The past few weeks have flown by, and it feels like a whirlwind. Days are filled to the brim, and I quickly slip into sleep each evening under the comforting canopy of mosquito netting. I gaze at the 1 inch hole to my right, reminding myself that is not large enough to permit entrance of the resident African Hedgehog or the domestic mouse/gecko who leaves gifts in my sink every evening. Hamna shida. Hamna shida (no problem).
I've grown close to 2 registrars (doctors who have graduated medical school and 1 yr of residency "intern year") and a few interns. A few of our sicker patients' families wave and greet me with big smiles around the hospital campus. These patients and their families speak Maasai, and it is always a little search to find a nursing student or aid who speaks both Maasai and Kiswahili to help communicate at the bedside. Thankfully, greetings and warm feelings have never necessitated a common language. I feel particularly fond of my older patients. I've been rounding with the Internal Medicine team for the past 2 wks, and we have had a very low census. We have a few people in their 30s-40s with gastritis or malaria, and then we have people in their 50s-60s with HIV who are on or off of anti-retrovirals and present with clinical pictures consistent with TB or PCP. The group of patients that I particularly enjoy are those > 65 years old. The women often have COPD from years of cooking in an enclosed home with smoke. This often leads to cor pulmonale, and they present with heart failure and/or COPD exacerbation. One patient in her mid 70s was quite ill, but she greeted me each day with the most beautiful, relaxed smile. Each day she would report to me about her status in Maasai, and then we would begin the search for someone who spoke Maasai and Kiswahili. My patient and her family recognized quickly that speaking to me in Maasai led to perseverance until we interpreted her message all the way to English and addressed her concern. It is not an expectation that the medical staff update the family/patient each day as in the States with bedside rounds, but the internal medicine registrar with whom I work is particularly devoted. I watch him including the family in conversation and educating the patient whenever possible. I often watch the family members during rounds and report to him when they seem frustrated or confused. He immediately takes them aside and explains in more detail or asks them what's on their mind. He has this calm, quiet, comfortably-paced speech that looks to be greatly appreciated by the patients. This past week I have learned much about the Tanzanian healthcare system and perspectives from this registrar and a few interns. Motivations for choosing a career in healthcare vary, as in the States. The unreliable timing and amount of paychecks for doctors is accepted, while steps are taken for improvement in the future. In the meantime, the majority the doctors and students with whom I'm working have this thirst for knowledge and need to help those around them have an improvement in their lives. This core desire combined with an intense community spirit is something incredible to witness. When I am able to contribute in my part, I am instantly enveloped in this community. It's hard not to feel very grateful for the opportunity to live here for a few months, making the world just a little bit smaller.
We had 20 international expats visiting for a field trip during a class last week, and it was interesting to hear their thoughts and impressions of Selian Hospital. One doctor noted that it would be easy to know what to do if we only had the resources here. Discussion with other expats from Minnesota and the graduate of MN residency who began the 2 hospitals in Arusha has covered this territory. Loads of supplies have arrived at the hospitals in the past, yet they are not found when needed in the process of medical care. It would be silly to think they would be used exactly in the same manner as in their country of origin. The key is to creatively think through the pathophysiology of the illness at hand and apply resources in unique ways. It is not too uncommon to hear expats complaining that Tanzanians often have an external locus of control or learned helplessness... not looking to improve situations when barriers to advancement or success are encountered. I suppose I am am growing more and more certain that human nature is universal. Culture just wraps up the variety of personalties in any group with different colors, papers, and ribbons. We had a diabetic patient who took 1 mo of metformin and then did not have access to a refill of her medication (or maybe didn't prioritize it as highly as healthcare providers might). It is difficult to adhere to a diabetic diet anywhere in the world, but more so in her community. We were injecting subcutaneous insulin to cover her high blood glucoses, and she was requiring much lower doses after when it was difficult to find food at the hospital. We found a way to be sure she has food (not all carbs), and we checked her blood glucose three times daily. One morning she had no blood glucose reading in the chart, and the nurses had not given her her injectable insulin as they had no glucose reading to doublecheck. We had finished our supply of glucose monitoring strips. The registrar and intern and nurses immediately shook their heads, explaining to me the problem and adding that this is unacceptable. There are shortages of medicines and supplies at all times, but certain essential supplies and medicines were simply necessary. The administration of the hospital has a very open door policy, and the intern and registrar walked over to explain the situation. Calls were made, and by the end of the day we had a box of glucose monitoring strips. Where was the Tanzanian inertia-- the inability of Tanzanians to identify a problem and find a solution? Experiences like these give hope. This is the way to future improvements in the system, and the intervention was wholly Tanzanian. We have nicknamed the exceptional pediatric registrar at Selian Daktari Hamna Shida (Dr. No Problem), as it is his most common phrase. Instead of panicking and making a ruckus everytime he notes an "opportunity for improvement," he calmly voices his mantra. Hamna Shida. Hamna Shida. You can see him beginning to brainstorm, and later he can be found in the cafeteria or under a tree with hospital administration discussing the situation and working on a sustainable solution. Although it might appear at first glance that he is simply dismissing medication and supply shortages, he is carefully working toward improvement with an eye toward sustainability. People recognize his value, and he is given much respect. As others follow suite, it is possible to see improvement on the horizon. Cautious optimism shared among hospital staff. Cautious optimism allows for perseverance in the face of adversity-- even if the adversity is deeply engrained corruption to the core of the country.
Ryan and I have been able to try to understand together the current status and future of healthcare at Selian during the beautiful walks to and from Selian each day. We alternate between learning kiswahili numbers and body parts, greeting fellow Tanzanians sharing the path, and interacting with schoolchildren learning English. We vary our greetings, trying not to miss anyone...with the responses we receive sounding something like this... "poa, mambo, poa, mambo, jambo, jambo, poa, GIVE ME MY PENCIL!, jambo, jambo... " The spontaneous humor from our neighborhood children never fails to send us chuckling. Creative responses are very appreciated, and we now shout back requests for anything from a book to a bag. Our colleagues from New Zealand have even inquired about the price of a large cow being herded by us on the path. Some days are more frustrating than inspiring, but one thing we can always count on joyfully unpredictable conversation en route to the hospital each day.
I hope this message finds everyone healthy and in good spirits -- Hope
Pictures from the walk to Selian, with Mount Meru in the background of the last two pictures
The ALMC Health Center (open air greenery in the center of the hospital complex)
Looking at an x-ray outside the male IM ward
