Ilula Monday and Rounds

Today was sort of a more “normal” day at Ilula, except for the appearance of a Norwegian first year medical student, spending 3 weeks at an orphanage nearby.  She had spent 6 weeks there a few years ago, but was then not a medical student.  We adopted her.  She has been given the name Aisha, because her Norwegian name, Ingebjorg was too difficult to pronounce.  Believe me, I tried.  That “o” is supposed to have a slash through it, which removes any ability for anyone but a native Norwegian or Swede to do it justice.  And I’m not so sure about the Swede.

This morning, I was introduced at morning rounds.  Dr. Saga announced we would have a 15-minute presentation tomorrow by one of the students.  Ten minutes for the talk, five minutes for questions, no more.  (I think I overheard one of the students say, “I’m going to have to revise my talk.”  Expletives deleted.  Just kidding.  No expletives.)  At the end, Dr. Rite, presiding over the meeting, came to me and said, “We would really like to have the students talk about treatment of septic abortion (i.e. miscarriage with infection, sometimes intentional) and rashes.”  Now this was nice for me, since I just delegated the two talks to some of the smartest people in the world, and all I have to do is kibitz.  Carl and Laura will tackle treatment of septic abortion and I assigned Jake to talk about rashes.  I will help on that one.  Will and Laura B have not been tapped, but likely will be.  You guys are great!  I appreciate your devotion.

Rounds were humbling for me, realizing I have no ability to ask questions, even yes-no questions, to take a history.  And I know I had better learn.  The students are all working hard at doing so.  Serena has a ring of 4x6 cards she has already compiled phrases and words to use.  Way to go Serena!  A little Swahili returns, too slowly.

We voted last night and tonight is movie night  A few of the students even have dates.  Of course, they are married to them.  Still counts!  "Ides of March" is the answer to your next question.  I am not psychic, but I am 9 hours ahead of you, so I just knew.

Update on Plumpy'Nut will be forthcoming.  We have some refinement to do on the protocol, but on a very positive note, the nurses in the Maternal Child Health Antenatal program already do exactly the kind of teaching we will need for our mamas and bebes to have.

Junior Execs

Nursing School Residence Foundation

Work has started on the Nursing School Residence.  Note the junior execs supervising.

Iringa - Boys Day Out

Iringa, Boys Day Out

Well, the car is only so big.  So Dr. Saga, myself in the front, Carl and Will in the back and Jake hanging on to the roof rack for dear life, came to Iringa.  Jake let his hair fly.  Think of the wind rushing through his hair.

We went straight to the bank and put the students in queue for place markers as Dr. Saga and I went to the Immigration Office.  There we handed over my passport and forms, the latter which I had completed in duplicate.  Then back over to the bank.  There we scoped out the queue and saw our compatriots only inches from where we had dropped them a half hour previously.  We opted for Shilling Grease.  The CTA permit cost $200 plus 10,000 Tsh (the Shilling Grease, about $6), 15 minutes.  Dr. Saga and I sent Carl, Will and Jake (hair back in its prior ponytail) on to Neema Crafts for primo internet – when it is working.  Back to the Immigration Office, hand over the bank form, wait for the passport stamp and receipt, 30 minutes.  Me off to BKB and Dr. Saga off to DIRA on official business.  I spent a few minutes with Don and Eunice, met Rich and Joan Dornfeld. Rich has been teaching math at Tumaini and readying for the trip home.  Jim and Betty Wolf stopped by too.  I left, stopped by TLC to say hello to Jo and went to Neema.  Internet is not working at Neema, so we are at IringaNet.  That’s us up to the moment.  I see it is 3:48 AM in Burnsville and many other places.  It’s about 10 minutes to 1 PM here.

We are going back to Neema now for lunch and will head back to Ilula soon after.

Of course I was joking about Jake and riding on the top of the car.  It was Carl.

Arrival in Ilula

Ilula 1-29-2012

It is Sunday.

Yesterday was a comfortable, if long, drive from Dar, with Steve Clarke, an agronomist consulting with Millenium Challenge Corporation, but here representing his other passion, Compatible Technology International, working with Roger Blomquist at Tumaini’s Ag Project.

He said, “Your name is vaguely familiar,” but digging back, I couldn’t get a grip on any mutual past history.  Eventually, we got around to “Where are you from?”  Burnsville.  “Oh, I have a sister-in-law who used to live in Savage.  Kelly Hosford.”  Whom I have known nearly thirty years!  And of course, now I remembered Kelly telling me about Steve and his work and how we should meet someday.   Somehow, I don’t think she actually meant in a car on the way to Iringa.  We had a great time visiting about our mutual interests and will meet at home to discuss them further.  Hopefully, Kelly, you’ll join us!

I gave Steve and Pastor Daniel a whirlwind tour of the IDH campus.  Not long enough by my standards, but we hit the high points and I wanted him to get to Iringa before dark. 

Then I had a nice long visit with the students to catch me up on lots of stuff.  They are all doing well and their first two weeks went well.

It is time for church.  I can hear myself saying, ”Jina langu ni Daktari Ken. Natoka Burnsville, Minnesota, Marekani.”

The next words you read will be after church.

See, it’s after church.

The service was fine.  Dr. Saga interpreted for me.  I do need to get a copy of the hymn book for myself, maybe a Swahili Bible too, but I will check to see if there is an “app for that.”

Otherwise it was a lazy day for all of us.  We visited at lunch and then most took naps.  Mine was an unbelievable 3 hours.  It is not 10:00 PM here and I am ready for sleep despite the nap.

The students have been negotiating about the food.  Anna is a great cook and has been serving wonderful food.  Perhaps too much food.  But of course, as Americans, we eat it all.  As we compliment Anna’s cooking and finish what she has served, we think perhaps she sees the empty plates as a sign that we have not gotten enough.  We have opted for slightly simpler meals in lieu of higher prices.

Dr. Saga has been very concerned that we have not gotten our CTA pass, so I did not go on rounds today.  We are off to Iringa in the morning to stand in line at Immigration and again at the bank where I will pay the fee, then again at Immigration to get my passport stamp.

Some of the wheels have been previously greased, so it should go smoothly.  We hope.

The students are all charming and bright.  They are a pleasure to be around.  I am tapping them for suggestions as we develop curriculum and consider selection criteria for future students, if the rotation should become so popular as to require it.  I infer that the students think that is possible.  How we have been so fortunate to have such great students so far is amazing.  Perhaps that is simply a characteristic of the fine people interested in this experience.

The students and doctors love having the pharmacists around. Laura and Carl have been great and are real assets in the patient care.  I realized this did not surprise me, which surprised me.  I am truly excited to have the interdisciplinary model present.  Then I realized that the Philips Neighborhood (U of M student-run) Clinic is an interdisciplinary model, which is why this feels so natural.

Dar es Salaam and FPCT

Got in, no sweat from Amsterdam.  No sweat that is until Kili.  It is hot!  Dar too, about 90 degrees F.  Note to self: you didn’t need the T-shirt underneath. 

Peter from Tumaini U. picked me up.  First time I have been greeted at an airport by a sign with my name on it!  I love FPCT (Free Pentecostal Church of Tanzania) Guest House at Kurasini Beach.  Nice, simple room.  Breakfast this AM.

Met Steve Clarke from Compatible Technologies International (CTI).  We are now putting ourselves together to get going to Ilula and Iringa.

FPCT - the oasis

Indian Ocean

Amsterdam

It is 6:35 AM in Amsterdam, 11:35 PM in Burnsville.  The flight was pleasant, especially sitting next to a pretty young Swedish lawyer on her way home from holiday with her Duluth host family in Hawaii.  From a small town on the coast near Uppsala, she was an exchange student in Duluth in 2003.  Impeccable English, nice tan too. (Boyfriend, dear.)

I dozed through Harry Potter Deathly Hallows 2, but I don’t think I slept much. Didn’t open the Kindle.  I put a ton of .pdfs on the Kindle, some to read, some to use as references as needed.  “You’ll erase them, won’t you?” the Kindle owner said.  “Ya, sure,” said the borrower.

I was pleased to have phone conversation with Gary Moody before I left.  Back safe and sound and already back in the fray working.  He told me of the group’s adventures with transportation.  There was so much baggage from the Day of Grace that they needed to rent another vehicle to get it to Iringa!

Here is a paraphrase from a book called something like “If Life is a Game, These are the Rules.”  One of the rules is: “You will have lessons.  You will have the same lessons over and over until you learn.”  (I am a slow learner, but I can recognize that I am having the same lessons over and over.)

Here is how that relates.  As time goes on, “we” are bringing fewer things to Tanzania, e.g. medicines, and in this case some bulky things we may have been able to get in TZ.  Not only are some things bulky, making travel a bit uncomfortable (and with unanticipated consequences, like a second vehicle), but buying what we can in TZ benefits the economy.

Regarding medicines, if we are bringing samples of expensive new drugs, usually in small bottles with only a few doses, where will the refills come form when the samples run out?  We do not bring outdated medicines.  If they aren’t good for us, why would we use them for our Tanzanian brethren?

Also, equipment made for American electrical systems does not work well in Tanzania, even when converted to the 230 volt system.  It wears out sooner, so I am told.  Of course, “better than nothing” still applies in many cases.    I believe the above is our current thinking, certainly mine, but here I am with 100# of luggage and a really heavy backpack.

It may be a couple days before more appears on this blog.  I should arrive in Dar tonight, leave for Ilula in the morning and get to Iringa Monday for my work permit.

Jambo!

Here I come, ready or not!

Well, departure day is finally here!  It is hard to believe - I am sitting n MSP, at Gate 6, so far with only a few others.  That's what I get for following the get-there-three-hours-before-departure direction when I printed my boarding pass.  Three hours?  Wow!  Didn't forget anything that I can think of, except maybe the stuff pillow I meant to bring.

I have now been thoroughly "sent."  First, the pastors offered a "Sending" at church on Sunday.  Second, our children, their spouses and grandchildren were over last night for a little celebration.  Niece Katelyn and our mutual friend Amanda (congrats on the new job, Amanda!) joined us too.  It was a laugh-a-thon.   Brother Mark, that's my brother Mark, not a Franciscan or other friar,  offered a prayer for safety and blessings before I left.  He is so generous and caring.  I look forward to his coming with us someday.

I have been packing much of the week, collecting things for the past month.  My two checked bags are carefully weighed, one at 49# and the other just over 51#, but the kind agent at check-in said I was all right.  Some of it is staples, staplers, manilla files, health packs and 100 pairs of "readers."  No M&Ms.  They are in my backpack, too heavy to put in the suitcase.  I figure even TSA might find M&Ms a temptation!  I doubt the metal surgical retractors would generate anything but curiosity.

Here are some thanks.  First, Marge Larson pointed me to some "Health Kits" that our parishioners have put together. Sorry, I cannot thank them in person, by name. Next, thanks to Bob for the hand carved crosses.  I will find people to give them to.  Sadly, I doubt I will get to Idunda this trip.  Pastors Will and Walt sent two clergy shirts ("Friar Tuck" brand, no joke.  And I am Robin Hood, getting them to the deserving poor!)

The photos are simply to demonstrate what I am leaving in Minnesota.

 This is Sawyer. Below is Parker.  Boy, did they love the thrill of sledding down a 30 yard slope!

It is 83 degrees in Dar es Salaam. 

About 15 minutes until boarding.

Asante sana!

Plumpy'Nut, Measles and more

By now I may have said all anyone wants to know about the Ilula Nutrition Project.  Regardless, I am posting the description below.  I don't know if anything has happened yet, but I will in a short week!

Will Amundson, MS4, was impressed with seeing a case of measles.  Kelsey Watt and I saw a case last year too.

This is from the WHO Fact Sheet on Measles:

Key facts

• Measles is one of the leading causes of death among young children even though a safe and cost-effective vaccine is available.
• In 2008, there were 164 000 measles deaths globally – nearly 450 deaths every day or 18 deaths every hour.
• More than 95% of measles deaths occur in low-income countries with weak health infrastructures.
• Measles vaccination resulted in a 78% drop in measles deaths between 2000 and 2008 worldwide.
• In 2010, about 85% of the world's children received one dose of measles vaccine by their first birthday through routine health services – up from 72% in 2000.

We don't think twice about measles, but it is still a killer!

Ilula Nutrition Project

Purpose: Improve the nutrition of hospitalized children, especially non-nursing children between the ages of 6 months and 3 years to reduce the risk of irreversible effects that occur in the first “1000 days.”  (Secondary emphasis on children up to five years and nursing mothers.  Tertiary emphasis on all other hospitalized persons.)

Background:  About 38% of children in Tanzania are nutritionally deficient; Illness causes added nutritional stress, thus all hospitalized children need nutritional support.  Because families provide the food to their hospitalized loved ones, nutritional stress is maintained.  Other challenges include hospital supply chain issues such as availability of supplements including vitamins and minerals, even when appropriately ordered by medical staff.  Ready to use therapeutic food (RUTF), such as Plumpy’Nut and Lishe Bora (nutritional porridge) are available.  Plumpy’Nut is available in Dar es Salaam and Lishe Bora is available in Iringa.

Pilot Program for IDH

Protocol:

According to published standards, nutrtionally support all children between the ages of 6 months and 3 years admitted to IDH with Plumpy’Nut during their hospital stay (discharge with their partially consumed packages).  Teach mothers how to use commercial Lishe Bora and how to make their own nutritional porridge.

Inclusion criteria:

1)               All non-nursing and partially nursing children 6 months to age 3 years

2)               Any child over age 3 demonstrating signs of nutritional deficiency, especially with signs of wasting, stunting, or edema.

3)               Others as recommended by evaluating staff.

Step 1:  Feed Plumpy’Nut during hospital stay, according to inclusion criteria, no doctor order necessary.  (Address necessary changes to hospital bylaws or regulations so this can happen.)  Dispense unused (open) portions of Plumpy’Nut with patient at discharge.

Baseline measurements: Wt., Ht., MUAC (Mid Upper Arm Circumference), OFC.

Step 2:  Teach care-giver (mother) preparation of Lishe Bora (nutritional porridge) for use after discharge.  This needs to be developed on site with nursing staff and taught by nursing staff to patient’s care-givers in Swahili. 

Step 3: Follow-up.  Periodic visits to monitor progress every two weeks for 6 weeks, then monthly for three months with Wt., Ht., MUAC and OFC.  Review Lishe Bora with care-giver (teach-back).

Amazing, surprising, dismaying, all at once

I asked the students what they found amazing, surprising, dismaying,  etc.  I will intersperse some comments.  

From Laura Melcher:

Hi Ken!

Thanks for the email! I hope all is well with you as you prepare to join us at Ilula.

To cut to the chase--yes, I am having a great time! Here are short answers to your very good questions:

Amazing: the resiliency of these children (and adults, for that matter). With my interest in Ob/Gyn, I've spent a lot of time on labor and delivery, seeing firsthand the challenges infants face as soon as they enter the world--minimal resuscitation available, lack of basic antibiotics, and most saddening, the low availability of enough good food. And yet  most kids grow up ok!

Surprising/Dismaying: the lack of physical exam and history-taking that the medical and clinical officers perform. I would have supposed that given the lack of resources for laboratory and imaging diagnostics, there would be more emphasis on easy, cheap physical exam. But typically the patients in the clinic and hospital have minimal if any vital signs recorded, much less cardiac and abdominal exams. (In my studies with online USAID modules - I have achieved Novice status, I see many things we might be able to improve on. I am not sure where the energy will come from with over-burdened staff, already doing yeoman's work.  Here in the US we do many things just for the sake of documentation.)

Haven't given out any plumpy nut yet, but I think it's because we haven't made it obvious enough to the medical staff that we have it. Certainly several children I've seen could use it! Delivered 6 babies, though 2 did not make it.... ...Interesting and sad stuff. Assisted on 2 C-sections, hopefully more to come! Performed about 4 OB ultrasounds with Dr. Tessmer-Tuck, which is amazing learning! Discussions are underway for Dr. Saga to get more US training soon.

Looking forward to seeing you soon!  (And likewise, I can hardly wait!)

Laura

 And from Will Amundson:

Hey Ken-

It's going great so far!

I can't believe the variety of illness we see on the wards. Crazy things I've only read about, like cerebral malaria and cryptococcal meningitis (both patients that would have been intubated and in an ICU in the US), to healthy, happy women just waiting to give birth. Clinic has also been fascinating, with parasitic infections galore.  (Uh, wear your shoes!  And take notes.  At rounds next year, I want you to say, "Well, when I was in Africa....)

I've been discouraged by the speed that rounds must usually progress in, due to the staff being stretched thin, and the very limited physical diagnosis employed by the staff. It has been a great learning experience for us to be here, and I think the staff like to hear our opinions as well.  (As you all can guess, I am very sensitive to the "stretched thin" part.  It is an unfortunate fact of life at Ilula.  Not enough time for all the work.  The staff is extremely generous in having us there!)

See you soon!

Will

Here is a photo looking out from the guest houses.  Probably hasn't changed much since 2011: