warmly greeting from Wuhan

Wuhan Infectious Disease Hospital

i am super squirrel
storing it all in my cheeks
leaping tree to tree

here i come to save the day
PPTs are on their way

(too bad squirrels are mostly ignored)

Hangzhou No. 6 People's Hospital HIV department

after a workshop
Hangzhou 6 HIV crew
i'm the one with teeth

hooray! i'm blogging in China!

I made it to Kunming! As you can see in the photo above, Kunming is a large urban center with loads of people and concrete. If you squint through the smog, you can see some mountains in the background. I'm hoping to get to one of those hills this weekend. It's May Day (International Labour Day, Worker's Day) in China, so I don't have formal work duties on Monday. This is great because I have been working my butt off over the last several days (and in the weeks leading up to this trip). Yay for 3-day weekends!




Michael Pollan would approve of my breakfasts in China! Almost all of what I eat has a single whole food ingredient: bok choy greens, snap peas, soybeans/tofu, watermelon, honeydew, some fruit I don’t know the name of which has white flesh and small black seeds that come out in my poo.

I am slowly settling into life here. The downside of jet lag is that I get up each morning exactly at 5 am, and since I am going to bed at midnight because I am working late at night, that means 5 hours of sleep each night. It's not quite enough for me. The upside is that I have enough time before I go to the hospital to do sitting meditation for 30 minutes, yoga for one hour, and sometimes 30 minutes of deep relaxation thrown in. It's a great way to start my day, and I think it keeps me grounded amidst all the work intensity.




Above is one of the Yunnan special treats: rose petal cakes. It consists of dry flakey dough with fragrant sweet rose petals inside. The best part is that I bought it from a bakery next door to the apartment I will be moving into tomorrow called RAMBO Bread Works. GRRRRrrr…

In terms of work, it has already been interesting, rewarding, and a big (though good) challenge on this trip. I don’t have any pictures of me at work (since I am often running around at the hospital), but perhaps later.

I enjoy this work. I am tired from my 12 hour days, but this work definitely feels meaningful in a big way. I saw a bunch of patients yesterday, and feel more grounded to be connected with patients (who really put up with a lot here, as witnessed when the 27 year old man totally discolored and wasted from his advanced liver disease, TB in his lungs and belly, and another painful disease – MAC- smiled and shook my hand and told me how grateful he was to be examined even though it hurt like hell), and also happy that I can offer concrete, practical and real help to the clinicians. There are of course internal politics and power issues I need to navigate, so it will yet to be seen what we can accomplish. I have already a list of concrete interventions that I think we can help with, including big things like task-shifting to community organizations and small things like hand sanitizer. It's great to see it all coming together in a real, tangible way.




This Chinglish bag from my hotel room contained the Ethernet cable I’m using right now to tunnel to my blog (boy, that was an interesting challenge!). It says how I feel sometimes: while the internet miraculously connects me to you from around the globe and allows me to do this international work, it is also the “Non-Gift” that keeps me from being fully present to my environment. With that said, I’m going to upload this post, turn off my computer, and go out to explore the May Day parade and the temples of Kunming!

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.

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!

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.

Moshi

[above: aerial view of Kilimanjaro at dawn]

Ahhh, back in Moshi, my home away from home. It’s funny how familiar everything feels, even though we stay in hotels. I stay at the familiar Bristol Cottages, where Mama Sakina and Mr. Aggarwal and the staff take good care of me. I also have my friends Mei and Joelle, transplants from Chengdu, China and Southern California (respectively) who always welcome me back. They speak Kiswahili and know the lay of the land. It is always good to have advice and guidance from two local strong, sassy and experienced women who are also living far away from their native homes.

Plus, Mei owns Panda Restaurant in Moshi and cooks us real home-style Chinese meals. She uses winter melon and greens from her own garden. And she makes amazing fresh tofu each day!!! How spoiled can you get: fresh tofu and Chinese greens in the mountains of Tanzania.

Joelle first landed in Moshi to teach at an NGO secondary school focused on providing education to the most vulnerable young people (often orphans). She’s now moved on to a women’s village health and empowerment project in Shimbwe, a mountain village near Moshi. I am hoping to link Joelle and the women in Shimbwe to a potential microfinancing project in which the women would make cool accessories out of Tanzanian fabric to be distributed by a San Francisco-based textile artist.

The training in Moshi went as well as a training goes. There were 15 relatively interested and engaged participants from the Kilimanjaro region – lots of rural mountainous villages. As usual, the participants were a mix of nurses, clinical officers and medical officers of highly variable experience, English proficiency and background knowledge on HIV care and treatment. There were no pharmacists this time, though there should be. Happily, as a group, they seemed to understand some key concepts (antiretrovirals, TB diagnosis and treatment, treatment failure, paediatric HIV issues…) and did remarkably better on their post-training exam than on their pre-training exam. I only hope that they are able to remember what they learned and take it back to the health centres in which they work. That’s what really counts.

Zanzibar

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

Zanzibar.

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.

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.

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.

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…