Flying Medical Squad

I am home in Arusha alive and barf free from the flying medical squad. It was absolutely amazing. I met the team Monday at 7:45 at the airport and we loaded the plane with suitcases of medications and equipment and then we set out around 8:30. It was me, the pilot Jack - a polish guy who's lived here for 7 years now, and Trudy, a Swiss woman who is the secretary for a medical flight company there and is going to help organize the office here at some point. I got to ride in the co-pilot's seat for the first day, wearing the headset and hearing the air traffic controllers, etc. (But of course I didn't touch anything.) The plane seats 6, or 4 comfortably, with a small cargo area in the back and a small cargo area underneath. We flew about 25 minutes south to Emberet where we dropped off our overnight bags at a catholic mission and picked up the clinical officer that goes out with the team. We were flying at 5000-6000 feet which actually seems really close to the ground and you can still see a lot of detail. The runways are just mowed strips of dirt and grass. We had to fly over the runway once before landing to make sure that there weren't any major holes or animals in the way, and the tight turn going back around was always the hardest part of the flights for me from a nausea perspective. We did clinics in 3 tiny villages on Monday, flying between them - they were all within 25 minutes flight or less.

My job was pregnancy checks - I checked the blood pressure, looked at the eyelids for signs of anemia, checked for edema, and then measured the uterus for an estimation of age and identified the position of the baby if they were over 30 weeks. I then attempted to ask them if the baby moves and if I couldn't get that answered, I would just do a quick ultrasound for the heartbeat. The first day, I ultrasounded almost everyone but on Tuesday and Wednesday I was doing better with the phrase "Baby moves" in swahili and massai. I did between 5 and 20 ladies at each spot, except at the places were there was no bed or cot, in which case i just did the blood pressure, anemia check, and edema check. I found one baby at 36 weeks that was breach, and I asked the clinical officer what we should do, thinking at least we should warn her that it might be a rough labor etc, or that maybe she'd be advised to try to get to the hospital to deliver. His response was "Sometimes they turn around." so we did nothing, other than note on the pregnancy cards they all carry to follow the progress that it was breach. So I'm not sure what the point of checking is, but oh well. I wish I was able to take a picture of my 'office' in some of the towns - only one had an actual bed, the other were cots made of wood and twigs that were in various stages of coming un-made, or once 2 church benches side by side. Unfortunately, the Massai don't like having their pictures taken (and who can blame them - I'd be pissed if some foreigner came into the clinic while I was seeing my doctor and started taking photos) - so all the photos from this trip will be landscapes or from the air, no people. I generally try to avoid pregnant ladies at all costs, but the pregnancy checks weren't that bad and with no privacy or gloves, and no way to do anything with the results, I was in no danger of having to do a bajanginal exam.

Once I was done with all the pregnant ladies, I helped Jack and Trudy with immunizations or I helped the clinical officer, Moshi, with counting medications. Like in hospice, medications are dispensed from a large plastic bottle of pills into a small (1.5x3 inch) zip lock bag. The bottles of pills are kept in 2 rickety old hard backed suitcases, there is a third for liquid antibiotics for the children. Almost everyone gets an antibiotic if they have bothered to come see the clinical officer with a complaint - the favorites were Cotrim (bactrim) and doxycycline, though penicillin V and erythromyacin also did well and cloxacillin was popular with the children. The often also get 12 paracetamol (Tylenol) or 18 ibuprofen. The kids are all brought with their vaccination / growth charts - the mamas keep these - and weighed and then given any vaccines they are due for. We saw a lot of newborns - 6 months who were getting DPT and oral polio, but some measles and mumps were given and the pregnant mamas get at least 4 tetanus. Kids still die of tetanus here - Jack told us about a kid he flew to a hospital with tetanus - they had started vaccinating the previous year in that village but the mama didn't think he needed it. He died a couple days later in the hospital at Haidam. Frustrating.

So we did 3 clinics Monday, with a break between the second and third when we set up the folding table in the shade of the airplane wing and ate a lunch of bread and marmalade and coke. At the end of the day we returned to Emboret where we had a excellent dinner of rice and beans and greens and a beer and Jack played the guitar after dinner and we sang together. Tuesday, we set out at 8:30 and again did 3 clinics, the last in a brief thunderstorm - there was no bed here so I was helping Jack vaccinate babies and mamas under the wing of the plane while it was raining. Trudy got to sit in front Tuesday so the airsickness was worse, but I did manage not to barf. Tuesday night after dinner - rice and cooked greens from India (one of the priests brought some seeds and grows his favorite greens) and an eggplant dish and fries - we played Uno. Jose, the priest from Brazil, was terrible - he loved making up rules to give other people extra cards. Not priestly at all, but fun. Today we had one clinic, which was actually in a nice church at a town where people were less pushy (most of the time, they were crowding as close as possible to be next, which is fairly claustrophobic and pretty hazardous from a needle safety perspective while vaccinating. Then we flew back to Emboret and had lunch at about 12:30, and then home to Arusha. Lunch was Ugali - a corn meal dish kind of like pollenta but unflavored - at Trudy and my request - I hadn't gotten around to trying it yet. Most muzungus think it is terrible, but I actually enjoyed it quite a bit - it may be totally flavorless but it has a nice texture and consistency and you eat it with curry or sauce.

I am really glad I got to go out with the flying medical squad. Aside from the landings, the flying was actually surprisingly pleasant and fun for someone with fairly severe motion sickness, and I feel like we actually helped a lot of people (at least with the vaccinations) and I got to see some beautiful places. So often it feels like we're not really doing much for our patients here - maybe making them feel better in that they have received care but rarely fixing big problems in the hospital. (To be fair, many of them are problems that just can't be fixed given the resources they have here) It was nice to do something that is tangibly useful like vaccinating - even if you don't need to be a doctor (or even a nurse) to do it, you can do it and it will prevent childhood deaths.

To clarify for anyone reading the blog that doesn't know me well - the Marmalade listed at number one on my things I miss list is my cat, Marmalade, not the jam product made of oranges. :)

Top ten things I miss / will be happy to come home to

So I've been trying not to write this post, in part because it's kind of negative and partly because I knew writing it would make me more homesick. But in a week I'll be home, so I guess now is the time. So here are the top ten things I've missed while here in Africa:

1) Marmalade
2) Bacon
3) Martinis. They have gin here but no olives or vermouth.
4) Paved roads. The roads here are for the most part insanely bumpy and just keeping upright and in your seat is a full time job for a passenger.
5) Being able to easily talk with family and friends (sorry guys, you only make 5 cause I can still e-mail you and call if necessary.)
6) Not having to great everyone I see. Usually 3 times. Sometimes impersonal interactions are nice.
7) Being able to go out to dinner. (Here, we have to be home by dark or take a taxi home because white people aren't safe after dark on foot. It just makes eating out too much of a hastle)
8) Things getting done in a reasonable period of time. (African Time!) As an example, Thursday morning they admitted a guy to the medicine ward who had newly diagnosed HIV, kaposi's sarcoma with extensive lymph node involvement causing severe leg edema, and an oxygen saturation of 63 (Normal for my non-medical readers is >90. 63 will get you on a ventilator in America, or on 3 litres of O2 by nasal cannula in Africa) with a pleural rub. Our working diagnoses were pulmonary kaposis or TB. The chest x-ray we ordered? Not done yet Friday at noon. I have a bet with Eric that it still won't be done when he rounds with the medicine team Monday, based on my past experiences here. That's high quality medical care!
9) Washer and Dryers - don't get me wrong, we're spoiled in that our housekeeper does all our laundry, but my jeans just don't fit right.
10) This is a tie between Bacon and Whiskey. I really miss bacon a lot, possibly enough to be on the list twice, but I also miss manhattans.

You'll notice some notable exclusions from this list: My computer, reliable internet access, snow, the TV and radio / any media source, the 70 hour work week, (that's one thing that's nice about no one feeling personal responsibility for their job or patients - much shorter work week), driving. I miss being independent, but I haven't really missed driving while here - I haven't been behind the wheel since January 13th. Minnesotans would be wise to watch out for red geo prisms doing crazy stuff on the road starting March 14th. :) I suppose I'll happily adjust back when I get home, though I'm sure I will miss the more relaxed lifestyle / timeline here once I'm home.

Winding down

As my time here in Africa comes to a close I've been trying to get some things done that I've been intending to do but hadn't gotten around too. (I blame African Time). This week I completed my review of oral morphine prescribing by the hospice team. The number of patients receiving repeat prescriptions during 2008 could be counted on 2 hands, and even the repeat scripts were not frequent enough to achieve adequate ongoing pain control, at least by American standards. And of course we still don't have any morphine - when I got here in January I was told we should be getting some soon, but that doesn't seem to have materialized. I will leave the data I copied (by hand) for Dr. Hartwig and perhaps he can get something more useful or encouraging out of it. I am scheduled to give a talk on pain and symptom management to the doctors and nurses at Selian next Thursday. I am having a pizza party for the hospice team on Thursday evening. And of course there's the Flying Medical squad Monday-Wednesday.

I spent this morning doing some final shopping and ordering the last of 3 outfits I am having made - the first, a skirt and shirt made by Mama Makule's tailor (who also made my traditional Tanzanian dress) turned out wonderfully, so I am having a dress made there. There is a tailor in town who caters to Muzungu (foreigners) though, and she also runs a non-profit home for developmentally disabled children, so this morning I went to order a dress from her as well. It will be 10 dollars more than the other tailor, bringing the total cost to 25 dollars, but it benefits a good cause. Plus, it's still amazing to have something custom made for 25 dollars (plus the 6 dollars I spent on the fabric - but that includes lining, zipper, all other notions, and the sewing itself.) After the market, where I bought the fabric, and the tailor, I hit Shop Rite for some milk and the coffee store for some coffee beans to bring home. I'm fairly certain it's not illegal to import coffee because it's roasted. Then I headed back up hill (Shop Rite is at the bottom corner of the town) and across town past the little grocer that sells tomato sauce cheaper - 1.50 for a large can vs 1.30 at shop rite for a tiny one. I made it to the Meat King just before they closed at 1 and was able to get the mozzarella and chicken for the pizza party. We won't put pork on the pizzas because almost none of the locals eat it. Laden with my purchases, and now on the opposite side of town (but at least not as far down hill) I headed home. At the foot of Il Buro road (the road we live on - it's about a 15 minute walk from the base to our house) I twisted my ankle. The locals seemed genuinely concerned, and surprisingly none of the taxi drivers that park there tried to take advantage of the opportunity to get an extra fare. I managed to hobble to one of the many pharmacies on the way home and buy and ace wrap and Bryant and Eric kindly came down the hill to meet me and help me home. I'm fairly certain nothings broken, but it's definitely sprained which is going to be a pain in the ass. Today I am icing and elevating and I'm considering skipping church tomorrow for more of the same, particularly since I am committed to working Monday through Wednesday.

Which brings me to the flying medical squad. Apparently, the flying medical squad does mostly well baby checks, vaccinations, and pre-natal care. None of which I am specifically trained for, and all of which I have decided not to do as a practicing doctor in America. We will fly out Monday morning to somewhere in the bush (they told me the name but i forgot to write it down so I've forgotten it.) We'll spend all day with the patients - I will probably be in charge of blood pressure checks and fundal heights, while the pilot (who is not medically trained) will take care of vaccinations. We'll spend the night in a mission settlement nearby and repeat the clinic Tuesday and Wednesday. Eric is kindly allowing me to borrow his tape measure and obstetric emergencies cheat sheets, though it's unlike we'll have any of the drugs or equipment we'd need in an obstetric emergency. Apparently, when they don't have any volunteers to go along, the pilots do everything. The pilots get their medical training from a catholic priest who also has no formal medical training. So I'm trying not to feel woefully unprepared for the patient care I'll be doing, but not entirely succeeding. At least Jane gave me some anti-nausea medications - she went on one flying medical squad flight and barfed the entire time. So I have lots of exciting things to keep me busy till it's time to come home, and while my time is winding down, my list of stuff to do seems to be ramping up. :)

African Time

In Africa, like much of the rest of the world outside the US, things happen slower. On my days with hospice, we often spend 2-3 hours in the morning getting ready for the day - getting the medications we are going to take in order, having tea, buying any other supplies, etc. This is all done at a leisurely pace and we rarely do any actual patient care before noon. Rounding on the Medicine wards is similar - if someone wants morning tea, we have it before we go see the patients. The change has been both pleasant and incredibly frustrating to someone who is used to the American medical system where practically every moment spent at work is spent working unless you are actually forced to wait for something and there's nothing else that can be done during that time. The westerners here roll our eyes and wink at each other and refer to 'African Time' when we think something is taking too long or not being prioritized appropriately. However, we've also gotten used to this system. As my departure date approaches (I leave next Friday, the 13th) I feel like my time is accelerating back to American time and I have a lot of things on my list of stuff I was planning to get done eventually while I was here that now needs to get done soon. For example, I was planning to give a CME (continuing medical education) talk on pain and symptom management on my last Tuesday here. Unfortunately, yesterday I ran into Sarah, who coordinates with the flying medical squad and had arranged for me to go out with them next Monday through Wednesday. She forgot to tell me that she had arranged this and I had assumed she had forgotten I was interested and I wouldn't get to go. So now I will be in the bush somewhere doing basic medical care on Tuesday morning. Hopefully Dr. Kipuyo, the selian hospital director, will let me give the presentation Thursday. I kind of miss African time already, and I've not even left yet.

Weekend Shenanigans

It was a busy weekend. Saturday morning Bryant, Eric, and Laura left for safari for 3 days. I spent the morning working on some materials I am preparing for the team before I go and a pain and symptom management talk I am hoping to give before I go. (There is a lot to change where this is concerned. Just today in Continuing Medical Education lecture the MD who is the head of the hospital now said that narcotics were poisons and the interns should not be prescribing any meds, particularly not multiple medications when they don't know exactly what's going on. This is an absolutely ridiculous statement, particuarly given that most of our labs take >24 hrs to come back and are unreliable anyway, we have limited lab tests available, x-rays and ultrasounds are done after mid-afternoon only if they are true emergencies, and there is no CT or MRI.) Anyway. . . about noon on Saturday Mama Makule texted to see if I wanted to go to the 'Send off' party with her that night. I did, so I walked downtown and bought a small gift and some blue beaded sandals to wear with the dress I had brought from home and then climbed back up the hill and changed. The whole hospice team picked me up on the way to visit the family that got broken into. In Tanzania, when something bad happens, you are supposed to visit right away to show your support and sympathy. I think this is actually probably fairly traumatic for the person to whom the bad thing has happened, but it would have been hard to explain this to them, plus they had already bought a large bouquet of flowers. So we returned to town, had the present wrapped, did some other errands, and then paid the visit. By the time this was all done, plus we had dropped off the other team members at home we were fairly late to the send-off, but it was still and interesting experience.

A send-off is a party that is held for the bride before the wedding. It's usually on Thursday but this one was on Saturday because the wedding is taking place in a different city, so this was the main celebration for a lot of the bride's friends and family members. We arrived after the part of the evening where the bride has to find the groom who has been hidden somewhere in the room, after the cake cutting, and a couple other traditions, but in time to have some dinner - salad, rice, chicken, beef, bananas (the non-sweet, main course kind) and potatoes. The bride was dressed in a gold slim dress with beading and sequins on the bodice and there were between 10 and 20 young women aged maybe 10-30 in gold and white satin dresses. They are apparently the family members and friends of the bride and are all part of the wedding party. The bride will have a different white dress for the wedding itself. After dinner, the MC did some announcements and a prayer and then began the processions. First, the bride's family all lined up and danced into the center of the hall with presents, which were handed to some of the attendants, and then they kissed / congratulated the bride. Throughout the procession, the women in it and those in the audience yelled/sang "lelelele" in celebration. Next was a procession of friends of the bride, which I joined with my gift. Then came the family and friends of the groom - a smaller group but presumably they are mostly located in the other town where the wedding will be. Then, there was a procession of all the women. Some friends / family distributed household items (I got a blue plastic pitcher with a lid) and we danced into the hall waving the gifts in the air and deposited them in a basket in front of the bride. Finally, we returned outside and got our kitangas (brightly printed 2 meter swatches of cloth, sold here for between 5 and 10 dollars) and again processed in, this time wrapping the mother of the bride in the cloth to congratulate her on a job well done raising her daughter. (Perhaps to simulate swaddling a child?) That was the end of the processions, the last thing was to introduce all of the people who were on the Send Off committed. Mama Makule was in charge of the decorations, so she went up front with about 20 other people and was introduced. Then the bride, bridesmaids and groom processed outside and the bride and groom left in a decorated mercedes. The decorations were fabulous - again white and gold satin, with large bouquets of flowers and lots of white lights intertwined as well. There were probably 200-300 guests. I think Mama Makule said the bride's family pays for the send off while the grooms pays for the wedding. It looked like the send off would be about equal in cost to a wedding with the decorations and full meal, so it seems getting married here might be even more ridiculously expensive than getting married in America - at least proportionally. I do like the idea of getting 2 fabulous dresses though. :)

After the celebration ended, Mama Makule's husband, a doctor at the local government owned hospital came and picked us up - he had been working in his dispensary all evening. We went to the AICC club (Arusha International Conference Center) which is near the Makule's old apartment and had a beer and some nyamachoma (barbecue.) I tried cow intestines - grilled - for the first time (they told me after I had tasted them) - despite being grilled / roasted, they were still incredibly fatty. In addition to knowing they were intestines, the layer of fat that adhered to the roof of my mouth while eating them was enough for me to decide they may be a delicacy, but they're not my new favorite food. (Ironically, I really miss bacon which is also crispy and quite fatty.) But the grilled mutton and chicken was delicious and the grilled bananas served as the starch are kind of pretty much the same as fries - salty and crunchy without a lot of overwhelming flavor of their own. I got the last Castle Milk Stout (my new favorite beer) in the place and Dr. Makule had a couple Ndovu - one I haven't tried but he likes it because it is very light, so I doubt I will like it a lot. On the way home from the club (now after 11) Dr. Makule decided we should drive through town so I could see what it looked like at night. As we went past the Kibo Palace (one of the top 2 hotels here) he discovered I had never been inside, and insisted we go in for a drink on the terrace. The hotel is fancy - it is a round building around a central atrium that is probably 7-10 stories high. That's pretty high by Tanzanian standards. It's an interesting building and the terrace by the pool was certainly an enjoyable place to have a glass of wine. I got home well after 1 AM, which is the latest I've been out since getting here, and was pretty tired, but it was wonderful to have a couple local cultural experiences.

Sunday was church, followed by the Ngaramontoni market with Mat and Jane and Jane's Mom Margaret who is visiting from New Zealand, more computer work in the afternoon and dinner at Mat and Jane's. I stayed there Sunday night because I was feeling less comfortable about being at home alone (Bryant was on safari) after hearing that there had been not one but several attacks last week. Bryant is now off the Zanzibar with his girlfriend Brooke who is visiting, so I should be staying with Eric and Laura tonight. Unfortunately, I got home just as dark set in and while being a Muzungu in a house on Ilburo road is risky right now, walking around on Ilburo road after dark is certainly much more so, so I'm here alone tonight and tomorrow will go up to stay with them till Bryant gets home. Luckily, we have our old guard back, so I'm feeling only mildly anxious.

Last weekend Joel drove Me, Bryant, Eric, Laura, and Charlie (Eric and Laura's 18mo) to Arusha national park, which is about 1/2 hour from our house, though it took about 45 minutes because they have installed approximately 24 large speed bumps on either side of a bridge on the Arusha-Nairobi road after a recent medium-sized bus accident killed 16 people. Ok, I exaggerate there may have been 4-8 speed bumps on either side, but it was slowing traffic down significantly. (Which I'm sure was the goal. I hope the families of the 16 fatalities feel better now.) Anyway, in one day we saw a lot. We saw the elusive colubus monkey (but I didn't get a great picture) and some baboons, we saw a crater and 2 kinds of lakes. We saw some giraffes, zebra, water buck, gazelles, warthogs, flamingos and a bunch of other birds. It was really a fun day. Charlie was amazingly well behaved for an 18 mo old - he was curious but polite and never got upset or tantrumey although we spent at least 6 hours driving. Pictures follow, plus a few of Zanzibar. . .

Me + Giant water buffalo skull + alkaline lake:


Flamingos in the alkaline lake:


The regular lake at the park:The Meru Crater at the park:Me on the beach at Matemwae:
One more beach picture - the view of the seaweed harvesting at Matemwe:

Good News / Bad News

So the good new first. I continue to enjoy my work with the hospice team here. I got to do an inpatient consult on my own earlier in the week and I think I added some (hopefully beneficial) therapies that would not have otherwise been considered to the patients plan. I have adapted in many ways to an African way of life. The long waits for things and minimal productive time no longer really bother me at all - I realize this in contrast to Bryant who has been quite frustrated by the pace of his work at the new hospital. In some ways I was prepared for this by my time in Budapest, where there is also a more relaxed work flow. But I still found it a bit frustrating when I got here and have now adjusted to it. It will probably be hard to get back into an American schedule when I get home. I went to the Maasai craft market with the hospice team today to get some presents for the Exempla Team from Denver who are leaving today or tomorrow and Mama Makule said that I bargain better than she does, even. She was probably exaggerating, but she did seem impressed with my bargaining skills. This will also likely be a counter-productive skill because I can hardly go into target or the grocery store and say "Four dollars? Pshaw! I'll give you 2!" And finally, today we went back to Monduli, the site of the first day care I attended, and apparently one of the patients told Mama Makule I looked like a Tanzanian in my skirt and new scarf from Zanzibar. Last time I was there, almost exactly 4 weeks ago, I had on my pants and tennies. So it feels like I am finding a place here that is more than "Muzungu" or foreigner.

But then I got home and heard that one of the ex-pats who has been here for several years with her husband for several years doing what is essentially mission work was the victim of a home invasion robbery last night. The Jacobson's had this happen to them in October and November, so she is the second person in our neighborhood to have their home invaded in the middle of the night. She was alone at the time and I'm sure it was terrifying. She is OK physically, but one wonders if she will ever have the same trust and love for the Tanzanian people that she had yesterday morning. Just yesterday at the hospital, where she has been rounding with the pediatrics team (she was a practicing NP in America with her own clinic in Amish country, but has been out of medicine for a few years her) she was telling me somewhat guiltily about a family of malnourished children. One of the children came into the hospital at 3 mos or something with marasmus. The social worker discovered that the child's parents were both dead (likely HIV) and the child and 2 siblings was being cared for by the grandmother who could afford to give them only tea. The social worker asked my friend if she should send for the other 2 children who are almost certainly malnourished, implying that my friend should pay for their hospital stays. She replied that she didn't know and inquired about the usual procedures in these situations. (There are some funds / organization in place for orphans etc. but she didn't know the details or whether they would apply.) But later in the day she was clearly feeling guilty about not saying yes. This from a person who has uprooted her whole family and life to come to Tanzania with her husband (a physician) and improve medical care here. They have a couple kids in college, one in boarding school for Americans in Nairobi, and I am sure they are not making American doctor's salaries. While they are certainly not poor by local standards, I'm sure they don't have money flowing out their ears the way the social worker seemed to think all foreigners must. So it is frustrating that my friend, who was rounding with the peds team at Selian to try and help out and teach (and learn from Joel) yesterday, and feeling guilty about not taking care of a family of needy children that weren't even her responsibility, has now been the victim of a violent crime simply because she is a foreigner and people know that we have cars and computers, etc in our homes.

Interesting Morning

I woke up this morning and made some coffee and headed out to our porch to sit and read for a while and wake up in the early morning sun. Joel was already up and after saying good morning told me that we have a new stream running through our yard. "Stream of what?" I asked, picturing a parade of ants or chickens or one of the other ubiquitous pests here. (One morning Ann and I both heard what sounded like a heard of cattle go through the front yard at 3AM. They were probably actually out on the road, but that still doesn't explain why someone was herding cattle at 3AM.) I emerged to the porch and indeed, there is now a stream of water running through one corner of our yard. It didn't rain tremendously last night so we are speculating that someone must have opened a gate somewhere uphill from us. In investigating the stream, I also found a small avocado lying on the ground. I picked it up and followed the stream to where I discovered an avocado tree in our yard loaded with ripening avocados. They are small, because the tree is small, but I bet they will still be tasty. Finally, later this morning a large bird (maybe the size of a Canadian goose) glided into the yard landing near the stream. I told Joel that there was a large water bird in the yard and he said "Oh, yeah, that's the heron that comes to visit sometimes." So in 2 hours this morning, I experienced 3 new features of our yard - the stream, the avocado tree, and the heron.

Home safely

I am back in Arusha after my trip to Zanzibar. A week was enough time for me, for this trip. More even than here, Zanzibar is filled with people who want to sell you something or convince you to give them something, and telling them no (after a prolonged greeting process where they test your Swahili) is fatiguing. I will summarize the worst / most hilarious of these interactions. The first night we arrived, Ken and I were given a tour of the beach near our bungalows by a guy named Ally who was in some way associated with the hotel although perhaps not employed by them. About 20 minutes down the beach I decided that I would rather be swimming than walking on the beach, so I turned around to go home and get my suit and swim before it got dark or the tide got any lower. On my walk back to the bungalows, I was joined by a young man who spoke fairly poor English who walked along with me for most of the journey. I am still not entirely sure what he wanted - to practice his English perhaps or to recruit me for the full moon party at the nearby town of Jambayani that night, which he continued to ask about even when I said that I would check with my friends but it was unlikely that we would go. However, after I told him I was going home to go swimming, he asked me repeatedly whether I wanted anyone to shower with. I am fairly certain that he meant swim and it was a translation / understanding area, but it made me fairly uncomfortable and even though I told him no several times, he still walked all the way back to the hotel with me. I changed and headed out to the beach where he again approached me and asked if I wanted someone to shower with. I told him clearly and firmly that I wanted to be left alone and preferred to swim alone and he did go away at that point, but it was already 20 unpleasant minutes that I could otherwise have spent enjoying the beach, the warm weather, the water, etc. The last night in Zanzibar, I was sitting on the beach near our hotel (literally maybe 10 feet from the fence/ bushes that designate the hotel as a hassle-free zone) when I was surrounded by a cadre of small African girls in the 4-8 year old range. They yammered on at me in Swahili although I clearly didn't understand what they were saying, and pointed at my jewelry and theirs (I think they wanted to trade a bead ring for a silver one.) After a few minutes of this, which was not really unpleasant just somewhat distracting from the reading I had been intending to do, I was approached by 2 young men who seemed to be associated with the girls. They did the introduction / greeting test routine and then one of them asked me "Do you want husband." I looked at him skeptically and he repeated the questions. I replied "Not right now" and he said "Oh, you don't have husband?" He then asked me why I did not have a husband. At this point, I was tired of the whole routine and told him rather pointedly that this was a very personal question, it was rude to ask it to a stranger, and that if I were him, I would not do that again. Then, he asked me if I was interested in arranging a snorkeling trip the next day, told me I should give the girls some pens for school, and moved on to the next pair of white people down the beach when I was clearly uninterested in any of his suggestions. Obviously, some of these situations are comical in retrospect, but at the time, when you are having these conversations many times a day, they are just tiring, distracting, and annoying. The same things happens in Arusha to some extent, but not nearly as frequently or persistently, so I am glad to be back here.

After Mbweni and Chumwe, which did have excellent snorkeling, food, and a relatively interesting nature walk in the afternoon, we went to stone town and met up again with Ann, who had arranged a spice tour for us on Tuesday. The spice tour was interesting - we got to see cardamon, cinnamon, pepper, cloves and vanilla growing as well as seeing and tasting a wide variety of local and imported fruits, all of which were harvested along the way. Then we visited some relatively new abandoned Persian baths, and had lunch of spice rice, curry, and the ubiquitous spinach in coconut sauce (the main/only vegetable side dish in Zanzibar). After lunch we visited a nearby cave where slaves were hidden after the slave trade became illegal, the sombre nature of which was obliterated by the hokeyest guide ever, and had a quick swim at a fairly nice beach. That evening, we had dinner at the tower top restaurant which is recommended in all the guide books. The food was OK but the view out over the city and harbor at sunset was fabulous. The next day, Ken left for his brief Serengeti Safari and Ann and I went to Matemwe where we had a lovely air conditioned bungalow and a swimming pool, (the water is very low at low tide.) We spent most of the last 2 days swimming and reading but did walk up and down the beach and explored the tide pools as well. Yesterday we flew home in the same plane with the broken windshield and bargained from 20,000 shillings to 10,000 for the taxi ride home from the airport, which we were proud of. Today, Ann set out for home and Joel took Bryant, Eric, Laura, Charlie and I to Arusha National Park which is about a half hour drive from our house. It was nice and cool there in the morning.

Warning to all Minnesota readers: The following paragraph may be upsetting for you - you way what to consider skipping it.

Zanzibar was a beautiful and relaxing vacation destination and I can definitely imagine myself returning there again, especially since I didn't really get to see much of the historical sites or museums I had read about in "The White Nile" but it was too hot. Even with t-shirts and skirts, it was often uncomfortably hot and it didn't cool off at night. If I go again, I think I will splurge on hotel rooms with AC every night. And I will definitely take a friend - all the hasteling from the touts would be just too much to handle alone. But I think it would be a nice place for a family vacation if what you really want is fabulous sand, plenty of sun, and lots of fresh fruit and fish.

Monday I return to work at Selian and I have some projects in mind to help out the hospice team and interns so I'm eager to get started with the second half of my time here.

Pictures

The beach at Bweju at dusk:


The ruins and gardens at the hotel:


From Left to Right: Some Dude, Ann, Ken, Moses (the bartender and main staffer?) and Me at Mustapha's:

Me on the dock at the Mbweni:

Zanzibar!

Ken and I arrived safely on Zanzibar on Friday, now 48 hours ago. We flew on a very small airplane from Arusha - there were no flight attendants, just the 2 captains and one of the windows in the cockpit was held together with duct tape (a small one.) It was incredibly noisy but we arrived safely, and we got to see Mt Kilamanjaro which Ken had recently summitted, and I hadn't seen yet. It is incredibly tall.

On arrival, we took a 'taxi' arranged by our hotel from the airport. This was nice because we didn't have to bargain with all the taxi drivers there or deal with touts trying to arrange tours, snorkeling, etc while doing so. But the taxi ended up being a small jeep - like a rav 4 or smaller maybe, with 5 people in it, so it was a very close and warm ride. We stayed Friday and Saturday nights at Mustapha's Nest in Bwejuu, which was described in both guide books as a friendly rastafarian establishment. Rasta it was - I may have heard more Bob Marley in 1.5 days than I've listened to for the preceding 27 years of my life. It was also friendly - on arrival we were taken on a walking tour down the beach to nearby Paje and we were warmly welcomed every time we returned to the hotel by the staff. The staff was between 5-10 young men. I never figured out exactly how many, because they seemed to come and go, and some of them may just be friends and not really staff. They had the overall attitude and apparent thought processes of a group heavy pot smokers in America, although I suspect there is no marijuana in Tanzania, as it is probably severely punished. There must be something about living on Zanzibar or listening to too much Bob Marley that makes one pleasant, friendly, and fairly simple. While we were waiting for our ride this morning (for over an hour - Tanzanian 10-10:30 is 11:15, but we were prepared for this) three of them were content to sit around the fire circle with us, teaching us words in Swahili at a very leisurely pace and occasionally getting up to dance or wander around. For us it was amusing but if I did that on a daily or weekly basis, it would become mind-numbingly boring quickly, and they seemed to be sincerely very happy and amused.

On Friday night I caught the tail end of high tide for a brief swim. The water was the perfect temperature - warm enough to be easy to get in and too feel a bit chilly when you get out. The sand was amazingly soft in Bwejuu, fine, and white. The low tide is low - the water goes out at least half a kilometer - so I was lucky to have a few feet of water to paddle around in. Friday night I had delicious grilled king fish - a large white fish with good flavor and texture, a beer and a half, fries, and coconut spinach all for under 10 dollars at Mustapha's. We had good breakfasts both days - an egg, a mini loaf of bread, coffee or tea, and multiple varieties of fruit. And breakfast was included in the cost of our $35/night bungalow! Saturday, Ann arrived to join us in the morning and we spent the middle part of the day walking down the beach with stops for swimming and inspecting the seaweed farms of the local residents. We had pizza, which we had all been subliminally craving until we heard our table mate talk about it the night before, for lunch at Paje By Night and had a leisurely walk home with more swimming and sitting in the shade to read. After a rest and a shower, we set out in early evening and walked 2 km up the beach to a Belgian hotel that was recommended in the lonely planet for interesting food. The food was mediocre and expensive for Tanzania, but the place was beautiful and we enjoyed the walk. And "The REAL Beligian Chocolate Mousse" for desert (the only desert on the page listed in red letters) was excellent. And the walk home under the nearly - full moon was nice too. We did not take our hosts up on their offers to accompany them down the beach to Jambazi for the big full moon disco party - at 11 they had not yet set out and none of us felt particularly inspired to disco.

Today, Ken and I got a minibus ride back to the west side of the Island to the Mbweni Ruins Hotel which is a splurge for both of us but is proving to be quite enjoyable. They greeted us with warm towels and passion fruit juice as we checked in, the beach is very nice (deeper for swimming even at high tide than Bwejuu, and the hotel kitchen is excellent and very reasonably priced. For lunch I had a 3 course meal - carrot soup, fish curry in traditional Zanzibar style, and wonderful mango sorbet - for 12,000 shillings which is less than 10 dollars. This afternoon, we explored the gardens and ruins of a girls school on the hotel grounds seeing many fruit trees, palm trees, and other interesting plants and we also saw a fruit bat in the ruins. Then we had a nice swim on the beach and in the pool when the tide started to go out. Tomorrow, we get to go to Chumbe Island nearby for snorkeling and lunch. They only allow 12 guests per day on the island which is a nature reserve / preserve and is supposed to have some of the best snorkeling around, so we are feeling very lucky to have gotten a spot. Zanzibar has been relaxing and beautiful thus far.

Hooray Internets!

Yesterday we got a new housemate, Bryant. He is an public health grad from MN who is here to help with systems set up and admin at the new hospital. And he brought a laptop, which is not 10 years old and as speedy as our tortoise! Our hostess Linda got the internets hooked up in record time (24 hrs - imagine if comcast could do it that quickly!) so I can actually post a picture tonight. It seems like one is about the best I can get, so you may get one a night when I get back from Zanzibar, where I depart to tomorrow afternoon. Beach, snorkeling, seafood, here I come. . .

Me in our Jeep on safari:

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Reflections on my experience thus far

Last Thursday marked 2 weeks here in Tanzania and 1/4 through my trip. I haven't written much about my clinical experiences here in part because it is hard to know what to say, and in part because I don't want to exploit the people I am meeting here for a good story. But they are a good story, and the longer I stay the more apparent it becomes. Yesterday, at church, I was chatting with Ashley, the Denverite who arrived on the same flight with me from Amsterdam and shared my ride into town from the airport. On the flight, she had told me she is working with a non-profit organization that helps women's groups here, particuarly the Massai girls school. (Women are valued somewhere between cows and goats in Massai culture, as far as I can tell.) Yesterday, another ex-pat was asking her how she got involved with the group (while she was still in college - she graduated last spring) and she said "I founded it." The ex-pat community here is composed of tens if not hundreds of people like this - people who have found some need here so motivating that they either pick up and move here, or come once a year, once every couple years, etc with resources and knowlege to help. It is really an inspiring group of people. I imagine it must be very hard for their children - who grow up here in this selfless, caring, relatively tight-knit community to go off to college in America (which most of them do) and realize that not everyone's family is like theirs.

The locals that I have gotten to know are no less impressive. I had the honor of having saturday dinner at the home of Elizabeth, the head nurse/administrator of the Selian palliative care team. Over the course of the afternoon, she told me about how she had been to conferences around africa to improve and broaden her skill set - and then has been a faciliatator at similar things locally and throughtout Africa as she became and expert in home care. She even left her family and studied in Leeds for a year. Her husband, an internist at the local hospital has studdied abroad as well, in Boston for an MPH and probably other places as well. He works at the government hospital during the day and then at a private dispensary (small clinic and pharmacy) at night and on the weekends. Both of them put so much time and effort into bettering themselves so that they could afford the best education possible in tanzania for their two children.

As far as medicine itself goes - it is harder and in many ways more rewarding. When I go out with the pal care team for daycare, they are now having me see patients independently - with the help of one or sometimes 2 interpreters. (Eg: english->swahili, swahili->Massai.) We have no labs or xray equipment available and most of the patients we see do not have resources to get into town to a hospital that would have these facilities. So my therapeutic decisions are entirely based on history and exam. History is hard with the language barrier, and culturally people here are much less time-sensitive, so it is often hard to get a good idea of how long something has been a problem or how it has been changing over time. Add to this the limited supply of drugs (we bring a suitcase full with us) and time (we usually see 15-30 patients in 2-3 hrs at these visits) and it is very challenging to feel like you are giving your patient the best possible care. But then again, if it weren't for the pal care team these patients wouldn't get to see a doctor at all, and usually I do feel fairly confident that I can offer them relief for one or more of their problems after a through history and focused exam. And I feel confident that every patient I see needs a doctor, wants to get better, and can benefit in some way from my time and knowledge. (My American patients often do not meet all 3 of these criteria.) It is certainly frustrating to see problems that would be easy fixes in America and we can do nothing about here - my patients with cardiac chest pain symptoms or valvular heart disease really have no options here - we have no cath lab or cardiac bypass capabilities - but it is also rewarding when we can help someone feel better, particularly given the limited array of tools we have. And I can see why people who come here once keep returning.

obama night picture

Me with my Tusker on Obama night:

Ok, so I got one picture uploaded (after 15 minutes) and then the computer stopped recognizing my flash drive for long enough to upload any more. Maybe tomorrow!

Safari!

The Safari was fun, I'm really glad I decided to do one, as I had been thinking that I would probably skip it due to costs (the quotes we got prior to arrival ranged from 330 - 600 dollars per person per day.) Dan managed to find a much better deal, however, for a 3 day 2 night tent safari. The camp ground was no where near the national parks so we were not in any danger of having lions prowl past our tent at night. (We had heard some stories about this.) Saturday morning we set out in a 6 seater Toyota land cruiser - our driver guide was Goodson and our cook Charles. There were 4 comfy captains chairs for Dan, Ann, Ken, and me, and the top popped up about 3 feet allowing us to stand up (or on our chair in my case) and see 360 degrees of scenery without windows obscuring the view. Our first stop was Terengiere national park which is a dry, hilly somewhat wooded expanse with a river running through the middle that was nearly dry as we are at the end of the dry season. We saw some zebras and wildebeest off in the distance almost right away. We were super excited, and stopped to use our binoculars and zoom lenses to get a better look and some pictures. However, as we continued our drive through the park, we got increasingly close to a wide variety of animals - hundreds if not thousands of zebras and wildebeest, several troupes of elephants, giraffes, warthogs and the occasional buffalo. At our lunch stop, we saw some baboons steal some lunch from some older German or french tourists. Goodson had reluctantly informed us that we should eat in the car because baboons frequent the picnic spot and are afraid of black people, but are very aggressive about stealing lunch from white tourists. We continued down into the river valley after lunch where we came across our first troupes of baboons, black faced monkeys, and black monkeys. The baboons were the most interesting as the largest of the groups was involved in a fight when we arrived. We also saw some beautiful birds, including a saddle billed stork and some (ugly) vultures. The highlight of the afternoon, however, was probably the lions. You can tell when there is a more rare creature being seen by the larger number of jeeps clustered along the road and the longer time they all stay. We came upon a large cluster of jeeps in the river valley and eventually were able to see 4 lions across the river - 2 under a tree and two in a large nearby bush. They were mostly resting in the heat of the afternoon, but the did get up occasionally to stretch and one walked from the bush to the tree. After about 20 minutes, a lone elephant approached and Goodson informed us that he would probably kick the lions out of the area. (Apparently, elephants tell lions what to do and not vice versa.) Unfortunately, the elephant had business elsewhere, so he turned about 50 feet from the lions and headed around them. It started to rain a bit, so we headed out of the park, but on the way we got to see more animals including a number of zebras, elephants, wildebeest and gazelle that crossed in front or immediately behind us on the road. By the end of the day, we were laughing at ourselves for spending so much time with binoculars looking at distant herds on the way into the park.

We had a short drive to the campsite, which ended up being in the center of a small town / commercial area with glass topped walls around the edges. It had a swimming pool, bar, and some fairly sketchy bathrooms. We quickly learned that the bathrooms in the park are by far the nicest 'facilities' as Goodson called them, so we'd use them on the way in, at lunch and on the way home. We had a swim and some aperitifs, and then it was time to eat. For dinner, we had popcorn, vegetable cream soup and bread, beef with sauce, potatoes with chives, and mixed roasted veggies. We were introduced to warm powdered milk with sugar, which was actually quite tasty.

Sunday was the Ngorogoro crater, which is the remains of a volcano that erupted thousands of years ago, spewing all it's magma, and then the cone collapsed in on itself. It was beautiful grassland with scattered forested areas and jungle on the walls in and out. It actually remided me a lot of driving over the hill from Bailey, Colorado into South Park - coming over the hill and seeing the grassland spread out in front of you and surrounded by distant hills. Of course, there aren't cape buffalo, rhinoceroses, hippos, wildebeest, water buck, and cheetahs in South park. We drove around again, stopping when we saw something interesting (or a herd of jeeps indicating something interesting) We did see 2 cheetahs and another couple lions, heyenas, wild dogs, jackals, and elands, buffalo, waterbuck, hartebeast, dik-diks, impala, several brightly colored birds, and probably some other animals I can't remember the name of. We did see hippos and the rare black rhinoceros (from a distance.) As we lunched at a small lake (in the car because of aggressive birds this time - I do not think they distinguish between the races however) an elephant walked by quite closely. On the drive out of the park, we saw several families of warthogs - the babies are really cute because they run with their tails straight up in the air, and another couple troupes of monkeys.

It's 6 o'clock here, and my hour of internets is almost up - and we have to walk home before dark, so I'll have to finish the safari details later. I did take upwards of 500 pictures, but the net is pretty slow today, so I won't be able to upload them. Hopefully soon!

Busy week!

Well, it has been a busy week. Monday was my first day with the palliative care team - in the morning they oriented me and 3 visitors from Iowa who are here with an orthopedic surgeon on a medical mission. Their group is called STEMM - Sioux City Area (Something) Medical Mission - they have the surgeon and a number of people from several church congregations that are building a village for some orphans and then some that are visiting orphanages and things like the palliative care program. Monday afternoon we did 2 home visits - both to extremely frail cancer patients with open wounds for dressing changes, food and supply delivery, and they sing a song and pray at the end of each visit with the evangelist. (Pastor)

Tuesday was more home visits and then - OBAMA NIGHT! We went to "The Greek Club" which is an ex-pat hang out in the ritzy part of town arriving at around 6:45. My housemates managed to snag a table, though the bar area was already quite crowded. We drank Tusker Kenyan beer in honor of Obama and waited for the inauguration which was at 8PM our time. It is luck we got there early, because Dr. Jacobson was turned away, apparently there was not room for any more land rovers in the parking lot. (Gated, as all lots are here) The bar had a giant tv and we got to watch all the proceedings on CNN, the crowd was excited and there was lots of cheering. It was a really nice way to celebrate the inauguration, and we probably wouldn't have gotten to watch it at home because we would have been at work.

Wednesday was my first hospice 'Day Care'. The concept of day care in western hospices is respite care for the patients care givers- there are usually volunteer drivers who pick the patients up once a week or once a month and bring them to the hospice center for nursing visits, meals, entertainment, and stuff like hair cuts and nail polishing during the day, giving the care givers at home a day off. Here, it has had to be adapted. The Selian hospice volunteers arrange for a location in the town- usually the church or the school and make lunch for everyone. The Selian team brings medicines and some small food gift and our Evangelist and for the most part the patients come on foot, although they do sometimes go out with the land rover to get people. We had introductions, a brief prayer service, lunch, and then Namayani the clinical officer (like a PA) and I saw between 20 and 30 patients from 30-70 with HIV/AIDS - we look at their blue cards which is the official record of their antiretroviral treatment and CD4 counts, ask if they are having any bothersome symptoms and get a brief related history to those symptoms, and then prescribe any medications we think they might need. We did all of this in 2.5-3 hrs. Meanwhile, part of the team and the visitors from STEMM went out and visited a patient who could not come in and one who was in the hospital, both of whom ended up dying Wednesday evening or Thursday morning. It is clearly functionally very different from the western hospice concept of day care but it seems to provide a valuable service for the patients - a quick, free visit to the doctor for minor complaints (we did tell those with issues too complicated for us to manage in 10-15 min or without further diagnostic testing to go to the clinic or hospital) and some nutritional flour and fruit. And it is more efficient for the team than going to each patients home, so they can serve more patients this way. They are not constrained by the Medicaid definition of hospice, so they provide palliative care services to anyone with HIV/AIDS or cancer. (and probably a small hand full of other illnesses)

Wednesday night we had an Obama party for the interns. We made pizza, which was a big hit, passion fruit juice, and Dan and Ann got some cheese and crackers and chips. And of course we had beer, but the interns seem to drink mostly Fanta and Coke. Very unlike American interns. :) We toasted the election and had some good conversation and food.

Yesterday (Thursday) was an administrative day for the palliative care team here so I rode into town with Joel, Dan, and Ann and we confirmed our safari plans. We are going on a 3 day, 2 night safari visiting Tarangiere national park, Lake Manyara national park, and the Ngorongoro crater for a game drive. We will be staying in tents, but hopefully the lions won't be walking past at night. (We've heard some stories about this.) I finally got my walking tour of town and so now I know where to go for the internet cafes and the best Samosas, and we started looking into Tanzanite, but it's fairly expensive even here so I doubt I'll end up buying any.

Today - daycare again, then preparations for our safari! I'll find a fast internet connection Tuesday or Wednesday for some pictures.

Palliative Care in Tanzania

I walked up the road from our house - my first time out on my own - to the Il Buro Safari Lodge, where we heard there was some internet. For 3,000 shillings (2 dollars) I have a half hour. Unfortunately, The computer sounds like it is a jet engine about to take off when loading websites and the zip drives appear to be broken so no pictures today. Il Buro is the name of our neighborhood. Some other time I'll take a picture of the Il Buro shopping center, which is across the street from our house.

I met with Dr. Hartwig yesterday. He is the director of the ELCT's (Evangelical Lutheran Church Of Tanzania) hospice / palliative care coordination program. He is trying to establish palliative care here in TZ, primarily for AIDS patients but also for a growing lung cancer population. He has been here since 2005, I believe. He and his team of another, Tanzanian doctor, a nurse, and an accountant coordinate a network of about 14 hospitals with palliative care programs in various stages of development. They all have at least one dedicated staff (a nurse) and a team of volunteers from their catchment area, almost all have cars now and Dr. Hartwig's organization supplies them with medications and resources, as well as having training sessions and site visits regularly. It seems this is a really great foundation and it is rare for palliative care to be provided by a network of hospitals - most hospice / palliative care programs are free standing. They get support from the ELCA (American Lutherans) the APCA (African Palliative Care Association) , the US fund for faith based HIV/AIDS relief work, and several hospices in Colorado. The major hiccup in all of this is that they have no narcotic pain medications at most of these sites. There are only 4 sites in the country that have government clearance to get and use oral morphine - 2 in the capitol Dar es Salam and one in southern Tanzania and Selian here in Arusha. The one site in the country that makes this medication, however, is out of the preservative needed for the liquid formulation (which is the only legal formulation.) So even Selian's hospice team has been out of oral morphine for a few weeks. But the other 13 or so sites in the palliative care network have only NSAIDS (mainly diclofenac which isn't used much in the US) Tylenol, Amitryptlyene and Tramadol for pain management. Once in a while they'll get some codeine tabs. (Somehow that is legal but all other opioids are not) Since the main principle of palliative care is effective pain management, for many of their patients, they cannot provide true palliative care services. Still, it seems like they are establishing a network of well trained, caring people and they are working on applications for the other sites to get morphine (though how they will more than quadruple their supply, since there is only one supplier, is another question.) In a country where more than 90% of all cancer diagnoses lead to death (there is only one center that does chemo/rads, in the capitol) and where the death rate from HIV/AIDS continues to climb, effective palliative care supplied to as wide an area of population as possible does seem critical.

Yesterday afternoon was quiet for me - I took a nap - I'm not over my jet lag / chronic sleep deprivation - and then Joel made us chicken with veggies and rice for dinner. I tried Castle Dark African lager, which I quite enjoyed, and read some of The White Nile and went to bed early. This morning we attended the non-denominational ex-pat christian church here in Arusha and then went to Shop Rite. The church service was nice, with lots of songs (I was prepared to be annoyed by all the new age hymns, but then we sang Here I Am Lord, so I really can't complain.) Shop Rite is a large grocery/dry goods store, basically like a grocery store at home (maybe like Aldi - limited selection). Pretty home-like though, they even had my favorite Irish cheese. Now we have a lot of eggs and some pizza making supplies for our party Wednesday to celebrate Obama's inauguration. Yes, people are excited about Obama here - there are copies of his red and blue face logo everywhere - dala-dalas (minibuses), roadside stands, personal cars, etc. Maybe we'll even be able to borrow a laptop from someone and watch his speech on you tube.

Tonight I must prepare for my first day with the Selian palliative care team and figure out some sort of carrying system for my white coat that prevents it from getting wringled or dusty. It did not fare well in the land rover on Friday.

Safe Arrival

My new home, with the tortoise making his rounds.

I arrived here Thursday night, to Killimanjaro airport which is a drive from town. It was well below zero when I left MN on Wednesday morning, so I am really grateful to Sandy for driving me to the airport - If I'd been busing it I would have had to take my snow boots and warm coat with me. And I would have had to lift my 45 lb suitcase (thanks Dad!) onto the bus. Getting it into the trunk was hard enough. ALL the liquid items will be staying here in Africa on my return. My flights and layovers in Amsterdam were uneventful. I stepped off the plane onto one of those outdoor stairways into 84 degree weather Thursday night. I was fortunate to be sharing a ride with Ashley, a Denverite who is working with a Maasai girls school and has been here before so she helped guide me through the visa process (which was basically just handing my passport and a hundred bucks to a guy in uniform and then waiting for him to return.) We found our bags which had been unloaded by the time the visas were processed and a driver was waiting for us with a sign outside the secured area. We loaded the land rover and set off for my new home. The reason for the land rover was clear as soon as we turned of the main (paved road) - all other roads are rutted 4 wheel drive dirt, flanked on both sides by large groups of pedestrians and not infrequently too narrow for 2 cars to pass. The house is beautiful and there is a guard at night (And maybe during the day) who opened the large gate for us. Apparently, there is no guard on weekends, however. There is a tortoise that lives in the yard who is at least 2 feet long and must be middle aged by human standards. The ceilings are high, the floors are concrete that is is washed regularly, and there are nets on all the beds. It is dusty here - I will get good use out of my 6 pair of khakis, and I assume that is the reason for the easily mopped floors.





Friday morning I rounded with the medicine team at Selian, seeing maybe 20 adult men and women who were inpatients, then we had chai and chapati (a sort of flat bread) before lunch at the hospital canteen. Friday afternoon was the trip into the new hospital in town (which just opened last week) for peds and HIV clinic. I was starting to get tired and hadn't had the opportunity to get shillings yet, so I walked to a nearby atm while my housemates were in clinic. My housemates are 2 fellow residents from the Minnesota med peds program, Ann and Dan, and Joel, a med-peds ID staff from southern California who is here for his 3rd trip and has a great grasp of infectious disease in Tanzania. We are lucky to have him as a resource. Dr. Jacobson, the main U of M connection and the director of the new hospital in town (and former director of Selian) took us all out for dinner at a Somali restaurant (after I had a nap) and I had my first Tanzanian beer - Serengeti. It was unoffensive. This morning, I am meeting Dr. Hartwig, the palliative care director here, who is kindly letting me use his internet, after introducing me to his program and giving me some suggestions of drugs and ideas to familiarize myself with.



So first impressions - it is warm, (wonderfully!) dusty, very friendly, relaxed, and incredibly different from home. I think it will be a great experience.

Preparations

It's minus 6 degrees Fahrenheit here in Minneapolis. (That's minus 21 for our Celsius friends) This morning, it was even colder when I went to the bank. I finished firms night float at the University yesterday morning, 75% of which is admitting people with organ transplants or chronic pain syndromes, and it is probably impossible for me to express how happy I am to be going to Africa. I get away from the cold and the drug seekers, and the patients that I can only make not worse, but not better either. But, more importantly, I get to experience the practice of tropical medicine for the first time, and to assist in providing palliative care from a different cultural perspective. Am I ready? No. I hope to be packed on time tomorrow, though sadly I will probably not get my pre-trip cleaning done. But on a less superficial level, yes, I think I am.