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 cafĂ© 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.