Muheza: Week 4

This week was my last week in Tanzania :( I went out to the villages with the mobile Maternal/Child Health clinic again this week. The village we went to was even more remote, and we traveled for an hour over the dirt roads through the “bush” to get there. I spent the time there weighing more babies and amusing the older kids who thought my reading out of the weights in Swahili was hilarious.

There is a rotavirus outbreak going on in children in Muheza right now, so the pediatric wards are extremely full (up to 3 kids per bed- probably not the best for preventing further outbreak spread). They called in some epidemiologists from Dar to come and investigate the outbreak, so it has been very interesting to hear their process and the results of their investigation- especially having been on a diarrheal illness investigation in the US. They seem very competent, but sound discouraged by the state of the health record keeping here, which definitely leaves something to be desired. It is a hard job anywhere, and without good records it makes things even harder. Nevertheless, there does not seem to be one focus of the outbreak, and so they think it could be linked to a common source of drinking water. I have my doubts, but they are still investigating this hypothesis further.

I spent the majority of the week with Dr. Mbago on surgery, which was definitely an eye opener. On ward rounds, I saw people with huge hernias, a lady with a burn covering her skull, a woman with a visually and palpably obvious breast cancer, and a huge sarcoma enveloping a 20-something year old woman’s upper thigh and bursting out into a large black fungating mass. I will never forget the sight of that. Most patients are awaiting surgical repairs- hernia reductions, skin grafting, leg amputations. It was interesting to watch Dr. Mbago interact with the patients, and to see him break bad news to patients.  For example, when we told the patient with the leg sarcoma that she would need amputation, there was very little reaction. The patients are much more stoic in Tanzania than they are back home. They are also much more accepting of the doctor’s judgment. Often during rounds the patients are not even really informed of what will be happening to them that day, and then before you know it they are being whisked off to the OR. There is a lot less discussion with patients and families than there would be in the States.  I observed a thyroidectomy for a patient with a goiter- it was done under general anesthesia which means that the nurse anesthetist had to bag ventilate the patient with halothane the entire time. The anesthesia was also rather light in my opinion. I also was the first assist for a hydrocelectomy and subcapsular orchidectomy for a patient with prostate cancer. Instead of using medication to target androgens in these patients (androgens exacerbate the cancer’s growth), they surgically remove the insides of the testes to basically remove the hormone producing cells. I have never heard of or seen anything like it back home. Dr. Mbago is a very good teacher though, probably the best that I have encountered here. He spends a lot of time teaching me practical knowledge of what to do in emergencies in a resource-poor setting- from using a pen/latex glove to remove pressure and create a valve in someone with a tension pneumothorax, to how to relieve urinary retention, to classification and treatment of burns. It is very helpful, and is actually knowledge that I might have to use in the future.

Thursday was a national holiday, so there were not normal duties on the wards. We went with the British OB/GYN and her family to the Tanga Yacht Club (mostly for expat members), and hung out/went sailing on their old wooden dinghy and their Laser. There, I met a family from Riverside, CA who have been living here for the past 5 years doing physical therapy work. They used to live only a few blocks away from the Riverside Wondollecks! What a small world. I also met a family from Texas who have also been here for 5 years doing education and clean water projects. It was really interesting to speak with them about their experiences as Americans living abroad in Africa. It is rare that you meet Americans who are living in this area long term, it is much more often British and other European people. But it is definitely nice to see Americans also getting involved.

I spent Friday in the microbiology lab with Ben, the British OB/GYN’s husband. He taught me about their laboratory capabilities here and showed me a little of what they do every day (looking at malaria blood slides, growing bacterial plates for speciation, ongoing research project studies, etc). He is a wealth of knowledge on malaria and the other infectious diseases in the area. I asked about outbreaks, of which he says there haven’t been too many, but they have had cholera, rotavirus, and Rift Valley Fever outbreaks since he has been here. They have also isolated a new virus in the CSF of encephalitis patients that is derived from bats (scary because of the number of bats living in the trees around the hospital). It also turns out the Teule is a big research site and has contributed data to a number of high profile multi-center studies published in elite journals. It is nice to see that they are so involved in collecting data for science and hopefully for the advancement of medicine in the area. The lab itself is fairly well-equipped with freezers, microscopes, liquid nitrogen, blood culture machines, and everything else you might need. It still does suffer from some of the negatives of life in Africa- such as intermittent power (with backup generator) and (today) ants walking in bacterial culture plates and then spreading potential cholera bacteria all over the bench top.

I am in Dar es Salaam right now waiting to fly home! Last night in Dar, I met up with the English couple who I met at Peponi and were here doing palliative care. We went to dinner at a fabulous Ethiopian restaurant- to get me in the mood to fly Ethiopian Air home!

As I have reached the close of my elective time here, the following is a list of favorites/least favorites from my time here…

Things I will miss:
-The people here- both Tanzanian and wazungu
-Chapati
-Fish curry and naan from Food Palace
-Tanga Tuesdays
-Living on the campus of my workplace
-Tiny bananas
-Living at the foothills of the mountains but also by the sea
-Banana fritters
-Greeting everyone you pass on the street
-Speaking Swahili
-Really cute kids
-Pace of life here
-Chickens and monkeys walking around the hospital
-Chickens everywhere!
-How colorful life is here
-Waking up in Africa every morning
-Learning the intricacies of tropical medicine in a resource-poor environment

Things I won’t miss:
-Heat and humidity
-Peanut butter and bananas at every meal
-No running water
-Living with rats
-Language barrier
-Using DEET and sleeping under a mosquito net
-Having to go shopping at a million specialized shops (ie- water guy, banana guy etc)
-Having to be so careful about what I eat/drink
-Feeling dirty all the time
-Bats
-Feeling isolated from the rest of the world
-Jokes in a different language at my expense
-The smell of burning garbage
-Intermittent electricity
-Feeling helpless with limited resources in the face of advanced disease, and watching patients die because of these limited resources

 Flying out in just a few hours... I still can’t believe how quickly the time has flown by. Thanks so much for following my experiences on the blog, and I can’t wait to see you all!

Weekend 3: Lushoto

This weekend, we decided to go to Lushoto, which is a town high up in the West Usambara Mountains. It was very nice to be at higher elevation where it was cooler- I actually felt cold for once in a very long while! While there, we did some long, pretty hikes through the mountains to see the Magamba Rainforest and to the Irente Viewpoint which overlooks the valley and plains below the Usambaras. From this high up, we were able to see very far into the horizon. We had lunch at a farm near the viewpoint, which makes fresh cheese, jams, and bread. It was delicious! That night, we went out to a pub that was recommended by our guide where we were by far the most popular people there. At first it was amusing, but quickly became annoying. Then, when we left to go back to the hotel, we found that the front door was locked up and so we had to scale the garden fence to get back to our rooms. The next day, we went on a hike to a waterfall, which reminded me a lot of Step Falls in Maine. It was a nice hike, followed by a local lunch at the infamous pub. We then caught the bus back to Muheza, and went out for chipsi-mayai.

Muheza: Week 3

I started out the week by going with a few nurses on the mobile clinic to do maternal-child health in the surrounding villages. This was one of the most interesting days I have had so far. We started at the early hour of about 9:30 by promptly stopping for breakfast before even leaving the town of Muheza. It is nice that people often go and have breakfast/tea together about an hour into their workdays here. We then traveled about 45 minutes on winding dirt tracks to very remote villages where mothers had gathered. There, we conducted baby weighing (took me right back to my days at the dispensary in Moshi- every mother brings their baby complete with homemade pants with harness attached to hang from the large hanging vegetable-style scale to be weighed). We weighed all the babies, then collected all the health records from the mothers to write in the new weight. I provided an endless source of amusement as I had to read the names of each baby and then listen to the mother tell me the new weight in Swahili. They definitely thought my pronunciations of names were hilarious. The mobile clinic returns to each village once a month, so we were also able to follow-up and administer vaccines.

 The most interesting part was the health education that the nurses then delivered to the gathered mothers. At the first village, we had probably over 100 mother-child pairs gathered for the events. The education ranged from family planning to STD prevention, to where to go for help regarding post-childbirth fistula formation (which is a big problem in the remote villages where mothers can’t get to larger healthcare centers when the delivery is not progressing in a timely fashion). The mothers were all very attentive and participatory in the education, and it also seemed to provide a bit of comic relief. Although I could not understand most of what was said in Swahili, the mothers at times would be rolling on the ground laughing- for once not at my expense. I was extremely impressed with the lead nurse, Harriet, who was very attentive to the needs of the mothers and tried her best to provide good standard of care to these women. We provided contraceptives- Depo shots, BCPs, and boxes of condoms. All of the services are free of charge as the Tanzanian government funds healthcare for children under 5, family planning, and antenatal services. Harriet told me that there is still so much need, and they have a hard time providing all the services necessary with such limited staffing. They provide HIV counseling, but currently do not have means to bring HIV testing out to the villages, which they are hoping to do in the future when they have more staff to do so. They also have difficulty with the remote villages because it is hard to maintain the vaccine cold chain (less than 4 hours should pass between when refrigerated vaccine is removed from the fridge to when it is administered). As we had to go to 2 villages today, way more than 4 hours passed, but Harriet said it was still better than nothing (probably true).  Overall, an extremely interesting day and I think I will go out with them a few more times in the future.

I have spent the rest of the week on OB/GYN. I am working with an English OB/GYN who has been living and working in Tanzania for the past 10 years, along with her husband and 3 sons. We spend the mornings rounding on the labor and delivery wards, as well as the gynecologic ward. This includes post-partum rounds, antenatal rounds, and checking in on the laboring mothers. The majority of births are done by the midwives, unless something goes wrong and a c-section becomes necessary. Interestingly, most doctors are qualified to perform c-section, so when one is necessary it is done by whoever is staffing the operating room at the time. There are a lot of women with eclampsia here who actually have surprisingly good outcomes (in contrast to what we learn in the US). The majority of women who have bad outcomes are due to sepsis/malaria post-partum. Interestingly, they presumptively treat all pregnant women for malaria in the third trimester due to poor outcomes with malaria in pregnancy.

On the gynecologic side, most patients are admitted for issues related to miscarriage or gynecologic cancer. After rounding, we go do ultrasound as needed, and then clinic. Clinic varies from antenatal clinic, HIV+ mothers clinic, and gynecologic clinic. Every day at 10am, she stops whatever she is doing to go and have coffee with her husband, who works in the microbiology lab. It is nice because these breaks have given me an opportunity to learn more about what it is like to come and live/work in Tanzania. There are definitely a lot of frustrations both with living in general here, as well as with working as a physician in the hospital. It is also a very big commitment and risk. Both of them have had to be on HIV post-exposure prophylaxis due to needle stick injuries at various times during their stay here.

 I have been learning a lot about HIV in pregnancy here. It turns out that they try to get everyone with CD4s less than 350 on antiretrovirals (not just when less than 100 like I was previously told). The women continue through pregnancy and also during breastfeeding (and then beyond as they wish). This last part is somewhat controversial since it is known that breastfeeding can pass the virus on to the baby, however formula is prohibitively expensive and given the other benefits of breastfeeding it is difficult to recommend otherwise in a place like Tanzania. There have been studies that suggest that when the mother has a high CD4 count and is on antiretrovirals, there is a greatly decreased chance of passing on the virus through breastfeeding. Conversely, if the mother has a mid-lower CD4, then it is more beneficial to have the baby on prophylaxis while breastfeeding. Either way, it is thought here that the benefits of breastfeeding outweigh the risk and so most mothers continue to do so. The HIV+ mothers clinic is a great place for the antenatal and postpartum mothers to come together to give each other support, and also to see the MD to discuss any problems. I was very impressed with how happy the women were to be at the clinic, and how proactive they were about their health and their now chronic infection. There seems to be much less stigma now than there was years ago when HIV was still an emerging disease. People are open to education and to discussing it, and although those that attend clinic and come to the hospital to deliver are a self-selecting group, even in the community it seems that stigma has decreased.

I also spent some time teaching some of the nursing students on the wards, they were very interested to hear my opinions on some diagnoses, and to learn more about certain conditions. It was very nice to speak with them.

This week, it was my turn to cook for “wazungu” dinner, which is a dinner with the English OB and her family, as well as the elective students (two very nice British med students arrived this week from Oxford). The dinner went off with only a few mishaps- including the power going out as soon as the water that I had been attempting to boil for 30 minutes was just reaching a boil, and just as I was starting to cook the pieces. But after locating a gas burner and a kerosene burner, and carrying the partially boiled water through the hospital using scrubs as oven mitts to continue cooking elsewhere, I managed to get everything underway without further issue.

This weekend we are going to Lushoto, which is a town in the Usambara Mountains, to do some hiking and relaxing at a higher (cooler) elevation. Can’t believe I only have a week left in Tanzania before it is back to reality!

Weekend 2: Peponi Beach Resort

I decided to go to a beach resort called Peponi about 30km south of Tanga for my weekend alone. I took a dala-dala to Tanga, and then hopped on another one towards the resort. The resort was nice and I had a private “banda,” a beach hut, complete with running hot water! I spent a lot of time on the beach/by the pool, as well as using the internet at the café next door. The owner is a Tanzanian-born mzungu of British descent, and it was interesting to talk with her about what it was like growing up as a white person here and I learned a lot about tumultuous points in Tanzania’s history that I wasn’t aware of. The local staff at the resort were also very impressed by the fact that I was living/working in Muheza- I definitely earned street cred for living in a more “local” area, rather than the more “cushy” areas that foreigners usually go to like Arusha and Moshi.

The next day, after a nice leisurely breakfast, I went out to the main road to catch a dala-dala which was an interesting experience. As I was waiting by the road, I was propositioned by a young man on bike who thought I needed a “black boyfriend.” Haha. At the same time, a donkey pulling a large cart of sticks that was walking along the road all by itself got the cart stuck on a rock right in front of me. The donkey then looked at me as if it expected me to do something about it, so I tried to remove the rock but couldn’t. So all three of us stood there (myself, the donkey, and my new “friend”) waiting for the dala-dala, which luckily came quite quickly. I had to sit on a sack of potatoes/uninsulated heat shield covered with a questionable pair of men’s boxer briefs, facing backwards for the hour long trip. Dala-dalas are always interesting experiences, and this one was probably one of the most hilarious because a guy got on carrying in his hand a small juvenile live chicken in a black plastic bag, with just its head sticking out. So there we were- 20 people and at least 1 chicken crammed into the back of the bus (I later realized there was another chicken on board- it was in a basket with its head sticking out but was much quieter than the one in the bag). Nevertheless, I made it to Tanga and got some shopping and internet done. It was interesting because it was the first time that I had been out on my own in Tanga, and I got a lot more attention as a “lone mzungu” than as one traveling in a pack. Everyone was very nice and friendly though. They definitely look out for the “mzungus” around town and on the buses, someone is always making sure that I get a seat when one becomes available and that I get off at the right stop, it is very nice.

On the dala-dala back to Muheza, I sat next to a nice old man who spoke decent English. He talked to me the entire trip, all the while holding the baby of the woman sitting next to him. He explained that when you see a mother with multiple children, it is nice to help her out with one of them. Can you imagine handing your baby daughter over to a strange man to hold on a crowded bus in the US? This is not the first time I have seen strangers get handed other people’s babies on the dala-dalas. It is nice how trusting and helpful people are to each other here.

I had dinner that night with an older English couple who I had met at the resort who turned out to be staying at the other hospital guest house in Muheza. They had done work previously in palliative care in Muheza and a nearby village (Korogwe), and were back to check on how things were going. They were very nice and when they found out I was all by myself for the weekend they invited me to their house for dinner. It was interesting to hear about their experiences with palliative care here, and with doing extended medical work in Tanzania. It turns out they are flying out the same day as me from Dar, and suggested a good place to stay the night there, so we might meet up again there. Overall, it was a good relaxing weekend. I’m looking forward to meeting the new students this week!

Muheza: Week 2

Made it back to Muheza on Monday evening after an equally confusing day of travel from Mombasa (at least we were expecting all the bus changes etc this time). This week has been a very interesting week at the hospital. I spent the majority of my time on the inpatient medicine wards, mostly on the female ward, but also on the men’s ward, and the “infectious” ward. I worked with a very nice female doctor, Dr. Hadija, and we saw a lot of advanced disease- peptic ulcers, TB, HIV/AIDS, heart failure, stroke… and also a questionable “rat bite.” The amount of HIV/AIDs here is astounding. In the Muheza area, the prevalence of HIV is quoted at 8% (ranges in various areas of Tanzania from 2%-15%), but in the wards at least the prevalence is much higher. Today, Dr. Hadija and I counted that 50% of the female patients were HIV positive and admitted either as a new diagnosis or for some complication of the disease. She thinks that the true prevalence in Muheza is higher than the published 8%. It is interesting and sad to see the full spectrum of the disease process here, from people who are fully healthy and just with the “sero-positive” label, to patients wasted and suffering from active tuberculosis, to those blind with CMV infection and with herpes zoster and Kaposi sarcoma covering their skin. Dr. Hadija commonly laments on rounds about this horrible disease afflicting so many people, she wonders where it has come from and what they can do. She told me that even she is afraid to get married because that too can bring the problem of HIV and really no one is safe. Once again, treatments are limited, with ARV therapy started when CD4 count drops below 100 or when patients begin to experience opportunistic infection. There are many patients admitted for IV antibiotics or antifungals. There is also a palliative care team here, and they usually take over when patients are in the end stages of the disease.

The “infectious ward” is interesting, because the idea behind it is to segregate any possibly contagious patient away from the rest of the patients. There is a barrier room that maybe is for segregating active TB patients, although for the most part they are just in the regular infectious ward or even the regular medical wards. No one wears barrier masks around the TB patients, and the wards are open anyways so it probably wouldn’t make a huge difference. Some of the doctors and nurses have unfortunately contracted TB in the past. Also, all the diarrhea patients are admitted to the infectious ward which is probably good, although not if they also contract TB in the process.

Although there isn’t much sit down didactics during the day or during rounds, I still feel like I am learning a lot about medicine that will serve me well in the future. I am definitely honing my ability to tell “sick” from “not sick” just at first glance, and also to begin to formulate a diagnosis based on observation alone. It is really interesting here that there is not very much in the way of physical exam of the patients (besides observing them and maybe listening to the chest). I had expected that there would be a lot more reliance on the physical exam here because there isn’t much in the way of diagnostic studies. I guess a lot of diagnoses are so common that history and observation is all that it takes for the most part. I think that they are much more crude diagnoses than they would be at home, but then again, there isn’t much that can be done in a lot of cases so sometimes honing the diagnosis is just not accurate or feasible. In addition, the doctors and nurses don’t have a lot of time to spend with each of the patients- there is one doctor and maybe 2 nurses per 40ish-bed ward, and sometimes doctors are caring for multiple wards at a time. This doesn’t leave a lot of time or brain-space to really get to know patients or to mull over diagnoses. As well, it is often the family members who are providing most of the care to the patients (feeding, changing, washing, keeping away the flies etc), while nurses are more present to administer medications and follow-up on test results. It is also the job of the nurses to inform patients of lab results (ie- HIV diagnosis). This is interesting because it is something that is so casually done and dealt with, with the doctor providing a very cursory role. Back in the US, the delivery of an HIV diagnosis would be something discussed and planned for by multiple members of the care team. It is just very interesting to see how medical care differs in response to different needs and resources.

I was also able to spend a few hours at “Kids Club” which is a playgroup for kids with HIV. They were normal, healthy-looking cute kids who got together to play with stuffed animals and on a swing set, and also to sing songs etc. They all seemed to enjoy it immensely. This group is also part of the palliative care department, which is expansive and very well run.

Kevin, Cordelie, and I went for a day to Tanga to visit the “Youth with Disabilities Community Programme” (YDCP). It was a super interesting visit. The program, whose motto is “all different, all equal,” provides assessment, outreach, medical/physical therapy services, and assist-devices to children with disabilities. Funding comes from the European Union and Fida International, as well as a church. We toured their facilities, and were able to watch the artisans in the wheelchair/prosthetics shop make custom prostheses and orthotics for their clients. They make everything there (including custom wheelchairs) with money and supplies donated by the Red Cross. There were even a few prosthesis students who had come from all over the world to study at KCMC in Moshi and do rotations at YDCP. We also met with some of their physical therapists and community outreach personnel, and spent a few hours going to villages to visit children in their homes. Most of the children we saw were suffering from cerebral palsy, with varying levels of functionality. The community outreach provider was so good with the children, and would work on some physical therapy movements with them. They also assessed for improvement and for the need for wheelchairs or orthotics. We were told that a lot of children were being raised by family members or neighbors because their mothers could not/did not want to care for them anymore. But, the children were really happy to see the YDCP people, and seemed to have a great relationship with them. Overall, the program seems to be very well run and well supplied, and we were extremely impressed by the facilities and the overall program.

Friday we had a going away party of sorts for Cordelie and Kevin, who are continuing on to safari/Kili climb, and of course the party was complete with local beer and chipsi-mayai. I have a weekend on my own, which I’m spending at a beach resort south of Tanga, and then am expecting two fresh new UK med students on Monday. I can’t believe that I already halfway done with the rotation, time definitely flies!

Weekend 1: Mombasa, Kenya

We were given a long weekend for Easter, and after having a going away party for our UK friends, Cordelie, Kevin, and I left on a bus to spend the weekend in Mombasa. This was a long an interesting journey composed of many confusing parts. We first had to take a dala-dala to Tanga to catch our bus (incidentally, this bus was the Lamborghini of buses here- very nice especially compared to my previous experiences with long-haul buses in Tanzania: no one standing in the aisles, and even an action movie (American Ninja- look it up, it’s amazing)). It took a couple hours to get to the border, where we had to get off the bus and wait in a very long and pushy queue to go through Tanzanian departure customs/immigration. After we exited the building, we looked around for our bus, which was nowhere to be found. After looking very confused, a border official took pity on us and explained that we had to walk across the no man’s land at the border to get on the bus on the Kenyan side. He also gave us the helpful advice to not talk to anyone in this area because there were a lot of touts trying to hassle us. We walked across and went through Kenyan immigration, got our visas, and once again could not find our bus. The bus people had been super nice the entire time and one of them stayed with us to make sure that the wazungu didn’t get lost. They explained that the bus had gone ahead and that we needed to get on another bus to catch up with it. We were very confused because all of our stuff was on the bus, but what could we do, so we got on another bus and rode that to the inspection point where our bus was going through Kenyan customs. Finally back on the correct bus, we spent another few hours driving through the rural areas to Mombasa.

It was interesting to see the differences between Kenya and Tanzania, even just across the border. The road was definitely worse in Kenya, and rural areas seemed poorer. The people speak better English though. There were a lot more people of Indian-descent in this area of the country as well. When we made it closer to Mombasa, the bus stopped again, and a lot of people got off. A nice man explained to us that you have to get off the bus and cross on a ferry to get to the island of Mombasa, and then get back on the bus on the other side. We were again unsure but they were insistent, so we got off, walked onto the ferry which also carried the cars/buses/etc across and rode it the short distance across the channel. Once on the other side, we caught up with our bus again and finally made it to our bus station. We took a tuk-tuk to our hotel, and then to the dinner place (we were warned by the hotel never to walk outside at night).

The next day, we went to Fort Jesus and Old Town Mombasa. We met up with a tour guide who showed us the historic Portugese fort used for protection of the port city in the 1500s. Old Town was also interesting and we got to see how people still live down the winding narrow streets even today. We had lunch at a local Indian-influence restaurant. Then we made the journey to Diani Beach (supposedly the nicest of the tourist beaches on the Mombasa coast). This journey was also long and complex- a tuk-tuk from hotel to ferry, ferry across the channel, matatu (Kenyan dala-dala) to Ukunda which is a small village near the beach, then second matatu to our hotel. Our hotel was at the very end of the beach, so we had to walk the final short distance. We got checked in at our hotel, then went to look at the beach. As our hotel was not directly on the water (and therefore really cheap), we sat at the fancy resort across the street that was on the beach. We had some ice cream and drinks, and then we went in their pool. Until we got kicked out of the pool because we hadn’t paid the pool fee, which was a misunderstanding because we thought we were told by the guard that if we had something to eat we could use it. Oops. We went back to our hotel and then to eat delicious prawn curry for dinner at the restaurant next door.

The following day we walked along the beach in the morning and found a breakfast place which served disappointing expensive tiny crab omelets. We sat at our table for a few hours in the shade and watched the beach/read. We then went to the local hang-out “Forty Thieves” where we sat some more, went in the ocean, and had really good lamb burgers for lunch. We finally made our way back to our hotel and went back to the fancy resort across the street for their Saturday night “Easter BBQ” which was a freshly barbequed buffet of deliciousness, including all kinds of amazing salads, bread, and BBQ chicken, steak, huge prawns, calamari, fish, and sausage. We ate a ridiculous amount, and it was surprisingly cheap even being at the big fancy resort. We didn’t use the pool. If I ever come back to Mombasa I am seriously staying at this place, it was amazing. Although I think we got the best of both worlds by paying for a cheap room across the street and then enjoying their beach front and amazing restaurant. In summary, this day consisted entirely of eating and sitting.

This morning, we went for “Easter Breakfast” at the resort which was way better than our previous breakfast spot and also included a ridiculous amount of food. We then sank into a lethargic stupor when the heat of the day combined with all the food we ate. We wanted to go out on a dhow sailing boat to go snorkeling at the reef, but we weren’t sure how to arrange this. We decided to go leave our bags at our hotel and then walk along the beach and try to find someone to take us out. Amazingly, as we were leaving the resort a guy on a bike stopped and asked us if we were staying at “Tropical Oasis” (we were), and then told us that the manager there had asked him to arrange us a dhow snorkeling trip and he would be ready to go in 15 minutes. This was an amazing coincidence because we had been talking to the manager about it but figured nothing would come of it. So we dropped our bags and double checked that this was someone the manager knew, then we sailed to the reef! The dhows are small wooden boats carved out of one piece of wood, with an outrigger for stability on either side. There is one sail. We sailed out to the reef at low tide and then actually walked along the top of the reef (although not good for coral) and then sort of walk-snorkeled in a shallow cove. We saw a lot of colorful fish, starfish, sea-urchins, and even an octopus. The tide came in fast though, so we hopped back on the boat and headed back to shore. Feeling proud that we managed to drag ourselves out of our stupor and actually do something, we then got cleaned up and went back to Forty Thieves for lunch. I think you are sensing a theme here. We then made the trek back to Mombasa city, where we ate Kenyan BBQ and we will spend the night and then tomorrow morning take the long bus-ride back to our home.

It was a great, relaxing weekend, and it was nice to see a part of a new country that I have always been curious about! I’m definitely looking forward to being back to our Tanzanian home and to all that I will see and do in the hospital next week. Talk to you soon!

Muheza: Week 1

The month of April I am completing a medical elective at Hospitali Teule in Muheza, Tanzania. Muheza is in the northeast part of Tanzania, an hour inland from Tanga (a large costal city). Last Sunday, I was dropped off at the bus station by my friend Ibrah, the B&B owner, and Joe. They put me on the bus and waved goodbye, then were gone. I was the only mzungu (white person) on the bus. The bus ride itself was an experience- we would stop at every little town along the way to pick up more and more people, who crowded into the aisles and stood the entire length of the journey as all the seats had long been taken. At each stop, there would be vendors with cardboard boxes stuffed full of water bottles, snacks etc, and ladies with buckets full of tomatoes on their heads that people would purchase through the windows of the bus. A few hours into the journey, we heard a loud banging noise and the bus broke down. We pulled over to the side of the road and the driver and other bus personnel spent the next hot and sweaty hour fixing it. We finally got back on the road only to stop a little while later at a rest stop for food/bathroom break. I didn’t know how long we had to be off the bus, nor really what was going on, so I stayed put. We finally made it to Muheza after a 7 hour trip (complete with a police raid towards the end). I found my way to the hospital and checked in.

The hospital grounds are very pretty with lots of tall trees surrounding the main hospital buildings. The only problem is the trees are literally covered in 1000’s of fruit bats that you can see and hear hanging from every possible niche in the trees. At night they all fly away, somewhere. The student hostel is on the hospital property and is a very basic but homey set up with 6 individual rooms, a lounge, a kitchen (with its own live-in rat), and some toilets and shower areas. There is no running water, but every day some women come and fill up a lot of buckets of water so we have all mastered the art of bucket/sponge showering. Sometimes you even get a frog in your bucket. It is rustic but quickly became home. It also reminds me somewhat of the cabin in Maine. I am sharing quarters with 2 of my medical school classmates, Cordelie and Kevin, and then last week there were also 2 medical students from the UK (Matt and Alex) who were finishing up their elective. Everyone oriented me to the hostel/hospital/town the first day, and we cooked together.

The next morning, we all went to the morning meeting that is basically a meeting of all doctors, head nurses, and clinical officers (mid-level providers) to go over the hospital census and morbidity & mortality cases. The hospital (run by an Anglican diocese) has a census of 150-200 patients, including adult medicine wards, pediatric wards, OB/GYN ward, and surgical wards. There is a large outpatient center where patients will go for routine outpatient visits and also go to be admitted to the hospital (a crude ED). There is also a palliative care department and center. That day, I went to the pediatric ward rounds. There are 2 pediatric wards at Teule, both full of patients (at least one patient per bed, sometimes up to three sharing along with their mothers). The majority of cases are admitted for a combo diagnosis of “malaria and bacteremia.” Basically, any child with a fever is treated as a malaria case and completes a course of antimalarials even if the blood smear is negative for malaria parasites. When the rounding doctor asked me for my opinion on a child who was presenting with fever, cough, and runny nose with the warning to “remember that common things are common,” to which I replied that it could be a viral upper respiratory infection of some kind, I was quickly corrected that it is most likely malaria. I'm not quite sure about all the diagnoses of bacteremia (there aren’t any diagnostic studies to speak of and definitely no blood cultures), but the majority of the kids get a course of ampicillin/gentamicin as the standard drugs of choice (likely because of cost and availability). Let’s just hope that gent isn’t as damaging to hearing and kidneys in children as we learn in medical school. There are also many seizure cases, cases of umbilical sepsis, and a lot of malnutrition. The most entertaining patients that day had been admitted overnight after having consumed some of their uncle’s local drink of choice, and they were still quite inebriated. Ward rounds are interesting because instead of going bed to bed, the doctor and nurse sit at a table in the middle of the room and each caretaker brings their child/child’s chart up to the table to be reviewed for the day. Luckily, there are no HIPAA laws here because there is no privacy and sometimes the doctors and nurses comment on or chastise the mothers to the rest of the ward. However, all the caretakers and patients are very respectful of the doctor. There aren’t many questions asked.

That evening, we went to town and I learned where all the important spots in town are- the water guy who sells us 6L cartons of water, the banana guy, the bread guy, and where you can find chipsi-mayai (the local street/pub food- basically an omlette with french fries mixed in). The empty 6L bottles of water have come in quite handy around the student hostel, and had been used for making drip showers, buckets, and all other sorts of containers.

The following day was also spent on pediatric wards. I saw two really sick kids, one with severe anemia from malaria and another suffering from epileptic seizures. We ordered a blood transfusion and anti-epileptics. The capacity to diagnose and treat in the hospital includes: xray, hemoglobin level, blood smear for malaria parasite, and HIV test (usually first given to the mother in pediatrics if status is unknown); pediatric treatments include limited antibiotics, antiepileptics, and antimalarials, as well as medications for routine conditions such as asthma etc, IV lactated ringers (a saline solution) and oral rehydration solution.

That night, we took the most full dala-dala (local minibus) I have ever been on the 1 hour drive to Tanga. There were at least 20 people crammed in the back, sitting and standing, as well as 2 babies, some large bags of cement, and cartons of food, and a giant branch of bananas. It was interesting, at least there were no animals on board as well. The students have instituted “Tanga Tuesdays” whereby we go to Tanga every Tuesday and go to one of the small resorts there to use their pool, poolside showers, and internet, and also have a good meal. It was glorious.

The next few days were again spent on pediatric wards, and also in pediatric clinic. I enjoyed peds clinic as I was given a lot of responsibility and saw half of the patient load myself. It was interesting trying to communicate with the mothers in my limited swahili, but a lot of the medical phrases I learned in Moshi a few years ago are proving to be very useful and I am learning more. A lot were return visits for a check up post-hospital stay or for medicine refills, but I even admitted one child who still wasn’t doing well at home after hospital discharge. Sadly, I also learned that the two really sick kids who I had seen the previous day had died before receiving their treatments. The treatments likely would not have saved them, although those deaths would have been completely preventable in a US hospital with a full range of resources.

Overall, it was a busy and eye opening week. I am still getting a feel for the hospital and for our roll as students here, but I am already learning a lot about the challenges of medicine in a tropical, underdeveloped country, even at a fairly well set-up hospital like Teule. I am really looking forward to rotating through the other wards in the coming weeks, as well as doing some outpatient and community health activities. I’ll keep you posted!