Travel Update

Dear Carl, Jake, Laura, Laura, Meg and Serena,

I hope all your travel plans have gone as expected since I last saw you.  Meg and Jake, I hope you arrived in Rome with no further delays.  I can only imagine you were pretty bushed by the time you got there.  Assuming nothing else intervened, Rome is the reward in itself.  Just watch out for the pick-pockets.  Our experience a few years ago was a classic.  Lots of luggage, of course, we wer boxed in on an escalator by a team who frisked us as we got off.  We detected the attempt, but I know friends who had the same experience and weren't as fortunate with their fortunes.

Will and Laura, I hope you have found basking in the Zanzibar sun to be soothing and re-energizing.

Carl, Laura and Serena, I hope you arrived home without incident to loved ones and their hugs after your long journey! 

Now here are your assignments....  Just kidding.  Just so you don't worry, I gave you all A+.  I cannt understand why those other faculty members were thinking B!  Just kidding again.

You were all stellar.  We have had students two years in a row that really have set a high standard.

Well, I had a minor travel adventure.  After leaving the airport, I was Shanghaid, well not to Shanghai, but to the New Africa Hotel, where I was forced to live in the lap of luxury for a day.  Oh, the pain!  I could have been in any number of fancy hotels in the USA or Europe.  Except to go outside, I toally lost track of being in Africa, except for the poverty and street vendors, daladalas, buses, katangas, street corner beggars missing limbs and one or two other differences.

It was a relaxing time.  We got on our plane without a hitch, and though I was pretty relaxed and confident about it, this solo mzungu couldn't help but get a little twinge of anxiety.

Last night brought a couple of fortuitous events.  The lady at the KLM desk remained calm and kind throughout the experience.  When I understood that, I couldn't help but thank her for her courtesy and kindness, Meg.  Today, she was back and for us it was easy to be gracious and all smiles.  I thanked her again.  In Swahili.

The other is the acquaintance of Jim Dobbin, a consultant to big organizations who applies a comprehensive evaluation of business, social and cultural circumstances to give companies an integrated understanding of their potential business in a community, instead of the silos companies often have, limiting all concerned.  He taught me many things in a short time.  It was great!  I look forward to our paths crossing again in the future.

As I write, it is  AM at home and I am near boarding time for my flight.  Send me a note when you can.  I will be sending a group email about a couple things shortly after I get home.

I treasure the experience with all of you.  Each has unique gifts complementing your marvelous skills and knowledge.  See you all soon!

It’s a God thing….

2-17-2012

As noted above, I am supposed to be home in a few hours your time.  Add 24. 

Yes, a BROWN elephant!

Currently, I am sitting in one of the swanky Dar hotels, the New Africa Hotel.  I just had lunch at another swanky hotel, the Serena.  But that isn’t the half of it!

Last night, while I sadly left Jake and Meg standing in the Dar airport, with no control over the situation at all, I was ushered to a cab to take us to the NAH, sharing with an executive-type in a sport coat and tie.  In the Dar airport.  Our conversation quickly turned to our activities.

Pumba.  Hakuna metata!

His name is James Dobbin and he does consulting work for big companies in Africa.  His team studies sites in a comprehensive, multidisciplinary way, precisely to avoid the silo effect that so many companies can fall into accidentally, limiting their own profits and not maximizing communities where they are investing time and energy.

Elephant's cousin, the Rock Hyrax.

He was enormously interested in the Ilula Nutrition Project, although it needs a different, more inclusive name.  He liked the multi-layer approach with Ilula, Amani Orphanage and Ag Institute.  He offered me many insights and has offered an introduction to someone he knows at USAID.  Then we would have two contacts there.  Jim also said, paraphrasing, to ask for a lot of money, because USAID isn’t  likely to have much interest in small projects.   One beauty of ours is the potential scalability to a broader area.  Wow!  Serendipity, perhaps.  Or it's a God thing.

Golden-Breasted Weaver 

One thing he did not offer was money (no, I didn’t ask).  Does anyone know where we could find $500,000?  How about $50,000?  Does anyone know of benefactors who might be interested?  Does anyone know Mary Lee Dayton?  I think this would be right up her alley.  Think about it.  Please!

Here are a few fun photos.  I know you skipped to them first, but I hope you read this installment, perhaps even thinking I was going to describe the photos.  Nope.  Just captions.  I hope you enjoy them.  Come on over to watch the other one thousand I took!

Bubba Baboon

 Hopefully, I will get out on tonight's plane.  I have a boarding pass, a good sign, I believe.  Jim and I are confirmed for our flight.  Another good sign, I believe.

On the way home

2-16-2012

Well, some are and some aren’t.

We arrived in plenty of time to get registered, about 2.5 hours early.  After dropping us off at the airport, Will and Laura went back to FPCT with Peter. We had spent a nice afternoon at Wood Carver’s market, late lunch and shopping at Slipway and nice dinner at Sea Cliff. 

All of us were in line, but for a few of us it was for naught.  “There is big trouble with your ticket.”  Loosely translated, “We are over booked and you are bumped.”  Serena and Laura Brown got on.  Carl was bumped, but was later called up.  Meg and Jake were bumped too.  Meg and Jake were rebooked on a flight leaving at 3 AM our time and will miss there original flight to Rome.  That is rebooked too and they will get in (tired) about a half day late.  There wasn’t time for them to go back to FPCT, but apparently, KLM was going to feed them.  (We just came from dinner.)

I was bumped too.  Currently, it is nearly 1 AM and I am sitting at the New Africa Hotel.  I will be asleep in a few minutes.  I will ultimately get in about midnight instead of noon tomorrow.

All’s well that ends well.  Stay tuned for the end of this cliffhanger!  Now really.  Tis isn’t a soap opera.  It is a mere inconvenience.  (Still a PITA.)  See you all soon!

Free Pentecostal Church of Tanzania Hostel

2-16-2012

We arrived in Dar last night after a fairly grueling drive and ride.  If I say it was grueling as a rider, I hardly can imagine myself what it was like driving!  From Mikumi to the outskirts of Dar the traffic gets progressively worse.  We arrived in Dar what I imagine to be rush hour.  If it was not, I don’t know what would classify as “rush.”  Our driver, Peter, whom many of you know from your own trips is a great driver.  He accommodates the careening city buses with aplomb.  Pedestrians dart to and fro.  It is a nerve-wracking experience.  You cannot afford Valium as a driver either, or anything else that might slow the reaction time, although I cannot help but think some of the other drivers, many of the other drivers, have had something that disinhibits their brains from even self-preservation.

Along the road we did see several accidents.  Leaving Ilula, near the canyon, there was a semi a hundred yards up the mountain, on its side if I remember correctly.  I am guessing it was the product of a runaway, but with no deceleration ramp there to begin with.  There is now.  We saw a burned-out container trailer, I am quite sure was there three weeks ago and Carl confirmed it to be present five weeks ago.  As we neared Dar, there was a huge traffic jam.  As we passed, we could see the wreckage of a motorbike on its side lodged underneath the front end of a coaster bus.  We could not see the driver of the piki piki, and we presume he was extracted, but of course we do not know his condition.  I sure hope it was a walk-away!  The traffic on that side of the road was backed up for a couple miles.

Other than long and hot, bad traffic and terrifying drivers, the trip was slightly marred by the fact that one of us “got sick” (American, maybe Midwestern, possibly Minnesotan, euphemism for more graphic and colorful terms for vomiting).  We haven’t been able to figure it out.  Presumably it was food poisoning, but others had the same food.  It started two hours or so after eating and she is much better this morning, “90%,” she says.  (She looks 90% better too.)  No signs of more dire illness, either.  I am simply an observer here, so I don’t think any HIPAA regulations are trampled.

We ate at the New Africa Hotel, but none of us were very hungry.  The management did accommodate the patient with a temporary room for cool comfort.  Very kind!

The day dawned bright here at FPCT, but I promise you none of us saw it.  Carl and I were up first around 7:30 AM.  Ok, so I had been awake for an hour and I don’t know about Carl or Peter, for that matter.   Regardless, we slept “lala fo fofo.”  Like a baby.

It is 10:15 AM here, so I hope many who will read this are sleeping “lala fo fofo” currently.  We are leaving FPCT at 11.  This is after my shower.  We need not be in a hurry.  We will have plenty of time for the woodcarver’s market, Slipway and Sea Cliff at that.  Next report is likely to be from Amsterdam!  Safari Njema to us!

Ruaha and Mwagusi

2-12 to 14-2012

I asked her, “Does Mwagusi mean heaven?”  “Yes,” Connie the hostess answered without hesitation.  Can’t help but agree.  I think I would like to see how long I could stay at Mwagusi before I got tired of it.  I probably wouldn’t feel compelled to go on a game drive every day, but maybe.  I wonder if they need a camp doctor?  Bird, I think you have at least a dozen skills they could use.  Which ones should I check for on the “help wanted” board?

We had a wonderful buffet lunch with tasty salads and delicious small sandwiches.  I tried about half of the salads, all fresh vegetables.  There was also a nut-crusted veal that was equally tasty, then a small apple dessert.  That and a glass of wine topped it off.  The coffee was rich and flavorful too.

Peter did his stellar job of driving, as usual and had lunch with us.  It is 3:35 right now and we are going for our first game drive at 4.

Peter said the group two weeks ago saw a leopard.  I asked him if he knew what the word “fib” means.  Not that the big group was fibbing, of course.  Just saying….  We did see a few elephants, antelope, a giraffe and a zebra way off in the distance as we drove into the park.  The students eagerly got out their cameras.  I restrained myself from saying, “Don’t bother with those, cuz you ain’t seen nuthin’ yet!”  And we will probably see at least two leopards.  Regardless, I will be reporting our amazing animal sightings for the next two days.

We brought two kg of mushrooms from Amani Orphanage as a small gift for Chris Fox, the owner of Mwagusi.  They actually get the mushrooms they buy from the same place.

Well, if this were a plane flight it would be “wheels up” in ten minutes, so more later.

2-13-2012

We have now seen half a leopard.  Well, over half, I suppose, since half the group saw a full leopard.  Our half saw the kill and smelled it too, and when we returned it had been moved, presumably by the very same leopard.  And this does not include the woman from San Francisco who runs each morning in the leopard print tights.  We went back several times, but several other vehicles di also.  Only our other group got a glimpse of the leopard again.  And Carl got two spectacular photos.

We also heard that Ann and Phil saw fifty birds on their bird-walk.  Ha!  We saw a HUNDRED birds all at once AND they were all the same kind!  Seriously, we did see a lot of birds.  Got a couple great pictures and a new one for my “All-Time Favorites” group, a crown something, something crane.  Everyone has there fair share of great photos.

Well here we go again.  Our last drive in a few minutes, with mid-afternoon tea on the trail.  And yup, we had a great time.  The elusive leopard remained elusive, but we enjoyed the tea.  Both nights we had dinner dining on the riverbed.  You simply half to do this.  Lanterns and a bonfire, pre-dinner cocktails (with ice, if desired).  The cooking fire is built in a long, banked line of coals with the pots on the coals.  The staff stands behind and reports what each dish is.  Two words, duh-lishus!

2-14-2012

You would be bored if I listed all the animals we saw, so I will only name a few.  There was Hortense, Alvin, Edith, Bertha and a host of more African names that I cannot spell.  Elephants, lions (stalking, but not us), zebras, leopard, giraffes, warthogs, jackals, ostriches (I include it here because it is the TZ national bird and because it is big), water buck, Grant’s gazelle, impala, greater and lesser kudu (not kuru, that’s a prion disease, not big game), hippos, those monkeys with the red butts, oh yeah, baboons, water monitor (think 4 foot lizard, down-sized from my original estimate of six feet by Justen, our overly conservative guide, I’m sure), cape buffalo from a million miles away, rock hyrax (a relative of an elephant, by marriage, perhaps, because it is furry, climbs rocks and is the size of a punt pup), bands of banded mongoose, crocodiles, dikdik, and oh, so many more.  Many of the animals struck poses just like in pictures.  I think they have done this before.  A nice thing about Ruaha is the low number of vehicles you see.  At the Serengeti, there are lines of cars waiting in line to see the lion.  We saw two prides of lions and watching the one pride on the prowl was thrilling.  The lions wee down wind of the impala, but they did catch sight of the lions, did some sort of dance equivalent to nana nana boo boo and took off.  Lucky for them.  The lions looked hungry.  With the impala out of the picture, I started noticing what tender morsels we might be.  We left.  But not because I was crying or anything.

We left Ruaha by way of  another early morning game drive, but still didn’t catch sight of the leopard.  Another breakfast on the trail was scrumptious.  We ate late lunch at Neema and got to Ilula about six, all pretty bushed.  We invited a few guests including 7 from the Amani orphanage.  Anna made a great soup, enough for all and a heart-shaped cake, also enough to share.

2-15-2012

So here we are on the bus to Dar. Gifts we had brought.  We finished lunch at Tan-Swiss and have now passed through Mikumi.  Our good-bye this morning was like an Olson-family goodbye, delaying departure by a half-hour.  We gave away the many gifts the students had brought.  I gave all the crosses Bob had made to the chaplains at Ilula and gave a short closing speech. 

It was a great few weeks, by all accounts.

An Iringa Saturday

2-11-2012

Here it is nearly 5:30 PM.  We all spent the day in Iringa.  It started out just Carl and me, but then Tuli and Rita, two of the Ilula nurses, told the rest that they would be going to iringa, so with them as our guides, we all went.  They shepherded us to and from Iringa and the buses.  We took the daladala - actually, the Tanzanians call it "the mouse" because it is small - to Mtua and caught the bus there.  There are sort of three parts to Iula.  Isile is where the hospital is.  Mtua is next along the highway and a bit more commercial.  The third is Sokoni.  Collectively, they are Ilula. The whole community is spread out along the highway, between the highway and the ridge of mountains along the road.

The first stop was the BKB office, where no one was home.  We did see Gary drive by and waved. The next stop, without much pause, was the bathroom at the Lutheran Center.  I tried to get Dennis Ngede on the phone, but accidentally dialed Jake’s dad, Mike Feigal, a family doctor in Menominee.  At 1:30 AM.  I am truly sorry Mike!  At least he got to here Jake’s normal voice without panic or pain.

A little later, after I finished at the ATM and had just finished my business with Tatanca I ran into Gary.  He was standing outside the fourth bank he had driven Eunice and Tuti too on student scholarship business.  They need to hand write receipts, if I understood correctly, for all 1500 students and everything is done in cash.  Gary hopes (don't we all) to have a better accounting system by the time we get there this summer.

Then I went back to the apartment and worked on the computer.  The bank of four USB ports weren’t working.  (Don wanted to make sure there were enough USB ports on the front.  I don’t know if he has used more than the two on the front, but now he has six!  It was just a loose wire.  Took about 15 minutes for diagnosis treatment and cure.  My hypothesis is that one of the heavy cables got jostled in the transfers and pulled it out of the socket is.  Since it is Saturday, I charged like a plumber instead of a doctor.  (It is an old joke and not too funny.)

The others had been shopping and were now laden with baskets, spices, batiks, a tinga tanga (a special local style of painting) as we met for lunch.

After lunch at Hasty Tasty Too we walked back to the big bus station.  I understand the system a bit better now.  As far as I know there is no time schedule.  As the buses fill up, it takes off.  That may mean waiting until there are enough passengers or that the bus driver thinks there are enough passengers.  I asked Tuli about the passengers who would duck down.  My guess was correct.  There are regulations about how many passengers the bus and "mouse" can hold.

We caught the big bus home.  It is an hour and a half trip, and I feel like a veteran now.  We were all exhausted when we got home.  I still couldn't nap.  I am pretty relaxed tonight.

My granddaughter Parker Grace, whom I call Sparky had her second birthday yesterday.  Birdie said she came into the house and queried, “Grampa?”  Almost broke my heart!  I will be home in a week, but with plenty of fun left to come!

As I have been reorganizing for the return trip, I discovered a pair of socks in the suitcase Bev and Gary gave me to use and is staying here. I think they may be Gary's or one of the boys.  I think I should bring them home.  It would be novel to say they had been to Africa and back!

Nuts! This may be a few days late.  There is no power to the internet room.  Oh well, this is Africa!

Our last full day at Ilula

 2-10-2012

All days here seem to be good days, despite the lack of resources and terribly ill patients.

Today I gave a little presentation on the Ilula Nutrition Project – I am looking for a better name.  It went well.  The nurses and doctors were very engaged.  It helped to have Dr. Rite translate.  I got a few minutes into the talk before Mama Saga, the hospital Matron (head nurse) gently came from the back row to Rite in the font and whispered to him.  He politely suggested he could interpret.  It worked well.  I was supposed to take ten minutes, so I told the group I took ten minutes and Dr. Rite took ten minutes.

Then they played into my hands and asked many questions!  What could we do, but answer them?  We also let them sample the Plumpy’Nut.  The change in their expressions was a little like watching a kid see cauliflower and taste ice cream.

Meg Fiegal and I spent an hour reviewing a grant application she had done so I could get the gist of how they go.  Very helpful.  But still daunting.  One think we discovered is that the complete application does not need to be in, only the concept paper.  I have collected info from Institute of Agriculture and will get info from Amani Orphanage early next week.

I will publish the draft of the description, perhaps as a web page and not until I return home.

Rounds were busy.  We have seen some patients improving, which is very gratifying of course.  My sister Bev wonders who gets most out of the experience.  I hope it is at least equal parts.  Meg is doing a number of interviews for a video and one of the docs said what he wanted most from us is more to come and visit and see how we are doing!

I will head to Iringa in the morning to look at the BKB computer.  I assembled it, but the front USB ports are not working.  They did when I built it, so I am hoping it is a loose wire from transport.  I will know quickly.  If it isn’t I will get a replacement part and install it in July, when Birdie and I return.

Last night, one of the beloved suffered a laceration on the finger.   No tendon or nerve damage. HIPAA regulations prevent me from identifying Meg, so I won’t do that.  I can tell you that one of the near-physicians did a beautiful repair.  I can’t really tell you his name either, but I noticed Jake’s hands were a little shaky.  I didn’t tell him I noticed.  As I cannot in good conscience mention their names as noted earlier, I think I can say that this patient said it was the only time she would ever let this doctor work on her.  But I would!

Another hapless fool, not Meg

Tomorrow night we will party here in town I think at one or more of the watering holes.  Well, not me of course.  I have remained my staid and conservative self….  Then on Sunday morning we will head to Ruaha for R&R.  Two nights there, then overnight at Ilula to finish packing, say our goodbyes and start the trek back to Dar and home.  I don’t know when the next installment will be, but I will publish some photos too.

PS Meg gave permission and don’t let her tell you otherwise.  Jake isn’t covered by HIPAA in this case anyway, as far as I know.

 

The disappearing mountain

...now you don't.

Now you see it...

The Floating Mountain

2-9-2012

Here as I begin writing it is 7:08 AM, 10:08 PM yesterday, your time.  I wonder what your day was like?  Here we had a downpour last night.  We have had many days in a row of sunshine and no rain.  It was sorely needed.  The gardens were pretty dry and wilting.  The rain brought a halt to the progress of the nurse residence construction.  Although they resumed for a while before dark after the rain stopped, they have not returned this morning.  This is a change.  They have been starting before sunrise each morning until now, starting the cement mixer at 5 AM.  Today there was silence.  Oh, except for the arrogant rooster who struts around crowing for about an hour at that time too, just beneath our windows.  And of course the Muslim call to worship at 5 AM.  And the Christian church bells at 5 too.  Hmmm.  What time do you think Tanzanians start their day?  Do you think it is a hint or perhaps a suggestion?  Naaaah!

There are groups of children, generally segregated by gender, walking off to school, past our “rest house” as the staff calls it.  We refer to it as the more American term, “guesthouse.”  There is a fence 15 yards from the guesthouse porch.  As the children pass, they do not fail to look up to the porch.  Some respond to the Hehe greeting, “Kwameni.”  They all wear blue and white uniforms, blue sweaters and skirts or pants and white shirts.

The porch looks out across the savannah to the to the hills and mountains.  I consider this view one of the most beautiful places on earth.  We are high enough to see the savannah and trees from above, with crops and tilled ground, lush and green this time of year.  There is a mountain in the distance that magically appears and disappears in the mist.  Today it floats above the horizon.  How does it do that?  Straight above us, there are no clouds.  It is a beautiful African morning.

The workers are now straggling in to the construction site.  It is 7:55 and our meeting for prayer and chart rounds starts in five, so I will sign off.

We are done with chart rounds and another great student talk.  Will did a marvelous job on diabetes, with many good questions from the medical staff.  Now the students are off to ward rounds or simply “rounds,” and outpatient department (OPD).

I have a few more slides to finish for my presentation tomorrow.  I may ask Chaplain (I can’t spell Mchungaji, let alone pronounce it) Kikoti if I may “preach” tomorrow.  I am thinking about it.  Well, maybe not.

A couple updates.  I think I noted that some broken windows are being replaced.  Some of the windows are as well, but I don’t know at what pace.  The new ones are nice metal sliding panes with a screen.

Emmanuel, the lab director just gave me a nice long tour of the lab.  We really can do many tests here, thanks to him.  The hospital has plans for, first, a lab remodel and later a new building to accommodate the increased business and keep things up to date.

Randy, I have not yet checked on the Cryptococcal Antigen tests yet, but will tomorrow.  Gary, I have sequestered your modem.

It is 5:30 PM here, Kili time.  Off to the Peace Garden.

We get used to things….

02-08-2012

Which is not necessarily a good thing.

Today we were finishing rounds and Will noted workmen were replacing glass in a number of broken windows today.   Randy (I think) aptly noted to Dr. Saga, that to help keep morale up, things like the broken windows need to be replaced.  How true. 

I noticed them the first time I made rounds, but quickly got used to seeing them.  Many of them were hazardous, as Laura B. pointed out, with many jagged edges.  With children running around there was a true potential for injury.

Laura also noticed that not all the beds have nets and many of the windows do not have screens.  Except for the broken ones, the windows do have glass, but they remain open because it is simply too warm, even at night to close them.  They need screens.

I was looking at the walls and cement floors and thought how each could use a coat of paint.  The gray of the floors keep the general ambience drab, despite the worn but pleasant yellow walls.  Joann Sjogren asked me before I left to Tanzania about sheets for the beds.  All I could remember was that patients use colorful kangas as covers.  I am pretty sure they use their own kangas.  Joann, I did notice they use white bottom sheets on the mattresses.  These all have someone else’s logos or names on them.  They are the heavy, industrial kind of sheets. Today on one of the wards, most of the men had gone home and the sheets stripped, exposing the torn rubberized mattress covers, some of which barely hold together.  All of the beds are old-fashioned.  Nothing wrong with that.  They are reliable and simple to use.  But many have multiple coats of chipping paint.  And some are the simplest of metal frames with wooden slats.

Now I remember why a visit to Tanzania is a life-changing experience.

Of course there are many priorities ahead of these things, especially the care of patients.  Our students have done a marvelous job with their presentations – I know I said it before, but it cannot be overstated with this fine group of people.  I am sure that the pharmacy students will come back as faculty (assuming they get a passing grade from the old faculty member here, which seems highly likely).

On Friday, I get to speak to the doctors and nurses myself, this time about malnutrition and our hopes for the use of RUTF (Ready to Use Therapeutic Food, in case I haven’t pounded it in hard enough!).  I will have ten minutes to describe the protocol.  All the doctors and nurses I have talked to are aware of the need and are enthusiastic.  The main problem will be the cost of keeping the RUTF in stock.

The Corkscrew Extraordinaire

Corkscrew Extraordinaire

Need I say more?

Miscellaneous

 2-06-2012

Just had a really nice warm shower.  Yes, warm!  The students (Laura B and Serena) ingeniously filled bottles with water and set them outside in the sun.  Nice holes in the cap served as a great showerhead (thanks to Carl).  We have been having intermittent water.  We assume that is due to the construction of the nursing dormitory, currently going at breakneck speed to finish in time for the nursing school to start.  Part of the time during the day, there is plenty of water pressure.  But by shower time in the morning, there is no pressure.  So nearly half the time, we have been dipping water to “shower” and flush.  Cold water.  Even when we have good water pressure, so you perhaps can imagine the luxury of a warm shower. 

Another invention was a corkscrew from a clothes hanger.  Someone borrowed and did not return our corkscrew and we were not successful in pumping in air with a syringe or grasping the partly protruding cork with my trusty Leatherman.  I managed to push it further down.  So Laura said, “If we only had a clothes hanger, we could make a corkscrew….”  Meg said, “I have a hanger!”  Carl manufactured a fantastic functional corkscrew.  And I enjoyed the wine.  Well, several of us enjoyed the wine.

Someone suggested Post It notes and masking tape for a schedule.  Water bottles have been used for exercise weights (not by me).  I used duct tape for my bed net. 

There are probably more innovations, but I cannot think of more.

My little Optoma projector has worked pretty well for a couple movies.  We were all depressed by “Ides of March,” but “Bridesmaids” the next night took care of that.  We intended to only watch half, but we couldn’t stop.  It’s hardly enough for daytime use.  It simply isn’t strong enough light and we cannot cover the windows adequately.  We will need to find a bigger projector to use next year, one that stays here.  It seems likely that the Nursing School will need one for teaching too.

And we continue to see interesting cases, of course.  Today, a child was admitted with “Renal failure” because of swelling.  I looked it up and in the US we would see 2 – 7 cases per 100,000 children annually.  The Clinical Officers here are often under pressure with a ton of patients.  On rounds a little later, we examined the child closely and found some telltale signs of malnutrition, including the swelling.  The MUAC (mid upper arm circumference) confirmed profound muscle wasting.  Her belly was distended and the ankles swollen.  Her hair was fine, like lanugo or baby hair, another sign of malnutrition.  We started the Plumpy’Nut.

But the Nutrition Project has been slow overall.  The Medical Director of the hospital was gone all last week and I have not gotten the chance to review the overall plan with him and things must be sanctioned.  It really is a formality, but necessary. Today I will speak to Mama Saga, Dr. Saga’s wife and the hospital Matron (or head nurse) about the project.  We will need heavy buy-in from the nurses to succeed.  We have Meg who is a grant writer helping at least informally for the funding grant we may try to get, but if anyone wants to do some grant work, PLEASE let me know.

We have had the benefit of our pharmacy students to help with drugs and bacterial coverage, which the Tanzanian doctors appreciate as well.  We have been seeing a number of pneumonias and other infections.  The students have been giving great talks after morning report.

Another interesting case today is a seven year-old, quite small, malnourished, but also with enlarged lymph nodes at the neck and many other places.  Is this extra-pulmonary TB, lymphoma or infection?  Almost certainly there is underlying HIV, but we will find out tomorrow, when the tests are back.  There has been an expansion of tests available, but still profoundly limited and we reamin unsure of what is actually available.

Hot water!

We have a couple mobile clinics to go on this week, then off to Ruaha for two days of R&R before we head home.

The students are all collecting great cases for their (mandatory) presentations at home.  They also have been stellar on their presentations here, generating many thoughtful questions.  They are a real credit to all of us!   they will be great doctors.

(They better be.  They will be caring for us in a few years!)

Isimila

2-4-2012

Another fine day.  We left for Iringa about 7:40 AM.  Unfortunately, the daladala we had intended to take to Mtua to catch the bigger bus had left at 7:30 AM.  We walked to Mtua to catch the bigger bus.  Unfortunately, that one left before we arrived too.  We got on a daladala to Iringa, along with a cast of thousands.

A daladala is generally a converted Toyota van with the top chopped off and replaced by a roof with a bit more headroom.  Of course the headroom was for beings as tall as Tanzanians, generally shorter than Wazungu.  With really narrow butts, too.  These vehicles are wide enough to seat three across, but they also put an aisle between the seats.  People cram into the SRO (standing room only) area.  There may be some rules about occupancy, since a few of the SROs ducked down as we passed some highway officers.

Our understanding of daladalas was that they sped along, careening past other vehicles, putting lives in jeopardy.  No.  Not at the speed they travel.  No.  It took forever and a half to get into town.  Don Fultz and Gary Langness  picked us up and took us to Isimila.  It is a great place to hike around.  They now charge 20,000 Tsh and still worth it.  They also have a museum with interesting artifacts.  The artifacts and geology are truly remarkable.  If you are interested in seeing a marvelous site, call Birdie.  A group from St. James is going at the end of July.

We went to Sai Villa for lunch.  Fun and good food was had by all!It is a classy place.

Then back to Block A Apartment C, where Don, Eunice, Carol, Gary, Trish, Roger, Steve Clarke, Carl, Jake, Laura, Laura, Meg, Will and Serena sang “Happy Birthday” to me yet again.  I cannot remember a birthday where I have heard my name sung in that song so many times.  Marvelous chocolate cake with chocolate frosting and chocolate chip cookies and great fruit salad!  I have terrific friends!  And always willing to party.

Don took us back to the bus station.  We were just in time to get on the larger bus.  Half got on, but it was full.  Those got off.  We all ended up taking the daladala back to Ilula.   The engine apparently overheated, so we stopped for twenty minutes waiting while they refilled the radiator.  But it was only a minor breakdown and off we went again.  I was pretty glad to see Ilula.  So was my derriere.

Anna prepared a nice soup for us.  We drank a bottle of wine and talked about our favorite desserts, Saturday Night Live and other things that had us laughing.  But at 9:10 PM, we are all bushed and off to bed!

Carl, Will, Laura M, Jake, Serena, Meg

Will, Serena, Laura B, Laura M, Ken

Amani Orphanage and Mbigili Dispensary

2-3-2012

Fantastic day!  Meg, Serena and I went to the Amani (not Armani) Orphanage.  We originally made contact with them at their request when they wanted to know more about Plumpy’Nut.  The orphanage gets several children per year who are abandoned or whose parents simply cannot supply their needs.   Two such children appeared in the past week or two.  The Amani staff was directed by someone to get a protein shake supplement to help with the child’s nutritional needs.  Several problems.  One, it was 80,000 Tsh.  This is about $45 USD.  Second, although not harmful by any means, it is an adult formulation with inadequate amounts of everything for a malnourished child.  It would last a couple weeks, I guess, but for $60 USD, you could buy a full six-week course of Plumpy’Nut.  It takes only that long to reverse the severe malnutrition, then a child goes on a regular balanced diet.  I gave them a box to start treatment immediately.  We took the most recent admission, Harriet, to the Mbigili Dispensary, so that Dr. Singo could weigh and measure her

The orphanage is amazing.  It is supported by a German church, Lutheran, I think.  They have fifty kids.  They have a large garden, 8 acres of maize and some other veggies.  They have pigs, cows, rabbits, chickens and goats.  They collect the manure for biogas, raise some nuts for biodiesel and use some solar energy to heat water and some solar voltaic for electricity. 

They have a web site, but it is in German. Google will translate it for you.  Here is their site.   http://www.mbigili.de .

I hope we can work with them.

Meg Feigal and Friend

Serena, Alberto and Meg

Friendly future dinner for many

Tragedy and Pragmatism

First the mundane.   

It's my birthday.  I have gone from Daktari Ken to Daktari Babu in one day.  Babu is Swahili for  grandfather.  I am likely the oldest person on the campus, not a patient.  I had a great day with a little surprise party and fireowrks on a delicious banana cake.  Enough said!

There is a doctor’s strike in Tanzania.  Must be in Dar, since it certainly isn’t in Ilula.  However, the doctors here are aware of it.  The politicians are meeting with the striking docs.  The docs have been warned they must report to work.  Apparently not reporting for work is a serious offense.  So most are reporting for work, just not working very hard.  Or at least not very fast.  To add perspective, the politicians get 200,000 Tsh ($115 USD) per diem for being in Dodoma.  And they go out of the country for care!

Ilula is getting a “procurement specialist.”  This man knows how to work the system (in a good way, as far as I understand).  This could significantly help the supply chain.

Today, after lunch, I was chatting with Meg when Serena rushed in and said, “I need your help.  I don’t know what to do.  A set of twins was born.  One is not breathing.  They want me to certify death, but he has a heartbeat.” 

Before I arrived, Dr. Jen Tessmer-Tuck, Ob-Gyn and Laura Melcher, Jenna and dad  Dr. Dan Johnson, the ER doc, participated in a couple of failed resuscitations, which were very similar and both were twin pregnancies as well.

A few moments earlier, as Meg and I were sitting alone at lunch, we heard intermittent screaming.  We wondered if it was a woman in labor.  Generally, the Tanzanian women do not scream.  They tap, mutter, grimace, but they don’t scream.  Very stoical.  I don’t think we even noticed when the screaming stopped.  When Serena arrived, she told of how she had heard the screaming from the labor room and so went there.  She quickly related a nice summary of the events.

The first twin was already delivered when she arrived and did make some respiratory effort.  The heart rate was 120 – a little slow, but not terrible.  Baby hearts almost always and readily recover if they can get oxygen.  She tried to assist.  No oxygen.  Technically, if the baby is breathing, additional oxygen is not absolutely necessary.  She tried to use the bag and mask to assist.  It was way too big.  These twins were probably only 32 to 34 weeks gestation.  She could have intubated the infant, but there were no endotracheal tubes.  She did her best.  She assisted with delivery of the second twin, which did well, initially.

We hustled our way to the L&D area.  The firstborn was completely covered with an orange and black kanga.  When I pulled back the cloth, I found the tiny tot Serena had been working so hard to resuscitate.  Indeed, he was not breathing.  His eyes were closed, mouth open.  His skin was translucent and pale and blue.  As I put my gigantic adult stethoscope to his chest, I could not be sure if I was hearing his or my own heart beating.  I used my index and long fingertips.  Yes, I could feel the heart beat and Serena could see his thin chest wall move.  The heart rate was 40 per minute.  For just a moment, I used the two fingertips for chest compressions.  The heart rate did not recover.

We expressed our sorrow to Mama who was holding the second twin, a girl, “Pole, pole sana.”  We are very, very sorry.

Serena and I left the room to commiserate about this sad situation: no oxygen, no properly-sized mask or E-T tube.  Also, no tiny IVs, no incubator type warmer.

The airlines now carry some rudimentary resuscitation equipment, but for many years they did not.  Having the equipment carries with it obligation to have knowledge in its use.  With that comes extensive training and cost.

As I think of the priorities at Ilula, I am wondering where this level of technology can fit.  The equipment I mentioned above is a whole layer of technology over what Ylula has, not simply a few thousands of dollars of equipment and training away.  Would this be the best place to start?  No, I don’t think so.  There are too many people who can benefit from much less costly, simpler interventions – like the Plumpy’Nut for malnutrition and HIV medicines.  All the more reason to work hard at these things!

Serena and I went back to see the baby.  The heart rate was down to a few beats a minute.  We cannot be sure precisely when the baby “died.”  This time it was, “Pole pole sana, mtoto na amefuka.” We are sorry, the baby has died.  Biologically, he died moments after his agonal breaths truly stopped.  We could not let go of the traditional heartbeat as our unfailing sign of death.

The second twin died too.

Laura Melcher and Carl Sherman giving a lecture to staff at IDH

Laura Brown, Serena Thompson and Jake Feigal

African Skies

Day of Grace - Randy Hurley, MD

“Sometimes I have difficulty walking up small mountains”

Health assessments as part of a “Day of Grace” health, wellness, stress and spirituality seminar for Lutheran Pastors in the Iringa Diocese of Southern Tanzania

“Sometimes I have difficulty walking up small mountains,” replied the 62 year old pastor when asked if he had any concerns about his health.  He was participating in one of 3 day-and-a-half seminars held in January 2012 in Iringa, Tanzania.  These seminars were planned and sponsored by the Iringa Diocese of the Evangelical Lutheran Church of Tanzania in conjunction with the St Paul Area Synod of the Evangelical Lutheran Church of America.  The seminars, entitled “Day of Grace” were conceived and organized in response to the perceived need for support of physical and emotional health and stress management for a group of 185 pastors in the Iringa Diocese.  The seminars included worship and fellowship time, small group discussion, and a lecture on stress management.  Participants were also offered the opportunity to undergo individual physical health assessments.

Data without personal identifying information was reviewed from 155 of 159 pastors (24 female and 131 male) that volunteered to participate in the physical health assessment component of the Day of Grace events.  All were offered screening for hypertension and diabetes and underwent assessment of visual acuity, height and weight.  A health questionnaire was devised with the help of Tanzanian leadership so that only culturally appropriate questions were asked.  Pastors completed the health questionnaire and physical exam with the aid of an interpreter when needed.  Female pastors were interviewed by female medical staff, counseled on breast self-exam and offered pelvic exams.  Volunteer medical staff included physicians, nurses and pharmacists from the Minneapolis-St Paul area and 4^th year medical students and pharmacy students from the University of Minnesota

Pastors in the Iringa Diocese have completed secondary education and theology training at the college level. The age range of pastors participating in the health assessments was 23 to 80 with a median age of 45 years.  Most pastors had never undergone a comprehensive physical exam although most had sough health care for treatment of malaria and a significant minority had been treated for typhoid.  Most pastors live on an income less then $2 per day but many supplement their income with subsistence farming.  Nearly all pastors were married.  The median number of children per married couple was 4 (range 0-10) and a median of 6 persons (range 1-15) lived in each household.  Female pastors had a median of 3 children per married female pastor.  Forty percent had a water source in the home however some pastors had to walk up to 30 minutes to obtain safe drinking water.  The majority of pastors used mosquito bed nets routinely and the prevalence of tobacco and alcohol use was nearly zero.  The most frequent complaints were dental-related and related to presbyopia.  Gastrointestinal/gastritis symptoms and musculoskeletal complaints were the next most frequent.  The musculoskeletal complaints were suggestive of degenerative arthritis or complications of prior accidents.  Few pastors had ever undergone surgery with orthopedic procedures following trauma being the most common.   It as very rare for pastors to be on medications on a daily basis

Visual acuity was strikingly normal with most pastors having distance vision of 20/20.  A significant number, however, were in need of corrective lenses for near vision and reading. Only 12% of the pastors examined had an elevation of blood pressure greater than 140/90 mm Hg however 30% of the pastors above the age of 42 had an elevated blood pressure.  Relatively few abnormal physical exam finding were identified and when present included issues such as soft tissue infections, hydroceles and hernias.  No abnormal breast or pelvic exam findings were noted.  Only 8 of the 155 pastors tested had an elevated fasting blood sugar above 110mg/dl.

For the medical examiners, the physical assessments were an opportunity to understand the health and lifestyle of a relatively homogenous group of Tanzanians.  Moreover, the standardized history and physical exam forms allowed for systematic evaluation of many of the social determinants of health of this population.  The presence of interpreters allowed examiners to enhance their own knowledge of Swahili medical terms

The medical examiners were perhaps surprised at the overall general good health of this cohort of pastors.  Pastors are a relatively highly educated group.  In developed countries, educational level and marital status are both associated with improved health outcomes.  In addition, “healthy worker effect bias” may help explain the relatively good health of this group.  This bias would suggest that those with underlying health problems and disability are unable to remain employed as pastors.  Therefore, only healthy workers remain as part of the cohort examined.

Overall, pastors were highly satisfied with the Day of Grace events and felt the physical assessments were the most important component of the health, wellness, stress and spirituality seminar.  Most indicated they would like to see the Day of Grace concept repeated with the opportunity extended to spouses to also undergo physical health assessments. 

This first attempt at a health, wellness, stress and spirituality retreat for pastors was, in some respects, also a feasibility study.  The co-leaders now have a better understanding of what can be accomplished in a day-and-a-half event.  Evaluation forms and a post-seminar debriefing have generated ideas for improvements and for future events.   Having an understanding of baseline health issues will allow closer tailoring of these assessments to better meet the needs of this underserved population.