mentally for the arduous journey with its strange sights and smells. I also know how to find accommodations in transit that provide enough security to let me close my eyes and survive the night.. The photography part has narrowed. Instead of trying to paint a hodge-podge panorama with my camera my focus will be limited. I've been given an assignment by Emirates Airline, which is sponsoring my trip, to do a piece on the children of Africa. That's still a huge subject but having been there I know where the stories are and intend to capture them. The medical part, however, has taken front position. When I left Sumbawanga and it's large, under-supplied hospital last summer I was devastated by my inability to provide even the simplest care that could have been lifesaving. Severe burns and serious infections went untreated or inadequately managed simply because the means to treat them were not there. I performed major surgery using only the barest of essential equipment and got surprisingly good but not acceptable (to me) results. I am taking a good supply of sutures and other equipment, as well as some medications with me and have been successful in getting others to donate items. However, I have no illusions about being able to solve all the problems. My focus this trip will be to provide training for the many people who, thought barely educated, make up the bulk of the hospital staff and provide care on a daily basis. This will not be easy. They are a proud group and jealously guard their positions. However, as a returning physician and not a one-time interloper, I believe I will have their trust. The main challenge right now is to get ready physically. A dumb skiing accident in March resulted in complicated shoulder surgery April 1. With intensive physical therapy the goal is to get the shoulder at least pain free if not fully functional by the time I have to leave. I'm working hard at it and it's not fun. Other tasks include stuffing as much equipment as possible into a duffel bag, getting politicians in Tanzania to grease the customs wheels for me so I don't get hung up on my way in and contacting the doctors and other personnel with whom I will be working. There's lots to do. Stay tuned.
The time to departure is beginning to move quickly. I've been in touch with the people in Tanzania which in itself is not an easy process. Without making judgments I can report that the culture of East Africa is not really amenable to modern technology. Broadband web access is surprisingly available and relatively low cost computers are becoming ubiquitous in developed areas. In spite of that there is a cultural disconnect when it comes to reliably checking and answering email. The easy going, laid back lifestyle simply refuses to generate the sense of urgency necessary for instant communication to work. Though that is probably a good thing for them it poses some challenges for me. After some phone calls to Sumbawanga I managed to confirm that my presence there is anticipated. I continue to accumulate supplies. The Ethicon corporation, a subsidiary of Johnson and Johnson, filled an order for sutures that are unavailable in Africa. The $4000 order was custom assembled for free. Kudos to them. Now I have to get it there. Fortunately I can ship some of it to one of our team members to hand- carry. I cannot ship anything. Even if it got there unmolested it would take weeks to negotiate it out of customs. I also have an assortment of disposable surgical staplers donated by the Autosuture company. These, also worth thousands, will need to be hand carried. Using such devices advances the level of intestinal surgery by 75 years. Meanwhile I am faithfully attending my physical therapy sessions 3 times a week and working the shoulder at home. It won't be fully functional by the time I leave but if the present level of progress continues I should be able to do what needs to be done with minimal discomfort. Now it's about paying attention to the details of being away for 6 weeks. Getting bills paid, arranging home maintenance, arranging coverage for business obligations, assembling a meager travel wardrobe and a generous photographic toolbox, updating immunizations and the list just goes on. Yeah, I am beginning to get excited about this.
It's been a hectic week. For a while it seems like there is all the time in the world and suddenly everything is a rush. First I found that a cache of surgical instruments that I had been squirreling away in the garage went missing. A desperate two day scramble ensued producing almost more (better too) stuff than I can carry. People and institutions have been so generous. The next challenge will be getting a 70 lb. extra suitcase past airline officials. I'll let you know how that goes. The details are endless. Hotel reservations en route, bus reservations. Yes you need a reservation to go from Mbeya to Sumbawanga. Otherwise you may get to share a seat with a chicken or goat. I did that last year and the chicken was fascinated with my camera strap, pecking at it and occasionally missing and leaving dimples in my shoulder. Packing has not been easy. One suitcase for me and two full of medical equipment. My carry one has all photography equipment and a little space for personal items and that's it. Fortunately my wardrobe is tee shirts, scrubs, jeans and a few things to keep warm. The expected weather there at 6000 feet 200 miles below the equator is 70s in the daytime and 40s at night. I've been in contact with the doctors in Sumbawanga and they tell me they are gathering surgical cases from the entire district. The equipment I'm bringing will make a big difference, bringing them forward a half century in capability. I can hardly wait to see everyone's faces when we start unwrapping it all. So, now is the time to finish last minute packing, get some rest and get ready to set out. Are we ever completely ready for a trip like this? Probably not but that's part of the adventure.
The trip to Sumbawanga, which, for reasons I will explain, expanded from four to five days. The first leg was ma red-eye from Phoenix to JFK. It’s amazing how many people fly in the middle of the night. Used to be you could get some sleep on those flights but no more. Oversold. US Airways was very gracious allowing me to check the extra 110 pounds or so of medical equipment for free. So there I was with four pieces of luggage weighing more than I do taking the Airtrain between terminals that could not be farther apart. Arriving at the Emirates counter I had an hour wait for the flight to Dubai to open. Very interesting people fly Emirates. While waiting I met a real live sheik, a lady in a burka who had no compunction about telling me her whole life story and a man who owns, no kidding, an internet porn shop who does business by some subterfuge in the middle east. Emirates, too, allowed the overweight and over-number baggage for free. And what an airline it is. Emirates ranks right up there with the best along with Singapore and others like it. Even though I couldn’t wrangle an upgrade the seating, service and food were as good as any first class service I’ve had on domestic airlines. This was true for the connecting flight to Dar es Salaam making this portion of the trip pleasurable. This was good because total flight time from Phoenix to Dar with layovers was 29 hours. I was met at the airport in Dar by a charming lady from Paraguay named Carolina. As a Healthcare Volunteer, her job was to get me through Dar and on to the bus the following day. I had her take me to a hotel at the O’Willie’s Irish Pub on the ocean. I remember having the best shepherds’ pie ever at that place and I wanted it again. I was not disappointed and the hotel there was passable for one night. At 5 in the morning my stuff was loaded into a cab by 2 guys in full Massai dress and I was off to the bus station. The human mind has a merciful component that allows it to forget pain. For this reason I had put out of my memory just how unpleasant 2 days on an African bus can be. Though it looks small on the map of Africa, Tanzania is actually bigger than France. I took what I thought was an express to Mbeya, a distance of about 500 miles. Here "express" means they sell you a specific seat. After that all bets are off. Stopping at every town and village to take on or discharge passengers the bus is often packed with people in the aisles hanging over the seats and giving one a very cramped feeling. Still, I was able to read some and sleep. Thirteen hours later the bus pulled into a dark, dusty bus station in Mbeya. Thjs was the good leg of the trip. I had decided to stay there an extra day, partly because I had some things I wanted to do and also because I wasn’t going to endure 2 days in a row on the bus. Last year, not knowing that Mbeya is a fairly large, cosmopolitan city, I stayed overnight at a murky inn near the bus station that had all of the charm of a Turkish prison. (Think Midnight Express.) I was scared to death and got out of their fast in the morning. On the way home, by private transportation, I got to see the city and stayed in a fairly nice place called the Golden City. It’s a hotel that caters to wealthy Muslims and is clean and safe with beautiful sculptured gardens in front. The interior is done completely, walls and floors, in shiny white tile. Alcohol is not served in the restaurant so if you want beer with your saffron flavored beef and rice you are relegated to the bar. A small, comfortable room with internet service and decent food for $25/night, what more could you ask? My reasons for staying an extra day were to re-visit the hospital there to see an American acquaintance working in an AIDS project there and to seek out an orphanage I had visited to find a very special child. Those of you who have been to our home know that I have been displaying a photo of an adorable 3 year old that I happened on last year. In the photo she is wearing her Sunday best red dress and throwing a killer smile. I wanted to see and photograph her again but I did not know the name of the orphanage or where it was. I went one for two. My Dr. friend had returned to the states so no contact there. When a foreign doctor shows up at a hospital he is treated with great respect and introduced all around. Among the people I met was the director of social services for the area and, from my description, he was able to tell me exactly where the orphanage was. I had hired a driver for the day and we immediately set out and found it with no trouble. The place was almost deserted with a Massai guard and a badly crippled woman overseeing the place. They told us most of the children were gone on some sort of holiday but we were welcome to look around. I talked to and photographed 3 small boys who told me there were no girls there. Disappointed, I wandered over to the grove of trees where I had seen the little girl last year and unbelievably she emerged with a companion. Her name is Priska. She has grown in a year. She was in dirty play clothes but the face was unmistakable. She immediately started laughing and flashing that smile and I had what I came for. Then off she and her companion ran laughing into the woods. I must have some kind of karma going on with this child. Don’t worry though, it is not permitted to adopt out of Tanzania.
In the last post I mentioned hiring a driver. That deserves some explanation. When a European appearing person (read: white) gets off a bus in a place like Mbeya there is a particular kind of person waiting. It is an ambitious local young man, who is nicely dressed, unintimidated and speaks reasonable English. He smells money. My fellow was named Charles and he immediately offered taxi service to my hotel. Since he had a driver of his own I was grateful for 2 sets of arms to haul the load. Remember, I’m still nursing a shoulder that is about half capacity. By the time we reached the hotel he had ascertained that I would be there all the next day and checking out the day after that. After hearing about my plans to visit the hospital and orphanage as well as a few errands he offered to be my guide with his driver. We negotiated a price that, for me needing assistance in a strange city was a bargain and for him a windfall. Promptly at nine they picked me up and we set out on a successful day. About 2 in the afternoon the missions were accomplished and he suggested I see a local attraction called the Bridge of Gold. (at a small additional fee, of course.)We drove for about an hour to a place that was absolutely breathtaking. A series of small waterfalls flowed under the largest and most beautiful natural bridge I had ever seen. It glowed golden through the mist in the late afternoon sun and I was in photo heaven. Just down the river was a huge waterfall accessible from the top but not the bottom. What a treasure I gained because I was willing to trust these 2 guys. Why? After all, they could have taken me our there, robbed me and left me in a ditch or worse. First, he had given me a receipt with his name, phone number and vehicle number after the first ride from the bus stop. Second, he seemed like a good person and I’m rarely wrong about people going on gut feelings. Third, I’m in Tanzania and crime is almost unknown here away from the big cities. You wouldn’t use someone without a reference in Kenya or South Africa. At 5am just the driver came to convey me back to the bus station. After he deposited me with my luggage near the bus I noted that the small canvas travel bag I was carrying was gone. It contained some reading material, food, water and the small digital camera I was carrying as a backup. I was upset, realized there was nothing I could do and went into damage control mode. Then I looked up and saw the car reappear in the emerging dawn. The driver got out, came over to me holding the missing bag. Wow, talk about vindicating trust. I was extremely grateful and let him know it. Shortly after Charles showed up and made sure my luggage and I got on the same bus together which, considering the confusion of thirty or so busses loading in the semi-dark, was not a done deal. Anyone going to Mbeya let me know. I’ll give you his number. The day was downhill from there. The bus was old, crowded and noisy. Would you enjoy loud, bad hip-hop in Swahili for 7 hours? The bus was configured 3 and 2 across. I was number 3 on the isle sandwiched between two very fat women and the armrest which prevented their sheer bulk from displacing me out into the aisle. I have a bruise on the left side of my abdomen from the pressure. There were no animals this time but I think I would have preferred the chicken from last year. The road was still unpaved, bumpy and full of holes but not as bad as last year at the end of the rainy season. We only had to get out of the bus once at a road washout to allow it to cross a makeshift repair. When I arrived in Sumbawanga somewhat the worse for wear, a cab was waiting for me and the driver deposited me and my baggage there. I was finally rid of the burden. I felt like Henry Knox bringing the cannons over the mountains to General Washington from Fort Ticonderoga. (if you don't know that story look it up. It's a good one.) I was off then to settle in at the Forest Way Country Club and (thankfully) Bar.
Specifically: The afternoon of my arrival day was spent unpacking and setting up my room/office to my liking. The Forest Way is a comfortable place consisting of 5 guest rooms, a restaurant and a bar. I take all my meals here. Breakfast is included and its the usual eggs a samoza (small, triangular deep fried meat pie) toast and coffee. Dinners are decent but variety is limited. Several kinds of tough local steak, spaghetti Bolognese (best thing on the menu) and chicken (often the one that woke me up that morning) are offered. The fish is inedible. Not much fiber and of course it is not a good idea to eat raw produce. They do cook up a mash of spinach, cucumbers and beans that is actually quite good. All cooking is done over open charcoal braziers. Unfortunately there is no longer internet service here as the owner is away for medical treatment so all communication is being done in town. More about that later. Since last year a new cell phone tower has been built nearby so that service is excellent. The town center and hospital are about a 30 minute walk over a dusty dirt road followed by a paved street lined with shops. Though I have a driver at my disposal I have resolved to walk at least one way each day lest I come home looking like a bowling pin with legs.. Only two streets in town are paved but I'm told that is about to change. Right! Remember, this is a town of about 25,000 people with a surrounding population of 250,000 more in scattered villages over an area about the size of Los Angeles county. It is located in a region (corresponding to our states) called Rukwa which is huge. Unfortunately, Rukwa is treated as an afterthought by the government and is badly underserved in every way. It is far from the center of power in Dar es Salaam and produces none of the tourist income of the northern regions nor does Rukwa produce much of anything for export. The economy here is mostly subsistence farming and produce for local trade and from what I can see the locals to a good job of it. The lack of economic output means that there is no paved highway in or out and social services, though the infrastructure is here, gets woefully inadequate funding. Add that to the usual level of corruption and the people do not get much. The road problem turns into a chicken and egg situation: There is no progress because there is no road and there is no road because there is no progress. Watching TV I see endless meetings of government organizations endlessly discussing this problem or that but little gets done. To their credit the Tanzanians have an open democracy. Every meeting of Parliament is televised and they even kicked out their prime minister earlier this year after a corruption scandal. It seems he was in cahoots with a corporation that was supposed to be buying electricity for resale. They borrowed the money, didn't buy the power in the way promised, managed to corner the market and drive up prices and everyone got screwed. Sound familiar? The methods of Enron were not lost on them. The consequences were. Speaking of electricity, I'm experiencing many more outages than last time. The power goes down for short periods several times a day. It is very disruptive. While at the intenet cafe yesterday posting to the blog I had to start over twice. What should have taken 10 minutes took an hour an a half. Power to Rukwa is obtained from neighboring Zambia and is supposedly pretty good but the distribution of it here is not adequate. All this is the result of lack of government attention and incompetent private enterprise. The internet cafe is a very iffy proposition. There are 5 ancient Compaq desktops working off a very cranky pirated Windows 2000 operating system. The network varies from very slow to passable depending on traffic. It is subject to the same power outages. They have surge supressors but no backup power so when it goes down you just sit and wait. I had originally planned to offer links in this blog to pertinent sites but limited time for posting does not permit. I'd rather use the time to put in pictures. I needed to do a little shopping at the town market where I found out that (a) mens underwear is hard to find and (b) they never heard of a sweatshirt both of which items I was seeking. After wandering through hundreds of stalls periodically lowering my belt to reveal the top of my Jockeys I managed to score 2 pair of semi-bikinis with no fly. I will not be bringing these home but they will do for now. No sweatshirt appeared so I bought a bizarre looking long sleeve tee shirt and a vest. Hey, it's cold here at night - down into the 40's. Walking by the food stalls a guy tempted me with a beautiful potato omelet that I washed down with a coke. Street food.....yeah
My student arrived from Oregon yesterday bringing the duffel bag full of donated suture material that I had shipped to her. The bag was almost bigger than she was and we shared the burden of dragging it down to the hospital this morning. Her name is Catherine. She is well educated and bright, seeming quiet and reserved at first. We were just sort of getting acquainted when she got into it with Piet over dinner. Not only did she hold her own but was able to back him down several times. Go girl! After that I knew I had a keeper on my hands. Having never been in surgery before she showed an ability to instinctively follow along, anticipating events enough to actually be quite helpful. Catherine also knows a bit of Swahili which is making my life eaiser. She happened along in time to share one of the most stressful and bizzare days of surgery that I have ever had. Hospital_edit The day started simply enough, four or five patients referred for "the Professor's" opinion. (I love that - makes me feel like one of those old time European guys). We scheduled some resonable cases for the next few days and then went off to do the first of two scheduled for today. The first was an 80 year old man with a large mass attached to one testicle. It was not possible to determine pre operatively if it was benign or malignant but it was hurting him. Given the option of living without the pain and one testicle he enthusiastically chose the surgery. The anesthetist gave a super smooth spinal and the surgery went off without a hitch - almost. Near the end of the case our overhead surgical light died. It wasn't a big deal because the room was well lit from other sources and we were working at skin level when it happened. The next case was to start soon after but without the light - no way. Four hours later we finally got our light working and began the case around two thirty in the afternoon. This was a 24 year old male patient who had evidently been suffering with a partial intestinal obstruction for four years. He was almost emaciated looking with a hugely distended abdomen - not unlike the pictures you see of starving children. But this abdomen was filled with blocked gas in the intestine. Lacking any facilities for making an accurate anatomical diagnosis and going on history and physical examination and a poor quality abdominal x-ray we opened tha abdomen to find not the three foot large intestine dilated as I had expected but rather the entire 20 feet of small intestine. Normally the diameter of an ordinary household candle, these loops were the size of dryer vents, Once out of the abdomen there was no way they were going back until they were decompressed. The obstruction turned out to be a twisted loop that had been ignored for four years with the patient having spent the last month in the hospital undiagnosed. This is unacceptable by any standard. Emptying the small bowel is a difficult, dangerous process the details of which I will spare you. Midway through this process all lights in the OR went out leaving us with the window light of early dusk. We then found out that the person responsible for turning on the generator in such instances was nowhere to be found. No flashlights were available. We continued until most of the fluid and gas had been removed and then closed the intestine. Fortunately I had brought a modern bowel stapling device with me so I didn't have to waste a lot of time sewing it. We were rapidly heading toward darkness. There was one more thing that had to be attended to and that was placing a drain tube in the stomach. Otherwise the gas could re-accumulate before the intestine regained its function. The easiest way to do that is to pass a tube into the patient's nose and down to the stomach and tape it in place. These tubes cost about a buck and a half and are standard equipment in every OR and ward. Not here. The anesthesiologist seriously suggested that we send a family member out to a medical supply place to buy one. I declined and went for the other approach - a tube directly through the abdominal wall into the stomach using a baloon urinary catheter that was available. The problem now was that I could barely see under the incision to place the tube into the stomach and suture it securely. It was only because I have done this maneuver hundreds of times that I was able to pull it off, practically by Braille, without spilling stomach contents all over the abdomen which would have been a disaster. I quickly closed the deep layers of the abdomen and then in near darkness my assistant closed the skin while I fixed the stomach tube in place. Elapsed time - two and one half hours. The whole thing should have taken less than an hour and been finished before lunch. The sad part is that I don't have any of the fluids or equipment to provide the concentrated intravenous nutrition that his patient needs and he could just starve to death before he regains intestinal function. Catherine asked me what the patient's chances were and I told her at home you could count on him walking out of the hospital. Here and now the chances are under twenty five percent. This one case points up so much of what's wrong here. The equipment problem has gotten worse. Things like NG tubes , suction equipment and functioning, reliable lights should be available. They don't cost that much but nobody cares enough to see that they are on hand. It's easy to blame the administrative personnel but I accuse the doctors. The same physicians who let this boy languish with an obstruction all that time can't get it together to make sure they have basic equipment. There is one cardiogram machine in the hospital and it is in the office of the physician/administrator who never sees a patient. The excuse you hear over and over is "Well, this is Africa. Things will get better poli-poli (little by little.)" Well, people, poli-poli isn't cutting it. I've been away from here over a year and from what I see things have gotten worse. They've gone from an occasional power outage to four or five a day with no improvement or even deterioration of back-up capacity. The conditions in the wards are dreadful. Most even lack a place to wash your hands. Some improvement is noted in the availbility of pharmaceuticals but most of this is through donations. The medical record system is atrocious with almost no ability to trace a patient's history. Pathology services are non existant and lab and xray are rudimentary when available at all. They have allocated a fortune to build a new surgical unit which will be beautiful but how can they use it when they lack the ability to supply the unit they already have? When built it will be a showplace to display to visitng dignitaries who have no idea that it is an empty shell providing the same crappy care as the old one. OK, enough ranting for one post. What's my role in all of this? For now I'll just continue trying to provide for one patient at a time as best I can. But before I leave I'm going to make sure someone high up who just may care knows exactly what I've seen and how I feel. Maybe that someone will get that it doesn't have to be this way.
Today, Saturday, has been interesting. Originally we were not going to work but attain because of electricity problems we did not complete yesterday and had to carry one case over. Yesterday I had to take the boy with the bowel obstruction back for a second look when we completed the first operation in the dark there were some things I was unable to verify. Had I waited for any missed problems to show themselves his nutritional status would have deteriorated to the point where it would have been impossible to correct anything. So I decided to take another look and fortunately found everything in order and today he continues to do rather well despite the second operation and the scant resources to manage him. We arrived at the hospital after breakfast intending to start our case which was an 80 year old man with a huge combination hernia and hydrocele. We found one of the staff surgeons about to begin a procedure to correct abdominal adhesions from a past appendectomy that were causing pain. This was a private case on a woman who appeared well-to-do judging by the appearance of family members who were waiting around. I volunteered to scrub in. The case was exactly as expected. Surgeons reading this will understand completely. For everyone else I will say only that in the States we used to call these procedures B--- S--- laparotomies. We then got my guy on the table and wouldn’t you know it, just after we started the lights went out. Now last night, after Piet (That is the way he spells his name) heard my horror story from the other day he went out to his truck and presented me with a small halogen headlamp that he sometimes uses when he works at night. "You need this more than I do" he said while I took it from hom gratefully. Sure enough I did nearly the whole case with it today and the procedure went flawlessly. Working with the junior surgeon (the adhesions guy) on my case too I managed to show him a better way to close skin and also new bandaging techniques. He seemed happy with it and everyone left the OR in good humor. Unless there is an emergency that will do it for this week. Tomorrow, Sunday, I plan to take my camera around and catch pictures of children in their Sunday best. OH, and also I met a woman from a town about an hour from here who has come from Germany to start an orphanage. She had come into the internet café. Catherine and I are planning to visit her next weekend for an interview and a photo session. We’ll probably get out to Lake Tanganyika while we’re at it. Also, two medical students from Sweden are scheduled to show up some time next week. So the routine is going to change considerably
In the last post I mentioned that Sunday was to be a reflective day of reading, writing and photography. Well, it didn’t turn out quite that way. The morning was as planned with hospital rounds going well and by 11 I was able to check email at the internet café. Then I began the long trudge of about 2 miles back to the hotel, which is uphill, stopping to take pictures of children and families as I went. Just as I reached the hotel a hospital Landcruiser with a driver and Catherine in it blew up a cloud of dust as it stopped in front of me on the dusty dirt road. I was needed at the hospital and would I please get in the truck. OK, back down the hill to see a patient suspected of needing urgent surgery. No, she didn’t but it’s a good thing they asked me to check. The nurse in charge of that particular ward is one of the few who speaks fluent English so she charmed me into seeing 2 other patients that, though they have interesting problems, were not going to get the troops out on a Sunday. All this consumed about 2 hours and we found the driver to take us back up the hill. Arriving home I ran smack into my friend Godfrey. He is a young physician who, for the last 2 ½ years has been in charge of the other hospital in Sumbawanga. Sent there by the government after his internship his task was to modernize an old facility originally built by the Catholic Church ands raise the level of care. He has done a marvelous job of it and is now leaving to take a residency in Pediatrics. He is the leader of the group of young physicians practicing in the area, some of whom I met last year. They had flattered me then by asking my advice and now, as soon as they heard I was back in town, convened a meeting last night during which I heard all their complaints of insufficient supplies and equipment and other government inadequacies. The message I gave them was the same as last time. They need to be involved and exert their influence. As physicians they will not change the system. That will be left to others. What they must do is change the priorities of the system in regard to medical care. They can do that by making themselves heard collectively at all levels. Each will have to put aside a little bit of his personal quest to see to the common good. They do have a hard road ahead. I wished Godfrey well in his new position and his upcoming marriage and plan to keep in touch with him. He is a gifted leader who can go a long way. By now it was after four and I figured I could still get some writing and reading time in before dinner. Entering my space I was greeted by the sound of hundreds of bees flying around the room with unknown intentions. I backed out quickly and closed the door, scurrying off to find the person in charge for the day. As I sputtered out my story he said, "Oh, the bees are back." "Back," I said. "Do they come often?" "No, just once or twice a year" he replied. With that he casually strolled down to my room with a can of "Red Cans Kill All Insects" and commenced spraying this into the air. Now I don’t know what’s in that stuff but the bees literally dropped out of the air – at least 500 of them – and died a rapid torturous death on the floor. Another fellow came along with a broom and dustpan to dispose of the remains leaving my room a lethal gas chamber. Hoping the rest of the swarm had passed I opened the windows, locked the door and left. That was four hours ago and now, after having disposed of a few residual bees myself, I think the room is safe to sleep in. Let’s hope so.
I mentioned in a previous post that Sumbawanga is located in the southwest portion of Tanzania near the borders of Zambia and Congo. I talked about the population numbers and all that but I have never really described the city itself. The first word that comes to mind is dusty. There are only two paved streets in town and auto traffic over the dirt roads raises a continuous cloud of fine, brownish red dust that settles everywhere. Where the paved streets intersect in a "t" is the only building downtown that looks even vaguely modern and houses the elite businesses of the town. On both sides of any street are three foot open ditches, sometimes covered by slatted decking to accommodate pedestrians crossing. These ditches, thankfully, no longer convey sewage as modern septic tanks have arrived. They serve as runoff canals during the rainy season lest the whole place gets flooded. In the dry season there is no water in them and the population considers it perfectly natural to toss whatever trash they may he holding into them knowing that when the rains come the refuse will be washed away. The concept of avoiding littering is unknown. I have never seen a public trash receptacle. OK, with that unpleasantness out of the way let’s talk about the good stuff. There is a special energy here. Everyone is hustling something. There are throngs of people everywhere fixing bicycles, making furniture, repairing cars, driving taxis, selling fruit running small shops and engaging in all the kinds of familiar commerce and some we probably don’t want to know about. All of this is occurring in buildings that look like they were built yesterday out of scrap bricks, wood and tarpaper and covered with a corrugated tin roof. The surroundings may appear squalid but the attitude is beautiful. Most people are decently dressed, some strikingly with women in beautiful native designs and men in worn but serviceable western clothes. They go about their business cheerfully greeting each and when they see me they smile effusively testing out their English while I try to answer with my nascent Swahili. Everyone seems to be trying to make something happen. Most have cell phones and delight in using them. Entrepreneurs carry some of the most creative business cards I’ve ever seen and most shops offer several separate types of goods and services. There are a few nice neighborhoods,of course, with houses built in the Euopean style. These belong to local politicians and business pople but the average living conditions are simple and primitive. All in all this is not an especially attractive place. The only tourists I’ve seen are a few South Africans on their way to Zambia. It is a far cry, however, from the cliché of a stagnant third world mud hole. Cars are everywhere. They are mostly 80’s and 90’s vintage Japanese, mostly Toyota. I have not seen an American made vehicle anywhere in Tanzania and rarely see a European one. These are all four cylinder jobs with full sedan bodies. The most remarkable thing is that they are all immaculate. Whether a taxi or private car they are always clean and polished, rarely dented and recently reupholstered with pristine if sometimes garish leather. I have not seen one junked vehicle anywhere in town. There are a lot of motorcycles, mostly dirt bikes and a very strict helmet law. And everywhere there are bicycles, the chief transportation of the masses. Bikes here are very inexpensive, imported from China by the hundreds of thousands. Walking around town one might ask if this town is coming or going. It’s a good question and the answer is not at all obvious or certain. Rukwa province is the stepchild of the government. Being a region of subsistence farming and small local markets there is nothing here for export. There are no other saleable resources other than good year round weather. Unfortunately the way things are is that the region that does not contribute much to the economy gets largely ignored. Even electricity is unreliable as we spend at least a portion of each day without power and have just ended an 18 hour outage. Water is plentiful but there is not a purification system worth the name so all consumed water is boiled or bottled. Whether the city is coming or going in terms of development depends almost entirely on transportation. Sumbawanga remains a very wide spot on a very bad road. From Mbeya 90 miles to the south to Mpanda 150 miles to the north the only road is a rutted, potholed, often flooded and impassable mess. Everything and everybody moving in or out of Sumbawanga uses this road. The government has been promising to pave it for years but nothing seems to happen. This may be the year however. The new Prime Minister of the country is from this area. His name is Mpinda and I had the opportunity to meet and photograph him several times last year as his previous duties brought him through town and he stayed at Forest Way. My personal feeling is that when that road is completed this area will soar. The potential for manufacturing and organized farming is tremendous. Lake Tanganyika 40 miles to the west is one of the most beautiful places on earth and is located near spectacular waterfalls and almost untouched wildlife preserves. Tourism there could be as important there as it is in the North Country around the Serengeti. It all depends on that road. After that the investment will come and Sumbawanga could become one of the most important cities in south central Africa.
The key to my effectiveness here in Tanzania is Dr. Jasper Nduosindi. He is the senior of four or five physicians assigned by the government to staff Rukwa Regional Hospital. It is a daunting task particularly as one or more of the junior docs seems to be away at a meeting most of the time. I have not been impressed with any of them except Jasper. He has had surgical training, how much I’m not sure. Nevertheless, he has been responsible for all surgery, crossing all specialty lines, for several years. He does it all, OBGYN, urology, orthopedics and general surgery. As I’ve indicated, he has very little to work with in terms of equipment and supplies. There are almost no x-ray or laboratory diagnostic methods available. His diagnoses are always strictly clinical, arrived at by physical examination supported by experience. He must act on them every day knowing that he might be wrong. Under these circumstances the most important things he needs to avoid are exceeding his limits and getting into situations where he runs out of options. Jasper is a bright guy. He attends postgraduate seminars often in Nairobi or Dar. He can put little new knowledge to use here because of equipment limitations. WE sit for hours sometimes talking surgery and as I describe the developments of the last 20 years he is incredulous. I brought intestinal stapling devices with me. Although they have been in use in the US for 40 years he had never heard of them. I can show him how to use them and leave my stock. It will be up to him to cajole the government into getting him some more. I’m not real hopeful about that. We have a neat relationship. Going about the day with him I get to help set bones, treat malaria and do other things that I’ve either never done or long forgotten. He gets to assist me in surgery doing the things that I know well thereby upgrading his own technique and decision making. Where Jasper is rapidly becoming a formidable expert is in the area of repairing fistulas caused by obstetrical damage which is a huge problem here. Each year he works with a dedicated team from Nairobi that comes for two weeks to work and teach. He’s getting really good at it and may be forming a team of his own. Doing medicine for the government doesn’t pay much here – perhaps ten to twelve thousand dollars a year. The good news is that things are very inexpensive here outside Dar and the northern tourist areas. Jasper has managed to raise a beautiful family and acquire a few houses and a sizable piece of ranch property not far from town. His wife is currently away working on a nursing administration degree in Dar. He sees himself getting out of government medicine before too long and settling down as a gentleman rancher and perhaps running a small private clinic somewhere. Those are positions in life that he will have rightfuly earned
Lots has happened since my last post. When one begins to become involved in a place events seem to pile up on one another. I’ll just start writing and see how it comes out. For openers let’s catch up on the hospital. We’ve been doing a lot of surgery. "We" means the little team I’ve put together and not me being full of myself. Some cases have been routine and others have been extraordinary. The routine ones have been hernias, hydroceles, various GYN cases, rectal problems and such. All have done well and it almost seems like home. The weird stuff that one would only see in a place like this makes the trip really interesting. For instance: Take a look at the before and afters of this 22 year old girl who went through some ritual mutilation of her earlobes and developed keloids (out of control scars) that are the size of small oranges. Even if you’ve got a large plastic surgery practice in the states chances are you will never get to treat anything like this. Operating these was a fascinating 2 ½ hours of seat-of-the-pants decision making about skin flaps, reconstruction, etc with the goal being to come out with something resembling an ear. Also this week we have a local nun who ignored my advice last year to have her localized melanoma removed from her foot and now requires a below the knee amputation. Another one in line is a stunningly beautiful young woman who needs the middle three toes of her foot amputated because of sarcoma (soft tissue malignant tumor). Yeah, life can be a barrel of laughs around here. And then there are the fun cases like the 75 year old guy we operated today who had lemon sized stone in his bladder. Why is it fun? Because starting tonight he no longer has to stand on his head to pee. There is one sad and strange story I have to report. Yesterday afternoon a 3 month old child was brought in seemingly in abdominal distress. The child’s abdomen was distended more than any I have seen. It appeared about to burst. With no x-ray to help (the unit has been down for 2 months) we made a decision to operate based on what we saw feeling that something in there needed to be decompressed. When the anesthesiologist put the baby to sleep the distention was relieved and the abdomen appeared normal. Puzzled, we cancelled the surgery and placed the baby back in the pediatric ward. By morning he had died. Further questioning of the mother revealed that she had taken him to a traditional healer (read witch doctor) for a belly ache who had evidently given him an overdose of some powerful local herb. Yes, the baby had been poisoned. Welcome to Africa. On the social side I seem to be falling in with an expanding circle of South Africans. Last night I had dinner with a couple of guys who are about to open a resort on Lake Tanganyika. Last year I visited the lake which is the longest and second deepest in the world. It is positively spectacular and a long neglected asset to the Tanzanian economy. All that is about to change. Heretofore the only place to stay was a posh fly-in-fly-out $900 a night resort that only a few could experience and added nothing to the economy. These guys, Chris and Ben, are building a low and middle end place that should attract ordinary tourists from everywhere. We had a great time talking about their plans for the lake and the upshot is that we are invited there over the weekend to sleep in a deluxe tent and get the feel of the area. I intend to do an interview and photo essay on the place and try to get it published in an American travel magazine. More on this next week. And finally, I had dinner tonight with the regional administrator of Rukwa Province. The appointed equivalent of our state governor the honorable Daniel Njoolay (pronounced July) is the head guy for a huge territory that I have described before. We met last year and have finally gotten together again. Dinner was at Forest Way and he brought his wife who remained silent through most of dinner. . My agenda was to lobby for hospital improvement. His was to find out about Barack Obama. Neither of us was disappointed. I carefully laid out for him which deficiencies I thought could be remedied. There was no sense bothering with those that can not. Most of what I told him he already knew. One or two thins genuinely shocked him. He asked me to send him a written report which I will, being careful not to point a blaming finger at anyone in particular. I’m told that’s how one survives here. Then I described the current nature of American politics bearing in mind that Bush has been extremely popular here. It seems that one of the few things the administration has done right has been to earmark significant funds for African health care and it has been appreciated. Looking to the future I described the Obama-mania in the US that robbed Hillary of her shot and assured Daniel that the nominee would be a good choice for everyone and will probably be elected. Over coffee the Commissioner/Governor launched into an explanation of how African politics work that I found fascinating. I can’t comment on it because it was only an hour ago and I haven’t had time to digest it all. Maybe I’ll write about it later. Feeling privileged to have had this conversation I picked up the check. After all, where else can you take a governor and his wife out to dinner for under 20 bucks? Meanwhile, poor Catherine missed this event because she has come down with a case of what I call the Tanzanian three-step. She spent the day sitting on the can with her head in a bucket while Jasper and I took turns running back to the hotel to give her shots of anti-nausea medication. She seems better tonight and may even emerge from her room in the morning. Well, that’s the news from Lake Rukwa where the women have perfect balance, the men have perfect teeth and all the children think white people are funny looking. Until next time………….
I haven’t written for 3 days and it’s amazing how many things happen and how many interesting people cross my path. Let’s start with the weekend. I arranged a car and driver for the weekend to take us to Kipili which is a small village on the edge of Lake Tanganyika. It is not an easy trip but well worth the effort. The lake is the longest and second deepest in the world. It is also one of the most beautiful places I have ever seen. I took my signature sunset picture there last year and hoped to get one even better. We were invited by Chris and Louise Horsfall, a South African couple who are building a resort on the beach dedicated to the adventurous traveler who loves water sports, especially scuba diving. The location is dramatic and yet very peaceful. They have been living there for some time in a semi-open air dwelling, perfectly suited to the climate that provides visual and physical access to an environment so idyllic that once there it is difficult to leave. Their mission is to build the perfect space to share with about 40 guests in either super-deluxe or just plain beautiful accommodations. They are well on their way and expect to receive the first paying guests in September. The food for the resort will come mostly from their organic gardens. Power is self generated from solar panels leading to a huge battery array. Chris hopes to add wind power soon so that the resort will actually add power to the local grid. During the day the place is abuzz with building activity. At night the quiet is perfect, broken only by the gentle lap of waves on the beach that are the whisper kiss that only a lake can deliver. There were other visitors there for the weekend including Tony and Ann whom I’ve mentioned before. We also met Ross and Heidi Lloyd, a young coupe from South Africa who have quit their jobs and are touring all of Africa in their Landcruiser. Just them, no guide and no set itinerary. What stories they tell. After hanging around all day Saturday enjoying the surroundings and downing a few beers while watching cricket and rugby (yes they have full satellite TV and internet service) we had a delightful dinner on the beach. After determining the true nature of our relationship (they had only met us once briefly) they set up 2 separate tents for Catherine and me and, fears of snakes, giant lizards, spiders, etc, notwithstanding, I slept like a stone. Awakening at dawn to watch the sunlight coming from behind me reach out over the lake was awesome. Oh, and by the way, I did get a killer sunset shot. Back in Sumbawanga Sunday evening after another 3 ½ hour kishka krunching Landcruiser ride it was time to review the week ahead and plan for the new medical students due to arrive Monday. I will need to give then my full attention as I will be leaving here on Saturday. Wow, a month goes by fast. I’ll need to enlist other physicians to provide a program for them after I’m gone. There are several options and at least one will work out. We have some interesting cases to do. It seems the word has spread among the ear keloid afflicted that we’re taking on most comers. We scheduled two more of them for the coming week. There are a bunch more interesting surgeries to do and we’ll pack the schedule with as many as possible. Today I made a belated tour of the AIDS/HIV project going on at Rukwa Regional Hospital. Five years ago people were literally dying in the streets. The HIV infection rate was upwards of 30%. Starting in January, 2005 the CTC (Care and Treatment Center) for AIDS/HIV was started here funded by the US government. It is a carefully managed, highly accountable program. We were shown around by a well trained, carefully spoken nurse named Matilda Ulinyeusya who has made this program her life’s work. She explained that over 3000 people locally have registered for the program And over 1400 have been placed on medication. The medications, known as AVR’s, are given free, again courtesy of Uncle Sam and the program has been a huge success. Besides diagnosis and treatment there is a strong outreach program to the outlying villages, condom distribution and massive education. The result is that we now seldom see aids patients at the hospital the HIV positive rate has dropped to about 7-8% of the population which is low for sub-Saharan Africa. Most of these people have good control of their disease. This program works on a similar scale nationwide. The problem is that the US aid package, known as PEPFAR, is in danger of not being renewed for political reasons. If you want to directly save the lives of countless people Google the program, learn the facts and then climb all over your senators and congressmen. This program cannot be allowed to lapse. Another interesting character is Paul Graham Philips, the director of Sumbawanga Agriculture and Animal Food Industries. He is a black man from Zimbabwe who’s first language is perfectly elegant English. He is working for a member of the Tanzanian parliament who owns a huge cattle ranch not far out of town. He is dealing with a group of Jordanians who stayed at our hotel last night. Unfortunately his boss got fleeced by these guys and signed a huge contract to deliver beef in unsustainable quantities at a price that will bankrupt the company. Paul’s job is to figure out a way to make it work. I mention this only because at dinner tonight we had an in depth discussion of how the nascent African agribusiness works. What I learned is that most Tanzanians have no head for anything above day to day business and are very vulnerable to being taken advantage of. There is a great need for imported talent like Paul to help realize the tremendous potential of farming here. Tanzania could be a major player in the continental food supply if they could just get past "poli-poli" and get their act together. Paul’s a very savvy guy and I’m betting he’ll find a way to pull it out. Our three medical students arrived this evening. I met them briefly. Fortunately they are staying at another hotel. I don’t think I could handle three more 24/7 shadows. Catherine is enough. We’ll meet in the morning and I’ll plunge them into the wonders of primitive surgery. I've given them some warning as to what to expect. Off to bed............my mosquito net beckons.
The intensity has picked up around here. Our new students are wide eyed and eager. Susanna and Charlotte are Swedish women going to medical school in Poland. Second and third year they have, surprisingly, almost no clinical experience and none in surgery. It has been interesting watching Catherine, who has not yet been to medical school, orienting them as to operating room protocol and procedures. That girl learns so fast it\rquote s almost frightening. I'm really proud of what she has accomplished the last four weeks. I hope she chooses surgery later on because she's good at it and is definitely temperamentally suited for the field. It's fun having a class now. Our new students have the academic background for me to explain things in medical jargon and to coax out answers to questions based on what I think they should already know. Actually, they're not bad though Charlotte as a third year is more advanced. Their English is almost southern California. They learn our language almost from birth and watch a lot of American television. Anyway, they walked into a storm of clinical activity. Surgical cases are coming at us thick and fast. It's necessary to pick and chose the cases I want to do in the limited time I have left here. We can only do three a day and I have just three days left in which to work. Tomorrow we will tackle a case of what is probably colon cancer (remember, clinical diagnosis only, no x-ray help) and a weird neck cyst about he size of a large orange that keeps recurring and who knows what emergency will show up. The new girls will alternate assisting as it seems Catherine has become the darling of the OB department and has taken to first assisting the two or three caesarian sections that happen each day. I'm going to relate another very weird story now. About three o'clock this afternoon we were called to see an elderly man who had been hit by a falling tree several days ago. On his right side there were four fractured ribs and his collar bone was fractured and the ends collapsed and overlapping by at least two inches. Either the ribs or the collar bone fragment had pierced his chest and the lung was 80% collapsed. We took him right to the OR to reduce the fracture and apply a brace to his shoulders. He also needed a tube in his chest to re-expand the lung. Luckily, one modern chest tube with an introducer was available. As we were starting our procedure the next case, an emergency caesarian section was brought to the operating room door. While she was waiting there she delivered spontaneously and suddenly we were surrounded by people running around trying to resuscitate the baby, tend to the mother and keep the equipment going. After reducing the fracture and prior to placing the chest tube I sensed things were not going well and stopped what I was doing. Moving over to the nurse who was frantically trying to revive the infant I began external cardiac massage while the nurse administered oxygen. Now all this was going on in a room less than 20 feet square. The infant did not respond and after 15 minutes I abandoned CPR and returned to my patient placing the chest tube uneventfully. When it was all over I turned to the students and told them to remember this day because they will probably never experience anything quite so bizarre. That case finished all that remained was to tap into the chest of the young woman with the toe amputation two days ago. It seems she had developed massive fluid around her right lung and was having a lot of trouble breathing. We had no idea of why this was happening but it was clear from the chest x-ray we managed to get by sending her over to the other hospital that something needed to be done fast. Over in the ward we simply stuck a plastic covered needle into the chest, removed the needle and left the tube. Minutes later about a quart of fluid had drained, she was breathing better and we could all go home. From the looks of the fluid we're considering TB aggravated by anesthesia and surgery. We can get the fluid tested to make sure and if we\rquote re right she\rquote ll do well with treatment. We really hadn't expected the students to come as I had suggested that they be sent to another hospital because they were arriving so late. Jasper has arranged to go on vacation during the middle of next week. Fortunately there is a young man her, Dr. Haan, who is practicing internal medicine and pediatrics. I had met him only briefly and had mistaken him for an assistant medical officer. Fortunately not only is he a highly qualified doctor but his English is pretty fair too. He has agreed to take over responsibility for the students after Jasper and I are gone. We have a meeting tomorrow morning to arrange the details. By the middle of next week I think Charlotte and Susanna will have had enough of surgery anyway. It's time to start arranging the details of my departure. I sent out the last batch of laundry, had a new pair of jeans altered and some dry cleaning done. Now I need to decide which clothes to take back with me and what things to leave behind. There is still more work to do here and I plan to utilize all the time remaining. I'll post my final thoughts on Tanzania from Dar es Salaam on Monday. There is a not so enjoyable two day bus trip in the meantime. Hopefully I'll get a private ride for the first half.
This is a post I never expected to write. In all the traveling I have done on these missions, two trips to remote Pakistan and now two to Africa, all the complicated transportation plans have been remarkably hassle free. Yesterday was payback time. Anticipating an uneventful trip to Dar I had already begun composing my philosophical review of my time here. You’ll get that later but first the nightmare. I did get a private ride from Sumbawanga to Mbeya – sort of. The hospital supplied a Land cruiser and driver assigned to pick up supplies and seven other unidentified people. We were packed in so tightly that the bus would have seemed comfortable by comparison. No one spoke any English and the driver played very loud African music through the entire 4 ½ hour trip. Its only a hundred miles or so but the dirt road, even in good dry season condition, equals a class 2-3 off road trail in Arizona. OK, it was uncomfortable but not so bad. After buying a best class bus ticket to Dar es Salaam for the morning I checked into my usual Spartan, clean and safe hotel. The Mbeya bus station : Dozens, perhaps hundreds of young men scurry about grabbing peoples’ luggage and, for a fee of course, showing them where their particular bus is likely to show up. The traveler unfamiliar with the system is at their mercy. In the four times I’ve been through the place my “guide” has never failed to get me and my luggage on the right bus. Tucked away in my seat with my carry on with me and my big suitcase in the luggage boot under the bus I settle in as we pulled out heading east into the just rising sun for the 500 mile trip. I’ve got my Ipod, noise canceling headphones and even some leg room. The road is paved all the way and this is going to be a pleasant 10 or 11 hours. The bus had TV soda and bottled water on board and even a bathroom for limited use. (We still take pee breaks by the side of the road.) What the vehicle did not have was a fuel pump that was going to last the trip. I was seated in the front row next to Omari, who looked a lot like a taller, bigger version of Richard Pryor. His English was good so we exchanged pleasantries and then hunkered down for the ride. About four hours later we noticed the bus slowing down and the driver muttering to himself in Arabic. As we wheezed into the parking area of a roadside stop called the Aljezeera restaurant and bus stop it was obvious that we were going no further without some mechanical attention. The scene and terrain were so much like the movie “Babel” it was freaky except no one got shot. During the next three hours I finished a book, ate 6 skewers of roasted beef cubes, downed a Coke and 3 bottles of water and became increasingly agitated about not getting to Dar that night. The mechanic had been sent for but still had not arrived. After the 4th hour he finally showed up and confirmed what everyone already knew, the bus needed a fuel pump or at least a filter. In true African style he had not brought parts and declared that they would send to Aringa, 50 miles back and have one sent out. I calculated the time and figured if everything went on schedule, and why should it, we would be in Dar some time around 4 am. Enter Omari. It turned out that he is a big time business guy and president of the largest labor union in the country. He had made a call hours before and someone drove out from Dar to pick him up. He offered a ride to me and a couple whom he knew. We would be 3 people literally squashed into the back seat of a very small car. There was no room for all of our luggage. We found out that the luggage was inaccessible anyway because for safety reasons the luggage boots on the bus cannot be opened if the motor is not running and this motor was definitely not. It was time for a tough decision. Do I leave my large suitcase in the hands of the baggage gods or wait it out with the 50 or so souls camped out at the Aljezeera? I asked myself is there anything in that suitcase that justifies my sleeping on the cold hard floor of that place rather than in the bed of the deluxe room I reserved for myself at one of my three of four favorite hotels in the world. I’m outta there! We piled into this little cracker box, my carry on with my computer and cameras safely stowed behind me and my knees pressed into the seat in front. The young woman in the middle was pressed against me so that lateral shifting was impossible. It was like being trussed up so that all I could move was my elbows. The next problem was that the car had an exhaust leak so that no matter how we adjusted the windows fumes came into the back seat producing a headache that increased with each breath. Next of course was the music. Africans cannot stand quiet. They must have every nearby TV or radio turned up to full volume. If conversation is necessary it is shouted rather than turn down the music. Such was the ambiance of the trip. Last, I noticed that my seat mate did not say anything. I found out why when she answered her cell phone with a croak that could only mean severe laryngitis. Her subsequent cough confirmed the diagnosis. I was trapped in this position for 5 ½ hours and could have not designed a more perfect version of hell. The floor of the Aljezeera began to look sort of cozy. Pulling into Dar around 1 am we dropped off the plague ridden couple. Omari got off at his office and another guy got in to drive the car. I was feeling a little uneasy as we set out for my hotel. The driver made an illegal u-turn and we were stopped by two uniformed people carrying assault rifles. One came over to inspect me in the back seat and told me to keep quiet and everything would be all right. They proceeded to verbally work this guy over for a full 30 minutes. All the time I was thinking: Am I going to be one of those people who get in the middle of some African vendetta and get shot in a car? No, they let us go and around 1:30 I was finally safe in my hotel room enjoying a hot bath and a room service club sandwich while turning on my computer, getting on the internet and watching the Diamondbacks blow a 3 run lead in the ninth. Oh, the suitcase? I had written it off and it’s amazing how situations work out if you become detached from them. Early this morning I had the concierge call the bus company (I’d have done it myself but my Swahili still leaves a lot to be desired) and we were informed that the bus in question, now get this, was not expected at the garage until 3pm today. That means all those people were 21 hours overdue! Stuff like that just happens here. I had planned to go to the Kariakoo market today and the National Museum. I did both and they were great. I’ll talk about them in the final post. At 3pm I took a cab to the bus station and there it was, the big black ugly suitcase I had said goodbye to 24 hours earlier. Sometimes you just have to wonder. And by the way, there are no refunds if the bus breaks down. There’s lots more to talk about before I leave here but I’ll save it for after happy hour and dinner.
It’s hard to believe more than five weeks has passed and the time has come to tally up my cases and go home. Paradoxically the total time has gone by very quickly while the down time, and there has been more than a little, has seemed excruciatingly slow. I have experienced disturbing mood swings here ranging from exhilarated and commanding to feeling helpless and depressed. The dark side, I’m sure, stems from watching tragedy unfold under my gaze and being powerless. Idle time intensifies the frustration which lasts until the next triumph. Fortunately the triumphs have outnumbered the tragedies but by far less than I am used to in clinical practice at home. The highs have been many. The standouts are seeing the three year old girl eating normally for the first time in her life, the woman who nearly died from intestinal obstruction laughing with her family as I removed her stitches and the pretty young woman going about for the first time in years without a shawl to hide her horrible ear keloids. Then there are the open ended cases. What will happen to the nun who lost her lower leg to melanoma? How will the young woman with the malignancy on her toes be able to walk on a foot that looks like the middle of it was bitten off? Will the man with the huge lymphoma on his neck really get to Dar es Salaam for proper treatment? The biggest question of all is have the powers that be really listened to my pleas and suggestions to bring some order to this chaos? Or, has my presence here been like sticking my finger in a bowl of water. I can stir things up and make lots of waves but when the finger is gone it’s as though nothing happened. I believe something will stick. I feel emotionally tied to this place though if you saw it you would certainly wonder why. The people have gotten under my skin and I think I have finally started to really understand who they are and how they think. Believe me when I say that there is not much in our American experience to help me relate. Being here, now for a total of ten weeks and finally being able to settle into the indigenous pace and mindset has left me connected in a way that is not always pleasurable but certainly challenging and, I believe, irrevocable. East Africa is now part of my being. The night before I left Sumbawanga I was invited to the home of Daniel Njoolay,the Regional Administrator (Governor) for dinner. You remember that I entertained him and his wife a couple of weeks ago. This time it was him, me and Jasper sitting around his dining room table seriously discussing hospital problems and what to do about them. Jasper, unaccustomed to such meetings was sure he would lose his job over this. In Africa frankness is not common in such conversations. Circumlocution leading nowhere is the norm and that’s why so little gets done. Because of his education in Canada Daniel understands my style which is polite and certainly not blunt but gets to the heart of matters fairly quickly. I made my points carefully, surrounding each with background facts that locked it into an inescapable discussion pattern. Daniel was very frank with me explaining where the bureaucratic resistance to change is and what are the extents and limits of his own power. By the time we were half way through the second bottle of wine Jasper was giving a pretty good account of himself. He is the senior and best trained physician in town and has the respect of everyone including the politicians. We went on for over four hours and in the end had formulated a restructuring plan. We determined that the reason for a lot of the shortcomings at the hospital is that no one is running it. The regional medical director who is responsible for all of Rukwa has his office in the hospital and he is the de facto administrator but does not function in that capacity. Daniel has decided to move him out of the hospital into the regional government office building where he belongs and replace him at the hospital with a real administrator. I suggested he get a newly minted health care MBA out of Dar or Nairobi to come in there and kick some butt and make a name for himself. I must, of course follow up this meeting with a report and I’m happy to do it because I finally feel that I have done more here than just care for one patient at a time. Back at the hotel I packed my stuff and prepared for my morning departure. You’re already familiar with the details of my trip so we’ll skip to today. The National Museum in Dar es Salaam is no Smithsonian. Located near the waterfront about four blocks from my hotel it is a smallish building with displays in two parts. The first is an interesting somewhat sanitized version of the country’s history before and since independence in 1967. It is mostly pictures of revered but outside Tanzania, obscure individuals who played some part of the “bloodless revolution” Looking at it closely though one gets a sense of the intensity and fervor that was involved and still lingers in the minds of Tanzanians. Forty years is a short time for nationhood and the pride is still there. The second section is the anthropological history of the country. Because of the great geological rift that runs through it Tanzania is a great repository for fossil evidence. Someone very knowledgeable has taken very great care to reconstruct and illustrate the fossil record of humankind creating a remarkable journey through our evolution that is truly worth seeing. All in all the museum, though lame in parts, gets pretty fair marks for giving the visitor some idea of what this country is about. Then I went off to the Kariakoo market. This is one of those places where the guidebooks and travel mavens tell you to stay away from. There are pickpockets, thieves, murderers and perhaps even worse just lurking there waiting for the unwitting visitor. As my 10th grade English teacher used to say, Balderdash!! The market is a huge place built like a square stadium, Inside are hundreds of stalls each, apparently, its own individual business. It’s sort of an impoverished version of the Reading Terminal in Philadelphia or Pike Place Market in Seattle. What interested me is what they sell. In a city of nearly three million people who have access to cell phones, satellite TV and all of the associated hype what would you expect to find in a central market, electronic toys, gadgets and such? There are some but not much. Most of this building is dedicated to simple farm implements, seeds, fertilizers and garden tools. There are multiple stalls selling sewing machines, some of which are Chinese knock-offs of the ancient foot treadle Singer that my grandmother used. They sell for about 100 bucks as do the best of the Chinese bicycles. Almost all of the merchandise here is dedicated to people making their living. The place was packed and I met some of the nicest people there. I was the only white person not only in the market but in the whole neighborhood so my presence did not go unnoticed. Parking myself on the corner of a balcony I was able to get some great candid pictures and walking among the crowd people were only too glad to pose. My only detractor was a local Imam who accused me of stealing peoples’ souls with my camera. I assured him that out of respect I do not take pictures of Muslims without permission and if I have stolen any Christian or heathen souls I promised to take very good care of them. He actually laughed and was satisfied with that. The lesson of the market is that these people are hard working and, so far, basically uncorrupted by the “I wants”. Families come to the market to buy the things they need to sustain their lives and one can see on their faces the joy of the shared experience. Maybe it’s a good thing that the guide books steer people away from the place. They really don’t need us there. Then it was time to reclaim my suitcase and head back for the hotel. Happy hour was fun. I met some nice people here for an international financial conference. Dinner was, to use an old fashioned term, splendid. I’ll not go into details. Back in my room I finish this piece, make final preparations for my flight to join Marcia and Ara in Paris. It is our wedding anniversary and his birthday on Wednesday and we plan to celebrate. So the Africa 2008 adventure is over. I know it has changed me in ways that will emerge slowly over the coming months. Of course I’m already planning when and how I will return and which of the many people I’ve met that I will continue to contact. When one’s world expands there is no stuffing it back into the old container. You just have to try to keep a handle on it and go where it takes you. If you’ve been a fan of this blog thanks for reading. Go out and have your own adventure. I’ll be glad to read about it. Watch for a pictorial review on this site after I have had a chance to review and edit my photos. Tutaonana (until next time – Swahili) Skip Apply now
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