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!
Thursday, January 29, 2009
obama night picture
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!
Wednesday, January 28, 2009
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!
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!
Friday, January 23, 2009
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.
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.
Sunday, January 18, 2009
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.
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.
Saturday, January 17, 2009
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.
Wednesday, January 14, 2009
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.
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