Jambo from Arusha! The last three weeks have been filled with highs and lows, blessings and tragedies, surprises of both extremes. I continue to work mostly in internal medicine at Selian Lutheran Hospital. The hospital census seemed to be quite low for a time, which most people attributed to the harvest season. Some of the local doctors suspected that, even if they had fallen ill, most of the population that would typically come to Selian could not afford to take time of during the harvest. Several days in the last few weeks, we had only 2 or 3 male patients, and those we have taken care of have been quite ill or elderly. It is a far cry from the hospital lulls that we can sometimes experience in the US during a major sporting event or a spell of bad weather. I can fathom suppressing certain symptoms to make it through the Super Bowl or March Madness, but not the weeks long harvest season. I can only imagine what some have to endure in order to provide for their families.

As I mentioned in the last update, Joseph, my friend and colleague, departed for China to begin his residency training. It was also with mixed emotions that we had to say good-bye to another pediatric registrar, Linda, this week. She has been a tremendous pediatric advocate at ALMC hospital, but we are excited that she is pursuing further education in health care policy with a masters program in Dar Es Salaam. Last week, we were happy to add two recently graduated attending doctors to the Selian Hospital staff, Amon and Ilbariki. They are both Arusha natives who went through internship at Selian and have now completed their specialty training in Internal Medicine and Surgery, respectively. Working with Amon this week, I have been so impressed with his connection to patients and families, along with a fortuitous commitment to improve the system of health care at Selian for the betterment of patient care. It has been some time since Selian had a true internal medicine consultant, and I am so pleased to know that he is advocating on behalf of the medical ward.

For the Swahili lesson this week, I would like to present a word that is rather a concept: uzima, which means, wholeness. I learned this word from our mentor of mentors here in Arusha, Professor Mark Jacobson. As I have mentioned previously, Prof, as they refer to him here, is the missionary doctor who first came to Selian Hospital 30 years ago when it was a small medical dispensary on the outskirts of town. Through his commitment, along with support from his wife and the Lutheran Church and many trusted associates, he vastly improved the resources and care delivered at Selian. Through his experiences working amongst the Maasai and other tribes represented in Arusha district, he has gained much insight into the beliefs behind health and disease. Though no two people are exactly alike, let alone two people from different tribes and geographic areas, there is one interesting concept that seems to be common amongst natives to Arusha and the surrounding area, the concept of uzima. Uzima, he explains, represents all the factors that make a person whole: right relationships amongst people in community, right relationship with God and spiritual forces, personal health, and community wellness. Each factor affects the other in such a way that disturbing one part of wholeness disrupts the whole person. As is common in many cultures, traditional animistic beliefs may contribute to this concept. This can lead to attributing medical disease to spiritual forces, like a curse from a neighbor or a disgruntled ancestor.  But even more commonly here, I have seen how interpersonal conflicts are often the central focus of patients in the hospital here. Many illnesses are attributed, at least in part, to conflicts with neighbors and friends, and are not expected to resolve until the conflict is addressed. The balance of wholeness becomes disrupted when one factor is disturbed.

There is one key part to this whole concept. Unlike our individualist cultures, the smallest unit of identification is usually not the person, but the family or community. The health and relationships within the family or community are tightly interwoven to bring uzima to all.  One person does not experience uzima alone, it can only be present in community. Many decisions are based on a community level. If a patient were to need certain services or financial support, the community must decide together whether or not to support this effort. Seeing this concept at work from the outside, it can be difficult to understand the decisions that are made by patients and families. Compliance with medications, willingness or ability to pay for medications or diagnostic services, and requests for early discharge from the hospital are a few frustrating situations in providing medical care here.  I often think, ‘Why can’t these people just follow our directions for the care of the patient, is it really that hard?’ But what I am noticing more and more is that our “medical plan” is so often narrow-minded, leaving out entirely crucial factors in the overall wellness of the patient. Though it is impossible to assess everything that one person needs, let alone the complex interplay with their community, I am increasingly appreciating the intricate, yet vital sources of wholeness valued by people here. Family, community, spiritual wellbeing are just as important, if not more, than the medicines that we write. No one earthly person can bring uzima and no one person can experience uzima alone. If we as doctors think that we alone can restore wholeness, we fall short of the needs of our patients. I look forward to continuing to experience this concept at work and to let it stretch my view of medicine and the world.