Internal Medicine Resident Daniel Townsend's week 2 update from his international rotation in Arusha, Tanzania

“There are two sides to everything" Cultural highs and lows. As is the norm when you immerse yourself in a new culture, at first the newness/excitement carries you as you soak it all in, but soon after, there usually is an emotional low as everything catches up to you.

The electricity goes out pretty much every day, and usually in the evenings when I'm home. In fact I'm writing this in the dark with a headlamp, hoping that the power will come back by the time I finish this so I can send it. At first it was somewhat exciting, "I'm reading by candlelight!", but now I just have questions and a faint annoyance that I try to keep at bay. Why does it go out every day? Why is their infrastructure unable to support uninterrupted power? What if they invested more in solar energy since it is almost always sunny here? Why do I feel entitled to electricity in the first place?

Work is a continual reminder of how lucky I am to be in the Western medical system. They do their best, but there's just so much that's lacking. The chemistry machine is still not up and running. It was supposed to be working on the second day that I arrived. The reasons for delay aren't worth mentioning but needless to say, there is no major setback that would have made it impossible for the machine to be up and running a week ago. Everything moves slowly, and I am learning patience. I saw cutaneous anthrax and cerebral malaria for the first time. I have found that although resources are lacking, one resource that they do have, but is underutilized is ultrasound. I have taken this on as my project for the month, and I am doing an informal ultrasound training course for the interns and registrars. Ultrasound adds so much ability to their physical exam. For instance, they are often diagnosing heart failure based only on the patient having peripheral edema. We've now gotten in the habit of looking carefully at the jugular vein for added diagnostic value, and now we can do a bedside ultrasound. I hope to also teach on abdominal and lung exams as well. I hope that with some further coaching that it will become a part of their routine. Since Dr. Eggert will not be here this next year, it's on us to push this and develop this. They also do not have an EKG machine at Selian, which I think is something that might be a manageable goal to attain over the next year. Thanksgiving week. Mark and Linda Jacobson have a massive feast every year, and they have about 50-70 people show up at their house. They hand carry a turkey from Nairobi, Kenya (because there aren't any turkeys in Tanzania apparently?) and it truly was a great time. Things I'm thankful for: normal bowel movements (no diarrhea yet! I always get diarrhea when I travel, TMI?), my family, my medical education, and clean water. I had a chance to meet a lot of interesting people who are here in Arusha for various reasons at the thanksgiving meal. I got into a discussion w ith several others about their opinion on constantly being called "Mzungu". For me, as I walk along the rural back road to Selian, I am constantly battered with this word. I have not been in this culture long enough to feel like I can have an opinion on it, but it does often seem to be directed at me in a more condescending way. Some of the expats found it offensive, and interestingly mentioned that it had less to do with the actual word, and more to do with the way in which it is said. In this culture, you never yell something at your elders, so when someone yells "Mzungu!" at you, it is disrespectful. On the other hand, other expats, felt it did not have any negative connotation and simply was a word meant at getting your attention. I will say, at a very basic level, it doesn't feel great to constantly be lumped into a category of being different (whether by race or economics etc, but there are two sides to everything, so I have chosen to think that the word is not a negative term, and even if it is, I have spent my entire life in a position of privilege, so on some level, I get it. So I have come out of this week that had plenty of emotional lows believing that I can in fact look at the situations around me as two sides to a story. I can either see inefficiency, lack of accountability, and slow delivery of care, or I can see it as- hey, maybe we need to slow down a bit in the states, start actually listening to people, and stop hiding behind our lab results and computer screens. I can look at lack of electricity as an annoying infrastructure deficiency, or I can look at as an opportunity to find some peace and quiet, when my life in the States is often cluttered and noisy.

Hope all is well back home! I'm ready to start a new week. I'm planning on doing some hospice work this week.