Jambo, from Arusha! Hope this finds you well! Since my last update, I have shifted into spending more time on the internal medicine ward at Selian Lutheran Hospital, the government district hospital at the outskirts of town. The walk to Selian, as I have mentioned previously, is quite beautiful and offers plenty of time to interact with the school children who come and go at similar times as us. I would suffice the walking experience to say that the only thing you can truly expect is the distance. The walk is long, literally up hill the entire way (but not both ways), but it is often quite refreshing and one of the closest interactions we have with the community around us. Work at Selian has engaging, with many interesting cases and a great group of coworkers. The Xray machine, which has been a prolonged saga of working, not working, working again, not working, is currently working! It is something that I have taken for granted in my practice to have a simple device such as an Xray; it is a luxury that I had come to rely on, but being without it has definitely stretched our skills in physical examination and creativity. That being said, it is a relief to have it back.

This week for our Swahili lesson I would like to introduce kwaheri. The meaning is simple,; it is equivalent to good-bye.  Literally, it means go with luck or happiness, which adds some richness to the expression, in my opinion. I wanted to introduce this word today, not because I am leaving (still have about 4 months left here), but because a good friend is departing. If you remember from some of my wintertime updates, Joseph is one of the pediatric registrars who has been at Selian for about 3 years. Beginning my time in Tanzania on the pediatric ward at Selian, Joseph was a peer with whom I was completely impressed. There is something entirely different about Joseph: a joy in the work that he does, a commitment to improving the care of patients, and a curiosity in the science and art of medicine that makes him one of Selian’s best young doctors. His knowledge of pediatrics is impressive, especially for not having formal training in the field, and he is always looking to add to it. On top of his skills in pediatrics, he also has a rich personality, both humorous and introspective. I had the great opportunity to host Joseph while he spent one month in Minneapolis taking the Tropical Medicine Course offered at the University. It was then that we really became friends. This year Joseph was accepted into a pediatrics residency program in China, which is a tremendous opportunity. He plans to return to Selian to continue his work in pediatrics after his 3 years of training. Selfishly, I am entirely sad to see him leave. It is an odd feeling to be in Arusha long enough to see many people coming and leaving; but of all the people I have met, I will certainly miss Joseph the most. But I recognize the significance of his departure, that he is becoming the future of Tanzania; this opportunity is part of the fulfillment of his goals and a new piece of hope for Selian. Thus, it is with a heavy and hopeful heart that I say, kwaheri, go with luck, my friend.

Amekua!

Jambo from Arusha! Hope all is well amongst you! I am writing to you today at the one-month mark of my time here. The learning curve has been steep in the past few weeks. I have been challenged in many ways, especially working in the Neonatal ICU at Arusha Lutheran Medical Center. As I mentioned in my previous email, the NICU at ALMC is a really incredible place. Even since I last saw it in February of this year, they have made great strides in caring for sick newborns in this young city. Another great joy that I have experienced this month is working in the pediatric’s clinic at Plaster House. The Plaster House is basically a children’s rehabilitation home, providing a beautiful place where children with various medical conditions can stay while receiving medical care. Many come from remote villages throughout Tanzania with conditions like skeletal fluorosis (similar to Rickets), club-foot, extensive burns, cleft lip/palate, intestinal malformations, and others. The house is set with an incredible backdrop of Mt. Meru, a 14,900 ft volcano, in a peacefully removed plot of land. Therapists, medical providers, and other professionals care for the children between their surgeries or casting. One of the incredible things about this place is that these kids, though their medical or orthopedic condition may otherwise keep them on the margins of normal childhood in their village, at Plaster House, they have a place where they can be kids. They constantly run and play with each other in the yard. Laughter, dance, and singing are constant. They have different disabilities, casts, and burns; they each have their own way of getting around, whether crawling, tip toeing on a casted and bowed leg, pushing in a wheelchair; they come from so many tribes and backgrounds, the stories of which I have not even scratched the surface. But they are all kids, and here they are at home.

For today’s Swahili lesson, I would like to share a phrase I learned in the NICU: amekua, which means: he/she grew. This phrase comes from the word kua, which means to grow. Each day in the NICU, we weigh the babies to see how each is progressing. To summarize NICU care into an overly simple objective, it is essentially the goal that each neonate would grow. Most problems occurring in the neonate are a factor of them being too small, lungs too immature, skin and bones too undeveloped. Growth is the answer to making it out of the neonatal period. Simple as it seems, this takes the efforts of many devoted persons: nurses, parents, doctors, and many more. Each contributes in a different way to grow the infant: one may come up with the general plan, but no one person can carry out that plan by their own effort. Growth is a factor of not only nutrition, but of caring for all of the details. For example, the child will not grow if the lungs are not supported, they will use all the calories received for breathing. Thus on a daily basis, the plan may include the following: The feeding must be given correctly, in the correct amount, at the right time, in a feeding tube or by mouth. If oxygen is being used, it must be by the right method, in the right amount, not too much or too little, and the cannula must stay in the nose, which is a constant battle against the tiny, uncoordinated newborn hands. Intravenous lines fit into veins in such tiny arms that a light held behind a hand or foot can display them all like the veins of a tiny leaf. Subtle signs in the newborn’s condition and behavior must be observed (such as breath-holding, tachycardia, change in abdominal distension), as they can herald serious infections, heart problems, or other life-threatening situations. The team cares for these details, amongst innumerably more, each minute, hour, and day. The circumstances in Arusha magnify the difficulties in caring for these little ones. How can one diagnose a serious infection with an armament of lab and radiology tests that can be counted on two hands, compared to the hundreds that we use on a daily basis in the States? How can we teach a mother correct feeding of a premature infant with an exact amount of breast milk fortified with an exact amount of fortifier to achieve 24 calories per ounce in the amount of 30 mL every 3 hours when she cannot read or write? How can you explain the condition of a sick neonate or the medical plan to someone who may have never been inside a hospital before or who does not speak the main language, Swahili? Despite these challenges, it has been a joy to see the staff at ALMC and the parents of these neonates watch their babies grow. Amekua! became a daily reminder of the small victories being observed most days. If the opposite was true, if the child had lost some weight, it was a reminder of the fragility of our work and a motivation to improve our strategy.

Each day here, I am challenged to grow to meet the challenges that the day brings. There are small challenges: dodging motorcycles on the street, finding my way around town, and communicating in an unfamiliar language. Then there are big challenges: how can I help in any meaningful way with these huge problems of poverty, disease, and injustice? what are my true motives for being here? am I becoming the person that God is calling me to be? Each day, I hope to see a bit of growth, to rise to meet the challenges presented. Some days, of course, I don’t. But here’s to hoping that at the end of this, I can say, along with these kids, nimekua! I have grown!

Ryan Fabrizius

Me with some of the kids at Plaster House (http://www.theplasterhouse.org/)

Me with some of the NICU nurses

Karibu Tena

Jambo from Arusha, Tanzania! I returned here to Tanzania three weeks ago and I have been so blessed to reconnect with friends, reacquaint myself with the neighborhood, and reintroduce myself at the hospitals Selian and Arusha Lutheran Medical Center (ALMC). For those who do not know, I have recently finished my training in Internal Medicine and Pediatrics, graduating from the residency program at the U of M, and I have taken a role this year of Global Health Chief Resident. Essentially, this means I will be in Tanzania from July to December, then return to the U of M from January to June to work in the hospital and help manage the residents at the U of M, namely those interested in Global Health. It is a joy to see certain things have changed for the better since I was here 4 months ago, namely the NICU at ALMC is setting new standards in Arusha for neonatal care. When I first saw the NICU in January of this year, it was a cramped room about 15ft x 15ft, there were a few oxygen flow meters and an eclectic group of donated incubators that seemed to be in different states of disrepair. The lighting was poor and the general mood was tainted with general unease and despair. One of the big projects for Steve Swanson and Derrick Matthews, two of the visiting physicians to ALMC from the States, was to renovate a new space and to begin to develop the first truly functional NICU in the Arusha. The city has such a need for good maternal and child care; Selian alone sees about 180 deliveries per month, which is a small fraction of the whole city. The new space has two rooms, about 8 incubators, a plethora of oxygen sources, and the ability to do CPAP and rated CPAP. The nurses and local doctors have gained a huge amount of confidence and pride in working with the babies, which is even more inspiring than the space itself. There is a general feeling of positivity, among staff and parents alike, that even a few children born at less than 1kg (less than 2lbs), stand a chance to grow up. This would not have been possible by any stretch of imagination, even 6 months ago. I believe they are beginning to see the possibilities now that there is a functional space, support from Drs. Swanson and Matthews, and an excellent group of detail oriented and caring local healthcare workers.

As I did last time for blog posts, I would like to continue to relay some Swahili lessons that I have learned. I find my language skills are still comprised of basic survival phrases, but I wish to continue to learn and experience the richness of the language and culture. This week’s phrase is Karibu Tena, it means “welcome back”. There are a few uses of this phrase, such as when you are leaving a store and the shopkeeper hopes you will return for more business or when you are leaving work for the day. The context I have experienced these past two weeks is a “welcome back to our community”. Having spent two months here earlier in the year, I have been so happy to reconnect with friends that I made at that time. As many of you know, we hosted two Tanzanian doctors in Minnesota for the Global Health Course, which is offered through our Department of Medicine. We were so happy to have David and Joseph visiting during the month of May, to share the sites of Minneapolis, show off our Midwestern cultural quirks (they can’t believe we eat cold sandwiches and drink “foul” tasting beer), and give opportunity to continued cultural exchange. It is now full circle to see them and our other colleagues back here in Tanzania. Some are surprised to see me return (some of the shopkeepers and kids seem to remember me); some may not have noticed I was gone. My favorite is the child at the top of big hill on the long walk to Selian who always jumps out to karate chop me. He did not miss a beat, welcoming me back with an array of chops and kicks. Coming back has made me feel closer to Arusha and to my colleagues than I ever did last time. I have a bit more comfort, knowing some of what to expect on a daily basis. But it is more than that experience which draws me closer. When people say Karibu Tena, I can feel their acknowledgement that I have a vested interest here. It reaches out to challenge me with the notion that change does not always come quickly. Being in a relational culture, I can see that working towards the common goal of improved healthcare in Tanzania involves committing to each other. The “welcome back” recognizes a bit more commitment, hopefully a bit more trust, and ideally will advance our mission together. Until next time…

Ryan

Drinking Chai with Dr. Sameji, pediatric registrar

The NICU with Dr. Linda, pediatric registrar, and Sarah, NICU nurse

The walk to Selian with Lizzie, medical student from New Zealand