Nitakumisi

Jambo from Arusha! It has been an incredibly fast and wonderful month since I last wrote. I had the opportunity to climb Mt. Meru (14,977ft), the idyllic volcano that keeps watch over the city of Arusha. As one approaches the summit, Kiliminjaro looming in the distance seems to grow taller and mightier. We were blessed with a beautiful snow at the top and the sun revealed an epic coating of snow on Kili reflected on the horizon. I also traveled with Flying Medical Service for preventative care clinics, which they hold in remote Maasai villages in Northern Tanzania. We travelled to Simanjiro region loaded up with preventative medicines and vaccines, mostly going to pregnant women and children of the villages. The whole experience was simply incredible and I greatly admire the mission of Flying Medical Service to reach the rural inhabitants of Tanzania, who suffer from drastic disparities in health care. Work on the internal medicine ward at Selian was busy and extremely fun, with some new interns moving over from ALMC. We had a breath of fresh air with 2 visitors from Minnesota, Ron and Colleen Johannsen (a cardiologist at Hennepin County Medical Center and an experienced cardiac ICU nurse, respectively) who came to teach cardiology, particularly echocardiography and EKG. They gave us some fascinating perspectives on rheumatic heart disease, their major project of interest, and plan to return for regular teaching in diagnostic skills, which are so greatly needed in Tanzania.

For this weeks Swahili lesson, I chose a phrase that is slightly interesting, but mostly selected for it’s timeliness. Nitakumisi, as some might be able to guess, simply means, “I will miss you”. It is not a particularly deep phrase, it can be used lightly, such as when you miss a day of work and you are welcomed back the next day. But like all sentimental phrases, it is only as deep as the relationship it represents. If it is used casually with a casual acquaintance, it will, of course, have little meaning. But when the roots run deep into the soil of common experiences and shared goals, it stirs a myriad of emotions. In the past month, after a whirlwind of busyness at the hospital and fun social events about town, I found myself suddenly at the end of my time in Arusha. I had known that the end would come eventually, but I had no idea what it was going to feel like or even that it was coming so soon. Saying goodbye is never easy, especially at the end of a defining chapter of life. But I have been imagining for a while: what am I going to miss most about Tanzania? I know for sure that I will miss my friends and colleagues, who have so graciously welcomed me into their homes, lives, and work. I will miss the beautiful children that I pass by every day on my way to and from work, even when they shout “good morning teacha” at all hours of the day or sound the “mzungu” alarm (shouting mzungu with the volume and frequency of a car alarm). I will miss the Maasai families in their red and blue shukas, adorned with beads, who would move heaven and earth to care for their sick loved ones. I will miss the serene landscape and epic mountains of Northern Tanzania. I will miss participating in the amazing efforts that others have poured their lives into: Selian, ALMC, Plaster House, Flying Medical Service and others. I will miss the pace of life, walking to my destinations, and greeting everyone I pass.

I am comforted when I think about the beautiful memories that I have, especially looking through the pictures that capture a piece of the experience that I had. I am filled with joy when I think about the successes that I shared with my colleagues: patients who recovered, families who were grateful for our service, and colleagues receiving new opportunities and dreaming big for the future of their country. I am reminded that Tanzania is a land which is not as far from my own as I once imagined. As I think about the phrase, nitakumisi, I see the blending of Swahili and English words and grammar. It combines east and west, uniting the influences of Bantu origins of Africa and “Swahili-fied” English. I see in it that our lands are not so distant that they cannot exist together, that our cultures so different that they cannot be understood one by the other. I will hold Tanzania in my heart as I return home. When I will return, only God knows. But until then, I will miss you.

Ryan

Imeisha

Jambo from Arusha! Hope this finds you all well. November in Arusha begins the “short rains”, which is a lovely, cleansing time. The dust of the dry season is replaced with greenery, the cool breeze, and flowing streams. Crops are planted and seem to grow almost instantly. Again, as in harvest time, the hospital seems to have emptied, since people are busy planting their crops for the year. I still wonder how sick someone lets himself or herself become before they are able to leave the source of their livelihood to seek treatment. But there does seem to be a sense of joy and renewal with the coming rains: children playing, people gathering under shelter together, farmers planting. This month, for me, also was a time for renewal with the visit of my parents. It was a blessing to have them in Arusha, to show them daily life and the places where I work. There is something powerfully centering to see one’s family after a time of very new experiences.

Today for the Swahili lesson, I have chosen a common phrase with a bit of a negative meaning, but a significant one, nonetheless: imeisha. It means, “it is finished”, but is usually used to say, “we’ve run out”. For example, imagine being in a restaurant on a hot day after a long walk. There is nothing better in a moment like this than a cold drink (fill in your brand/drink of choice). You ask the waitress for your drink baridi sana (very cold) and they reply, sorry “imeisha”, it’s run out, try something else. You run through your second and third options, perhaps finding these have run out too, and settle for a warm purple Fanta. This pattern occurs on a daily basis, and requires one to be a bit flexible, but can be a frustration. It can be quite ironic, at times: the bar that has run out of beer, the sushi restaurant that has run out of fish, the ATM that has run out of money. Many of these are frustrating only to Westerners, myself included, who have come to expect establishments to supply what they advertise. The concepts of shortages, disrupted supply lines, rationing, poor business management, and other similar root causes do not often affect us in our home countries. 

When it is only the lack of a cold Coke on a hot day, it seems like life will still go on, despite the parched throat and betrayed expectations. But when it occurs in healthcare, it borders on injustice. During medical rounds in the hospital, at least 3-4 times daily, we send a nurse to check on the availability of a medicine or piece of equipment that a particular patient requires. Often she/he returns to tell us “imeisha” and we return to the drawing board on our plan for that patient. We discuss with the patient and family about the probable cost of buying the particular medicine or equipment outside of the hospital, and try to determine if they will actually be able to buy it. Because most patients themselves do not bring money to the hospital, this often involves mobilizing relatives from near and far to collect money. If they can collect the needed money, a relative often has to search many pharmacies to find what was requested, causing a significant delay in the patient receiving it. The medical team is often forced with decisions about how important is this medicine, exactly; is it really worth the burden on the family? Will the cost push a poor family further into poverty? What if the medicine does not actually help? Is there a halfway suitable alternative that might be a bit cheaper or more available?

I understand, from talking with medical providers who have been in the country for a while, that the situation has definitely improved over the years. Generic drug manufacturing has made a wide variety of medications available to the poor, and this is a miracle. People with HIV and TB get free medications in a reliable fashion from the government, and this is lifesaving. But one lesson that I learned from Professor Mark, our mentor and leader, really hits home in moments of “imeisha”. To paraphrase his wisdom: “Nothing is more frustrating than having something, when you have it only part of the time”. It is here, though, that I see the resilience and creativity of the local doctors and staff come on the scene. Often, with some improvisation, and a lot of patience, a suitable plan can be created. It stretches the boundaries of medical knowledge, cultural wisdom, and street smarts, but I have been so impressed with how the way forward can be found. Sometimes it cannot and the patient may suffer. Other times, you may realize you did not actually need the medication or test that you usually rely on. In the end, I have faith that the people I have met are making a future with more equitable medical care for the poor in Tanzania. In a global sense, I think it is vital for people in resource-rich countries to know the reality of what occurs in resource-poor countries, and to receive the challenge of creating a just world.

Ryan

Uchaguzi!

Jambo from Arusha! Happy fall to you northern hemisphere dwellers! Hope this message finds you well, surrounded by the changing seasons, falling leaves, and aromas of the best season known to mankind. In the weeks since the last update, I have been continuing my work at Selian Lutheran Hospital. We were happy to welcome back two volunteers who had been in Arusha previously. One is Dr. Elena, a pediatrician from Australia, who had previously spent 3 years working in pediatrics at ALMC and Selian. It has been nice to have her back in Arusha and to gain from her wealth of experience. Another volunteer is a Canadian NICU nurse named Lisa who has come to collaborate with the NICU nurses at ALMC to continue improving the level of care for our littlest patients. It is refreshing to have new faces, with new perspectives and skills, to contribute to improving health care in Arusha. It has also been a nice time for getting to know the new interns, most of whom started in early October. As mentioned previously, the medical interns come fresh from graduating 6 years of medical school, which is usually (but not always) undertaken directly after secondary school. They then begin a one year internships, which rotates them through the four major specialties: OB/GYN, pediatrics, internal medicine, and general surgery. At least at Selian, when they stay overnight to take “call”, they must cover the whole hospital. That means performing C-sections, presiding over the whole medicine and pediatrics ward, and sometimes performing other surgeries. This was the way medical internship had been in the US in the past, however, I could not imagine having so many responsibilities! They seem to handle it well, and they have the back-up of more senior doctors on which to rely. The ones who have started this year are a good bunch so far; they seem to enjoy their work and are eager to learn new things. We have enjoyed doing weekly introductory teaching about bedside ultrasound and have reintroduced regular radiology sessions for X-rays (now that the X-ray machine is working consistently—thankfully).

Today, for the Swahili lesson, I wanted to introduce a word related to current events: uchaguzi. This word has the same root as chagua (to choose) and means election, as in the democratic process of choosing the nation’s leaders. It has been such an interesting time to be in Tanzania: witnessing the campaigning, the hope for change, and the general excitement of people. To explain Tanzanian politics briefly, since independence in 1961, a single party has ruled the country: CCM (Party of the Revolution). At first, this was because the country was designed to be a single party system. However, for the last 20 years, there have been other parties, though none have gained enough momentum to challenge the ruling party; that is, until this year. With an interesting background as a former prime minister under CCM, Edward Lowassa left his party to join the opposition, Chadema (Party of Democracy and Progress). With his influence and experience, along with increasing desire for change, Lowassa and Chadema presented a real challenge to the political status quo. With this backdrop, it seemed there were not many Tanzanians who were not swept up in the fervor of uchaguzi. Young and old, educated and laborer, Christian and Muslim, all seemed engaged in this monumental democratic exercise. The children, even, would hold up the sign of CCM (thumbs up) or Chadema (peace sign) or shout “Peoples… power”, the call of Chadema. Flags and placards were visible from almost every corner. It was difficult to understand exactly how the parties differed, though it seemed they were calling for many of the same things: less corruption, better education, health care, and infrastructure. It was hard to tell if one really would be better for Tanzania than the other, and if I had to vote, I do not know who I would vote for. But what was most interesting to me, besides the general passion for politics that Tanzanians show (a stark contrast to the ambivalence many of us feel during US elections—as demonstrated by poor voter turn out), was the deep hope for change. I heard many impassioned speakers explain, with such hope in their candidate, that they would bring about the change in this country that would give their children a better life than they have experienced. Many of them have known desperate times: struggling to make ends meet, suffering from preventable and treatable diseases, commuting on sketchy dirt roads, sleeping in poorly built and un-electrified homes, drinking untreated water running from dirty streams. They hoped for better infrastructure, consistent power, educational and employment opportunities, and a better way of life. Though I explained in my last update how change can seem to happen quite slowly here, people appeared ready for it to happen in a dramatic way with this election. With the results declaring CCM to have won, many people seem to have lost some of this hope. But, as an outside observer, it seems that this fervor for change goes much deeper than which candidate or party has won. I hope that this momentum will carry this generation into building a just, peaceful, and equitable future to pass on to posterity. The people are ready to build a better Tanzania, and I have faith that they will.

Ryan, Global Health Chief 2015-16

Jambo from Arusha! Hope this email finds you all well! It has been quite a busy last month, with a great mix of work and fun. I had the great opportunity to travel for a few days with one of my best pals, Beau, who came to Tanzania for a visit. Highlights included gazing over Africa from the summit of Mt Kiliminjaro (19,000 ft!) and seeing some major wildlife in the epic Serengeti and Ngorongoro national parks. I also had a new experience traveling to visit one of the rural hospitals connected to the Lutheran church in Orkesumet, a 5-hour bus ride south from Arusha through Masaai grazing land. There, I was introduced a bit to life outside the big city, the experience that more than half of Tanzania lives day to day. Health care at Orkesumet was refreshing, with less patient volume and a smaller, but very committed, staff. While there, I had the opportunity to do a few house calls with the palliative care team into the Masaai bomas. From these visits, one can begin to catch a glimpse of what daily life might be like for the Masaai. As some of you know, the Masaai are a semi-nomadic tribe, whose major livelihood is tending to cows and goats. In more recent years they have become less mobile, which seems largely due to restrictions placed on the territories they can use for grazing. Being a polygamous society, they can have very large families, though this practice is also decreasing. Some of the Masaai that I have met who work in the hospital have 40-60 brothers and sisters! They traditionally live in bomas, which are a group of mud huts with thatch roofs for one extended family, surrounded by a fence made from sticks and thorny bushes for containing the livestock.  Entering the boma, one is privileged to enter a world apart. Curious children dressed with brightly colored cloth draped over their shoulder run to investigate. Masaai mamas dressed in bright blue and red, with dangling beaded earrings hung from large holes in the ears come toting the littlest ones on their backs or in their arms. The men, always with pastoral baton in hand (usually with mobile phone in the other), emerge with interesting mixes of traditional clothing and ski jackets or Manchester United hats. Respected elders lean upon walking sticks, sitting or standing. The homes are dark, relatively warm, and smell of the wood cooking fires.  The smiles are broad and the laughter seems constant. They seemed as perplexed by me as I by them, trying to fit each other’s appearance and lifestyle into any framework that could fit.

For this weeks Swahili lesson, I chose a rather cliché phrase heard constantly here: Pole Pole. It means slowly, carefully, or gently. For those who have been to East Africa before, this phrase is almost as overused as Hakuna Matata. It is often spoken both to Swahili speakers and to tourists who seem like they are in a rush or flustered in some way. It is meant to say: slow down, enjoy the moment, don’t worry. The phrase is also the official motto of climbing Mt. Kiliminjaro mostly based on the acclimatization strategy of hiking so slowly that you feel like you might be going backwards at times. Let’s just say that I got much more sick of hearing Pole pole than sick from the altitude, which I guess is the purpose. Pole pole, like most of the phrases that I find interesting, is more than a saying, but representative of Tanzanian culture. The only aspect of daily life that is clearly not pole pole, are the pikipikis (motorbikes) and daladalas (minibuses), which are all crazy. But apart from these, daily life is clearly a different pace than Western culture. People stop for long conversations on the road and enjoy frequent breaks for chai. Fastfood is mostly non-existent and even the suggestion of taking chai, coffee, or a meal “to go” is a bit confusing to some. People seem much more patient, especially as they endure long waits at places like the doctor’s office, the bank, and, coming soon, at the ballot booth. Change is also quite pole pole, which is multi-factorial, but can be observed in the way people dress, the cars they drive, the medical practices, and many of the cultural practices (some good and some not so good). It can be frustrating for a Westerner to get used to “Swahili time” – not just the different numbers they use for time, but the fact that most things are a bit late. It is true that this also frustrates many Tanzanians, especially in the hospital when it delays medical care. There is much to be said about the ways pole pole might not be the best strategy in certain circumstances, however, there are many lessons that we could take from this mantra. Clearly, the fast pace that we live our lives in the urban Western world has detrimental effects on individuals and communities. But what would it look like if we lived a little more pole pole? I think that we would spend less time doing things and more time together. I think our education and careers would be focused less on the length and strength of our resume and more on the relationships we build. I think we could pause long enough to enjoy the moments that pass.

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.