Tanzania photos, album #2

Check out my second batch of photos from Tanzania! (first batch is on my blog at the beginning of February) Click on the album here to get to a bigger online album to see the photos more clearly.

“You Japanese hate Black Man.”

It was innocent enough. I was walking along Nyerere Street in Moshi, on my way to pick up a tailored shirt that was being altered by a seamstress who set up her sewing machine on one of the side streets. I was almost there when I start to hear a familiar sound. An irritating, persistent voice.

“Hello, how are you? Come to my shop!”

“Hello, how are you? Come to my shop!”

“Hello, how are you? Come to my shop!”

“Hello, how are you? Come to my shop! Nice paintings.”

“Hello, how are you? Come to my shop!”

“Hello, how are you? Come to my shop!”

“Hapana, asante,” I replied, each time. No, thank you. It is almost a reflex now, since I get typically get bothered several times in a single walk down the street with similar phrases.

“Why not? Come to my shop!”

“Hapana, asante.”

“What are you looking for?”

I walk into a fabric store to try to get away from him.

“Want fabric? Come to my shop! I have nice fabric.”

I stop answering him and keep on walking to my destination.

“Where are you from?”

No answer. I keep walking.

“You must be Japanese. You Japanese hate Black Man.”

I looked right at him. He was a young black Tanzanian man with a shaved head, wearing an oversized Timberland shirt and jeans. I said, very sternly, “No, I am not Japanese. I do not hate Black men. Please leave me alone.”

“Yes! You are Japanese! You are Japanese!” he giggled, like he just discovered a new race. He tried to grab me.

I moved away quickly, into the shop associated with the seamstress I was looking for. He continued to harass me about going to his shop until one of the men from the shop managed to kick him out. Much to my sadness, the seamstress was out at lunch, so I had to come back in 15 minutes.

I made it to the corner of Nyerere Street when I heard that young man’s voice again from behind me.

“You, Japanese! You Japanese hate Black man!” He grabbed my arm, and I pulled away in a quick jerk.

“You Japanese MF!” he laughed and pointed at me.

That was the last straw. My seed of anger cracked open with a sprout. I turned around and noted that he was now surrounded by four of his hooligan friends, all staring at me, trying to look tough.

“Do NOT EVER say such a thing to anyone again! I will never go to your shop and buy anything, and I will make sure my friends will not go to your shop and buy anything.”

I turned again and walked into the street to cross it and get away from them. A speeding dala dala almost ran over me, but I sprinted across the street and made it in one piece.

A few minutes later, I told Steve what had happened. Thankfully, he walked back with me to pick up the shirt from the seamstress, just around the corner from that young man’s shop (or really, the shop he “represented”). It turned out that Steve knew the young men at the shop. I wanted to leave as soon as we had figured out that the shirt fit me OK.

“No, come with me,” Steve said. I hesitated. “Come!”

I walked over to the shop with him. The young man came up to us.

“Come to my shop!” he said, looking at both of us.

“I know her,” Steve said, pointing to me.

“You know her! She is the one I followed. You know her?!” the young man said, pointing at me, laughing.

“I know her. She’s a doctor. She told me what you said to her. You can’t say those things to her,” Steve said.

“You shouldn’t say those things to anyone,” I added.

“Oh sorry,” he said half-heartedly. “OK? Come buy at my shop!”

“No! I’m not buying anything at your shop!” Steve said, disgusted.

“Oh sorry,” the young man said again. “OK now? Come in and look at my shop! Just look!” he
attempted again.

I shook my head and walked away with Steve.

kitenge kraziness!

check out swatches from the kitenge cloth i have purchased from markets and shops in Tanzania! Almost all are made in Tanzania, a couple are made in the Congo.

Usangi and the Pare Mountains

above: Mama, Juma, and me at the Usangi clinic

above: Ally and his flapping origami crane; he wants to be a doctor! We'll work to make that happen.

Interesting things happen when the power goes out:

The world gets quiet.

You start to hear each other and the animals and the water and the wind.

You take your time.

Your laptop works.

So here I am, sitting in the dark on a lousy foam mattress with unwashed sheets in my Mhako Hostel room, my spine sinking into the bed, listening to the insects and birds outside, the flying insects inside, the chatter from the bar downstairs of men talking over cigarettes and beer and the noise from battery-powered radios… and typing this on my laptop.

I guess I could have sat in the dark with Guy and Steve downstairs, but being the only female guest in a room full of smoking, drinking, belching men is not very fun – with power or without.

Despite my downgrade in standard of living here, I have been enjoying my stay in Usangi. Usangi is a remote town in the Pare Mountains of northern Tanzania. There is a district hospital up here for no other real reason besides that an influential politician is from Usangi and buttered the ministry up to build a district hospital here. People from the district have to travel up several gnarly mountainous dirt roads in order to get to the hospital. In fact, we visited a lakeside village called Kagongo today, in the valley between several of the mountains. The patients in the HIV clinic have to be ready at 4 am to catch the fish truck up to Mwanga, then two separate dala dalas (minivans) up the mountain to get to the clinic by 10 am. And it costs 10,000 shillings, the equivalent to a fourth of a month’s salary for the average Tanzanian.

We are here to start rolling out HIV care to the rural health centres, so that people with HIV from Kagongo can get their care in Kagongo rather than spending 12 hours a day in rough transport and paying half their month’s earnings to get to the Usangi clinic. Right now, there are about 30 patients coming up from Kagongo to Usangi for their care. But the ministry of health suspects that there are at least a hundred more people who need to be in care and treatment in Kagongo. The fishing village is full of young men making lots of cash money from selling fish… and young women trading sex for food. It’s like Lake Victoria in that way. If that’s not a breeding ground for HIV, I don’t know what is.

Kagongo needs our help to become an HIV clinical site. It only has one clinician and two nurses. The clinician is straight out of school and internship. And one of the nurses is planning to transfer to Moshi as soon as she can. That leaves us with a limited staff with limited experience who need a lot of support to become competent in caring for HIV-positive patients. And HIV is one of the most complicated chronic diseases to manage.

We’re making it happen. Here’s how: the health centre staff gets a week-long HIV/AIDS training session. A few weeks later, we bring them up to the district HIV clinic in Usangi to see first-hand how the clinic works and to work with an experienced staff member from the Usangi clinic. We (the UCSF TZ crew) train the Usangi staff to mentor the Kagongo (and Kifula) health centre staff for at least two clinic days in Usangi. We also do a bit of teaching for all staff and some direct mentoring when we see mistakes in clinical practice. After we ensure that the health centres have infrastructure (rooms, furniture, medications, forms), we start transferring some of the patients seen at Usangi to their local health centres. The Usangi site sends a clinician and a nurse down to the health centre during their clinic days to mentor them twice a month. Once the health centre staff feels ready to take off their training wheels, they start having clinics on their own, and the Usangi staff comes to mentor and monitor quality once a month. The Moshi EGPAF Tanzanian staff also visit periodically for quality control. We do a follow-up visit in about half a year.

This model of intensive mentoring is new in Tanzania. Most practitioners are simply thrown into clinical situations and are expected to figure things out. This results in very mixed safety and quality of care. We’re hoping to prevent this from happening to HIV care.

We have a good team now at the Usangi district hospital; they are key in making this plan work. Previously the Usangi site was one of the least organized, but now with Makapa Fellows (Tanzanian superstars picked and hired by the Global Fund given higher salaries to work in remote and rural areas), the site has improved tremendously. It makes an enormous difference for my quality of work to be able to mentor and teach a staff that is interested in learning and developing their skills. It is also a treat to be able to work with smart, savvy Tanzanian women like Tersesia Kasunga – the Makapa clinician that spends most of her time working in the HIV clinic in Usangi. She’s a quick learner and very good with patients – traits that I wish I could find more often in other clinicians.

It was quite gratifying after last week’s fiasco in Karatu to show up on the first day in Usangi and see 15 eager health centre and Usangi staff wanting to learn more about HIV care and treatment. Then the health centre staff stayed to get mentorship from Usangi staff on their two clinic days. We visited the Kifula and Kagongo health centres today to ensure that they have what they need to start seeing patients. And on Friday we will put together a roll-out strategy and work plan for the district. This is exactly what we came to do. Imagine being able to do it! So nice.

Tanzanian travel peeves

Pet peeve of the moment #1

Would you sleep on a sponge?

I didn’t think so. The foam mattresses here in East Africa look like (and act like) giant car wash sponges. After a few nights of an obese mzungu tourist sleeping on them, foam mattresses get sunken in. It’s like sleeping in a worn sponge bowl. Forget about spine support. The floor would do a much better job of that. Too bad the floors are generally icky and buggy.

Pet peeve of the moment #2

How does it feel to be treated like a second-class human being all the time?

It’s bad enough to be a woman here in Tanzania. Imagine being a black African woman. Despite Nyerere’s African socialism, one thing that he forgot to help equalize is the status of women. Many women here seem to just assume that they are second-class humans and fail to speak up for themselves – or for anyone else for that matter. Nearly everything is deferred to men. It’ painful to see women constantly swallowing their voice and being stepped on.

I am facing an uphill battle with wanting respect as a small-sized, loud-mouthed Asian American female physician. Since I have been traveling with Guy (a very very tall white Dutch American man) and Steve (a relatively tall African American man), most Tanzanians get confused when I am introduced as the doctor, Guy is introduced as the nurse, and Steve is introduced as the peer educator. I’m happy to encourage people to challenge their stereotypes, sexism and assumptions, but dammit – it is hard work!

Kazi Safari: a different kind of work adventure

above: mama and mtoto (child) at the Karatu district hospital

My fourth week marked the beginning of a very different work experience. Guy Vandenberg, a nurse and social worker by training, Steve Williams, peer educator, and I are now traveling to different district sites in the Arusha and Moshi Kilimanjaro regions to assist them with the rural health centre HIV care roll-out process. Team TZ (what we call the group of folks from UCSF who come to Tanzania to do HIV care work – originally the TZ boyz: John, Guy, Royce and Steve – and now plus me) dubbed our program the “Mentoring of Mentors Intensive,” otherwise known as MOMI.

MOMI is really what it sounds like. We are “mommying” (mothering) some of the HIV Care and Treatment Center (CTC) leaders to become better leaders and to help them train lower-level health centre staff so that the rural health centres can also provide HIV care and treatment. This sounds simple, but Tanzanian bureaucracy and politics makes it incredibly challenging. Karatu is a perfect example of this.

Our first MOMI site was Karatu Designated District Hospital. It was originally a faith-based hospital, paid for and run by the German Lutheran Church. The Lutherans decided that they wanted a nice view, so they built the hospital way up on a hill, 7 km from the actual town of Karatu. Imagine a sick person trying to walk up the 7 km hill. Not-very-smart move #1.

When we arrived, we had the mandatory meeting with the District Medical Officer (DMO) and the CTC-in-charge. The DMO was supposed to be notified at least a week in advance so that he could arrange for us to work with health centre staff. The CTC-in-charge failed to notify him, so nothing was arranged for us. And after we requested him to arrange the visits, he still did not arrange them. (We can’t arrange them on our own because we don’t know whom to contact, so we are beholden to the Tanzanian DMO or clinic administrator to do this for us.) Not-very-smart move #2.

The CTC-in-charge, Elitumaini Mziray, is the key person that we were going to groom as a mentor of the health centre staff. We found out on the day we arrived that he was going to be gone during the week. Not-very-smart move #3.

In summary, nothing was arranged or organized for us, no one knew we were coming to train them, and the key person I was going to train was gone during the time we were there. Awesome. How does one get work done in this setting?

On top of all this, the medical officer I was left to work with is a sexist buffoon who continuously referred to me as “the mzungu” (“the whitey”) instead of my name. And he even argued with me in front of a patient when I asked him to call me my proper name and that I am Asian, not white. This is not even to mention that he had a terrible bedside manner and made some flagrant medical errors. I think I picked out over a dozen instances that would have clearly constituted medical malpractice in the US.

Then, on the last day, I found out from a patient that the clinic had run out of Efavirenz for the last TWO months, a key HIV antiretroviral that many patients (particularly those with TB) have been on. Instead of telling anyone about this, the pharmacist simply failed to give the patients the drug or switched it on his own to another antiretroviral. And let me tell you, he doesn’t know squat about managing HIV. None of the clinicians there admitted to knowing about this. There was no clear plan on procuring the drug either. This is what we call a total disaster.

Can someone poke my eyes out? I’ve already pulled my hair out.

Patience.

Letting go.

We did the best we could. Guy worked with Mama Agnes, the lovely and caring but incredibly overstretched nurse, who is a victim of her culture’s ingrained sexism. I tried to teach the medical officer some proper ways to manage cryptococcal meningitis and TB-HIV coinfection. And happily, we identified a motivated, smart young women clinical officer who was interested in becoming an HIV clinician. I taught her how to initiate patients on HIV antiretrovirals. We summed up our findings and recommendations in a dense document and presented it to Elitumaini. He made a work plan with us to tackle some of the problems. We really hope these things happen. Or the HIV-positive patients in the Karatu district are in serious trouble. At least I know that our support for them will only make a positive difference at this point - there is no other direction left to go.

Speaking of hope (a liability and an asset), I hope the next three sites are in better shape.

Tanzania Kazi: work

What am I really here to do?

A couple principles to keep in mind while working here:

-Our ultimate goal here is to make ourselves unnecessary.

-It is not impossible to get things done; it just might take much much much longer than you would ever expect.

The first three weeks of my time in Tanzania consisted of prepping for and running two week-long training courses on the management of HIV/AIDS.

The first training was in Tabora, at Kitete Hospital, one of the government-sponsored district hospitals. Teaching a mixed group of ESL nurses, pharmacists, clinical officers (equivalent of NPs or PAs) and medical officers (equivalent of general practitioners) on the finer points of HIV opportunistic illnesses and treatment failure is an interesting challenge. There were a few Makapa Fellows in the group – these were clearly the best and brightest of the bunch. Makapa Fellows are part of the program funded by the Clinton Foundation – they are nurses, clinical officers, medical officers and pharmacists given extra training in HIV/AIDS and higher-than-normal salaries to work in exceptionally under-resourced parts of Tanzania. And then there were a few old-school nurses and clinical officers who had very little English proficiency (the entire course was taught in English with very little Kiswahili mixed in) and health management proficiency (yikes). It was quite a spread.

It was my first time as a trainer in this group – Royce Lin was the lead trainer (he’s done this training many times already), and we had a few Tanzanians doing pieces of it: Elitumaini Mziray taught about HIV drugs and neurological complications; Amos Nsheha taught about pediatric disclosure issues; Werner Schimana (a German ex-pat) taught pediatric HIV drug issues. I taught a big section on pulmonary complications of HIV (TB, PCP, bacterial pneumonia), which I must admit was a big hit, as well as a difficult section on treatment failure. The usual Sub-Saharan African snafus happened, including several power outages (after I had spent hours putting together a great slide set of chest x-rays, etc.) and hospital meetings in our training room that went an hour over its slated end time, thus delaying us for an hour.

This is an exercise in patience and in letting go.

I remind myself of this often.

There are some absolutely awesome parts of this type of teaching, such as seeing nurses doing a perfect pulmonary exam and asking the appropriate sexual history questions and speaking out about the treatment of TB to clinicians who are doing it incorrectly.

The second training was with the Elizabeth Glazer Pediatric AIDS Foundation (EGPAF, whom we are sub-contractors for here in Tanzania) program officers, many of whom were rusty in their HIV care and treatment knowledge. Given that they are helping Tanzanian district hospitals and clinics provide HIV care and treatment, they figured that it would be good to know something about the actual practice of it. They asked us for the training, so we trained them. Since they have NGO money, we spent the week at the Millenium Seaview Resort in Bagamoyo. Posh. Is this the proper way to spend PEPFAR (i.e. American tax-payer) money? Hmmm…

Bagamoyo Represent!

above: sculptor Omari and me at the Seaview Sculpture Arts Center

Bagamoyo: lay down my heart
Aside from the eau-de-poo water, Bagamoyo is a pretty darn cool place. It’s a crying shame that I had to work from about 8 am to 8 pm (or sometimes later if folks decided to talk about work over dinner and after…), thus preventing me from really exploring the town. I was released from work duties on Friday afternoon and spent the rest of Friday and Saturday wandering around this ancient seaport, slave trade and coastal center.


The Swahili name of Bagamoyo has multiple interpretations, ranging from “lay down my heart” as a place of rest for weary travelers from inland and ocean routes – to “crush my heart,” spoken by people taken as slaves when they arrived to the port of Bagamoyo, because it meant that they were certainly going to Zanzibar to be traded and sold as slaves. There are remnants of the old Swahili culture, including the 13th century ruins of Kaole, which mainly consists of surviving coral-rock tombstones of inhabitants. The inscriptions, in Arabic, are still present on a number of tombstones. Tanzanian political candidates, particularly presidential hopefuls, make it a point to visit “Sharifa’s grave” – the burial site of a four-year-old girl who apparently performed miracles when she was alive and continues to grant wishes. Perhaps we should send Obama to Sharifa’s grave.


In town there are reminders of Bagamoyo’s past as a key transit point in the East African slave trade: the customs house and Old Arab Fort, a holding cell for slaves while they wait for their boat to Zanzibar. A few abandoned sites of German colonial rule remain (though quite run down), including the old Boma and Liku House, the headquarters for German East Africa. Since there is no money put into the preservation or the destruction of these old buildings, it’s similar to observing the natural history of untouched abandoned buildings.


At the Seaview Sculpture Centre, Royce and I met sculpture artists Shibani and Omari. We each bought pieces by them. I quite enjoyed Omari’s work. He takes wooden poles and carves the faces of the moon spirit into them.


The Bagamoyo College of the Arts (Chua cha Sanaa) hosts a showcase of student performance every Friday night. I went with Trinidad (an artist from Spain whom I met on the British Air flight from London to Dar) and Philipa (from Portugal), who are both volunteer teachers at the Seaview Sculpture Centre. A bunch of their students were drumming and dancing as part of the Friday evening show. See the previous post for a video and description.

Bagamoyo Uhuru dancers!

This is a low-res (point and shoot camera) video i took yesterday night at the Bagamoyo Arts College (Chua Cha Sanaa) weekly performance. There was some really great work by young artists, including the young people in this piece - a group called the Uhuru (freedom) dancers and drummers. Sadly, the sound on my camera is not working, so i had to splice it with a Gilberto Gil song to give it a beat.

Many of the artists presented work that was a good mix of traditional and modern influences. The video shown here was more traditional in drumming and dance style - though it's always interesting to see what people do for their dance outfits. In this case - colored plastic straw skirts over boxer shorts for the men... and t-shirts and tank tops with cotton wrap bottoms for the women. The video might make it look like a dorky college cultural show, but i assure you that it was way cooler. ;)

The best part of this performance was that it was in an outdoor amphitheater on the beach, and the audience was filled with folks from the Bagamoyo community - bibi, babu, watoto (grandmas, grandpas, children) were all present. It's great to see the community all come out and participate and enjoy the creative work of its young people.

There were only a small handful of wazungu (foreigners), including myself and a bunch of the volunteer art teachers from Spain and Portugal whom i'd met and befriended on the plane ride over from London to Dar 4 weeks ago. It's a small world after all!

Tanzania photos, album #1

Please click on the teeny slide show above to see the bigger version and/or individual photos more clearly. Asante!