Monday, September 15, 2008

Tanzania photos, July-Sept 08, album #2

Click on the photos below to see a larger slideshow!

poo irony

I spent two months in Sub-Saharan Africa, eating local food at street stands and at roadside holes-in-the-wall and had perfectly fine poops. Solid, every dang morning.

Then I come back to the US, eat some gourmet food at fancy restaurants, and have the most violent cramping diarrhea ever.

Go figure.

Nairobi’s not so bad after all…

OK, I have a bad attitude towards Nairobi. Historically I haven’t had any particularly good experiences with being in Nairobi. After all, my first night in Nairobi was spent running away from shady men in the street and in a hostel that ended up more like a giant brothel, dodging cockroaches with my suitcases barricading the door so that no one could break in. But I still think I’m unfairly dissing on it. I bet that the way Tanzanians talk about Kenya has also seeped into me. During the British colonial period, Kenya was given lots of attention and resources while Tanzania was completely neglected. Kenya also had a much more violent independence, Mau Mau uprising, and a more free-market/capitalist/fend-for-yourself post-colonial period. Tanzanians frequently will tell me that they think Kenyans are rude, in a rush, and don’t speak proper Kiswahili. Underlying all those sentiments is probably an element of bitterness about Kenya’s attention from the UK and their English fluency.

After writing my previous blog entry about being stranded in Nairobi, I had a perfectly lovely day in the city center. I tried to load Kenyan Zain cell phone vouchers to my Tanzanian Zain sim card – which didn’t work – but two really nice women worked with me for an hour to try to figure it out. I went to an internet café and a phone booth without any other wazungu in sight. I also found a wholesale wood crafts store and bought up a collection of beaded hand-carved bowls and spoons. Approximate Air had put us up in the Hilton Nairobi, so I spent the remainder of the evening swimming, in their sauna, and eating ceviche and fresh salad greens in their dinner buffet.

Though I would still certainly avoid being out on the streets at night.

Not a bad day in Nairobi after all. In fact, it was quite enjoyable.

Thanks, Nairobi!

Tuesday, September 2, 2008

stranded in Nairobi!

Within Tanzania, we use an airline named "Precision Air." We call it Approximate Air.

In the two months I was traveling in Tanzania, 3 planes were canceled, and the delay was anywhere between 4 hours to a day and a half. I thought we had it bad till I saw an angry group of Tanzanians who had experienced 3 canceled flights in a row to Tabora, and at the time, it was only flying 3 times a week - so they had been delayed a whole week!

I was of course skeptical about flying from Kilimanjaro to Nairobi on Approximate Air to connect to my flight to London. But it was the only direct flight. All week I was extra careful about everything: I confirmed the flight in person - twice - called again right before the flight, and asked about the flight statistics (they gave me a load of rubbish, but I figured I would try). I told my colleagues, "The LAST thing I want at the end of this trip is to be stranded in Nairobi."

So here I am, stranded in Nairobi.

...along with a group of angry, obnoxious Americans who had just spent a week hiking on Mount Kilimanjaro. It was a bit shocking to be surrounded by rude Americans again - after my two months among polite Tanzanians. At least there were a few Canadians and a Swiss dude to buffer them.

I missed my connecting flight to London by 10 minutes (the delay ate up the 3.5 hour layover I was supposed to have)... so now I a hoping to get on the flight tonight. It's a 9-hour overnight, and I will be annoyed if I can't get a window seat in order to sleep. They won't allow me to select seats ahead of time.

Nairobi is not on my list of favorite cities. It's not safe for women, especially at night, and has a large share of East African violence and theft. I've had to stay in Nairobi several times in the past for transit reasons, and now I try to avoid it when I can.

I had to cancel my one-day in London, which is a little sad (alas, no fashion month events)- but after two months of travel, I am just eager to go home and see family and friends.

I am trying to practice equanimity and peace with where I am. I know it doesn't sound like it... but I am still doing morning meditation on this every day. It gets heavily challenged when travel mistakes happen, and I have to change what I want to do and where I have planned to be. It also gets challenged every time I get treated like an alien creature. It's difficult to feel like a part of a community.

Let me go home!

Monday, September 1, 2008

Shimbwe Village: where there is no doctor

[above: Fides, Regina, Luciana and their families in Tesheni sub-village]

[above: a short video of Joelle and Beatus describing their work]

Last Saturday Joelle brought me along her round of home visits in the Tesheni sub-village of Shimbwe. She is coordinating the health program of the Minjeni Women’s Project, a small and very grass-roots organization started by a Tanzanian woman from Shimbwe who became a nurse. Joelle makes her rounds with the sub-village leader – in Tesheni, Beatus came with us and helped to identify where the sick people were.

We weren’t just seeing patients in the rural village – we are seeing patients in the rural sub-village. We hiked on the slopes of Mount Kilimanjaro on narrow, steep, packed-dirt pathways to get to the mud-brick homes. It is absolutely, incredibly beautiful. We are surrounded by lush mountain flora, waterfalls, and small family shambas (farms) with mixed crops of coffee, corn, and greens. If it was rainy season, I would have fallen multiple times and been covered completely with mud while evaluating people. Mud-covered, huffing and puffing Sophy, seeing patients where there is no doctor. And no electricity. And no running water. Thank goodness for Purell hand-sanitizer.

Yee-haw! It sounds super-cowgirl-medicine till I tell you that we traveled there by a beat-up mini-van from the bustling international town of Moshi.

Contrast this with the patients that we met at Ushetu lower-level health centre in Kahama District. People still walk 50 km on foot in the hot, dusty Shingyanga region to get to Ushetu. It takes them three days to get to their nearest clinic. This is an improvement; they used to have to walk 80 km to get to Kahama District Hospital before the HIV antiretroviral roll-out, just two months ago. I would be almost afraid to go there and uncover all the untreated illnesses there – it seems overwhelming.

Shimbwe village, on the other hand, is in the rural Moshi district. It’s a 30-45 minute, 800 shillingi daladala ride away from Moshi town and the regional referral hospital of Mawenzi and national referral (and private religious) hospital of KCMC. Yet it’s clear that the people who live in Shimbwe don’t have access to adequate health care.

I can identify three main reasons:
1) Health care is costly: 800 shillingi for each way of travel is still prohibitively expensive for people, particularly single or widowed mothers who also have to care for numerous children and barely make 2,000 shillings a day to support their entire families. At KCMC, people have to pay expensive registration fees. At many health facilities, they are also asked to pay bribes to be seen the same day. Unless they are HIV-infected, they have to pay out-of-pocket for their medications.

2) Getting to the facilities is arduous for those who are ill: People are simply too sick to make the journey down to Moshi town. They are also often turned away due to long queues. People often wait from the break of dawn only to be told at closing time that the clinician doesn’t have time to see them.

3) Even if people are seen by a clinician, the quality of care is often deplorable: Negligence, missed diagnoses, and mis-management abound. It’s sad but true, and individual clinical officers and medical officers are not entirely at blame for this phenomenon. It’s probably due to a mix of crappy clinical training (i.e. A physical exam? Differential diagnosis? What’s that?), poor pay (i.e. good people leave $200-300/month clinical jobs to take cushy office jobs with NGOs that pay at least 3 times as much), and poor conditions (i.e. who wants to be a doctor when you can’t even get a basic lab such as a gram stain or creatinine level?).

Back to Tesheni. We saw five patients that day. Home visits take a long time but are great because you can see the context in which a person lives. It’s a distinct privilege to get such a snap-shot into a person’s life. One woman had been subsisting on only ugali na ndizi (corn mush and banana) for the last few years had developed leg pain and weakness to the point of not being able to walk during her pregnancy. Her baby has significantly deformed legs. I think they have malnutrition, manifesting as B12-deficiency peripheral neuropathy for the mom and Vitamin D/calcium deficiency rickets for the baby (by way of Mom’s vitamin deficiency and breast feeding). If I’m right, we can treat this – and cure them of their symptoms. The sad thing is that this woman had spent a small fortune going to KCMC to be evaluated over the last year– only to be diagnosed with “hysterical ataxia” (a disrespectful way to say that a woman can’t walk because she’s nuts) and “weakness of unknown cause.” You would think that a national referral hospital of Tanzania would be able to diagnose a nutritional deficiency.

Another woman complained of coughing since 1995 and a constellation of vague symptoms, including abdominal and back pain. I think she has peptic ulcer disease, and we will give her triple therapy for helicobacter pylori.

It’s truly rewarding to do home visits in a place like Shimbwe, where there is no doctor. And where there is very little access to good doctors. Hopefully in this very short visit we have helped a few people with curable diseases.

KA: Kitenge-holics Anonymous

Hi, my name is sophy, and i’m addicted to KITENGE!!!! Yeah!

[above: Rita, the amazing tailor-seamstress-textile-artist, and me - with the bags she made with my design sketches]
[above: Joelle sporting a hoodie made out of kitenge]

OUT with a BANG!

[above: mentoring Team TZ - Jenny, me, Guy]

My LAST week of fellowship and work in Tanzania is now OVER!

We came back to Moshi to do direct mentoring at the Mawenzi Hospital HIV clinic. Mawenzi is dreadfully representative of the broken health care system in Tanzania. It’s the regional referral hospital for all of Kilimanjaro, i.e. the northeast part of the entire country. The director of the HIV/AIDS clinic at Mawenzi Regional Referral Hospital is an eye doctor. EYE doctor. With no training in HIV/AIDS care and treatment. ‘Nuff said.

Needless to say, it was a busy week with many gaps to patch. Hopefully we did something good here. Hopefully the 18 year old young man with ataxia, fine motor weakness and loss of sensation in his right arm and leg will get better after empiric treatment for toxoplasmosis while we figure out how to get him a CT scan. Hopefully the 40 year old woman who can’t walk because she lost her position sense and has a horrible burning sensation in her legs up to her thighs won’t get worse since we switched her from stavudine to abacavir… and gave her some pain relief medications. Hopefully the 35 year old woman with rip-roaring cryptococcal meningitis will get the repeat lumbar punctures she needs to relieve the pressure in her cerebral spinal fluid and improve on high-dose fluconazole.

Fortunately, I was able to work with Imelda, a clinician who was eventually receptive and happy to learn. And the eye doctor, Dr. Temba, was eager to improve the quality of care at the clinic. Both are relatively new to the clinic. Mawenzi can only go up.

My very last day of fellowship… and training… was quite insane. As soon as I showed up, I got pulled into seeing two complicated, sick patients. They were too sick to defer evaluation, so the teaching session got delayed and delayed. I felt horrible about this but didn’t feel that I could do a half-arsed job seeing these patients. On top of that, in the process of seeing patients, I got short with Jenny and said something disrespectful to her – which (rightfully) upset her, upset me, then delayed things further and of course I felt bad again. It’s difficult to realize that I am exhibiting the behavior of nasty arrogant doctors. I felt terrible and spent some time apologizing and processing. I am unlearning the bad habits that have arisen from years of hierarchical abuse.

I recovered enough to work with Jenny and Guy to teach for a couple hours on six HIV antiretroviral cases. Most cases were based on patients I saw at Mawenzi that week. On the whole, it went well, and hopefully the 20 or so participants learned something in the process.

We ended with some chai and bites (snacks), lots of warm handshakes, and big hugs and appreciation from Imelda. Imelda did a great job discussing one of the cases with the group and demonstrating the peripheral neuropathy exam that I taught her earlier in the week. That was gratifying.

And then I had a cathartic cry, unleashing some of the pain of fellowship, university hierarchy, misogyny and racism. I was lucky to have Jenny and Guy there to listen through some of my processing.

Out with a bang – and a stream of tears.

Now that I’ve had my catharsis, I contemplate the prospect of not coming back to East Africa for a long, long time.

Sunday, August 24, 2008

Mwanza – Wao!

[above: Kabula on the left and smiling at the camera, and Katega on the right focusing on her drawings]
[above: the view of the Mwanza valley in the mid-afternoon from the veranda next to my hotel room at Tai Five. I have no idea why this hotel is called Tai Five since it's supposedly Tanzanian-owned, though I can tell that it is constructed almost entirely using Chinese parts - and i don't know if that's related.]

“Wao”is the way my colleague Jesca spells “Wow.” I have embraced it was the Kiswahili word for “wow!!!” (complete with three exclamation points). Jesca is a nurse at Shinyanga Regional Hospital. She is incredibly smart and beautiful and is thinking about going for further studies. I want her to study what she wants, but I also secretly hope she becomes a clinician – for the betterment of Tanzanian primary care.

She has two lovely daughters, Kabula, who is 3 years old, and Katega, who is 5 years old. Kabula and Katega are their “botanical names,” as Jesca describes it. These are their Kisukuma, tribal names. In short, these are the names that everyone at home calls them. Their “trade names” (also Jesca’s terminology) are Joyce and Jocelyn… or something strange and unfitting like that. These are the names used to make them fit in to their English medium pre-school. Nice Christian names. I call them Katega and Kabula.

I miss Katega and Kabula this weekend. We had spent Saturday last week at their house in Shinyanga, engrossed in a pile of origami paper, ripped and intact flapping cranes, half-smashed origami paper balloons, mini colored pencils, and scraps of notebook paper. Kabula had filled several sheets of notebook paper with an endless supply of “3”s drawn in every color represented by the colored pencil set. Katega mapped out a nice survey of the different objects and words she had learned in English, including “door” and “flower”, as well as a rainbow representation of the numbers from zero to 100. She read them all out to me. This, of course, was a sign that Katega trusted me. She and Kabula had spent the first two hours of our visit completely mute.

Jesca, not to be out-done by her daughters in the charming department, had also not just prepared dinner for us, but had also bought a bolt of star-patterned brown kitenge and made tunic tops for Jenny and me. There is very little that impresses me more than someone who can appreciate my obsession over kitenge and fabric arts.

We were supposed to be in Shinyanga this weekend. Indeed, I was looking forward all week to the prospect of spending time with Jesca, Katega and Kabula again. And Shinyanga was becoming familiar to me, as my home-base in this dry, red-earth dusty region. I know exactly where to get Azam Mini Choc ice cream bars. I know which kitenge stores will rip me off and which won’t. I know where to bring people for good old rice ‘n’ beans or ugali and grilled fish when they’re hungry. I know every nook and corner and quirk of room number eleven at the Karena Hotel.

Not only were we supposed to go to Shinyanga, we were also supposed to go to Maswa for mentoring next week. Maswa is a remote, rural district with roads that can only be navigated by 4-wheel drive vehicles. Everyone was excited to get a chance to spend time in this remote region, where providers were hungry for mentoring and teaching, where we knew our presence would be greatly appreciated and well-utilized.

But instead we are in Mwanza. One day before our return to Shinyanga, we were told by EGPAF that we no longer have any transportation for the Maswa district. The could spare a land cruise to bring us there straight away (and thereby not allowing us to stay in Shinyanga for the weekend) and then leave us stranded there. Wao! (That translates to “Wow!!!!”) EGPAF had already done this to us once, for the Kahama trip, but we mustered a taxi substitute. This time we couldn’t do that, since there are no 4-wheel-drive taxis around.

So Guy put his long, lanky Dutch leather-sandaled foot down and came up with an alternate plan. Jenny and I were on board too. Instead of going to do mentoring in Maswa and Bariadi, we are now flying out of Mwanza airport on Monday to go to the Kilimanjaro region. After we arrive and meet with the EGPAF folks there, we’ll piece together some mentoring visits for my final week in Tanzania.

I am not complaining about this change in plans. In fact, I prefer it. I had been sad when I was told at the beginning of my trip here that I would not be returning to the Kilimanjaro region to do follow-up mentoring at places where I knew people already. This added to my feeling of alienation in Tanzania – I’ve been unable to settle down in one place and root. In fact, I’ve been not allowed to settle down in one place and root. That’s why I won’t willingly do this in the future. But for my final week in Tanzania, anyway, I will be going back to a region in which I did mentoring visits back in February. It’ll be nice to have some continuity and closure with a familiar place before I say good-bye.

Mwanza is also a delightful city. (“Delightful”? Where am I picking up this vocabulary?) No, really, it is truly delightful. It’s quite refreshing to be here after a week in the dude-town of Kahama. Somehow Mwanza reminds me of Asia: lush, green, terraced hillsides, and weird rock formations. Twilight brings a rich luminous glow over the sounds of lake birds, boats, football (soccer) games, and children playing. I sit on the veranda next to my hotel room and watch the swallows dart, egrets wade in the fields, and storks soar, large and graceful in the orange-blue sky. The people here seem to be more worldly and cosmopolitan. Still, there are far fewer wazungu around in Mwanza than in Dar es Salaam – as well as far fewer vehicles. And for these reasons, it’s a much nicer city.

Tonight we are picking up some vegetables from the local market and going to one of Jenny’s nurse practitioner school friends’ (Suzanna) homes to cook dinner. This will be the first time I’ve cooked since I left our San Francisco apartment in mid-June. Mwanza – Wao!

Kahama: Dude Town from Hell

[above: dude carrying a load of sponge-bed-square-pants mattresses for one of the many motels for migrant miners along the main road in Kahama]

Kahama is a dusty dry dude town on the highway to Rwanda and Burundi, between Tinde and Bukombe. Its existence depends on gold mining, and all of its industry is built around mines and miners. That means a town full of miner dudes, their dude bars and dude brawls, and their ladies-of-the-night. With this set up, it’s no wonder that this mining region is Tanzania’s hot bed for HIV transmission.

The streets of Kahama consist of piles of red dirt and dust, dried garbage, and tons of motorcycles, bikes and transport trucks. There are huge numbers of young men hanging out at all times of the day, drinking and cat-calling to the very few women around.

Today, on my way walking to and from the hospital, I received the following greetings, all from men, of course:

Ssssss, SSSSssss. (~20 times)

Mchina, mchina! (~10 times)

Wao, mzungu! (~10 times)

Hee haw! (~5 times)

Hee haw! accompanied by a few sloppy attempts at a martial arts kick (1 time)

I have no idea how “Hee haw” became widely used as a way to name-call Asian-looking people. As far as I know, nothing in the Chinese language sounds like a donkey braying.

It’s not exactly a hospitable place for a young-looking Asian female (i.e. me).

My M.O. is generally to keep walking and ignore the obviously disrespectful attempts to get my attention. Except the faux-Chinese attempts. Then I say back in loud Kiswahili, Si Kichina, “That’s not Chinese.”

It was also difficult to ignore the young buck who revved up his motorcycle when he saw me coming and rode wheelies around me and cornered me every time I tried to escape. He was probably trying to show off and give me a ride, to which I replied “Nina tembea, asante.” (I’m walking, thanks.”) But he continued to follow and corner me, making a bunch of overtures in Kiswahili, most of which I didn’t understand. When he wouldn’t leave me alone, I sprinted across the street (in traffic – yikes! Frogger move) and onto a side alleyway where he couldn’t follow.

This is mostly irritating and probably harmless. I pay for my northern hemisphere lighter-skinned privilege by being treated as a stereotype on the street. Oh well – a minor annoyance. Not pleasant, but not deadly.

Where it becomes a problem for me is when it gets in the way of work. Which it does. On this particular visit to Kahama, it took the clinic-in-charge, Dr. Malulu (who is actually an assistant medical officer – kind of like a physician’s assistant) three days before he addressed me as “Dr. Sophy.” In contrast, he had been addressing Guy as “Dr. Guy” from the very first moment we arrived. The difference between Guy and me is that Guy is a tall white man – and that Guy is a nurse. On previous trips, Guy would actually say, “Please call me just ‘Guy.’ I am a nurse.” And he would call me “Dr. Sophy” to help remind others. But he has stopped doing that. The stereotypes live on.

The end result is that I am left to prove myself alone. A few days of inserting mentorship on complex medical management and demonstrating some mastery of antiretrovirals and diagnostic procedures – and then sometimes, just sometimes, they start believing that I am a doctor. It’s more than a minor annoyance because it means that there are often a few wasted days before people become open to what I can teach and contribute to their work. Since we are given only 4-5 days at each site, this wasted time becomes significant. Such stereotypes and prejudices are a major barrier to efficiency and learning.

But they are reality – the stereotypes and prejudices are constantly present. When I am here, I have to learn to deal with them. The question is whether I want to continue to deal with them in this way. My northern hemisphere lighter-skin privilege gives me a choice on whether or not I want to continue working in rural Tanzania doing these one-week long mentoring sessions and trainings.

I don’t.

After four months of doing this, I have decided that this way of providing mentorship in HIV care and treatment is inefficient and ineffective – for me. I can only speak for my experience and assessment.

My best experiences in global HIV work have been from rooting myself in one specific community, getting to know the people, and building working and mentoring relationships with them. You can ask Flo and Rosie at FACES in Kisumu, Kenya. Or Kibachio from our days in Eldoret, Kenya. These are the types of enduring work relationships I like to cultivate. And being in one place doesn’t mean that I don’t have far-reaching influence. At FACES, for example, I would have been able to reach dozens of providers and help decide on clinical guidelines that would affect almost 40,000 patients. I’ve decided that committing myself to one particular community is a much more efficient, effective and sustainable way for me to do global health work.

That’s what I’ve decided to do next.

As for the present, I have one more case discussion tomorrow morning at Kahama district hospital on a patient who developed hepatotoxicity (liver failure) on TB therapy and HIV antiretrovirals and another patient who came in with mitral valve disease leading to atrial fibrillation and heart failure, probably due to rheumatic heart disease – from streptococcal bacterial infection, a common cause of heart failure among young adults here.

Then – kwaheri Kahama!

Sunday, August 17, 2008

The waxing moon, three cats, and a bowl of tiny lake anchovies.

Tonight was a welcome departure from the norm. After a long day of training and some disappointing sessions from the doctor I’ve been trying to train (mostly disappointing to me and probably of relatively high quality for the Tanzanians - which illustrates the poor teaching they are regularly subjected to), I did not feel like socializing with the rest of the crew at dinnertime. I had ordered dagaa (tiny lake anchovies in a tomato stew), ugali (maize mash) and bamia (okra) this morning, and asked for it to be ready at 7 pm. I wandered to the outdoor dining area of the Karena Hotel and saw that Guy, Jenny and Werner had found an older white bearded male friend. They were all drinking and making loud conversation. I had an instant feeling that I would have a hard time enjoying dinner in such company and decided to sit in a different corner alone.

I should do this more often.

It was one of the best meals I’ve had here: I was able to fully concentrate on the Five Contemplations for my meal, eat in peaceful silence and pay attention to what and how I was eating. Eventually I was accompanied by three lovely little wild cats. They patiently waited for me to give some of my dagaa to them. We ate dinner together, silently. They provided the perfect company for me tonight.

When I finished, I sat back and watched the clouds roll over the bright waxing moon and create funky patterns. I enjoyed watching the luminescent lacy swirls.

The wait-staff was totally weirded out that I was sitting alone. It took them some time to adjust. “Why are you sitting over here?” I told them that I was tired. “Hey, the others are over there!” “Should I bring your food even though you are not sitting with them?” “Do you really want to eat your food separately?” It is unusual in Tanzanian culture to choose to sit alone. But they eventually embraced the idea and treated me very respectfully. In fact, I felt that they treated me with much more friendliness when I sat alone today than when I’ve sat with the others. That was interesting. Maybe they were being sensitive to my tiredness.

Ah, it was so nice, so peaceful.

And now, with the crickets in the background and evening prayer song emanating from the nearest mosque, I continue to enjoy my night.

Uksiku mwema.

a day in the life…

[above: HIV Care and Treatment Refresher Training participants, trainers and UCSF help-staff (i.e. the team i work with in Tanzania) in Shinyanga, picture taken on 15 August at the Ngoloko Hostel, Catholic Arch Diocese centre; this was a historic Refresher training because all of the direct trainers were Tanzanian and a majority of the training was conducted in Kiswahili! i served as the content coordinator and trainer of trainers.]

I have two radically different work schedules here in Tanzania. One is for trainings, and one is for mentoring of mentors out in the field. Each of these programs last one work week, so we tend to travel from place to place on Monday mornings, return to our favorite regional hangout on Friday afternoons, stay over the weekend, and leave again for the next destination the next Monday morning. That’s when I have a say in the travel schedule. When I don’t have a say, we often end up traveling over the weekend, so we end up not really having any days off. I count traveling as work. It’s more tiring than my work – and far more dangerous.

No matter where I am in Tanzania, I try to follow this routine:

5 am: occasionally get woken up by the morning call to prayer from the local mosque (this happens regularly in Moshi, Stone Town, and Bukombe)

7 am: wake up to my cell phone alarm for real; use the bathroom, wash up, and make the bed

7:05 am: sitting meditation (I have been meditating on the Visuddhimagga) followed by stretching exercises

7:45 am: get dressed and go to breakfast. When the breakfast is good (as it is at Bristol Cottages in Moshi and The Orion in Tabora), I can get a big bowl of fresh fruit, reasonably fresh bread (toasted), and eggs over easy. I bring my own loose tea in a tea strainer from home, and have a cup of jasmine green tea. When the breakfast is bad (as it is at The Karena Hotel, where I am staying now in Shinyanga), I bring one of my oatmeal packets and make myself some instant oatmeal to have along with my tea. I’ve also gotten into the habit of ordering my dinner at breakfast. It’s so nice to have it ready when I return so I don’t get hungry and annoyed waiting 1-2 hours for it to appear. (Yes, that’s typically how long it takes to get food after you order it here.) Plus, it reduces the stress on the chef and staff so that they don’t need to scramble to prepare food for the impatient wazungu. Afterwards I return to my room to brush and floss my teeth, get my backpack.

8:15 am: leave for work (in a small town, by foot; in large or further locations, by taxi or EGPAF vehicle)

8:30 am: work! Here’s where there’s some divergence-


are held in conference venues in the regional centers, such as Shinyanga (where I am now), Tabora, Moshi or Arusha. We live comfortably with access to most of the modern conveniences: electricity, plumbing, hot water for showers (except occasionally in Tabora), vegetables. Eating vegetarian is not very popular in the rural areas. When you eat out, you’re supposed to be eating meat!

Trainings generally following this schedule:

8:30 am: opening schmooze, energizer, wait for trainer to arrive

8:45 am: morning session

10:30 am: chai break (tea or coffee, stale bread, egg, fried thing)

11 am: continue morning session

1 pm: lunch

2 pm: afternoon session

4 pm: soda break (Coca-Cola monopoly sodas – coke, Fanta, Sprite, other junk I don’t drink)

4:15 pm: complete afternoon session

5-5:30 pm: finish the day, figure out how to get back to our hotel

6 pm: return to hotel, wash up

7 pm: dinner

Mentoring visits…

vary day-by-day and site-by-site. Some days we stay at the district hospital clinic and teach or mentor folks there. Some days we go to one of the lower level health facilities, which may take a few hours to get to on rough road, and ideally mentor the district mentors there. When we mentor mentors, it means that I am meta-mentoring. (Follow?) I am working with one of the clinicians from the district hospital who’s been managing HIV-infected folks for at least a year, observing her/him mentoring one of the inexperienced clinicians from the lower-level health facility. It can get quite difficult when something doesn’t happen quite right (i.e. something harmful to the patient is about to occur). I then have to respectfully discuss the issue with the district mentor, and suggest that s/he mentor and support the lower-level health facility clinician to correct the problem. It’s two steps removed from seeing the patient myself.

All of this happens in Kiswahili, so I need to derive quite a bit from body language and my limited command of Kiswahili. When something seems critical, and I don’t think I understand, I will ask the district mentor to interpret for me.

In an ideal mentoring visit, this is what the week looks like:

M- arrive around noon, meet and greet the District Medical Officer, schmooze, meet the Hospital in-charge person, and meet the HIV clinic in-charge person who usually gives us a tour of the clinic and the district hospital. In the afternoon, I teach some content (TB-HIV coinfection, IRIS, ART review, etc.)

T- district clinic mentoring

W- lower-level health facility mentoring of district mentors

Th – “

F- in the morning, district clinic mentoring and feedback meeting. Prolonged good-byes. In the afternoon, return to our weekend location.

In the evening, I have been eating dinner with my work colleagues. It’s usually a few hours long if I haven’t ordered at lunch time:

7 pm – order dinner, drink soda water or tonic water to bide my time and curb my hunger

8-9 pm – receive dinner and eat (typical meals for me: pilau rice with vegetables, white rice with beans and spinach, grilled fish in tomato stew with plain white rice and cabbage, palak paneer, dal fry)

10 pm – finish up dinner and conversation, return to room, shower if I haven’t already

10:30 pm – email using our super-cool USB sim-card modem which connects us to the satellite internet system via local cell phone carriers.

11 pm – stick in ear plugs, put down the mosquito net, take my malaria prophylaxis, sleep.

Lala salama! Enjoy your dreams.

Monday, August 11, 2008

Bruce Lee and Jackie Chan in Tanzania!

[above left: Tanzanian stamp honoring The Scholar and the Athlete, Bruce Lee… and above right: Tanzanian stamp sheet honoring Jackie Chan (The Clown and the Athlete?)]

Yes, my people are AWEsome. My colleague Elitumaini told me the other day that Tanzanians view Chinese people as friends. “We have been a socialist country, and so for some time the people of Russia and China helped us build our roads and schools and hospitals. Chinese people are our friends.”

While the people of Europe, US, and colonial South Africa exploit Tanzanian labor and natural resources, the people of China are helping Tanzanians build their own infrastructure. Granted, there are a number of opportunists here who have set up businesses, but apparently the Chinese business people are not seen as exploitative as the South Asians or Europeans. Nor do the Chinese people seem to pretend to assuage imperialist guilt by setting up feel-good-do-little NGOs. There are many Chinese doctors and civil engineers here quietly doing the work and not making big noise about it. It is a very different presence.

Even the Yellow Ones!

Bukombe is a trip. It’s a diamond and gem mining town in the interior of Tanzania, on the road towards the Rwanda and Burundi borders from Nzega and Shinyanga. Because this region is built around the mining industry, it’s filled with young men from all different parts of Tanzania (and other East African countries) who are trying to make a living from the hard labor of mining. The presence of many young men with intermittent cash jobs creates a robust alcohol and sex work industry. And this, in turn, results in a high HIV prevalence rate, around 15-20%.

It reminds me a bit of the islands of Lake Victoria, where there are many young male fishermen who will get boluses of cash for the fish they cash, fueling an economy of bars and sex workers. Unlike these islands, Bukombe is on land and has decent infrastructure (a paved road! electricity! running water!) so it doesn’t quite feel as wild.

Working and living in a town of men with excessive drinking habits is not my idea of fun. But there is much work to be done here in the realm of HIV care and treatment. So here we are in Bukombe.

We are celebrities here. Or rather, Guy and Jenny, my white colleagues, are celebrities here. When they sit at a local bar drinking beer, men around them offer to buy them more alcohol. Children surround them and simply stare, with their mouths open in wonder.

“Oh, I am so happy to have white man here in Tanzania!” people shout. (I’m not kidding.)

Guy and Jenny are the King and Queen of Bukombe. I am the weird alien attachment. One particularly drunk and overly “friendly” man bought Guy and Jenny several rounds of beers. I don’t know how, but Guy seems to enjoy the attention. I made the mistake of joining their table and being part of their court. Maybe I’m their joker. So I also became an object of conversation.

“We are all under One God!” declared the drunk man. “Even the Yellow One!!” he said, slapping my leg.

He pressed his hands around his head, seemingly to shape an Asian hair bowl cut with his hands. “Even the Yellow One, like this!”

He pressed his fingers against his eyes, squishing his eyeballs in. “Even the Yellow One, like this!”

“Oh, even the Yellow Ones who have bad haircuts and can’t see – they are also under the same god. Wow, is that so?” I said.

“Yes, and even me, the Black Man. We are all under One God.”

He laughed and slapped my palm.

Monday, August 4, 2008

chakula cha mchana: lunch at Tanzanian family homes

[above: (picture on left) Young Whan, Bibi and Babu of Valerie, sophy (picture on right) Valerie, Bibi, Babu, cousin, sophy, cousins in the front]

Tanzanians have a wonderfully welcoming culture. You don’t necessarily experience it as a tourist – Tanzanian tourist culture is an entirely different beast. You really have to be living or working within communities that are outside of tourist areas to get that Tanzanian warmth.

Probably in part because we are the token lighter-skinned foreigners, we frequently get invited to peoples’ homes. “You must come visit my homestead,” women will often whisper into my ear. There is no date set, no time set. Somehow, it magically happens, usually at the last minute, and I end up sitting in someone’s living room as their guest.

First, there are the innumerable and respectful greetings (see the previous entry on Kiswahilish). Shikamoo marahaba jambo sijambo mambo poa safi habari ya nyumbani salama nzuri mchananjema na wewe pia.” Valerie’s grandfather, who has served in the Tanzanian military, and was part of the battle to remove Idi Amin from power in Uganda, was as gracious as always and chatted with us in Kiswahilish about world politics and Barack Obama. “McCain is really too old!” he said repeatedly.

There is always food involved. At Valerie’s house, I had yet another delicious traditional meal with ugali wa mahindi (fluffly light maize mush) na kabichi (cabbage) na supu ya nyama (a beef stew, of which I just took the surrounding potatoes and stew and left the beef). Sundays and Fridays are meat nights at Valerie’s house, and they had leftover beef stew from the day before which they saved for us for lunch.

At Jesca’s spacious and well-appointed home, we had one of my favorite meals: dagaa na ugali wa mahogo na mahindi mix (small lake anchovies with cassava and maize mush). At Editha Kwezi’s home, we had pilau na kachimbari na supu ya kuku (spiced rice with spicy tomato and onion salad and chicken stew). All was delicious.

It’s infinitely better than the pseudo-westerner food we eat at hotel restaurants.

There are, of course, many awkward moments of miscommunication and silence that come with speaking different primary languages. There’s also the gospel video phenomenon, such as at Dr. Kwezi’s home: videos of Tanzanian gospel choirs singing and clapping and dancing about how the fires of hell will burn all the traditionalist heathens unless they convert. There was even one video of the Shingyanga choir that included depictions of heathen Chinese people flailing about with fake kung fu moves. They were followed by the flames of hell.

Sometimes people pick up the fact that I take a moment of silence before I eat. “Are you praying?” they ask. Ndiyo, yes,” I reply. A few people have asked me if I am Christian. “I am Buddhist,” I’ll reply. This is met with a longer period of silence. Perhaps they are contemplating what it means to have a heathen doctor in their home. (Heathen doctor – does this make me a witch?) Still, people remain respectful to me. And I definitely don’t volunteer any religious commentary in homes playing the gospel videos.

Religion plays a critical role in bringing communities together, though unfortunately at times with overtones of hate. But when hope is one of the few things people have, it is important to protect it.

African Standard Time (AST): living in the present moment

Haraka haraka haina baraka.

If you hurry hurry, you will not receive blessings.

The pace of life in Tanzania, particularly the rural inland region of Shinyanga (where we are working now), is pole pole. It is a remarkable departure from our compulsive, over-scheduled, and micromanaged culture at home in the US. Here, we are less encumbered by abstract details. We deal mostly with what is in front of us.

On one hand, this means that life can be mellow and take on the façade of hakuna matata, without worries. In non-work life, I take on more of the chilled-out attitude of the people around us. I can focus on the people and events in front of me. My morning meditation is clearer, simpler. I have fewer detailed worries clouding my mind.

On another hand, this means that most things are unplanned and happen at the last minute. It makes work challenging for me. Long-term strategy and vision are relatively foreign concepts. I like to work with both clinical and systems issues, both things that need to happen right now and things that need to happen over the next ten years. My ability to make any big picture changes is muted by the fact that systemic advocacy and activism is not culturally acceptable (from Tanzanians, and certainly from foreigners like me). Systems issues are under the jurisdiction of people in power, who are frequently and unfortunately quite corrupt. It makes me wonder about how things can move forward.

Pole pole can feel terrible when I still see young people dying of AIDS. It is heart-wrenching when I see people spending their week’s salary to travel to an HIV primary care clinic which doesn’t have adequate medications in stock and provides sub-standard care.

It makes me think hard about how effective I am in providing clinical mentoring if I cannot also provide advocacy over systems issues. For me these go hand-in-hand. I do not self-potentiate if I am not working on both. I will need to take this into account and think hard about my role and next job in global health.