Monday, October 27, 2008

Traditional Birth Attendants

Have I mentioned how much I love Tanzania? We drove down the escarpment today into some fairly remote villages to find traditional birth attendants. We went to Chem chem and talked with 2 of the more active TBAs. They have not had any formal training, and MIHV would like them to attend the next training session we are having. MIHV is using the Home Based Life Saving Skills manual provided by the American College of Nurse Midwives - which I think is fabulous. More than 80% of women in Tanzania delivery with a TBA at home - often miles and miles from the nearest health facility - so it's critical that these TBAs receive some formal instruction for what to do with complicated cases.

I'm dying to attend a home birth. We have our own nurses working on contacting the TBAs in the area to see if they can make that happen for me!

My weekend was pretty quiet. I went to Bytes with Meredith on Friday. Meredith is from Ohio and just finished law school. This is her fourth or fifth trip to Tanzania, and she will be here for a year working for Dr. Frank and his wife, Susan, as the "volunteer coordinator" for FAME medical clinic. Meredith first came to Tanzania to work as a volunteer at an orphanage and was here for a year that time. Her stories of all these children that are at Rift Valley orphanage that were either abandoned (usually by an alcoholic teenage mother) or whose parents have died of AIDS have brought me to tears. She is planning on adopting at least one baby before she moves back to the states. I am totally inspired by her ability to change the world one person at a time.

My account of the local hospital was fairly horrible, but that doesn't mean the people of Karatu are without good medical care or compassion. FAME medical clinic was opened this year by Frank - an American anesthesiologist - turned internist/family practitioner. I have mentioned him before. His clinic is absolutely lovely and clean! You could probably eat off of the floor there. He has 2 other amazing Tanzanian doctors working with him, plus 2 fabulous nurses (one is a nurse-midwife). I spent some time there last week reviewing topics like cervical carcinoma (for which there is currently no screening program here - aka Pap smears) and antenatal care. I also consulted on a patient for them who came to the clinic on Sunday. I am totally inspired by what Dr. Frank and his staff are doing there. I was offered a full time position - and have strongly been considering it. I told him if he could find a way to pay off my student loans and pay my mortgage - I might just stay!

Kim arrives tomorrow night - and I can't wait!! I have been working with various safari agencies to get us a good deal. I think we will spend a few days in the Serengeti, and then go to the Ngorongoro crater. Next week, we'll fly to Zanzibar for a few days of complete relaxation. I can't believe my time here is almost up!!

I like sharing some of the very random things I am learning about this culture. It is apparently much worse to be a thief here in Tanzania than it is to be a rapist or murderer. I was told that if I was ever in trouble or someone was seriously bothering me, I should yell out "thief" - which apparently will get anyone nearby to start beating the crap out of the person (sometimes to death). But I wouldn't get the same reaction if I yelled out "murderer." Crazy, eh?


Thursday, October 23, 2008

Karatu Lutheran Hospital


I have had some time to consider some of the things that I have witnessed regarding health care here in Tanzania.

Karatu Lutheran Hospital is located about 4 miles from the "center of town." As mentioned in a previous blog, the new building was built in 1999, but feels as though it is from the 1950s. The old part of the hospital is now the canteen. There are 2 free standing buildings near the hospital - one for HIV counseling, testing and treatment and another for Maternal/Child health - dedicated to the care of pregnant women and children (mostly for vaccinations). According to many Tanzanians that I spoke with, the government must provide service for any person that is HIV positive, pregnant women, and children under the age of 5.

Inside the hospital is a large waiting area with uncomfortable wooden benches, a chart room and 4 doctors offices that appeared ill equipped. This is the outpatient area that handles most of the routine cases like malaria.

Wandering through this room takes you to a courtyard around which the hospital is built. There is a small laboratory capable of basic tests like CBC, urinalysis and blood smears. They had a Maasai warrior donating blood for a family member while I walked through. Next is a small pharmacy. There is also a room for sterilizing instruments - with 2 autoclaves. It says on the autoclave "use distilled water only," but I'm pretty sure that they just tossed in a bucket of reddish brown Karatu tap water with the instruments. Fascinating. The woman there then packs up the sterile instruments in towels that have been drying in the sun. Sterile? I'm not so sure.

There is one main operating room, where any kind of procedure takes place, including a pelvic exam. This room has a small anesthesia station, with an ether filter and halothane gas. I could not find an endotracheal tube anywhere, so I'm not sure that patients are actually intubated. They had lots of glass vials with labelled bins on the cart, but looking more closely revealed expired medication. I found a vial of atropine in the "promethazine" labelled bin. They had a small cabinet with suturing material. And I found a big bottle of chlorhexadine that they use to prep the patients with. I'm not sure that the surgeons actually use anything to wash their hands with, though. I washed my hands outside of the OR using a squirt from a big bottle that said "disinfectant" on it. There were no suds, and it certainly didn't have the sting of alcohol on my cuticles - I think it was more water. The OR lights had blood splattered all over them.

The hospital is staffed by a handful of nurses and only 4 doctors. All of the doctors are able to perform c-sections, but none have officially been trained as obstetrician/gynecologists. One has a masters in surgery, and was proud to tell me that he is able to handle such difficult procedures such as uterine extensions. All of the c-sections begin with vertical skin incisions.

When I arrived at the hospital, I was supposed to meet with the chief physician. However, he was too busy with the German and Finnish doctors that arrived from Arusha - there to investigate hospital hygiene (and boy did they have their work cut out for them!), that I did not have to sign any forms. One of the staff workers at Minnesota has a friend who is a sort of scrub tech at KLH, Dawson, who showed me around. We went straight to the maternity ward.

The maternity ward was very interesting. There is a small reception area and then a short hallway with 2 large rooms off to the sides and a delivery room at the end. Each of these large rooms has 12 beds squeezed in there. On one side are the recovering c-section patients and on the other are the laboring and recovering normal vaginal deliveries. I rounded on the c-section patients with one of the doctors. The windows open onto the small courtyard, so the room was full of flies. There were no mosquito nets hanging from the ceiling. The doctor that I rounded with could not figure out who he had operated on the night before (despite there being the obvious IV bag dripping into their veins). He kept asking the nurse for their charts - a single piece of paper with their name and tribe name on it. He did make some notes about each patient though.

I was horrified by a few things in this ward. There was a mother who had given birth vaginally the day before to an infant that was charted to be "abnormal." To say the very least, this kid had MAJOR malformations - it had an open spina bifida with its frickin spinal cord practically hanging out of its back - merely covered by a dirty piece of gauze. And it was laying in its own shit which appeared to have been there for quite some time. The poop was creeping up towards this little babies back. The doctor kept scraping the bottom of the baby's feet - a test for reflexes - which was very obvious that there were none - but he kept doing it over and over as if by some miracle the kid would curl his toes. This little baby also had a huge head (hydrocephalus), low set ears and its eyes were very close together. The doctor barely looked at the mother, made a note in the chart that said "refer to KCMC" (one of the teaching hospitals in Moshi - a few hours away). My guess is that this poor mother, who probably lives in a mud hut outside of Arusha, probably doesn't have the funds to even pay for transportation to get her baby to KCMC. I don't think anyone expects this baby to live.

There was another woman there, post operative day #8 from her c-section for obstructed labor. The day before I arrived, they took her stitches out and noticed pus draining from her wound. The doctor that I was with made this huge show in front of all the patients in the room about putting on these sterile gloves - and then removes her dirty dressing with both hands. It was a bit ridiculous. He then proceeded to squeeze with all his might on her belly to express as much pus as possible. The poor woman was obviously in excruciating pain, but made absolutely no sound whatsoever. Tanzanian women are so totally stoic. I just wish they wouldn't put up with such treatment. After he was satisfied with the amount of pus extracted, I asked him if he was going to pack her wound (open about 4 cm) and do twice daily wet-to-dry dressing changes. He kind of looked at me in a funny way, as if that was such a crazy idea, you dumb american. He asked "why would you want to put something in there if you want it to close? watch this. It will close so nicely if there is no foreign body. Let us pray to god that there is no foreign body." He then proceeded to pour in furosol (I have no clue what that is), but it appeared to burn or sting because the patient was wincing again. The wound was then covered with a clean piece of gauze and the doctor went on his merry way and telling me that he was going to start 3 different antibiotics for broad spectrum coverage (not exactly necessary since there was no evidence of a surrounding skin infection). Not once did he address the patient or let her know what was going on or what he was doing or apologize for hurting her. I stayed with her for a minute and she let me admire her darling little baby.

Apparently, being an authority figure here gives you the right to treat people however you feel like it. Teachers here often beat or hit their students if they don't know the answer. And curiosity and asking questions by students is considered offensive - as if they are trying to challenge the teacher's knowledge. It's often punishable with a beating or such severe humiliation. Doctors and nurses regularly yell at patients, which I was witness to and it made my heart hurt.

There was an 80yr old woman, with only a few teeth left, who presented for consultation from the local dispensary. The patient had a few months of vaginal bleeding and they were concerned that she had cervical cancer. They wanted the hospital to do a biopsy and refer for further treatment. Karatu Lutheran Hospital, although equipped with some basic medical equipment (including an ultrasound - though the doctor who could do obstetric ultrasound had left), but they are not anywhere near being capable of doing a cervical biopsy. First of all, they don't have the equipment to even do basic cervical cancer screening with Pap smears, let alone biopsies of abnormal areas. And secondly, there isn't a pathologist around for miles (and maybe there's only a few in the big city of Dar) to actually read and interpret the biopsy results! Before subjecting this poor woman to a pelvic exam, I wanted her and her daughter to understand this. After a very short conversation in swahili, the patient was brought to the main operating room for the exam. It took one and a half hours to arrange for the exam. First they couldn't find a speculum, then they couldn't find gloves. Then we set up in the wrong room because the bed had no stirrups. After getting everything together, they brought the woman in. The nurse immediately began yelling at her and refused to help her onto the bed. When I asked if they could help put her legs in the stirrups, the did so so roughly I thought they might have dislocated her hip. Then I needed her to move down on the bed, so the nurse started yelling at her again. And they nearly laughed at me when I asked for a drape to cover her legs and give her at least some sense of decency. The whole thing was so awful. They brought me the largest speculum they could find - for this poor 80y old woman and her atrophic vagina. I'm sure it hurt like hell. The scrub tech was also highly annoyed when I told him I didn't need to prep the patient or use sterile gloves because the vagina is not a sterile place. Maybe I have it wrong - but it seemed like they have all the intention of being clean - but try to be sterile at the wrong times, and when things should be sterile - they aren't. Anyhow, this poor woman had the nastiest, fungating, infected pus filled exophytic cancer I hope to never see again. When I tried to talk to the patient and her daughter, my interpreter said we should speak to the daughter in private. I don't think my tone was conveyed, because he was also yelling at the daughter and pointing at the patient. The conversation was way too short.

I left the hospital after that and I'm not sure I'll go back.

Wednesday, October 22, 2008

Health Care


It is difficult to know where to begin in order to give you an idea of the way health care is in this part of Tanzania.

There are dispensaries located in many of the small districts. These facilities are equipped to care for basic medical needs, and deliver babies (but not if this is the woman's first baby or if it is her fifth or greater). They are often ill-equipped and understaffed. The government continues to build them.

There are "duka la dowas" (no idea how this is spelled!) - the main pharmacies in many towns and villages. Here you can purchase just about anything over the counter and without a prescription. Patients will arrive at the duka and describe their symptoms, and the duka will provide just the right medication without ever laying a hand on the patient. If you only have half of the money for the antibiotic, let's say, the duka will give you half the number of pills. This is one area in which Minnesota International Health Volunteers has made some progress. They have trained the dukas not to sell half doses, and then sent secret shoppers out in the villages to see if the dukas learned anything. And - they did! Most in this area will no longer sell half of the needed dose for malaria treatment, or other such remedies. That doesn't stop them from offering their own prescription though.

There are hospitals, too. There is a main teaching hospital in Dar es Salaam and one at the foothills of Kilimanjaro - called Kilimanjaro Christian Medical Center - KCMC -(which was primarily started by the father of the man who helped write Three Cups of Tea and is building schools in Pakistan). These teaching hospitals sound like good places, but I've heard some horrific stories. For example, there was a woman who delivered at KCMC and couldn't pay her bill, so they took her baby away from her!

There is a very small hospital in Karatu - where I am - about 2 hours northeast of Arusha. The hospital was built in 1999, but looks like something out of the 1950s. I went there for a tour the other morning, and spent the day there today helping with consults and examining patients. I also rounded on the c-section patients with one of the other physicians. I was prepared before going - by hearing a number of horrifying stories about what has happened there. So I was not completely mortified by the terrible things that I saw - but I do need some time to process everything before I can write about it competently. I was quite pleased to see that all of the mammas that delivered had their babies swaddled and with them - but, after all, who else is going to look after them? There are 12 beds pushed so close together, you could literally roll over onto your neighbors baby if you weren't watching carefully. This is where the women labor and recover. They have a separate room, very similar, with the same number of beds where the c-section patients recover for 10 days before going home. Imagine rounding! But some of these women live more than 20 miles away (with no car or money for a bus) and walked in for their deliveries. The hospital does a good job to ensure that their stitches are removed and there is no sign of infection before making them walk home 10 days later.

I am so fortunate - and take so much for granted...

Sunday, October 19, 2008

It has been the most spectacular weekend here in Africa!!

I still cannot believe how beautiful Tanzania is! I went hiking for a few hours on Saturday with one of the peace corps volunteers and it was incredible. I cannot describe the beauty of this land - it is at times completely breathtaking. We hiked up and down hills, among peaceful valleys and through countless lush coffee plantations. We hiked to the gate of the conservation area where the land near the Ngorongoro crater is protected - and so full of trees. We walked by many mud huts with so many adorable children running around - all saying hi to us. One woman who's house we wandered by tried to give me her 3 month old daughter, Mary, who was chewing on some sugar cane. This little baby was so adorable, I was very tempted to scoop her up and bring her home with me. I asked her mom if she would miss her daughter and she told me that I could just bring her back in a few years for a visit - as if it would be no big deal.

Today, Jolene made brunch again! She invited a few other americans over, and we gorged ourselves and played Farkel - a dice game. It was super fun. This afternoon, she, Peter and I went to Ngorongoro Farm House Lodge - an incredible place with a beautiful deck overlooking one of the smaller craters. We continued to play Farkel and watched the sunset. The manager of the lodge must have a crush on Jolene - he offered us dinner and drinks. As we were watching the millions of stars appear while eating, one of Peter's students appeared with his family. They apparently perform at the Farm House on the weekends. Peter's student, Celestine, his sister, Cecilia, and his mother and father warmed up for us with two beautiful songs. During the second song, Cecilia grabbed me and made me come dance withher and her mother - she was so cute! Celestine's father, Paulo, was playing a violin like instrument made from a gourd that he had built himself - with very nice carvings along it. He actually offered to give me the instrument when I told him how lovely it was! It was the most delicious ending to a fantastic African weekend.

Wednesday, October 15, 2008


There are so many ways to greet someone in swahili! I was very confused last week - but I think I'm getting it down now.

Mambo means - how's it going?
The usual response is "poa" - it's cool, I'm fine.

Habari? means - how are you?
The response is "nzuri" - I'm good/fine.

Hujambo? also means - how are you?
Sijambo - is the response for I'm fine.

There are some that don't have an English equivalent.
Shikamoo - is like a respectful greeting.
The response is "marahaba" - which means something like "thank you for your respectful greeting."

Unatoka wapi? Where are you from
Natoka Marekani. I'm from America.

I still can't believe I'm in Africa. I've told you a little about Karatu already. But there's so much more. I wake to the sound of cows mooing - yes, right in the neighbor's yard. And there are so many cows here - all wandering around grazing on the dry, brown grasses as their owners amble around, observing from a short distance. The cows are not like the typical american dairy cows - all black and white, either. They are brown, or tan, or grey, or mixed. Some are white. Some have masaii warriors tending to them. I also wake to the sound of so many roosters. They cry out all through the day, too - as if they are confused about the time. And there are tons of little chirping birds right outside the house - and at the office, too. Everyone seems to have a chicken or two running around in their yard. I just noticed that the house behind the office has a chicken with about 7 little babies running after their mamma. I fall asleep to the opera of crickets. It's sometimes so loud, I feel like they are right in my room!

I had my first shopping experience in Karatu market. It's sort of an outdoor farmer's market - difficult to explain. I will take some photos before I leave here. There is not a huge variety of produce. Most vendors sell carrots, potatoes and tomatoes. This area of Tanzania is also known for its red onions- so every nearly vendor has them. There is also garlic, greens, and cucumbers. I bought some bananas and a large, juicy papaya. The market also has a dried fish stand - perfect for Jolene's cat. And there are huge bags filled with rice and dried beans. Of course there are scruffy little kids sitting with their mammas - so cute, my heart just melts when they smile and say "jambo" to me.

I am trying some of the local beverages, too. I already talked about the tangiwizi - my favorite ginger soda. But they have a variety of beers - mostly lagers that taste very similar. Serengeti is becoming a favorite. I also splurged on a bottle of South African merlot - Tsh10,000 (about $8.50 - quite a luxury when the daily wage is much less than that).

Tanzanians think white people (mazungas) are all rich. And I suppose in comparison, we are. The average annual salary is about $360. But Tanzania is not a "poor" country - when you consider the booming tourism industry and the fact that it costs each person $100 to enter the Ngorongoro crater.

We are still waiting on the District Medical Officer to allow me to visit the hospital in town for a few days. In the meantime, I have been working on several powerpoint presentations for Dr. Frank and his staff.

Asante sana for reading!

Sunday, October 12, 2008

Jambo again!

It rained yesterday - which was wonderful! All that red dirt that was flying around is now packed down a bit. I worry that we are headed into rainy season, though. Jolene and the other NGO folks were discussing Karatu mud - it may be worse than the dust. I'm so thrilled I get to experience both seasons here...

Yesterday, Jolene hosted a brunch at her house. Peter, the Peace Corps physics and math teacher, made eggs benedict - so similar to my dad's recipe! Delicious! Ashley, the American ex pat who owns the art gallery, and Zoe, the Brit, were there. As well as Dr. Frank and his wife Susan (both from California, but live here now) and Jean, a Canadian who works for another NGO in Karatu called CPAR (they have a website). Dr. Frank moved here a number of years ago to open a clinic after almost dying while climbing Kilimanjaro. I am going to his clinic this morning to check it out. Everyone has been raving about how nice it is in comparison to the local hospital. He also wants to consult with me about a few patients and maybe have me give a lecture on current ob/gyn practices.

I wanted to share a little of what I've learned about female circumcision. It's illegal in Tanzania, but still widely practiced. There is apparently a small tribe near Lake Victoria that self-circumcises - but this sends a very powerful message to everyone in their tribe. The women there are not to be fucked with. Because it is now illegal, it is more common for female infants to undergo this procedure shortly after birth (rather than at the time of adolescence). Many men refuse to marry a woman who has not had FGM (female genital mutilation) because it means they are not a virgin. It can cause some serious problems with the delivery of their babies - which usually occurs at home by a TBA (traditional birth attendant). The TBAs are often the ones in the community also performing these circumcisions. This is a cultural practice that I hope will change with time and education. I will never understand it.

Saturday, October 11, 2008


Jambo again! I love that internet access is readily available here. Jolene, the Tanzania project director, has gone to Arusha for the day and left me her wireless modem. I thought I would start a blog.

Yesterday morning, I met with the DMO (District Medical Officer). He seems like an interesting man and has big plans for me. He seemed surprised at the number of c-sections I have performed at home and was just about to whisk me off the local hospital (Lutheran General) to start operating. However, Jolene wanted me to read through a few things at the office, and apparently the DMO needed to discuss this with the head surgeon at the hospital before I can do any work there. So I am off the hook for a few more days!

One of the other MIHV staff workers, Joyce, and I had lunch at a little outdoor cafe swarming with flies. The food was good - interesting. I asked for rice and beans, as it was so delicious from the day before. But Joyce said they had fried fish. So, I decided to give it a try. It appeared on the plate whole - scales, bones and head - along with a mound of fluffy white rice and a side of cooked greens, beans and some red soupy sauce. It was pretty good. I was disappointed that I didn't get to wash it all down with a Tangawizi - my favorite ginger drink here. Instead, I had a bottle of Sprite - which cost about 35 cents. (Lunch was about $2.50).

In the afternoon, Jolene brought me just out of town a few miles to the Fine Artz Gallery. This amazing little spot is nestled on a small hill overlooking a peaceful green valley. The site was so calm and incredibly beautiful. Inside, there is lots of local art which was actually quite good. I have my eye on a rather large carving of a pregnant woman. We'll see if I can afford it by the end of my trip here. But they also sell the bags that the Survive and Thrive group women are making. Jolene wanted to see if the owner wanted to put out a new item - some blouses made from many of the beautiful african prints here. She took 4 of them.

The owner, Ashley, is an ex-pat from America - who came on safari with her family 12 years ago. Through a number of chanels, she ended up coming back about 3 years ago and loves it. She is in the process of building a rather large and beautiful home on the same site as the Fine Artz Gallery. One of her workers, Zoe, is a lovely Brittish gal from Norfolk. She was traveling around Africa and met Ashley - who asked her to work for her. So she has been here for nearly a year now.

These gals invited Jolene and I to Bytes, a local restaurant in Karatu for dinner last night. Bytes is owned by Sandy, also an ex-pat. Her father worked for Brittish Airways, so she grew up all over, but calls Tanzania home now. Jolene was tired and had to work on a few things, so I ended up walking down to Bytes on my own. It was quickly becoming dark as I headed down the hill (about a 3 minute walk) and I felt like my skin was glowing in the dark. People were saying hello to me from all around, but I could barely see where the voices were coming from. It was quite a strange feeling. At our table was Ashley and Zoe, as well as Sandy. But there was also an older South African couple (Andre and Lysle) who now live in Tanzania. Many Serengeti's later (a very drinkable lager that costs about $1.50), we ordered dinner. I had a spinach pasty with salad which was delicious. I should have left the salad on my plate though....

I woke this morning with an unusual cramping sensation in my gut at about 4 am. This coupled with a migraine did not make for a pleasant morning. I finally made it back to bed at 7am after drinking an electrolyte solution and taking 4 pepto tablets. Fortunately, I feel pretty good now. It's a little after noon.

Some other not so great things about Africa....we have no water at the moment. None. Last week, there wasn't enough to shower, so I had bucket baths - but today there is no water at all. I may have to make friends with more people to see if they have water. I bet there's water at the Fine Artz Gallery....

Karatu - is the little town I am staying in. There is a huge variety of housing here - ranging from the somewhat luxurious house that I am staying in with tiled floors, a housekeeper and a tin roof. Not to mention plastered walls and a flushing toilet (well - when there's running water) with actual beds and mosquito nets and electricity. On the other hand, Karatu is full of little shacks - one room houses that may or may not have windows or roofs, sometimes made of red clay bricks and sometimes made of scraps of wood assembled together. These shacks have no electricity or running water. Women collect water from whatever source they can find in big plastic buckets and hall them around on their heads. They cook over open fires of burning garbage and wood in their front yard. Everyone wears flip flops. There are hundreds of roads in Karatu - none of them paved except the main tarmac road leading to the Serengeti and Ngorongoro Crater (paid for as a gift from the Japanese). The town stands on red clay dirt. It is very dry here and because of the location, there is a lovely breeze almost all the time. This lifts the red dirt sweeping it into the air and blowing it EVERYWHERE. No matter how many times the floor is swept or the counters wiped off - there is a fine dusting - like powdered sugar - of red dirt. It coats my skin - and stays stuck with the help of mosquito repellent. It's in my nose and ears.

Now that I am feeling much better, I think I will get dressed and walk outside of town to explore some of the many coffee plantations scattered along the main road.

Asante sana for reading!