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.