Sunday, March 16, 2008

Tanzania photos, album #3 of 3

This is my third and final Tanzania photo album. This album includes shots from Same, Huruma, Marangu, Keni health centre, Rombo district, Moshi, Stone Town and Prison Island Zanzibar. Click on this teeny slideshow to open a new window and see a bigger version of the photos (recommended). Enjoy!

Wednesday, March 12, 2008


above: kid next to the "door of no return" (which slaves passed through to leave their home forever) at Changuu Island, Zanzibar

dhows anchored at Stone Town, Zanzibar

twilight over Stone Town

aerial of the reef around Unguja island, Zanzibar

hallway at Beit-Al-Amaan ("house of peace")

chillin at Beit-al-Amaan's lush living room


Ahh… hearing the name alone makes people feel like they’re on an exotic tropical island. It needs no other embellishment.

Apparently the name was originally “Zangh Bar,” which means “Coast of the dark people” or “Negro Coast” in Arabic. For centuries Arabic colonizers and merchants used it as a base for its Indian Ocean slave trade. It’s a bit more racist and less romantic when you know that, eh?

The rest of Team Tanzania (the guys who are part of the crew from my department at UCSF who come to Tanzania regularly) was exuberant and happy that we were finally on a holiday in Zanzibar. Everyone loves Zanzibar. Even John and Royce, who were already back in San Francisco, were ecstatic for us. They all knew that we had worked hard and felt wasted.

Who wouldn’t love being in a gorgeous coastal environment with the richness of blended African, Arab and Indian cultures?

Zanzibar is gorgeous and lush. It still has intact, healthy coral reef full of fish around the islands other than Unguja, where Stone Town is.

But there is an element of Havana, Cuba in it. The concept of a former bastion of ill-gotten wealth which fell into chaos and redistribution. But unlike Havana, the new Zanzibari government was not very organized about the redistribution of land and buildings. Stone Town was previously a wealthy slave and ivory trading port, built on the backs and blood of black Africans from the interior. Countless black Africans were killed in the process. After centuries of slavery, there was an uprising by black African askaris (soldiers) in the 1960s which killed off nearly 20,000 Arabs. Since there had been quite a bit of intermarrying, it was probably quite arbitrary who got selected for murder – perhaps the lighter-skinned people, perhaps the people who owned more stuff. People say that Zanzibar is now a happy blend of people, but I wonder how much of this is the sheen sold to tourists like me.

By the end of my two months in Tanzania, I was happy to wander the alleyways of Stone Town with just my compass guiding me… and enjoy the warmth of the Indian Ocean and the living beings in it. But I am very ready to go home to San Francisco.

And I am happy that I did not decide to live abroad semi-permanently for my next job.

I would be a terrible expatriate. I don’t enjoy any part of that culture: creating insular little communities, living in a gated house with a house-girl and askari, driving around in a hulking SUV, having others cook and clean for me, going out to bars with the other ex-pats – most of whom drink and smoke and generally do nasty things, especially to the people native to the community (i.e the black folks). It is an obnoxious and unmindful lifestyle.

If I move to a place like Moshi or Tabora or Kisumu, I might try to make better friends among my black colleagues, but I could never really be integrated into their communities. There would be too many barriers from both sides. There are some ex-pats, especially the white people, who say they have good Tanzanian friends, but on closer inspection, theirs is really a paternalistic relationship – the ex-pats “buy off” their “friends” by giving them CD players, extra money, nice dinners at restaurants, scholarships. I cannot build friendships in this way. It’s just not balanced or sincere when it is clouded by favors.

It has become clear to me that I travel to East Africa really to work and build better HIV/AIDS care – not for vacation, not for the love of being an ex-pat, not for the lifestyle. Of course, there is the special-ness and challenge of working in a totally different culture from my own. But the magic veil of “otherness” wore off early on, when the reality of the work, of the sick and dying patients, set in. My skills and training have value here, if I use them well.

So – I am happy to return to my own “native” community in the Bay Area. This is where my partner and my family are, where I am building a sangha, a community of people who support my practice in being a good person, a person of lovingkindness.

With their support, I can rebuild my strength and resolve to return to Tanzania in July to continue this work.

i'm eating real chinese food in Tanzania!

above: Panda Chinese restaurant staff, Feng Yu (the owner) and me in Moshi

There are few things in life as lovely as eating freshly-made tofu, garden greens sauteed in garlic and good rice made by a new friend, who also happens to be a sassy, tough, adventurous Chinese-in-a-foreign country woman.

same same

above: Guy, Bonifas, the ART nurse and peer advocate at Keni Health Centre, Rombo district

Sara, a nurse, Steve and Keni Health Centre patients

above: the Matron of Keni Health Centre with Bonifas, the HIV clinician, in the clinical room

Same: everyone pronounces the district and town name as “Sah-may.” But there are some Tanzanians who half-jokingly tell the story of the British colonialist who drove through the Same region in his jeep, watching the rolling hills behind the expansive valley floor and announced that everything looked the “same.” And as another unfortunate vestige of colonial power, the name stuck. But it sounds better pronounced “Sah-may.”

Sadly, by the fourth week of my mentoring-of-mentors work at the HIV clinics, things were really starting to feel same same. Same was this way. Huruma was this way with the roll-out due to poor district leadership.

Clinics had run out of basic HIV drugs, such as efavirenz. Most clinics we visited had broken CD4 machines, which (when working) provided one of the few critical lab tests that we needed to manage patients with HIV. They have the machines but no one had been trained on how to maintain or fix them.

During a majority of the clinics, I was the only clinician there in the mornings. The patients very patiently waited from 7 am to see them. But I had to run around and look for the Tanzanian clinicians so that they could see the patients queued up to see them. It made me wonder what happens when there are no visitors like me to pull them from their meetings and such to go see patients. And then I realized from the patients what had been happening. Apparently sometimes only the nurses saw them, and even though they were untrained to give HIV medications, they gave them medication refills without doing a clinical assessment. Sometimes the hurried clinician came at 1-2 in the afternoon and just whipped through the long line of patients, nodding at their complaints but not doing a damn thing about them. Just refill, refill, refill, follow-up next month.

The reason I found this out was because when I saw the patients with the Tanzanian clinicians, they would tell us about some problem they’ve had for the last six months. Or over the last three years. These were big things, like “their legs have been on fire all night.” (A way that patients describe their peripheral neuropathy.) Or “I have been coughing and losing weight for the last three months but they keep on giving me amoxicillin and it doesn’t get better.” Or “last month they did not give me the yellow pill I usually take.” (This is how I found out that some of the sites had had be out of efavirenz, a vital HIV drug, for one or two months.) Yet there was no note of anywhere in the chart. The patients were probably just hurried through a long line, and the clinician just nodded to their complaints and gave them refills.

The patients put up with terrible service and even worse clinical management. Yet many of them remain grateful that they are receiving medications at all. The culture of acceptance is deeply ingrained. There is no ACT UP Tanzania.

There are, of course, a few nurses, clinical officers and medical officers who possess decent medical acumen, but sadly I found a vast majority of the clinicians to be very poorly trained. It’s the fault of the system and its complicit corrupt leadership. It’s hard to become a good clinician (or anything, for that matter) if your schools don’t teach you the skills you need to use – or if your leadership doesn’t allow you to do the duties you need to do, or skims off resources (such as using the HIV clinic’s land cruiser as his own personal vehicle). Tanzanian training lags behind that of the Kenyans’ I have worked with in the past. This was an unfortunate realization, as I had high hopes that the people led by the Mwalimu (Teacher) Nyerere would have a solid education. Not so.

Most people I worked with lacked critical thinking skills in their evaluation of patients. They stared at me blankly when I would say, “Do you think that the cough can be due to something other than bacterial pneumonia? What are other possibilities?” They stared at me again when I would suggest that they write down a differential diagnosis and follow-up closely if a patient did not get better with amoxicillin. There is very little concept of the provision of quality care. Most people just wanted to get through their day and probably be left alone by someone like me.

It is these clinicians, the ones who are entrenched in the bad habits established at their district HIV clinic sites, who we are trying to train to be mentors of the roll-out clinics in the more rural, remote sites. This is a frightening proposition: the blind leading the blind in HIV care. The patients suffer the most. In the end, the entire community suffers – everyone suffers.

I am not surprised that in a recent study from an HIV clinic in Moshi, Tanzania, 30% of the patients surveyed had treatment failure. With the system as fragile and poorly organized as it is, we will be seeing more and more treatment failure as time goes on.

Guy and I wrote several frank and thorough reports to discuss directly with the clinic staff and the EGPAF officers. I was told in a roundabout way that my writing might be too bold and brazen and that I would get resistance. That my writing was not culturally sensitive – because Tanzanians are never this direct. But I am not Tanzanian and can’t pretend to be. And the lack of direct feedback is partially why Tanzanian medical care is so impoverished. No one pushes them to do better. I don’t think that providing dangerously poor medical care is a “cultural thing.” I can’t imagine a culture that is happy to do such a thing on purpose.

Still, there is hope. There is no where to go but up. There are a few good leaders out there in the clinics, scattered but not yet swept up by NGOs and foreign countries. The clinicians at the rural and remote health facilities are happy and grateful to get any training or mentoring, since they’ve been neglected for so long. Since they are completely new to HIV care, there is the possibility of teaching them the smart, higher quality way to care for patients with HIV. Even if they don’t have the fancy equipment or facilities of the district clinics, they have time. They have time to start clinic in the morning and to listen to patients when they have problems. They have time to do a decent physical examination. They have time to think through a good management plan. But they need to be taught how to do these things. We just have to hope that they are moving in this direction after we leave and must rely on the in-country mentors to lead them.

even the immigration officials have to harass me

Dudes, leave a girl alone! Sheesh.

Mr. Chukah A. Manyenga* was dressed in jeans and a t-shirt, holding a couple of Kilimanjaro postcards. He kept trying to stop me while I was running around Bristol Cottages (our Moshi hotel) trying to tie up loose ends before flying out to Zanzibar. Finally, he stood in front of me and wouldn’t let me pass. I looked at him, irritated, thinking that he was yet another fly-catcher trying to sell me something I don’t want. Moshi is full of these young unemployed and immensely annoying guys. Except he called me by my name. I didn’t really want to find out how he knew my name. Maybe a hotel staff person ratted me out.

“Sophia, I want to talk to you.”

“Please – I do not want to buy anything. I do not want to go on safari. Please let me go about my business,” I pushed past him to continue along my way.

“No, I’m not trying to sell anything. I’m an immigration official. I want to see your passport.”

I looked at him. Was he joking? No he wasn’t. I checked his identification and it looked reasonably legitimate (as legitimate as things look in Tanzania). Why was he chasing after me? Why did he know my name? Why do these annoying young men harass me every day? Why can’t I be treated like a normal human being? Ick, ick, and ick.

I allowed him to look at my passport, but I held on to it, knowing full well that he would more effectively try to bribe me if he took my passport away.

“Hey, hey, it’s OK. I just want to see it,” he said, condescendingly.

“You may look at my passport, but my passport is mine. You have no right to take it away. I don’t want trouble from you,” I stared at him.

Three of his buddies (a.k.a. immigration thugs who came to help extort money from us) came to surround me. Steve and Guy came too. He asked Guy for his passport too, but barely even looked at it.

The immigration officer tried to tell me that I had the wrong visa and that Guy and I had to go to his office for “further investigation.”

Steve said, “We are leaving. We have a flight to catch soon.”

Guy said, “Unless you’re going to arrest us, we are leaving.”

I told him very clearly that I was a professional consultant, that I had fully paid for a professional visa (I did and was very careful to do so), and then I showed him my UCSF physician’s identification badge. Being fully legitimate didn’t matter. They wanted a bribe. Then I pulled out my only weapon.

“I am a professional, a physician, here to assist as a consultant for the HIV care and treatment roll-out under the National AIDS Control Program. I have been hired to work under the Elisabeth Glazer Paediatric AIDS Foundation to help your country with your medical care. If you want to make trouble, you can first talk to our country director, who is a friend of the Kikwetes.” There. And all true. President Kikwete is the current president of Tanzania.

They stood back for a second. One of them mumbled something about me being a VIP, and that they should leave me alone. “OK, you can go.”

Feeling most unwelcome in this country, I dragged my luggage through Moshi with Guy and Steve to catch our van to the airport. It made me wonder, really, what am I doing here? Am I crazy to be so far from my home, from my family and friends? Can this place ever possibly feel like home to me?

Up to that point, I had been meditating on “Being Home” where-ever I was in the world. Now I’m not so sure that I can practice it.

*Yes, I checked his identification and wrote down his name before I allowed him to even look at my passport. Certified by Afisa Uhamaji on 31/5/2007. No details overlooked! And now anyone will know the name of the person who harassed and tried to detain us unfairly.

climbing kili

Things people wrote right after climbing Kilimanjaro

a.k.a more reasons for me to not climb Kilimanjaro

and instead admire her awesomeness from a distance.

(posted at the Kibo Hotel in Marangu, where I stayed to do mentoring work at Huruma Hospital in Rombo District):

-Kili didn’t kill me but it tried.

-Damn my feet hurt.

-To hell and back but didn’t shit on myself.

-Never again.

-So hard it made my balls swell.

-Got chilly on Kili

Nearly froze off my willy

I felt very silly

When my willy

Rolled off the hilly.