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.

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