February 18, 2015 Tropical and Travel Medicine Seminar

LOCATION
Shriners Hospitals for Children
2025 East River Parkway
Minneapolis, MN 55414
(612) 596-6106

Update from Med/Peds Resident Ryan Fabrizius during international rotation in Arusha, Tanzania

Hamna Shida
         
Jambo from Arusha! This week, I did my last week of pediatric wards with the all-star team led by Joseph (the registrar- a role like our senior residents) and Dr. Steve Swanson (a pediatrician from Hennepin County Medical Center, now serving at ALMC and Selian full time) and comprised of Kahema (the intern), Sasita and Baraka (the two Assistant Medical Officer students- a role like physician assistant students). It has been a great experience working with this team, and I have been so impressed by their eagerness to learn, compassion for patients, and their cheerful attitudes. Joseph, as I have mentioned earlier, is one of the best assets at Selian Hospital. The registrar is a position given to an MD upon finishing the one year rotating internship and can be an indefinite position, or often one taken while seeking out a residency spot in a specialty. Their role is to attend on the wards and to supervise the interns, though there are many duties they fulfill behind the scenes such as teaching the AMO students, participating in hospital administration, and seeing patients in OPD (outpatient clinic). There are 4 registrars currently at Selian, all of whom are excellent, but Joseph stands above the rest in his medical knowledge, enthusiasm, ambition, and compassion for the community he serves. He actively pursues solutions to "upstream" problems that lead to the sad conditions that we often see: malnutrition, difficulty with accessing care early in the disease course, and recurrent respiratory infections. He often purchases essential supplies with his own money and stays late awaiting tests that return hours and hours after they were requested. He hopes to gain a residency spot in pediatrics this next fall, though this is a difficult task in Tanzania, since there is not a steady source of funding for these positions. Either a trainee has to pay their own way, which is thousands of dollars per year, or they must obtain a sponsorship from the government, church, or pursue an international training program. It would be a loss for Selian when Joseph leaves, but we truly hope for his success as a pediatrician, a field that is greatly underresourced in a country with greater than 50% of the population younger than 15 years old and two pediatric residency programs. 
                
Though learning Swahili has been quite slow for me, certain phrases seem to be preferred by different people. I have already discussed "Karibu" and the greeting ritual, but we noticed fairly quickly the phrase most preferred by Joseph. "Hamna shida" (no problem) is mentioned in almost every interaction with Joseph. For Lion King fans, this phrase is a close cousin to "Hakuna matata", though for some reason wasn't chosen for musical glory; perhaps because matata is more fun to say. Examples of it's uses include responses to: "Joseph we don't have any oral rehydration solution and we don't think we'll be getting it anytime soon", "the family cannot afford the antibiotics you recommended", or "all of the thermometers have disappeared". He uses this phrase so much that Hope and I have taken to calling him Daktari Hamna Shida. To an observer, I think this phrase could be generalized to represent the people of Tanzania as laid back, care free, no worries. The slower pace of life, simplicity of material possessions, and emphasis on relationships here fit this mantra well, but one might easily interpret this as laziness compared to the frantic lifestyle we pursue in the Western world. I have seen, though, that there is a different usage for people like Joseph. I really do not see him and others like him resigned to be worry free in the midst of a community suffering under the weight of poverty and it's ghastly burden. "Hamna shida" is not permission to avoid reality, but I think it is one way to accept reality but not to let it frustrate or corrupt. Though I am clearly frustrated with the lack of resources that I take for granted in the practice of medicine in the US, Joseph is able to see what is lacking but to not give in to despair. For him, it seems, "hamna shida" is a recognition of factors beyond control and a challenge to strive for the best for his patients with the resources available. I truly hope that places like Tanzania will someday have the infrastructure and resources that all people deserve, but I am encouraged by people like Joseph who are able to overcome these circumstances and to make Tanzania better.

Ryan's Hamna Shida pose

Dr. Steve Swanson's new NICU at ALMC

Path en route to Selian, with Mount Meru in the background

Registrar Joseph with Intern Christelle, blowing bubbles from soap and a plastic wand we gathered for a malnourished child with multiple readmissions

Arusha Part 2, by Global Health Chief Resident Hope Pogemiller working in Arusha, Tanzania

Greetings once again from A-town! 

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

Arusha Part 1, by Global Health Chief Resident Hope Pogemiller working in Arusha, Tanzania

Greetings from Arusha! 

As the children energetically yet patiently teach us each day, Jambo, Mambo, and Good Morning Teacha are just a few of the many acceptable salutations offered to everyone encountered.  This reflection of intense community spirit is a welcoming reminder of the incredible value of universal salutations and the respect they engender.  It's wonderful to be back in the land of long walks, random chats with new people, and compulsory salutations.  It is remarkable how respectful these children are with playful greetings and light conversation in Swahili (which I can pretend to understand by judging the nature of their smiles).  Some roll tires or bike wheels alongside us, greeting us in Swahili, trying a little English, or just smiling and staring up at us a little-- without chanting and only rare demands for money.  They seem to be accustomed to living with Mzungus, and they enjoy interacting with us as real people.  The 6 km walk to work is hilly, but it has been a delightful form of exercise with the accompaniment of schoolchildren.

My flight through Amsterdam found me a new batman wristwatch, and my voyage was only slightly delayed with de-icing in Amsterdam prior to departure and a little intense visa discussion at the airport. My taxi driver waited for me for a few hours, and he looked purely relieved to see me...the last person from my flight out of the airport.  I tried to explain the need for de-icing the planes in Amsterdam, but it was a complication that seemed rather peculiar to him.  As we walked to his taxi, his buddies at the airport all shouted out to him that they were glad he found me.  There was so much support and no irritation for my delay-- a lovely introduction to this culture.  We had a lovely chat en route to Arusha on a beautifully paved road.  My "host-mother" Linda (the wife of the doctor who moved here after residency at the U to start 2 hospitals) met me at my house around midnight and gave me some keys and a phone along with some basic orientation.  Linda is an effervescent woman with a heart of gold and a creative, quick wit that is a pleasure to experience.  She drove Ryan (med/peds resident staying in Arusha through Feb) and me to the " Pic n Pay" Middle-Eastern Grocery Store for one of the most lively grocery visits I've ever experienced.  She gave us a tour of the 5 aisles and greeted every third person whole-heartedly (they were close friends) as she shopped and advised us on our shopping.  It was a great introduction to the community, and it was followed by a visit to the Dutch fruit/vegy vendor.  We pulled up to the gate and noted that it was closed, but she was not deterred.  She found a way to slide open the gate and walked in to ask what their hours were.  It was 5:58, and she thought it had closed 2 minutes early.  She came running back to the car in a minute to tell us we could enter to buy food.  The market had closed at 5, but the vendor was more than happy to welcome us to buy some of the most delicious mangoes, avocados, greens, oranges, and tomatoes.  Arusha is a very large city, but Linda has delightfully created a tight-knit community that suddenly gives it the feel of a warm, small town.  Today we heard that she took out a few of the medical students from New Zealand cheese shopping, which caused a instant pang of jealousy and regret.  The Linda fan club is vast but devoted, and I can't wait to meet with her again!

We met with Dr. Mark Jacobson and Dr. Steve Swanson, toured the 2 hospitals of Arusha Lutheran Medical Centre and Selian, and have now had an opportunity to follow interns, registrars, and AMO students on rounds at Selian.  There has been talk of the creation of didactic sessions such as morning report and case presentations. However, presence during daily rounds and coaching with the ultrasound machine seem to be of particular importance for the hospital staff at Selian.  After a few more days learning the system, I plan to ask some of the staff what their needs are and try to match them with my skills to pave a position for the UN global health chiefs in the future.  In the meantime, I'm thoroughly enjoying refreshing rains, long walks to the hospitals on bumpy dirt paths surrounded by bright green foliage, banana trees, palms, and corn fields with cows herding by, the same African dog calmly watching, and an endless stream of energetic children walking to and from school and fetching water.

Sunset en route to Kilimanjaro Airport

One of the many beautiful hibiscus bushes blooming in front of our house

A pretty, but unlucky bird with a blue tail who slammed into our window and temporarily sat dazed under our porch chair

Ryan (aka the Flash) joyfully running from our house in the morning on the way to work 

Med students from New Zealand and Ryan, walking back to our house

Purple flowers marking the outside of our house

Final Blog from Chiang Mai, by Med/Peds resident Kristina Krohn during international rotation in Chiang Mai, Thailand

I can't believe it is my last week here. Was it really almost 6 weeks ago that I sat on a plane next to a professor of art history and scholar of Burmese religious objects, while on my way to Burma/Myanmar before coming to Thailand?  Besides being able to pick his brain about the historical sites and religious relics I should see in Burma/Myanmar, he introduced me to a different medical concept: that the government health care system could be the best health care system, even with a good private system.

This professor spends part of his life living in Thailand and part in the United States. He chooses to get his health care in Thailand due to the cheaper price tag. But it is more than that. He also chooses Thai government hospitals over private hospitals, because he says they are better.

I know Thailand is known for medical tourism, such as high quality sex change operations, joint replacements, cosmetic surgery, etc. Any elective procedure you can think of, you can find a boutique hospital in Thailand that caters to tourists looking for a cheaper option, generally in a hotel/resort type atmosphere, fully including relax time on a beach. 

But a government hospital? Where the money does not go to fancy beds, decorations or iced latte's?

The concerns in the United States about a socialized, single-payer health care is that it will decrease the quality, increase wait times, and provide poorer healthcare than our current system.  Although, working in the current system I still see the people who don't ever get care, the minorities who get worse care, and that US health outcomes are poorer than most of the high-income world.  But, put that all aside for a moment.

Recently the Veterans' Affairs' scandal about faked numbers and long wait times encouraged the belief that a federal medical system in the United States would increase wait times.

My own previous experience in Uganda was that government hospitals were considered worse than private hospitals. In Brazil, a nice upcoming BRIC country, where the government hospitals don't lack supplies, the physicians still wanted to work in the private sector to make more money.  They wanted to receive their care in the private sector, because that care was "better".

What made the care better?   The doctors and nurses had more time to see patients, and they didn't need to wait a long time. 

I wasn't certain I believed the professor that here in Thailand things were different. Yes, Germany, Sweden, the United Kingdom, Canada, and other very high income places have top notch national health care systems. But Thailand?  I knew they had great doctors, but had assumed that outside of universities they migrated to the private sector as well.

After seeing an Australian-Thai dual citizen who flies back to Chiang Mai to get his health care at the government hospital because he also thinks it is the best care he can get between the two countries, I decided to talk to the Thai residents.

Fern responded quickly, "I want to work in a government hospital." No hesitation.

"Why?" I asked.

"Because you get to see more interesting patients. You see everyone. You see lots of poor people, so you see lots of disease."

Ok. I can see that. That is part of why so many people like working at Hennepin County Medical Center (HCMC) and the University of Minnesota.  You see cool things that you just won't see other places. But what about for her own care? I continued, asking, "Where do you want to go for your health care? Where will you go if you get sick?"

"Here," she responded again without pause. "The best doctors and nurses are here. I would want to be taken care of here."

"Not at a private hospital?" I asked, just to be sure.

"A hotel? No, no."  Then she and the fellow began describing private hospitals as places that pay more for the decorations and the atmosphere than the medications and the doctors. Many of those places are for falangs (foreigners), and the care is not as good as the care you can get through the government if you are Thai. So why would you waste your money that way?  The overall impression was that it would be silly to go anywhere else.

I have a hard time picturing some of my wealthier patients in Minnesota being willing to get their care at a Thai hospital. I already had a suburban Minnesotan tell my attending that they would never get their care at a place like HCMC. Thankfully, my attending responded by saying that the patient would be lucky to get his care at HCMC if he had any disease that needed more than the small community hospital where we were.

But maybe if people knew it is where the best doctors were, if it were incentivized so that the best doctors wanted to work there, a government system could work somewhere like Minnesota.   I think it has potential, but I also think it would be a hard pill for many Americans to swallow.

Martha Montgomery, IM Resident on international rotation in Kampala, Uganda

So if you’re in Kampala, specifically if you live in the upscale neighborhood of Kamwokya (ky pronounced ch) and you find yourself unable to sleep at 3:18 in the morning, you’ll find that this is the quietest time of the day. It’s still not perfectly quiet. There’s still the incessant dog conversations going back and forth among the houses but Otis, our neighbor’s dog, at least seems to be asleep so it’s a distant barking. There’s also the sound of traffic, like an interstate nearby, only I know logically that there is no interstate. There’s only cars driving at excessive speeds taking advantage of the paved roads of the city and the lack of traffic at three am, and yet it is still a ceaseless flow of traffic. There’s an occasional boda (motorcycle) engine but otherwise they’re quiet at this hour. The birds are quiet too and the international rooster has not yet woken. Being in a decently sized metropolitan area, you have to try to listen for the rooster. He’s not immediately outside my window like he often is. As many others have found, the rooster is a universal barometer of just how urban your setting is. Perhaps universal urbanometer would be the more appropriate nomenclature. If someone were to study roosters around the world I’m sure she could find a significant correlation between the proximity of the nearest rooster and the reliability of internet, electricity, running water, paved roads, or ability to purchase any number of international foods (be it Thai, Greek, Mexican, American, Italian) by phone and have it delivered (thank you hellofood.ug) to your door. All of which is to say that living in Kampala has been quite easy. I have a great many things to be grateful for and many people who were invaluable in helping me settle in (namely, Darlisha, Darlisha, Darlisha, and not to forget Wendy, Mahsa, Nathan, Josh, and so many others).

Writing in public is to me an exquisitely personal endeavor, and I’ve always been impressed by how many others do it so easily. I’ve never been much of a Facebook-er. I often forget to check it (possibly because people seem to post with a frequency that is inversely proportional to how well I know them). And from the other end, I don’t have much interest in sharing what’s on my mind only to have it remain viewable in perpetuity. What in the world would I have to say that could be so remarkable? But I find myself being chided by a certain former global health chief, and so here I am, examining my reflections in writing. If I knew how to say, “not so remarkable” in Luganda I would instill that as the title of my entry.

So what am I doing in Kampala? Much as I am a one face in the throng of 2-ish million people in Kampala, my role here is a small cog in a much larger apparatus. My background in epidemiology and working on large cohort studies is just enough to keep me afloat (barely). The Infectious Disease Institute where I’m working is a powerhouse of clinical research and a “Center for Excellence” for cryptococcal meningitis. It has a feel that is equal parts Ugandan and International. My clinical skills, on the other hand, feel woefully inadequate as I have come to rely on the crutches of advanced chemistry and microbiology and sophisticated imaging (none of which I can perform on my own, I might add). Left alone we have the history and physical exam which, as we know from morning report, leaves an awfully wide differential by 8:30am. By 8:45am the advanced laboratory and imaging results have swept in to save the day. Here at Mulago Hospital we’re left guessing after the 8:45 mark. So we guess at treatment and watch day to day as the patient either gets better or worse. Of course this happens in the US as well, Mulago just seems to take it to a new level.

Chiang Mai part 2, by IM Resident Joe Messana on International Rotation in Chiang Mai, Thailand

Greetings again from Chiang Mai

Kristina and I continue to soak in as many experiences as possible.  We met up with Becky Weldon, one of Dr. Walker’s childhood friends from Thailand.  She works in museum studies and has an incredible breadth of knowledge regarding the political and cultural history of the Thai people and surrounding cultures.  We went to dinner with her on Neimmenhamen Road, the hip part of town.  Later in the week we toured two different wats [temples] in the Old City: Wat Chedi Luang and Wat Pra Singh.  Becky has such insightful social commentary and descriptions of the significance of different Buddhist architecture; it was an incredible tour of the temples.  She also provided us with a book describing the history of Laos as it intersects with her family, written by her father, Dr. Charles Weldon called Tragedy in Paradise.  Kristina read it first and I’m in the midst of it.  There is such an incredible depth and social complexity/history to the area, that it is hard to fully grasp it.

             Through our travels we’ve been introduced to a philosophy in Thailand called jai yen, meaning “cool heart,”  suggesting to maintain composure and staying cool despite the situation.  This is one of the 4 brahma-viharas or heavenly abodes of Buddhism, namely equanimity (upekkha).  The others being sympathetic joy (mudita), loving kindness (metta), and compassion (karuna).  Another important phrase is kreng jai, to be considerate or not impose oneself on another person in a negative way.  I outlined these concepts in my observations in my last summary, and now they have been crystallized into concepts with these phrases.  Trying to further instill these principles will not only allow for further assimilation, but also be healthy and help cultivate the middle way.

            There is also a striking difference I observed in the hospital that is a departure from that which is found in the US.  I’ve also experienced this in India, and that is the outstanding amount of deference for physicians from patients.  Patients seem to be very much appreciative of the care they receive, and often bring gifts to the attending in clinic. 

            We continue to experience the city and go on excursions in the weekend.  We went to the night market east of the old city to watch a show of Lady boys.  This is a term for either a transgender woman or an effeminate gay male in Thailand.  They identify with either the opposite gender, or sometimes a third gender.  Lady boys are not restricted to urban areas, but are also seen in rural settings.  While lady boys, or kathoeys, are more accepted in Thailand, and there are hospitals devoted to sex reassignment surgeries, there are still a sea of social obstacles and issues that surround them.  Kristina and I made it a point to see their show in the night market, and it was extremely fun. 

             The next day Kristina and I went on a 6km hike up Doi Suthep, and saw two waats along the way; Wat Pra Laat, and Wat Pra That Doi Suthep, which were incredible sites to see.  Wat Pra Laat is nested along a flat brook on the way to the top of the mountain where the latter wat is situated.  We continued our 3-4 hour hike up the mountain and finally made it to the destination.  Here, we toured the grounds, saw the outlook that oversees the city of Chiang Mai below, and circumnavigated the main reliquary three times clockwise.  This reliquary is encased in gold plating and shimmered in the evening sun.  At 5pm, the monks performed a chant outside it and then proceeded inside the temple to continue their chanting.  It was a blessing to watch.  

                                        

Sawatdee krup, by IM Resident Joe Messana on International Rotation in Chiang Mai, Thailand

Sawatdee krup from Chiang Mai!  _/|\_  (::looking like folded hands::)

Traveling half way across the world has been such a blur, particularly since I am just finishing up UICU.  It took about three days for the reality of this opportunity to sink in.  I am so fortunate to be able to have two months in which I can experience Thailand both from a medical and cultural perspective.  Upon disembarking the plane, the pervasive kindness, patience, and helpfulness of the Thai were apparent.  It is always interesting to me how different the general tone of a population is upon arriving in a country.  They are more than willing to offer assistance for whatever question or request.  There is an overwhelming degree of politeness in every conversation.  Sometimes it feels as if there is a song of “khaaAAaa” and “kruuupppp” [a polite way of ending sentences depending on gender] that rings through the city streets.  People are generally very soft spoken, perhaps not to create offensive loud noises that would invade someone else’s space.  Sometimes conversation is not louder than the level of a soft whisper.  Even if you make a loud noise by banging into something or moving a chair loudly causing a screech, one may apologize.  The pace of life is also measured.  It is rare to see someone running.  This doesn’t apply to the speed of motorcycles, tuk-tuks (like Indian autorikshas), and cars of course, but they still are considerate and will stop for crossing pedestrians.  You actually have to weave in and out of traffic to cross the street in most cases.

It is difficult for me to feel one step removed based on the language barrier.  In my past travels to India, Latin America, and Spain, I’ve been able to use my language skills and interact more personally.  Thankfully, people’s English skills are typically more than adequate, and they are as I mentioned extremely patient to entertain the nit-noy amount of Thai I’ve accumulated.  Thai, being tonal, is more challenging, but Kristina and I are doing our best to navigate the musical language.

Maharaj Hospital, where we are working, is a towering series of bright white buildings just down the road from our housing accommodations.  Walking to work in the morning you find a steady train of students and residents in their pearl white ward shirts with green Thai writing over their pockets, and nurses in their traditional caps.  Street vendors are beginning to set up their stalls and preparing various types of meat from pork to chicken on portable skewer sticks.  In the hospital, Kristina and I have been rotating on the infectious disease consultation service and seeing very compelling cases (a handful of which will be deidentified and shared upon our return).  There are afternoon rounds daily, weekly journal club, and several morning outpatient clinics we attend.  Rounding includes an interesting exchange in which our experience in certain cases is shared with theirs, thus there is ongoing team-learning.

  
For our first weekend’s excursions, Kristina and I sampled three different local markets.  The “old city” of Chiang Mai is a square mile surrounded by a moat with scenic periodic trees.  The moat was used for the city’s protection in times past, but now the surrounding roads are a major transit area and serve as a great daily running route!  There are 4 gates at each of the cardinal directions.  We visited the south gate market on Friday where we met Sansanee’s brother, followed by the north gate market on Saturday.  On Sunday there is a weekly tradition of a “walking street market” that is an extensive strip of tables selling crafts, paintings, foods, clothes, jewelry, lanterns, etc.  It’s full of “phalangs” or foreigners, and sometimes gets so busy the foot traffic comes to a complete stop on the street. 

              
We continue to appreciate and savor the experiences we are having and are looking forward to the following weeks! 

Mambo, by Med/Peds Resident Ryan Fabrizius on International Rotation in Arusha, Tanzania

Jambo from Arusha, Tanzania. I hope this update finds you all well, I appreciate all of your responses, thoughts, and prayers. This week has flown by and I have been blessed that it has been filled with great experiences, coworkers, and friends. I am becoming more accustomed to work at Selian Hospital, and continue to learn new things everyday.

This week I have been reflecting on community. As many of you have experienced, there is nothing quite like finding yourself in another culture to make you aware of your own. Though my experience of culture here in Tanzania is doubtlessly affected by my obvious "foreignness", I have been finding the community here particularly enchanting. It has been explained to me that Tanzania is made up of over 120 different tribes, each with their own history, beliefs, and sometimes language. This is thought to be a really positive for Tanzania, since there is no one tribe that can dominate the others, as has been the unfortunate reality of many other African nations. It seems, from my naive perspective, that several tribes have maintained their way of life in a way that is so obviously different from the typical city dwelling Tanzanian. An example of this is the well known Masaai tribe, prominently donning their red and blue patterned scarves, beaded ear adornments, and patterned scarification on their cheeks. As a pastoral people, they are often seen tending to large herds of cows and goats, even in relatively urban areas around Selian hospital. It is a regular occurrence for us to run into a traffic jam of livestock being tended by a young Masaai herdsman. This contrasts to some of the other urbanized Arusha residents, many from other tribes like Chaga, who have taken to city life, working as shop keepers, taxi drivers, and other urban jobs.

One particularly fascinating aspect of life here that I have seen in my limited exposure, is how these different groups interact with each other and with ousiders, like myself. A prominent display of these daily interactions occur in the greeting of one another. Each day, myself and Hope, take our scenic walk to Selian hospital and are pleasantly barraged with endless greetings. The most common greeting is "mambo", which is a sort of slang term, much like "what's up?". To this greeting, we have been learning new responses in unlimited combinations. So far, we have learned "poa" (cool), "safi" (clean), "mzuri" (good), "mcima" (well), "fresh" (fresh?), and my favorite "poa kuchezi cama ndezi indana ya fridji" (cool like a banana in the refridgerator). There is also "habari" (what's the news?) and shikamoo (I respect you), which are more formal. Then there are the many school children eager to use their English phrases, like "good morning teacher" and "how are you?". Though I can barely scratch the surface to communicate in Swahili, I can sense the rich feeling of community in people greeting each other. When I watch others great one another, it is almost never a short interaction. Honestly, I have no idea what is being communicated, but I can sense the sharing of their interwined lives. They stop to share a cup of chai, to rest in the shade, to carry their produce from the field together. 

In the hospital, I have seen how families rally to collect money for medicines and to search the countless "dawas" (small pharmacies) for the right medicines. I have seen how patients in neighboring beds support each other, like when a Masaai family cannot speak Swahili well and the neighbor will help fill in the details of whether they have received their medicines as ordered or have been taking the recommended refeeding formula. I have seen how the local doctors here will often buy necessary supplies with their own money, such as Oral Rehydration Solution, extra food, and even clothing for their patients. There is a sense of cooperation and support for one another that extends beyond family, tribe, and language. The people here have been gracious to greet us everyday, but I see that below this surface greeting there is such a richness of community here that amazes me. It challenges me to consider how I relate to others and how we as Americans (or whichever subgroup we find ourselves in) can look beyond ourselves to build stronger community with one another.