Week one in Tanzania...a running tab of our experiences and thoughts

April 20, 2008
Day one of the caravan: orientation

The center is beautiful… even more beautiful than I expected. We spent the day getting to know each other and preparing to care for an unknown number of women the next day. I had no idea whether anyone would show up, or whether we would have a mob scene. Mama Agnes predicted that people would send the brave friends the first day.
We set up tents, prepare the examination rooms, organized our thoughts and supplies and generally had a wonderful day. Several people came to speak to us from various organizations around town. Mama Minde was of course there and is as regal as I remembered her. There were also women from social welfare and an organization translated as “women against AIDS”. They described what the community is doing to help the status of women and I marveled at their perseverance and effectiveness. At this point they are paying for school fees for hundreds of children and checking on them with home visits… all with money that they raise from local donors and fundraising. It is wonderful to feel part of this network of like-minded people who are here just to help a common cause and to collaborate.
I got to see our resident at the shelter, whose story I had been following from afar. She is an HIV positive woman with no home, who came to us pregnant and with a 14 month old who was very malnourished. Agnes and Vicky (our wonderful volunteer from Scandinavia) had been working with the child to increase his nutritional status. The day we arrived in Kilema, Agnes had been awake all night with the woman, who delivered her baby at 730 am.
Sid had a magical day. She met and immediately became inseparable from Ava, Chris Fraser's 10-year-old daughter. They seem very similar in personality and interests. This instant bond may have contributed to Adam’s difficult introduction to the other children. He slept in till two and within half an hour of me picking him up and bringing him to the center, he had a very uncharacteristic outbreak. Although my instant fear was that this was a reaction to mefloquine, I think it was more of an adjustment/fatigue issue and perhaps feeling that he had parachuted into a social network where his only ally (Sid) was very much preoccupied. Thankfully everything settled down and we went with Bistra, her kids and Fraser's kids to the YMCA for a swim. It was a lovely late afternoon. We then went back to the hotel and had yet another three hour dinner, and went to bed with dreams of first day of caravan in my head.

April 21: The first patient day.

Although some people were disheartened at seeing one lone woman waiting for us, I actually was relieved that the first few hours of women trickling in afforded us time to get our stride. Deep down I knew they would come. And they did it. As Mama Agnes had predicted the brave ones came, it seemed like quite a middle-class group that first day. I was working in a delightful room with two nurses and two stellar translators. Marietta has a lot of experience with the caravans and was Karen's translator last year. She was able to impart a lot of knowledge to us. My translator, Elizabeth is a gem. I instantly connected with her and thoroughly enjoyed the day. She really just gets it!! She understood my questions and she was able to effectively explain what the patients were talking about. We got in a real groove quite quickly and were able to convince many people who had initially rejected the idea of an HIV test, to be tested. We developed “the spiel” which involved reminding people that it is much better to know if you're positive because of the incredibly positive effect that being on medication and being closely followed can have on one's health. It is always such a pleasure to work with a translator who has the language skills to be able to convey the key points.
Near the end of the day, I went to “karibu” the next patient and there was Vicki with the baby from upstairs in her arms. He looked near death. He was lying in her arms with his eyes open and rolled back in his head. We were unable to wake him up. Although he did not have a temperature at the time, Vicki said that he had had one during the day. The way he looked was a huge change from what I had seen the day before and I was extremely worried until Karen came in and confirmed that she had seen the child just an hour before and that he had been interactive, playful and eating. As it turns out he was just in the very deep sleep, exhausted from the date of going to the hospital with his mother for a check-up and to the social welfare office to speak with the community social workers. As it turns out, after much discussion between the social workers and the mother, she has decided that for good the good of all three of them, that she should put the new baby in an orphanage to be cared for by professionals so that she can concentrate on her own health as well as that of the 14-month-old. This decision initially shocked me, and seemed extremely harsh. However knowing the circumstances of the mother and the fact that a child with whom she came to the shelter was so severely malnourished and that their bonding have been severely impaired, it is probably the right decision. It seems that even over the last few days there's been a huge increase in the amount of bonding between a mother and child.
Once the last of 178 patients were seen, we returned to The Leopard, showered off the dirt of the day, and had another three hour dinner. There's certainly no such thing as rushing in Tanzania!! It takes at least half an hour to be allowed to order, and then you wait for, at the bare minimum, an hour to see the first spot of food arrive at the table. It was, however, a lovely dinner and then we got the kids to bed. Both kids slept with me because the night before Sid had had very vivid dreams that had kept Jess awake. Sid, of course, remembered nothing and said that she had had a great sleep…I kidded with Jess that it was actually her that had had the problems! Either way, Jess was exhausted and needed to sleep on her own. The vivid dreams of course furthered my concern about a mefloquine reaction in the kids, but I decided to take a chance and give them their next dose anyway since they were due. In discussion with Chris Fraser, we decided that the chances of being reaction were slim since it was the last night of the weekly cycle rather than near the beginning. It was most likely just fatigue and different surroundings at work.

April 22: Re-Group Day.

Tuesday had been planned as the regrouping day. We were able to sleep in a little bit and then went to the center to restock rooms, debrief and work on our health information sheets. It was a wonderful day. The mazungu wife of an Anglican priest in town came to speak about the part that the churches in the community were playing in the fight against HIV-AIDS. Unfortunately I missed most of first talk since it was right around then that Jess and I went back to the hotel to get our computers so that we would have them for people to work on the health-info sheets. I hear the talk was very refreshing.
When we returned people spent time with translators translating the information sheets and several people actually tried to type the Swahili version of their info sheets onto computers. I printed a couple of them up and Marietta and Agnes had a great laugh at the spelling mistakes. Clearly someone who speaks Kiswahili is going to have to correct on the computer.
I haven’t yet mentioned the other resident of the center. She was dropped off yesterday by social services because she was found living on the street and had a very sad story. I’m not sure how much of it is true. All we know is that she has significant mental difficiaentcies whether psychiatric or HIV-related, and is not a good candidate for our center. She is very disruptive and today she stole Sid’s bracelet and would not give it back until Adam took Agnes to get it. We will work on finding alternate plans for her!!

We called it a day quite early and planned for dinner. I invited Penina and Elizabeth to come as my guests. We went back to the hotel, showered and went to find a grocery store to find wine, Konyagi (papaya gin) and most importantly some form of non-wheat-based breakfast food. The booze was easy to find...non-wheat carbs… not so much.
We then met up with n the group and went to the Kinderoka roof-top garden restaurant for dinner. We had hoped to have a nice view of the mountain but it was too cloudy. Dinner was absolutely lovely, though. I had a thrilling time learning how to use my new phone with Elizabeth and Peninnah… I am now “so Tanzanian” with my cell phone! The kids had a chance to call Chris and I spoke to him for a few minutes as well. I really wish he were here. Jess, the kids and I left a little bit before Karen and the rest of the group so that we could get the kids to bed. Unfortunately, neither one of us had really paid attention to how he got there in the first place!! As we walked along the road, the lights became dimmer and dimmer, the activity became scarcer and our heart rates became faster. Just as I was feeling quite uncomfortable, Sid said “I don't like his mom”!! She also said that she thought that we were supposed to have turned right about five blocks before. We turned around, walked back the five blocks, and sure enough she was right… the hotel was just half a block down a side road. I've never really been one for directions!!!

April 23: Second day of seeing patients.

Well I guess we did okay on the first day, because the “brave friends” sure sent others, en masse! We actually closed the gates at 10 o'clock and still ended up seeing 378 patients. There are patients everywhere. We were seeing them inside, outside, under tents… wherever we could. Please see Karen’s blog for the full caravan report and the description of some of the heartbreakers of the day, but I think the patient that I saw personally that will stick in my mind was a Muslim man who came with his 10 year-old daughter. She was quite well (I think she was the decoy to get into the “women-only” caravan), but when I got to him, his triage note mentioned (among MANY complaints…again decoy!) that he had painful urination. I asked if the daughter should step outside and he laughed at my comprehension of the situation. After she was out, I confirmed that he had all the symptoms of an STI, told him that I was thrilled that he had been so responsible as to come to seek help, and then asked how many partners we should treat (we give antibiotics for the partners as well, even if they are not there). He laughed and said “one only”…I tried again and he stuck to the story…this went on for a longtime, with lots of laughter and joking. Finally, I told him that I would write on the form for our pharmacist that she should offer him meds for 2 or three partner “just in case he changed his mind”. She later told me that he accepted! It was a really funny interaction. Luckily, his HIV test was negative.
The kids spent most of the day helping in pharmacy…delivering meds to the interpreter and giving out toothbrushes and mosquito nets. It was so rewarding to see them at work each time I came downstairs for something (my station was on the upstairs balcony…under a tent but I still got roasted!!).
Around 5:30, we still had many patients to see, but Elizabeth developed a sudden headache, so we took a little break, got her some ibuprofen and water and talked a bit about her health. She had been having some pain that sounded like Peptic Ulcer Disease, which is extremely common here, so I got her the meds for Triple Therapy. I must say that her sudden headache gave me, the Emerg Doc, the inkling of “sudden worst headache of your life” which is classic for an aneurysm, but she improved so quickly that I chocked the whole thing up to dehydration and a VERY long hard day.
The kids and I left around 6:20 when there were only 5 gyne patients left to see. They had had a log day and were still acting like angels, so I wanted to quite while we were ahead!!
We went back to the hotel, showered and changed and went the hotel restaurant to eat and await the rest of the group. Jess had been in bed all day feeling under the weather, so we also were trying to get some rice for her. When the group arrived a few minutes later, I had a huge shock. Christa and Jess, who were at the next table, started to tell me about something that had happened to Elizabeth after I had left. They, of course, did not want to yell and so mouthed the words…clearly my lip reading is not up to par, because I thought that they had said “she passed away”, which sent me into a tail spin of sorrow and guilt (thinking that the headache had in fact been a subarachnoid). Five seconds (which felt like 5 hours) later, I realized that they had said that she was “positive”. Apparently, as the day wound down, she asked Christa to test her, and much to her horror, she had to tell Eliz that she was positive. My immediate reaction was to call her, but Adam then developed sudden severe abdo pain and I had to get him to bed, check on Jess, arrange for Val to be picked up at the hospital where she had been admitted for the day (she developed a gastro and got so dehydrated that she could not walk, so we sent her directly from the center to KCMC with Vicki)…etc. It was 11 before I was able to text her…she was understandably in complete shock but said that she would come to the caravan the next day and we would talk.
All-in-all an eventful, somewhat difficult day.

April 24th: Himo

Adam settled well and slept like a babe. We were three to a bed for the third night in a row, because I did not want either of the kids to sleep with Jess because she was feeling so sick. I wanted her to be able to get a good nights sleep and of course I didn't want the kids exposed to her in case what she had was contagious. In the morning I tried to wake Adam up just to check to make sure that his abdo pain had subsided. I think he was having some vivid African dreams because when I asked him how he was, he said that someone had just hit him in the penis with a hockey stick. Seconds later he said that he felt fine. I told him that it was most likely dreaming as there are very few hockey sticks in Africa!!

With much hesitation, I left with the group for Himo leaving a sick Jessica in charge of the kids. The plan was that Otto would pick them up at 230 and bring them to Himo and then we all drive up to Kilema together with Bistra and Chris.
We had some difficulty with crowd control, because within one hour of us arriving, there were already more people than we knew that we would be able to see that day and a few of them ended up waiting and not being seen. Thankfully that was large minority.

I must say that it was a bit of a difficult day for me. There are many patients to see, but I was somewhat preoccupied by the fact that Elizabeth, understandably, did not feel up to translating that day. She went outside for most of the morning, presumably just to find the strength to spend the rest of the day involved in the caravan. Not having a translator made things a little bit difficult for me, but I managed until at 1130, I received a phone call from Jessica stating that she was unable to get out of bed and was having excruciating belly pain. I spoke to her every half hour from then on making sure that things were not getting any worse. In the end, she was able to settle the pain and nausea down long enough to get into Otto’s car and drive up to Himo.

It was good to see them once they arrived. The kids just jumped in and started helping in pharmacy, and they also made some friends their age in the village.

Once the last patient was seen, Chris, Bistra, Jess, the kids and I piled into the CACHA vehicle and made the trek to beautiful Kilema.

Ah Kilema!!

Kilema is as idyllic as I remember… perhaps even more so now because the rainy season has brought with it an un-comparable lushness. The colors are unbelievable! The rivers and waterfalls are more active than you can imagine!! I must mention that in addition to the natural beauty that the rains have brought, they've also made the roads that I thought could not get any worse, into disasters zones. The craters are as deep as the wheels themselves in some spots. As we arrived in Kilema we were welcomed by a surprise attack of rain. Now THAT was the kind of rain could be described in books. It came out of nowhere and completely drenched us!! We had a wonderful dinner supplied by Ameliana and then turn in for an early night in the Valley House where Chris and I had stayed last year on the caravan. The shower water was brown due to the rain and the power was on and off, but it felt kind of like a homecoming.

First Day in Kilema

After breakfast, I took the kids over to the Fraser’s house and got them set up to do schoolwork. It was their one and only chance to prove that they would be able to do the morning school session with the Frasers. The Fraser kids have got it down to a tee. The three of them sit at their desks and complete their work without any problems or noise. I helped Adam do some math homework and then left he and Sid working away while I went to meet Chris in the HIV clinic. Friday is CD4 morning so the clinic was hopping, which of course thrilled me. It's amazing to me how much I have forgotten about HIV medicine, considering I had such an interest in medical school. In med school I did two extensive presentations on the subject, one about the interaction with TB (which was a very new topic at the time) and one about breast-feeding in HIV-positive women. I also did some work with the doctors Ford in the HIV clinic and did my second year research project in the Ivory Coast on AIDS Education. Despite all of that, I feel like I don't remember much at all. I guess another reason for this, is the fact that we rarely see HIV-positive people in the emergency department in Kingston because the HIV clinic takes such wonderful care of them and they rarely end up in emergency. In any case, the three hours that I spent with Chris in clinic showed me that the next couple of weeks will be an incredibly enriching experience for me.
I knew that Bistra’s brainwashing about allowing children to run free in Kilema was doing some good when I realized that three hours had passed and I have not actually visualized my children!! When we met for lunch, the kids told me about all the playing that they have done. About half an hour later though, when asked where the other kids were, Sacha informed me that they had gone off to another village. That was a little freaky, I must say! He went to get them at my request and when they came back they just told me that they've gone to look at the tractor-trailer that had fallen into the ravine a couple of days before. I was pleased to hear that Adam and Lockie had not followed some of the older children as they climbed into the truck as it teetered on the edge of the cliff!!

I spent the afternoon rounding on a few patients with Julius. One of them was a 20-year-old woman that we had sent from Himo the day before. She was HIV negative, but extremely sick and we are still not sure what's going on with her. Her respiratory rate was 80 in Himo and was still similar to that when we saw her in the hospital. Her chest x-ray was very patchy, and Chris and I had a discussion as to whether it might be miliary TB or failure due to perhaps a cardiomyopathy. We’re treating her for the latter and we'll see how she improves clinically. Another young men who has been admitted to the hospital for several weeks with type 1 diabetes, was complaining of four days of abdominal pain and bloating. He’s tender both in the upper and lower right quadrants and his sugar has been going out of wack even more than usual. It was clear to me that he needed both an ultrasound and liver function tests. Unfortunately, the ultrasound machine is kept locked up in Dr. Masawi's office and he was away. We went to the lab to see if they could do liver function tests, and they said that the machine was broken. So this poor man, with a differential diagnosis which includes serious things such as ascending cholangitis and appendicitis, would have to wait until after the weekend to get any investigations. I will try to remember this situation whenever I get frustrated at how long tests are taking to come back in the emergency department at home!

While Stephanie, Bistra, Jess and I were having happy hour on the porch of Valley House, the little boys, Adam included, appeared from the jungle valley below. They said that they'd just been down at the Kisilani school having long and high jumping contests with each other… it's pretty amazing to think that I can allow my six year old to go off with a five-year-old and an eight-year-old to another village and feel that they are safe, but the two families that have been in Kilema all year truly feel that everyone knows the Masungu kids and treat them like their own children keeping them safe wherever they go.

We had dinner and then the kids have a movie night while the parents continued happy hour. When it was getting close to bedtime, we got an interesting call from Ivan who had spent the day doing the caravan with the people in Moshi. They arrived in the morning to find approximately a thousand people waiting to be seen. Around 11 a.m. immigration showed up and put the whole operation to a stop. They kicked all the patients out of the grounds, and confiscated all of the Canadian passports. They tried to tell the group that they did not have the proper visas (despite the fact that we had volunteer visas that were issued by the Tanzanian consulate in Ottawa) and then took Karen and Dharma to their office and harassed them for the rest of the afternoon. In the meantime they had locked the whole group into the grounds of the center and told them not to leave. It is clear to me that all they wanted was a bribe; however they also informed Karen that we should have an independent facility license if we want to provide medical care outside of the hospital. Luckily Karen was able to reach the people at KWIECO who came and dealt with the situation behind closed doors (and presumably with a substantial amount of Tanzanian shillings!). The interesting thing is that the person who reported us is an optometrist in town, who came to the clinic, met Karen, pretended to be interested and caring, and to then went to see authorities claiming that we had injured a child's eye!!! The child in question had a corneal ulcer and was referred to ophthalmology because we realized that he needed to be seen immediately by an ophthalmologist. Reliable sources have told us that this particular woman makes an awful lot of money by selling glasses, and that she was presumably concerned by the fact that we were giving out free glasses to people in need. Some of our mutual acquaintances have some more choice words to say about her, but I choose not to write these in this public forum… ask me about it anytime!!
We, at Kilema, had some interesting conversation about the whole situation, and in particular we discussed what Mama Minde will do about it. The most graphic description of what we think she might do, involved her taking to the streets with 6000 women and speaking to the media about how immigration was trying to hinder women from getting free medical care. Chris also told me about an incident two months ago when immigration came up to Kilema and harassed two of the Canadians there. They tried to take their passports away, but thankfully Andrew knew that they had no right to do so and gave them to sister Matron to safeguard.
My main concern is that with these two inexcusable incidences against CACHA members have had with immigration in the past two months, but something must be done to avoid it them feeling that we are a good and constant source of pocket money for them. I will raise my concerns with Mama Minde and Karen is going to talk to the Canadian High Commission when she's in Dar on Friday. Their treatment of us is unacceptable and needs to be stopped so that we can continue our work at the center and so that I can feel that we can safely send our learners to this wonderful place.
After an interesting conversation about the events of the day, we all went to bed happy, tired and at peace.

Saturday in Kilema

Sid had had a sleepover at Ava’s so it was Adam who woke up in bed with me. We didn't really get out of bed until close to 10. It was a lovely, relaxing morning. While we were cuddling in bed, and I was telling Adam that we were going to go to the Kilimanjaro Mountain resort to swim and watch a soccer game, Adam asked who was going. I replied “everyone”. When I was questioned on who “everyone” was, I said “the three Muzungu families”. When he looked confused at the word Muzungu, I explained that Muzungu meant white people… he then said “but we’re not white, we’re kind of like peach”. Classic Adam comment!!

Chris took the opportunity for a run, but the rest of us walked to the dala dala stand and then I had my first experience on a dala dala. It wasn't quite as crowded as I expected… only four people did not have seats in the van and no one was hanging out of the windows. The Mountain Resort was beautiful. We relaxed with a glass of wine and watched the Manchester-Chelsea game. The kids played soccer and marveled at the huge tortoise in the garden of the hotel. The kids and some of the adults took a taxi home as Bistra, Dharma, Jess, Rainer, Karen and walked back in the phenomenal jungle.

Dinner and another movie/happy hour evening and we were all ready for bed.