Wednesday, November 15, 2006


Africa's devastating challenge: HIV/AIDS and extreme poverty
Sunday, August 6, 2006


I have never seen this patient before, yet she is like many others. She lies on a hospital bed in Dar es Salaam, Tanzania's capital, clinging to life by a thread. But even that will soon be taken from her. By the time we see her on our medical rounds, there is very little we can do. Her death this morning, like that of so many others, will be caused by a combination of two treatable diseases.

We come upon her in the far corner of the medical ward halfway through our morning rounds. Immediately, I am stunned at the general presentation of Mrs. S. She holds a blank stare out an open window. Her eyes are shifted back in their sockets. Her breathing is rapid but regular. Her pulse is also rapid, and her heart is not beating in a normal rhythm.

I recently completed my training in the core areas of clinical medicine at the best medical school in the country for teaching clinical medicine. I generally felt competent and capable to approach patients as medically complex as this one. The key is being systematic, but a systematic approach relies on having available resources. However sound my U.S. medical training, I've repeatedly felt unprepared to handle the difficult situations that arise when resources aren't available.

We have few precious minutes with this patient. Since there is no supervising physician, I tell the intern that we need to "call a code." This should set off a flurry of activity, such as supplying oxygen, preparing cardiovascular medications and obtaining a defibrillator in case we need to shock her heart. Two people should be ready to start CPR. However, we're in Africa, and, here, there are no codes.

Immediately, we need to give her some oxygen and intravenous fluids. While every second counts, the resident, intern and nurses are not prepared to act quickly. The nurse eventually wheels over the one tall, rusty oxygen tank that resides on this ward of 42 beds. A glass bottle with "sterile" water hangs from the tank by a rope and has a long rubber tube for the outflow of oxygen. After looking more closely, I realize that this particular piece of rubber tubing is normally used to suction out stomach contents. Further, it's been used for another patient. What Mrs. S. needs is a high flow of oxygen through a full mask, not a thin tube clogged with another patient's dried phlegm.

Her respirations are now becoming slow and shallow. Ideally, we should put a tube down into her lungs to connect her to a ventilator and take control of her breathing. It's already clear that none of these resources are available. Her breathing is rhythmic, and gradually becomes more delayed with each breath. Her eyes are fixed and dilated. I feel the irregular pulse in her neck, as she remains motionless on the bed.

Mrs. S. is a 31-year-old woman who is known to be HIV-positive. She has been married for seven years, but has no children. She was admitted to the hospital four days ago after she had been suffering from a week of diarrhea and vomiting. Since she was admitted, she has received one unit of blood. Nothing else has been done for her.

She should already have an intravenous line in her arm, so we can quickly give her fluids, but she doesn't. A nurse spends our remaining time trying to insert a catheter into a vein in her arm. The one portable heart monitor for the entire medical block is not on our floor.

Our activity is becoming futile. Her pulse continually weakens. Her breathing gradually becomes more delayed. I hold her wrist with one hand and feel for the pulse in her neck with the other. She is now getting some oxygen through the small tube, and the nurse is still trying to put in the intravenous line. She hasn't been given any heart-stimulating medications. As I watch her life slip away, I realize there is little reason to take this any further. We don't have the resources, and without them there is nothing we can do.

Although nothing is said, the resident stops giving her oxygen, the intern stops preparing an injection and the nurse stops inserting the intravenous line. She has no family around, and this is no way to die. I hold on to her wrist as she finally stops breathing. I watch, feeling helpless. I feel for the pulse in her neck, but it's not there. "She's died," I whisper.

After a few moments, the group of seven white coats moves on to the next patient. I stay behind to look over her chart. Her CD4 T-cell count is 17, which is extremely low (a T-cell count under 200 is low), and she had not been receiving HIV medications. Mrs. S. died because she had too few immune cells to fight off any infections. Mrs. S. also died because she was poor and didn't have access to HIV care and medications.

One might think that this story occurred in a remote rural clinic, but Mrs. S. died in one of Africa's national hospitals. Tanzania, where half the population lives on less than $1 per day, is one of the poorest developing countries in the world.

HIV/AIDS is having a tremendous and debilitating impact on the region. Almost 10 percent of adults are HIV-positive, and women are infected more than men. Further, over the course of the HIV epidemic, life expectancy has been decreasing. The child that I helped deliver a couple weeks ago is expected to live only 45 years, which is five years less than what it would have been 30 years ago.

By comparison, life expectancy in the U.S. has increased by six years over the past 30 years, and is now 77 years and growing steadily.

The national hospital deals directly with the intersection of HIV/AIDS and poverty. About half of the patients admitted to the medicine ward are infected with HIV. Most have never been tested for HIV and don't know their serostatus. Furthermore, since those with money choose private hospitals, all of these patients are extremely poor. These patients tend to seek medical attention late in the disease process, and many, like Mrs. S., have advanced HIV-related diseases by the time they arrive at the hospital.

Part of the medical problem lies in financing the health care system. The total annual expenditure on health is less than $20 per person and is about 400 times less than the annual health expenditures for an average American. Often, the problem lies with a patient's inability to pay a simple fee, which is a major determinant of whether we can validate a suspected diagnosis. Occasionally, the necessary testing materials may not be available. When the lab runs out of HIV tests, we rely on seeing a characteristic fungus growing in the back of the mouth, an almost sure sign of HIV in this setting.

Over the last 10 months, I've witnessed many mismanaged medical cases. It has been frustrating and difficult, and it has shaken my spirit. Most doctors here do want the best treatment for their patients, and they do what they can. On our medical rounds, instead of talking about what we would like to do for a patient, we typically end up discussing what we can do for a patient. But still, it is often not enough.

The need for addressing HIV care and extreme poverty in Africa is dire. Currently, more than 25 million Africans are living with HIV and about 6,200 die from HIV/AIDS every day. The disappearance of young parents and adults has left behind 12 million orphaned children and a depleted work force to support the battered economies. As of two years ago, few Africans had any access to life-saving HIV medications.

HIV medications are now being made available to HIV-infected Africans, and there is good reason for optimism. HIV care and treatment programs, which provide free counseling, testing, medical care and HIV medications, have now been established in several African countries. These programs have been lauded as a great success, and with good reason.

A major obstacle in scaling up their coverage is a very limited supply of health care providers. In this region there is one doctor for every 33,000 patients, while the U.S. and most developed countries have one doctor for every 500 people. Since the average doctor earns only $400 per month, many doctors leave in search of better wages. Given that they can make much larger salaries abroad, it is difficult to blame the physicians themselves.

The death of Mrs. S. was caused by two major diseases: HIV/AIDS and extreme poverty. Her death is far from being an isolated incident. The synergistic impact of HIV/AIDS and extreme poverty arises on a regular basis at the national hospital.

The good news is that both of these diseases are treatable, even in one of the most resource-poor settings in the world. Providing HIV care and treatment has been saving the lives of Africans. As we continue to fight in this battle, we must now begin to seriously address the world's other main disease: extreme poverty.

I share the stories of patients in Africa not to make you feel guilty or to ask you to give money to the next poor beggar or charity, but to lend you a perspective. The gap between rich and poor has never been greater in human history. The current HIV/AIDS epidemic has inflicted the most devastating medical impact of the past 600 years, and the disease of poverty continues to present the greatest barrier to good health.

HIV/AIDS and extreme poverty are the two most important issues of our lifetime, and if we lose this perspective then they will only continue to become worse. We must not allow the dialogue for eliminating HIV/AIDS and extreme poverty to burn out like a neglected fire. We must engage in the dialogue and retain our global perspective.

Friday, June 09, 2006

Commander Tatu
(‘tatu’ is a Swahili word meaning ‘three’)

The Embassy of The Republic of Cuba is located a mere hundred yards down a residential street from my house in Tanzania. I jog past it almost every evening on my typical running route. So, when I learn that Ernesto “Che” Guevara had lived at the Cuban Embassy in Tanzania, I just have to investigate further.

The Cuban Embassy lies in a residential neighborhood, and without the pictures of Fidel Castro in a glass display case along the street it might easily be mistaken for a house. I greet the High Commissioner inside the small, no-frills lobby. He is a black, middle-aged man with a few grey hairs around his temples wearing a casual short-sleeved shirt with two buttons undone at the top. Since I was expecting to meet a Latino-looking man, I was a bit surprised at first to be introduced to a man who could have passed for a Tanzanian.

The High Commissioner is energetic and sharp. He speaks quickly, and seems to say whatever comes into his mind. Shortly after explaining my work and reason for stopping in, he asks me my nationality. I had told myself I would only reveal my American heritage if he asked, since disclosing my nationality, I feel, would either set up a long tirade of how badly Americans are behaving on the global scene, and may even get me thrown out into the streets without accomplishing my goals. None-the-less, I’m honest with him. At the outset, then, he castes me into what he sees as a typical American, an uninformed critic of socialism and promoter of global American hegemony, and I end up fighting this stereotype for much of the rest of our conversation. I work hard to get him back onto my goals of discussing Che Guevara in East Africa, Tanzania’s early socialist system (Ujama), and the role of socialism in development.

As a believer in certain aspects of socialism, the U.S. public library system being just one of them, I feel that I have to present some of our commonalities in order to establish rapport. So, I praise the Cuban health care system. Cubans have an average life expectancy that is equivalent to Americans, despite having a much weaker economy. Furthermore, Cuba continues to send physicians around the world on medical missions, and there are currently twelve doctors working in Tanzania. He is clearly very proud of the Cuban health care system and the fact that Cuba sends physicians to assist in developing countries, and as well he should be proud. We transition from standing cordially to sitting on the couches in the lobby.

I first ask him about Ujama, the socialist system introduced by Tanzania’s first President and implemented for over 20 years. At first, he claims to not know much about socialism in Tanzania and referenced an obscure book written by a South African socialist (Hosea Jaffe) in 1971. Feeling that I’m not getting very far, I challenged him saying, “According to most people socialism had failed in Tanzania.”

“You know, socialism can’t fail if it is never implemented,” he says, now becoming more engaging. “It is like going to a dance and seeing a pretty girl. You think about inviting her to dance, and people give you advice on asking her to dance, but you never dance with her. You can’t say you failed,” he says holding out his hands, “Because you never really tried. Socialism will not fail when it is implemented.” Given my understanding of Tanzania’s socialist experiment, I feel that he has a good point and moved on to discussing Che Guevara.

During the early 1960s, after assisting Fidel Castro in the Cuban Revolution, Ernesto “Che” Guevara had been growing bored as Cuba’s Minister of Industries. During the same time period, halfway around the world, most African nations were gaining political independence from their European colonizers. Guevara was at heart more of a guerilla fighter than a political administrator, and much of his principles were set on fighting the forces of imperialism and colonialism around the world. Therefore, his attention was easily drawn to Africa.

I ask the High Commissioner about Che Guevara. He confirms that Che lived in this very same building about 40 years ago after trying (and failing) to initiate the African Revolution. “Just upstairs in a small room,” he says pointing up and towards the back of the long building. He again claims to have little knowledge of the subject, but we continue on.

In the Cold War era of the 1960s, the newly independent Africa countries became the battle ground in the race between democracy and socialism. Che Guevara had been growing in popularity and had become a leading voice in the fight for independence and socialism. In December 1964, he addressed the United Nations General Assembly in New York, where he brazenly called upon the “struggle against imperialism, colonialism, and neo-colonialism”, said the word ‘colonialism’ 10 times, and said either ‘imperialism’ or ‘imperialist’ 31 times! After his speech, he traveled to Africa for the first time and visited 7 countries, including Tanzania. After his audacious speech and a high-profile trip around Africa, Che Guevara had secured his role as a prominent international figure for liberation.

Che Guevara returned to a solemn reception by Fidel Castro in March 1965. The two men spent all night talking and by the morning had agreed that Che would lead Cuba’s first military intervention in sub-Saharan Africa. Shortly thereafter, Che dropped out of public view. Just two weeks after he had returned to Cuba, Che personally delivered the famous ‘Farewell letter’ to Fidel. In his resignation letter, Che wrote, "Other nations of the world summon my modest efforts of assistance." and “I carry to new battlefronts the faith that you taught me, the revolutionary spirit of my people, the feeling of fulfilling the most sacred of duties: to fight against imperialism wherever one may be.” After delivering the private letter, Che Guevara secretly slipped out Cuba’s backdoor in disguise and traveled to East Africa in order to take up arms against imperial powers.

Che Guevara’s whereabouts over the next two years remained a great mystery and was an issue of much speculation. A couple of months after his initial disappearance, Fidel announced that his location will be revealed “when Commander Guevara wants it known.” Rumors about his disappearance and possible death spread both inside Cuba and around the world. Later that year, Fidel confirmed to international reporters that he did know of Che’s location and that indeed he was not dead. The fact was, Fidel had been funding Che’s mission and following his progress and activities rather closely, even if from a large geographical distance. While it was strange that Che Guevara never announced his intentions pubically, few would have guessed that he was halfway around the world leading the next revolution.

Che Guevara’s intentions in Africa were to train revolutionary guerrila fighters throughout Africa and to mobilize the movement created by Patrice Lumumba in the Democratic Republic of the Congo (formerly Zaire). Lumumba was the Congo’s first elected prime minister after gaining independece in 1960. However, 67 days after coming to power, he was dismissed by the state president and forceably removed from office. Lumumba was suspected of being a pro-Communist, and the Western powers, particularly the Belgians, didn’t have the assurances that they could continue extracting wealth from the resource-rich country. The American and Belgian governments wanted to assure his removal from power. The U.S. CIA attempted an assisination, but failed. Finally, several month later, Belgian military troops assisted Lumumba’s Congolese opponents in carrying out his disappearance and eventual execution. Che Guevara openly discussed his outrage to continued imperialist influences within the newly independent Congo during his address to the United Nations General Assembly.

After Lumumba’s death, Laurent Kabila and Pierre Mulele planned to continue the struggle for independece from Western imperialism. They founded the Congolese Liberation Front, and started an armed struggle in eastern Congo, which was far from the political capital located in western Congo. Furthermore, the rebel leaders were based in Dar es Salaam, Tanzania, which was far from the front lines of battle in eastern Congo.

When Che Guevara arrived in Dar es Salaam in April 1965, none of the rebel leaders could be found. Kabila was abroad in Cairo, and Mulele’s whereabouts were unknown. (Mulele was later murdered in 1968 after Mobutu’s men lured him into Brazzaville with a false promise of amnesty.) Therefore, Guevara set out for eastern Congo in a secrete envoy with 13 men. The long trip over the horrendous dirt roads across the vast countryside to the far western border must have been strenous. While the Tanzanian government knew there was a Cuban envoy traveling to the west, they didn’t know the envoy contained the famous Che Guevara.

The group arrived in a town called Kigoma along the eastern border of Lake Tanganyika, the second deepest lake in the world and the natural border separating Tanzania and the Congo. At the same time Che and his envoy passed though Kigoma, just 20 kilometeres to the north, in what later became known as Gombe Stream National Park, there was a young female, who had recently earned a doctoral degree from Oxford Univeristy, studying cimpanzee behavior and social systems. Her name is Jane Goodall. Perhaps it’s not ironic that Jane Goodall spent at least the next 40 years living with the chimpanzees, and Che Guevava spent only 7 months training guerilla fighters for the African Revolution.

Che Guevara and his men crossed the lake and set up their training camp along the steep, heavily forested western shore of Lake Tanganyika. Two days after arriving at training camp, Che revealed his true identity to his fellow Cubans. He took on the name “Tatu”, which is a Swahili meaning ‘three’. At 37 years old and with no formal military training, ‘Commander Tatu’ established a base for teaching the Congolese rebels, as well as fighters from other African liberation movements, strategies of guerrilla warefare and preparing them to fight against the imperial armies.

However, Che was shocked by what he found amongst the rebel fighters. Not only did they lack any coherent political direction, but, according to Che, the rebels had formed a "parasitic army". Rebel soldiers often robbed the local men and assaulted the women. They would drink heavily into the night and get into fights. In conflicts witnessed by Che, the fighters would usually flee from battle. Che had hoped that by having experienced Cuban guerilla fighters alongside men without experience there would be a ‘Cubanisation’ of the Congolese. Instead, he found that the exact opposite had occurred, and over a period of time a ‘Congolisation’ of the Cubans had taken place.

Over the next several months, Che would become frustrated with what he percieved to be a lack of seriousness among his trainees. In a letter to Fidel in October 1965, Che wrote, “According to people close to me here, I have lost my reputation for objectivity by maintaining a groundless optimism in the face of the actual situation. I can assure you that were it not for me, this fine dream would have collapsed with catastrophe all around. You have to be really well tempered to put up with the things that happen here.”

In November, Che Guevara led an unsuccessful revolt against the Congolese army. The revolt included Laurent Kabila, one of the two rebel leaders. However, the rebel force was ill-prepared and underpowered, and was quickly suppressed by the Congolese army. Che had already become weary of Kabila and his dedication to the revolution. Kabila would arrive days late to provide supplies and was hardly ever present when battles were imminent. Che dismissed Kabila as ‘insignificant’. "Nothing leads me to believe he is the man of the hour," Che later wrote.

Che Guevara's dream of an African Revolution had collapsed against the reality of the Congolese forces' complete incompetence and lack of seriousness. With Congolese and foreign army forces starting to move in around his training camp, he hesitatingly asked Havana for help in evacuating his men. Since Che’s ‘Farewell Letter’ had recently been made public in Cuba, he felt awkward about the possibility of returning to Cuba. Che considered staying behind at the training camp in order to demonstrate his dedication and become a martyr for the Revolution. In Che’s words, “I had the feeling that, after my farewell letter to Fidel, the comrades began to see me as a man from other climes rather distant from Cuba's specific problems, and I could not bring myself to demand the final sacrifice of remaining behind. I spent the final hours like this, alone and perplexed, until the boats eventually put in at two o'clock in the morning and set off immediately that very night.” They crossed Lake Tanganyika at night and Che secretly returned to Dar es Salaam in late November 1965, seven months after he established the training camp. Six members of his initial Cuban column had died.

During the same month, a Congolese military general named Mobuto Sese Seko had forceably taken control of the Congolese government in a successful coup d’etat. Mobuto would preside over one of the most tyranical despotic governments in post-colonial Africa. However, due to his pro-Western and anti-Communist platform, he received continued supported from Western governments, who in exchange would extract the minerals and resources. Mobuto regime was exactly the type of government from which Che Guevara was trying to liberate the Congolese people.

Mobuto became one of the wealthiest individuals in the world, while the Congolese people became some of the poorest, over the next 32 years, until 1997. At that time, the Tutsis, an ethic group that had been executed in mass during the Rwandan genocide and displaced to eastern Congo, rose up to overthrow Mobuto. The leader of the Tutsi group to overthrow Mobuto in another successful coup d’etat was none other than Laurent Kabila, the man Che had considered ‘insignificant’ over 30 years earlier. Kabila’s rule, perhaps as Che might have predicted, also resulted and ended in a disaster.

Back in Dar es Salaam in 1965, Che Guevara took up residence in a small room on the second floor of the Cuban Embassy. Only a few select people were allowed on the second floor, since Che’s whereabouts were still a global mystery. Over the next three months, Che and the men at the Cuban Embassy spoke about problems that arose in the Congo and liked to play chess. In addition, Che also wrote his diaries, which were later compiled and published as ‘The African Dream’. Che cited ‘incompetence, intransigence, and infighting’ as the key reasons for the revolt's failure. In ‘The African Dream’, he wrote, “It should be emphasized that, although I have given a detailed account of various cases of weakness and have placed emphasis on the general demoralization into which we had sunk, this doesn’t make that effort any less heroic. That defiance, that clear stance on the great problem of our era, embodies the heroic significance of our participation in the struggle of the Congo.”

Two men were dispatched from Havana to extricate Che from Dar es Salaam and Africa. First, Luis Gutierrez, called “Fisin”, was put in charge of disguising Che. Fisin first met Che on the second floor of the Cuban Embassy in Dar es Salaam. According to Fisin, “[Che] was shaved and was working at a little table in his [underwear], because the summer there in December is very hot. Since I had come from a cold region, I asked for permission to take off some of my clothes. [Che] replied, ‘You can strip down to what I have on,’ and we laughed.” Fisin removed his characteristic widow’s peak, made his hair recede more at the temples, and fitted him with both upper and lower prosthetic devices to fit over his teeth. They tested the disguise on Major Edy Suñol, who was there heading a Cuban military delegation. Suñol only recognized Che after he started speaking with an Argentinean accent. Che and Fisin were satisfied.

The second man, named Ulises, was sent to orchestrate Che’s escape from Africa. Ulises booked them on a flight arriving from Madagascar, which he knew would be on an unpredictable schedule. The two men waited in a small cabaret bar alongside the road to the airport. Ulises figured that they would be able to hear the plane arrive and once they did could then go to the airport. “We must have gotten too interested in the show, and nobody heard the plane when it arrived,” Ulises said. Another Cuban brought news that the plane had been on the ground for over an hour and was ready to depart. Ulises and a disguised Che Guevara managed to board the plane just before takeoff.

Che Guevara left Tanzania late in the night at the end of February 1966, after spending approximately 10 months in East Africa. He would never return to Africa again. A year and a half later, Che would be captured and killed while leading revolutionary rebels in Bolivia. Che had been tracked, captured, and killed by a Cuban-born U.S. CIA agent.

The Cuban High Commissioner is now settled into his chair in the lobby of the Embassy. Now knowing that I have his interest and attention, I start firing off some more difficult if not challenging questions. Our conversation is fast-paced and jumps back and forth between and among topics. I ask him about global aid to developing countries and the recent efforts of the World Bank and International Monetary Fund (IMF).

“The World Bank and IMF have made the system much worse, but not just for Tanzania, all over the world. They have come in and said, ‘You have to reduce doctors’ salaries and invest more of your money into this sector’. It is like saying you can only see your wife twice a week or you can only wear a suit on certain days. It is not right.” He challenges me to describe a country in which the World Bank and IMF policies have been successful, but I can’t.

“In fact, the situation is getting worse all over the world, except Cuba,” he says. “You had socialism in Russia, and now that it has been converted to democracy, look at how it is doing.”

“Do you know the origins of the word democracy?” he asks. “It is a Greek word with two parts, demo-, which means ‘people’, and –cracy, which means ‘power’. Taken together this means ‘power of the people’. That is not what you have in the U.S., that is what we have in Cuba.”

As our conversation wears on, he becomes more interested in talking about current global events, the failures and calamities within the U.S., and the nature of Cuba and socialism. The more we speak the more I feel his disdain for the U.S. None-the-less, he is friendly and polite, and I like him.

I thank him for his time and he walks me to the door. Feeling that we are parting on friendly terms and with a general understanding, I can’t resist asking just one more question. “What about the post-Fidel era?” I ask.

“There is a movie called ‘Dying With His Boots On’,” he says. “Fidel is a soldier and he will die wearing his boots, meaning that he will die working.”

“But will socialism survive after Fidel?” I ask more pointedly.

“Of course it will. You know he has a young brother (Raul) who is very energetic. There are several younger people who would be very capable as well. You just have to go there are see it for yourself.”

“I would love to see the health care system,” I say.

“No! You can’t just go there and see the health care system. You have to go and see the people, see the culture, and see the countryside. It is a wonderful country.”

William Gálvez. “Che's departure from Africa” in Che in Africa. Ocean Press Pty Ltd.; 2001.
Che Guevara. The African Dream: The Diaries of the Revolutionary War in the Congo. Grove Press; 2001.
Dihur Godefoid Tchamlesso. “Che Guevara's War-Cry Still Resounds in Congo”. Havana, Cuba; Prensa Latina, May 22, 1997.
Che Guevara. “Farewell Letter to Fidel Castro.” April 1, 1965.
Che Guevara. Address to the United Nations General Assembly. December 11, 1964.
BBC News. "Profile: Laurent Kabila." May 26, 2001.

Tuesday, May 30, 2006

Tanzania's Founding Father

This Monday morning, I meet Rosemary, one of nine children born to Julius Nyerere, at her home in Dar es Salaam. Rosemary was born in the year before her father became the first president of the newly independent “Republic of Tanganyika”. She lives in a modest one-story house with her daughter. Some of her siblings live here in the city, and some live ‘in the village’.

Immediately, I’m struck at how similar she looks to the pictures I’ve seen of her father. Her hair is cut short, and she has the same smile with crooked teeth as her father. Someone later told me that all of the children resemble their father. We sit in the shade of her driveway and engage in a lively, jovial conversation. She is good humored and clearly enjoys laughter.

I ask her if she is soon departing for Dodoma to serve another session as a member of Parliament. “No, I got out of politics a while ago,” she says. “Now, I am not trying to set up a business in the village.” The village she refers to is along the northern border with Kenya, and is where her father is buried and her mother currently lives.

“How do you remember your father and how do you think others remember your father?” I ask.

“I think he is remembered well. Many people were very fond of my father. Of course, there are also some who didn’t like what he stood for.”

I ask about her childhood. “He didn’t want special treatment. So, we were just like all the other children, and we went to public schools.” She and her siblings were all born in Tanzania. They lived in a moderate house in an area just past the current location of the big American embassy compound. Nyerere had insisted that he and his family would live simply, like his countrypeople. Therefore, when I say, “He was probably the only African president to leave his position still as a poor man,” she just laughs.

Unlike other African leaders, the history books don’t write much about Julius Nyerere before he became president, other than being an intellectual figure. When I ask about how her father came to power, she replied, “Tanzania was not colonized by the British, but they had a mandate to protect the country. When the British said you can take over the country when you are ready, my father said, ‘okay, we are ready now.” Nyerere then found himself at the forefront of the movement for autonomy from the British Empire.

Rosemary has a continual energy that I imagine she acquired from her parents. After I told her I do research on HIV and nutrition, she said, “Oh, I’m very interested in this topic” and practically ran into the house. She emerged five minutes later with a small booklet on HIV and nutrition and wanted to discuss this more at length. Later in our conversation, she says, “I’m sorry about the mosquitos,” as she quickly rose from her chair and pulled some leaves from the bushes alongside the driveway. “They say this is a natural mosquito repellant,” she says. She beat the leaves against her legs and ankles, before handing me the bunch of green leaves. “It is just basil,” she says.

I ask her about the famous Ujama (“socialist”) system. She replies, “You know, it is just pulling people together to combine resources. It is like if you have some people here and there, and you bring them together to form a school. I still believe in it.” She says this last line with an air of caution that I don’t know how to interpret.

“Does the government still talk about that system?”

“You know they are. But, now, the government talks about forming cooperatives.” After describing the idea and structure of cooperatives, she says, “It is really the same thing, but now they don’t use the word socialism.”

I ask her more about Tanzania’s political history. She explains that when the country became multi-party state in the early 1990s, it was the other political parties, not her father’s party (which has been in power since independence), that first starting paying voters for their votes. Then, after seeing this, the ruling party decided that they had to do the same, “So we started giving out more money (than them),” she says with a rollicking laugh.

“Back then, it was okay to pay (for votes). When I was in Parliament, we passed something called the African friendship bill, which essentially made it okay to give out money during campaigns. We just called it friendship,” she says making quotation marks with her fingers. “Now, the current government has nullified the bill.” She explains that she didn’t enjoy going to Dodoma (Her father established Dodoma as the political capital of the country due to its central geographic location) and didn’t like the campaigning, so she ended her political career.

Given the country’s history of political stability, I ask her why development hasn’t taken hold in Tanzania more than the neighboring countries, which have suffered decades of civil wars and rampant political corruption. “I’m not sure I can answer that one,” she says before taking a long pause. “I think maybe we haven’t been honest with ourselves or with our contracts. If I can use the example of the mining industry. They (foreign mining corporations) have taken a lot of resources, but not much of that money has come back into the country. They have the technology and we have the resources, but there hasn’t been an equal partnership. I think the current government is doing more about this.”

“What do you think about the development assistance from donor countries, is it good?” I ask.

“There are many people who don’t do something because they are waiting for the donor money. This is what I saw when I was in Parliament. They are all chasing the donor money. Sometimes they choose not to do something because they are waiting for the money.”

“Is this making the people lazy?” I ask.

“In my opinion, yes it is. My father would always tell us, ‘don’t be a bug… or a parasite, be self-reliant’. He would say this over and over to us and to the people.” She repeated the Swahili phrase several times, bringing her fist down onto her thigh each time she did so.

“Do you think the country would be better if the donor countries stopped giving money and assistance?” I ask.

“The problem is there are so many different groups and organizations. I think it would be best if they would give it all (donor money) to one place, like the government. But then you have to make sure the government uses it the way they should. It should be clear that the money is for a specific project. We need to be able to police the government.” She then describes some examples of when she felt the government had not been honest with the money they had received for certain projects.

“There is a lot of optimism with the current government,” I say.

“Yes, there is currently a lot of optimism around the president,” she says. “We are all watching closely and hoping, praying that he does well.”

After I thank her for her time and carry the two chairs back to the sunlight porch, she says, “How do you find Tanzanians?” with a large smile. I told her my story of taking a train to Selous National Park and being stuck in a small village after sunset without food or accommodations. I told her that after providing two meals and a mosquito-net-covered bed, and escorting us 8 kilometers down the railroad tracks to the park’s main entrance, my host didn’t ask for any money. “Sure they won’t ask for money. It’s just some of the people here in the city. The Tanzanian people are really very friendly.” It is clear that she genuinely loves her country and its people.

I say, “Some people say the greatest legacy of your father is that he successfully united 120 different tribes into one nation.”

“Yes, he united 120 tribes and we all speak the same language.”

Then, she says, “Ah, it’s too bad I didn’t get to know you sooner, I could have taken you to the village.” I asked her if her mother still lives there. “She does. She is 76-years-old and she still works in the fields. You know after the rains came, a couple of months ago, after the drought, she was out in the fields planting crops with all the young boys.” She makes the motion of an old woman bent at the waist and working the ground with a hoe.

“If you have the time, I can arrange for you to go to the village. I can just call my brother. That’s how we operate, I just call one of the others,” she says with another chuckle.

Monday, March 06, 2006

HIV Clinical Story

I have never seen this patient before, yet she is like many others. She lies on a hospital bed clinging to life by a thread. But even that will soon be taken from her. By the time we see her on our medical rounds, there is very little we can do. Her death this morning, like that of so many others, will be caused by a combination of two treatable diseases: an HIV infection and extreme poverty.

We come upon her in the far corner of the medical ward halfway through our morning rounds. Immediately, I am stunned at the general presentation of this woman. She holds a blank stare out an open window. Her eyes are shifted back in their sockets. Her breathing is rapid, but regular. Her pulse is also rapid, and it’s not beating in a normal rhythm. She's in real trouble.

I had recently completed my training in the core areas of clinical medicine at the best medical school in the country for teaching clinical medicine. I felt that I was generally equipped and capable of approaching complex medical patients like this one. The key was being systematic in the approach, but a systematic approach relies on having certain resources available to diagnose and treat the patient. However sound my US medical training has been, I have been repeatedly unprepared to handle the difficult situations that arise when the resources aren’t available.

We have few precious minutes with this patient. Since there is no supervising physician, I tell the intern that we need to ‘call a code’. This should have set off a flurry of activity, such as supplying oxygen, gathering several cardiovascular medications, and obtaining a defibrillator in case we need to shock her heart. Two people should be ready to start CPR. However, we’re in Africa, and, here, there are no ‘codes’. In fact, there is no CPR training and only one portable defibrillator for the entire hospital. As a result, patients like this young woman typically die quietly in a corner.

Immediately, we need to give her some oxygen and intravenous fluids. While every second counts, the resident, intern, and nurses are not prepared to act quickly. After a minute or two, the nurse eventually wheels over the one tall, rusty oxygen tank that resides on the floor. One tank of oxygen doesn’t last very long on a ward with 42 beds. A glass bottle with ‘sterile’ water hangs by a rope from the tank. There is a long rubber tube, which pierces into the glass bottle, that will carry the outflow of oxygen. After looking more closely at the tube, I realize that this particular piece of rubber tubing is normally used to suction out stomach contents. Furthermore, it is dirty and has clearly been used for another patient. What this woman needs is a high flow of oxygen through a full face mask, not some thin tube with someone’s dried phlegm on the end.

Her respirations were now becoming slow and shallow. Ideally, we would want to put a tube down into her lungs and hook her up to a ventilator so we could take control of her breathing. It was already clear that none of those resources or equipment would be available. Even if there was an artificial ventilator, there is no electricity in this area of the hospital. Her breathing is rhythmic, and gradually becomes more delayed with each breath. Her eyes are fixed and dilated. I can feel the pulse in her neck as she remains motionless on the bed.

She is a 31-year-old woman who is known to be HIV-positive. She has been married for seven years, but has no children. She was admitted to the hospital four days ago after she had been suffering from a week of diarrhea and vomiting. Since she was admitted, she has received one unit of blood. Nothing else has been done for her.

She should already have an intravenous line in her arm, so we can quickly give her fluids, but she doesn’t. A nurse will spend our remaining time trying to insert a line into a vein in her arm. The one portable heart monitor for the entire medical block is not on our floor.

Our activity is becoming futile. Her pulse continually weakens. Her breathing gradually becomes more delayed. I hold her wrist with one hand and feel for the pulse in her neck with the other. She is now getting some oxygen through the small tube, and a nurse is trying to put in the intravenous line. She hasn’t been given any heart stimulating medications. As I watch her life slip away, I realize there is little reason to take this any further. We don’t have the resources and without them there is nothing we can do.

Although nothing is said, the resident stops giving her oxygen, the intern stops preparing an injection, and the nurse stops inserting the intravenous line. She has no family around and this is no way to die. I hold onto her wrist as she finally stops breathing. I watch, feeling helpless. I feel for the pulse in her neck, but it’s not there. “She’s died,” I whisper.

After a few moments, the group of 7 white coats move on to the next patient. I stay behind to look over her chart. Her CD4 T-cell count is 17, which is extremely low (a T-cell count <200 is low), and she had not been receiving HIV medications. She died because she had too few immune cells to fight off any infections. She also died because she is poor and didn’t have more immediate access to HIV care and medications.

We miss you in Tanzania Julia.

Thursday, February 09, 2006

Thanks, Kyle and Joy, for a nice visit and this photo of a dik-dik!

Wednesday, February 08, 2006

Clinical Journal

It has been some time since my last clinical posting. I thought I would take this opportunity to bring you up to date on the clinical happenings at Muhimbili National Hospital.

The strike among the interns and residents has finally come to an end. Shortly after my escapade of dodging the demonstrating group of interns and residents (see blog post on 11/26/05), the physicians on strike quickly lost public support.

About five days after the strike was initiated, hospital administrators offered to double the salary, from approximately US $200 to US $400 a month, of the interns and residents. However, they turned down this offer and continued their demand for US $1,200 a month.

The hospital administrators were then able to use the press in painting a picture of young, greedy physicians who care more about making money than treating sick patients. This shifted public support from the interns and residents.

The following week, hospital administrators fired the striking interns and residents, and brought in outside physicians to fill the void. Physicians from the military base, public health agencies, and the Ministry of Health were called upon to stop their ongoing work and report for clinical duty at the National Hospital. Most of these physicians were not used to the complexity of Muhimbili patients, the country’s main referral hospital, and many of the physicians simply hadn’t seen patients in several years. In all, the medical care became sub-standard, even by Tanzanian standards. The hospital stopped admitting any referral patients and many people started going to other hospitals for medical care.

At one point, we were down to 6 patients on my ward. Our ward normally operates with about 20 patients and has the capacity for even more, usually by putting mattresses on the floor. The medical care was less than ideal and I was taking on more responsibilities, which I didn’t particularly want to do.

A couple of weeks later, hospital administrators agreed to rehire the residents, but not the interns. Residents were requested to submit an official apology letter by the next evening. The Internal Medicine residents submitted their letter by the deadline, but the Obs/Gyn and Surgery residents were too late. The Pediatric residents were traveling at the time, so they were spared of the deadline. Thus, the Internal Medicine and Pediatric residents, which is about 15 people, were rehired among the striking group of about 300 interns and residents.

In the meantime, the rest of the interns and residents were without a job, and the duties of the supervising physicians, which are seeing patients two times per week, remained the same. Patients would go for three, four, or often five days without seeing a supervising physician.

When no physicians would come for medical rounds, I would run the major ward rounds with the medical students. Even though I would cringe each time they wrote in a patient’s chart “MWR with Dr. Paul”, I knew there was no alternative. If it was a Friday, patients would be lying in bed until Tuesday, up to five days, without appropriate medical care. So, we would do what we had to in order to get them through to Tuesday. We also couldn’t wait to follow-up on some lab tests. If we suspected malaria, then we needed to treat for malaria. After some time, a schedule of clinical time was developed for the replacement physicians, and the situation gradually improved.

In the middle of December, presidential elections brought in an new president and administration. The new government quickly brought resolve to the issue. At the beginning of January, most of the remaining Internal Medicine interns and residents were rehired. The Interns were excited to have their jobs back. One later told me, “We went for over 2 months without work or pay. We were just sitting at home doing nothing”.

This week, about 3 months after the strike was initiated, the full events of the strike have come to an end. The pharmaceutical interns returned on Monday, and they were the last group to return to work. In the end, all of the interns and residents agreed to a salary increase of 100% (to US $400 per month), not too bad, and also to never strike again.

The administration did manage to divide the striking interns and residents through their rehiring process, as I feared they might. They required each person to resubmit a job application and held interviews to learn who was behind the strike.

There are 29 physician interns who were not reinstated in their medical training. These interns were considered to be the ‘ring leaders’ of the strike. As a result, they will have to wait one year before they are able to resume their medical training.

In the end, the interns and residents who came back to work broke their association from the strike and accepted their positions knowing that certain people were not being rehired. This defeat to the solidarity of the strike will make their future bargaining power less solid. However, they have decided to accept a salary increase and continue seeing the country’s poorest medical patients.


Monday, January 30, 2006

Pictures from Safari with Mom

Wednesday, January 25, 2006

Safari with mom

My mother recently visited me in Tanzania. Sandy teaches art to elementary students, mostly African-American children, in the poorest neighborhood of Dayton, Ohio. She had 2 weeks off for her Winter Break, so she wanted to spend this break with her son in East Africa. My mother brought a fellow schoolteacher, Sophia, with her, and I had invited an American friend, Cathy, who lives and works in Dar es Salaam. The four of us spent two weeks in close quarters, and in the end it was a fun, interesting, and comical adventure, and a great opportunity for me to spend time with my mother.

The trip was off to an interesting start even before my mother arrived. They had put me in charge of planning an itinerary, and so I had wanted to give them an entire 36 hours to relax in Dar and give the 8 hours of jet lag a chance to wear off before putting them on any public transport. We needed to take a local bus from Dar es Salaam to Arusha, where we would start our safari to the Serengeti and Ngorogoro Crater. The bus trip would be about 10 hours, barring no delays, such as stopping to kick off some passengers before weighing the bus. As anyone, they would be tired after spending 24 hours of flight time, making 3 stops, and switching 8 time zones, and starting the bus ride and safari well rested would be key to maintaining happiness.

Shortly before her departure, I call her over the internet telephone. It was Saturday evening my time and Saturday morning her time. If was supposed to pick her up at the airport on Sunday night (my time), then I knew she must be leaving for the airport soon. “So, you must be heading to the airport soon.” I say.

“No! I don’t leave until tomorrow morning.”

I immediately knew something was wrong. “Well, how can you leave on Sunday morning in Ohio and arrive on Sunday night in Tanzania, especially when we are 8 hours ahead of Ohio?” Either she had already missed the flight or she wasn’t arriving on Sunday night. There was a pause as she searched for the ticket.

“Well, it looks like I arrive on Monday night in Dar!” Sandy says. Somehow, when talking to someone in East Africa, despite a good connection, most things are said with exclamations. I explain that it won’t be a problem. Unfortunately, they’ll now have only 10 hours to relax after they land before getting on a dirty, bumpy, speeding bus.

They arrived on Monday night full of energy and suitcases. They were passing out mosquito repellant, a variety of sunscreens and SPFs, and batteries like a pot-bellied Santa Clause in a mid-western mall. They also pulled out bundles of notebooks, coloring books, crayons, markers, toothbrushes, and toothpaste to give to a school classroom. I still didn’t have a plan for these supplies, despite the one-month lead notice. They finally went to bed around 1:30 am and were woken 5 hours later.

The bus ride took 12 hours. We arrived in Arusha in the late, dark evening and were greeted by a gentleman holding a sign with “Dr. Paul’s Mother’s Safari”. If it hadn’t just taken an 12-hour bus ride with almost no legroom and only one stop for lunch, I would have laughed at this sign a little more than I did.

The next morning, we woke up early and started the 3-hour drive to Ngorogoro Crater, nicknamed “The Garden of Eden”. While driving through the city, our driver pointed to a large tourist-oriented souvenir shop. “See that shop, President Clinton visited that place,” he says. After the driver dropped off his dry cleaning, we were eventually on the road out of town and driving through several coffee plantations.

The drive out to the Crater passes through the Great Rift Valley. The Rift Valley extends from southern Ethiopia to the northeastern Zambia and northern Mozambique. This area is currently considered to be the Darwinian birthplace of homo sapiens. About 5 years ago, archeologists working around the Rift Valley uncovered the oldest known hominoid bones. I think about how much progress has been made in this birthplace of humanity. The houses are still mud huts and the Massai warriors are still nomadic herders who walk and carry a spear. Ah, but the road has been paved since I last visited the area five years ago. This was now my third trip to Ngorogoro Crater and riding the new tarmac makes me smile. It is the only sign of infrastructure development I notice, but I convince myself that they are making progress, albeit slowly.

The road down into the Crater descends 2,000 feet and is narrow and steep. A week after we finished our trip, I learned about a tragic accident on this dangerous road just several days after we passed through. A young, female American student, who was studying as an exchange student at the University of Dar es Salaam, was killed as their safari vehicle blew a tire, overturn on the steep road, and ejected everyone from the truck. Although several were injured, the young female student was the only one killed in the accident. Furthermore, she was traveling with her parents.

After we reached the Crater floor, we first came upon some Massai warriors herding cattle. ‘What a strange place to be herding cattle,’ I thought, ‘given that there are many lions living in the Crater. And I think I would want a little more protection than just a spear.’ I realized they must be rather desperate to find green space for their livestock. It’s partly a result of the ongoing drought that has been hitting this area since 1997.

We had removed the roof of the vehicle, so I stood up and peered out the top like all the other camera-touting tourists. We slowly drove around the Crater floor stopped every few hundred feet to ogle at the various animals. Almost immediately, we saw zebra, gazelles, ostrich, baboons, wildebeests, and warthogs. The density of wild animals living together in this 12-mile wide crater is astounding. It also prompts many questions about co-habitation, such as ‘are hyenas and gazelles okay being this close together?’

Then, someone spots a huge elephant with large, white ivory tusks under a big umbrella-like Acacia tree a few hundred yards in the distance near the edge of the Crater floor. The soft wood Acacia tree has a flat canopy about 30 feet high and is a classic symbol of Africa. Seeing an elephant walk under the tree with a backdrop of the Crater wall is like newly discovering the eighth wonder of the world.

“Oh, look at that!” Sophia says. “This is just like the Discover Channel!”

“Wait, isn’t the Discovery Channel just like this?” I say. “You are seeing the real thing, right here.” There was no response.

We continue driving around and within an hour we spot the Crater’s most famous animal. There are only 13 black rhinos in the greater area and not many more in existence. They have long been poached for their horn, which is considered to be an aphrodisiac in the Far East, and are now on the brink of extinction. The large black rhinoceros is about 150 yards from the road and is walking directly towards us. We wait, cameras at the ready. As the large, strange looking animal approaches it turns slightly and crossed the dirt road just 20 yards in front of our car. Just wonderful to see this large, endangered creature from close range, but I couldn’t help thinking we were in its way.

Shortly thereafter, I spot a female lion lying in the sun on a small mound of dry grass. Then, we see a pair of cheetahs having a siesta in the hot sun. Finally, we arrive at the hippopotamus pool, and watch 20 large hippos resting in the water. They really don’t do much.

We parked the car and ate lunch at the hippo pool. There were 20 large, worn, safari-beaten Land Rovers lined up along the bank. The sun burnt tourists were outside the trucks sitting in the grass. Some had clearly spent a bit of time and money in an apparent attempt to look like Ernest Hemingway. As we finished lunch a large, 5-ton elephant decided to stroll past the row of trucks. The expensive cameras made their way over to collect more evidence that they were indeed on a safari with elephants. ‘The only mammal with four knees’ I thought to myself. As quickly as it started, the sunglasses and cameras were back in the truck and we were off for more game driving.

We drove around the remaining areas of the Crater for the afternoon. By the end of our day, we had seen elephants, zebra, flamingos, marabou stork, secretary birds, jackals, bushbucks, a lion, cheetahs, wildebeests, warthogs, a rhinoceros, hippopotamuses (or hippopotami?), hyenas, vultures, ostrich, baboons, vervet monkeys, Thompson gazelles, Grant gazelles, and Cape buffalo. I’m still not sure if the Cape buffalo are ‘water or land buffalo’, but that was a good question Sophia.

That evening we sat out on the hotel’s veranda at the upper rim of the Crater. We looked out over the entire Crater and watched the sunset. “You’re a long way from Ohio”, I said to my mother.

The next day we drove 3 hours to the Serengeti National Park. The Serengeti is an open plain with some small rounded hills that have been weathered with time. The landscape is much different from the Crater. The landscape in the Serengeti is expansive and gives the appearance that the wild animals and the environment have no boundaries. The animals could roam around for months, migrate hundreds of miles up to Kenya in the dry season, and come back in the wet season for plentiful grass over the endless miles of open land.

With the vast expanse brought about greater challenges in spotting and locating the animals. No longer were there 5 trucks parked around the two cheetahs that were 50 feet off the road. Most of the animals in the Serengeti would be off in the distance, through some trees, or hiding in the grass. The law in Tanzania forbids the trucks from driving off road, which came to appreciate as respective the animals habitat and space. The law is different in Kenya, and my previous safari driver in Kenya had no shame about pulling the truck within 10 feet of a lion napping under a tree.

In the vast openness of the Serengeti we were often looking in various directions when someone would shout, “Oh, look! A giraffe!” Hearing this just created a sense of panic. Everyone yells back, “Where? Where?” as we scramble to spot what might be the last giraffe walking out of sight into the trees. And if the spotter replies with, “Over there!” it just seems to make the situation worse.

So, Cathy and I introduced the clock system for describing the location of animals. We had already used it before with success on a short safari we took a few months back. We explained the only two ground rules. First, the car is the reference point. Secondly, the front of the car is always 12 o’clock. Therefore, if you see an animal off to the right of the car, then the animal would be 3 o’clock. If the animal was between the front of the truck and the right of the truck, then it was at 1 o’clock or 2 o’clock. On the previous safari, Cathy and I would try to be more precise saying, ‘3 giraffes at 1:30, and a 4th giraffe at 2:15’. Whether they were necessary or not, throwing in some minutes was always my favorite.

Everyone seemed to understand the clock system and I thought to myself, ‘this is now going to be an efficient safari for locating animals’. I was confident in our abilities to easily locate all the animals in our path. We could describe the exact location with pinpoint accuracy and eliminate the sense of panic. I would soon realize our accuracy was about as good as the laser-guided bombs falling on defined targets in Iraq.

We drove another 20 minutes before Sophia spotted a herd of zebra. “Oh, look! Some zebra!” she shouts. Panic starts to ensue.

“Okay, where?” someone says. I was standing just behind her in the truck, so I could see she was facing directly to the right, at 3 o’clock. As she searched for the answer, I felt like a parent watching a daughter shoot a free throw in a high school basketball game.

She raised her arm to point. I was mentally cheering her on, but she had to take the shot herself. “Over there, at... 11 o’clock” she says pointing off at 2 o’clock. ‘Oh, hits the rim and bounces out,’ I think to myself. Cathy shot me a look that said, ‘how can I find the animals if people are telling me to look in a different direction?’ I pretend to look for the zebras at 11 o’clock, and we both start laughing in hysterics.

“Well, she was facing 3 o’clock, so to her the zebras were indeed at 11 o’clock”, I say. “Perhaps Sophia’s positioning should be our permanent reference.” We all laugh.

During our game drive in the afternoon, we would see many lions, cheetah, giraffe, hippos, gazelles, hyenas, jackals, topi, baboons, buffalo, hartebeests, a crocodile, vervet monkeys, and tons of zebra and wildebeests. We settled into our lodge, located in the middle of the park, sometime in the evening. It’s odd to think of this full service lodge with a dirty swimming pool out in the middle of this vast national park. The lodge sits on top of a hill and is built into the rocks. Although I can see for miles and miles, there is nothing around but the vast openness of the infinite landscape. Watching the sun set over the Serengeti plain was magical.

The next afternoon, we drove up to a pack?, herd?, or cackle? of about 10 Land Rovers parked and watching a leopard resting in a tree. We joined the modern Hemingways and took pictures for about 30 minutes until it decided to climb down the tree. This brought out some ‘Ooohs and Aaaahs’ from the Hemingways in the pack of now 20 Land Rovers watching the cat.

“It looks like he might hunt the gazelles”, someone from another truck says after spotting a group? of gazelles nearby. Sure enough, the big cat was stealthy moving through the waist-high dry, savanna grass towards the Thompson gazelles. The cat was mostly out of sight, and occasionally the ears or tail would reappear to clue us in on his location. He was moving slowly but steadily towards the small pack of gazelles. I wondered how many of the 50 or so gazelles knew the leopard was in the area, and furthermore if any knew they were now being hunted.

Our driver explained that the leopard must get very close before making his move because although their speed can be explosive, it can’t sustain for very long. The leopard had finally settled about 30 feet from the nearest gazelle. His head was low, but it was fixed on the gazelles. The gazelles are still eating grass and I figured the leopard was being patient for a gazelle to wander over a little closer. There is now an air of intensity and the adrenaline is palpable.

I look around at the modern Hemingways and everyone has their modern gun ready to take the shot. Some had elaborate tripods to stabilize their modern gun, while others had huge telescopic lenses to capture the nose hairs of the leopard as it was making a kill. I imagine someone returning to France saying, ‘Ah, oui! Regard! Le nez-cheveux de la léopard!’ There are now close to 30 Land Rovers lined up along the dirt road, and some drivers had driven off road to position their clients closer to the front. Hoping that if there were to be a kill, their clients would have a front row seats, perhaps even get a little gazelle blood splattered on them. As the leopard had been moving in on the gazelles, so to had the Modern Hemingways moved in on the leopard. Each Hemingway had a camera at the ready, and the closest camera is now about 30 feet from the leopard. It had become apparent that as the leopard is hunting the gazelle, we too are hunting the leopard. Who is going to draw their pistol first?

The gazelles don’t appear to see or know about the leopard existence. They continued feeding and appeared relaxed, at least as relaxed as a gazelle could knowing they were almost constantly being monitored or hunted by something in some unknown direction. One gazelle had wandered over to within 20 feet of the leopard. ‘Go for it! This is your opportunity! Strike!’ I savagely and telepathically say to the leopard.

I study the close proximity of the leopard to the gazelles and the Hemingways to the leopard. Before the leopard has a chance to come of out hiding, grab a gazelle by the neck, and enjoy a good meal, the Modern Hemingways make their move. In an effort to move in on the leopard, one of the truck drivers started his engine. This spooked the gazelles and they ran out of the battle theater. Shortly thereafter, the leopard, realizing he had been defeated on this attempt, came out of hiding and climbed up into another tree. At this point, all of the gazelles now see the leopard and the hunt would have to be postponed for another time. I can’t be certain, but I think I saw the leopard give the middle finger to the Hemingways after coming to rest in the new perch. I silently wonder at what point the leopard will realize his hunting could be made easier by first dealing with the Hemingways.

It is our last day on safari. We are driving around an area of the Serengeti that is off the beaten path. We are the only Land Rover around and it is mostly quiet. It is nice to observe the landscape and some of the animals around the landscape. Announcing animals has all but stopped at this point. Due to Sophia’s never finding a frame of reference that worked for everyone and my mother’s poor eyesight, the clock system broke down. I think I must have asked my mother 3 or 4 times when she last had her eyes checked. A comical situation had built up to Sophia giving the wrong location and my mother, after scrambling to find the animal, saying, “where? I just don’t see it!” as she threw up her hands.

I reflect back on all the questions that had been asked in the previous days. There is a gradual trend in complexity with the questions, starting with the very benign and progressing to PhD dissertation research topics by the end of the safari. First-day safari questions are usually something along the lines of ‘do female elephants have tusks?’, ‘how long to the rhinos live?’, ‘does a zebra need water every day?’, and my favorite, ‘why don’t the animals leave the Crater?’. Over the courses of a safari, tourists seem to gradually remember their lifelong dreams of becoming an animal behaviorologist like Jane Goodall or Dian Fossey. By the last day are attempting to identify their PhD research topic and their questions start sounding like long, complex dissertation titles being presented at a graduation ceremony. Typical last-day questions such as usually unanswerable, and are along the lines of ‘If this lioness mates with the alpha-male lion, would the cub also be raised by other lionesses who mate with the same alpha-male?’ or ‘is that sound made by the zebra a mating call or a warning to other zebra that there is a lion in the grass about 50 yards away?’. Okay, I’ll admit it, I did ask the last question.

For the last-day questions, most of the drivers just start to make up answers. They are however very patient with the simple questions, and I’m sure some questions are asked by almost every group. I think the success of a good driver simply depends on his/her patience at answering questions. I know I would have failed. After the 50th question, I would have snapped back, “Didn’t you read a single damn thing about these animals before you came?” But the drivers don’t, and they are very accommodating.

We arrived back in Arusha on Christmas eve. We had a special dinner at a nice hotel, and ended up discussing poverty, health, and the American education system. So, naturally, it was a fun evening, at least for me. After dinner, Sophia wanted to visit the casino in the basement. She exchanged a US $20 for a small bucket of coins for the slot machines. Within 30 minutes of playing, she hit the jackpot of the machine and won $100! She cashed out and we took a taxi back to our hotel.

On Christmas morning, we flew to a small island off the southern coast called Mafia Island. Our plane was a simple 12-seater, and the 13th person sat in the co-pilot seat. There were three legs for our flight, so with a chance to rearrange on Zanzibar my mother made sure she would sit in the co-pilot seat for the remaining two flights. The landing strip on Mafia Island was nothing more than a clearing of the trees and a dirt strip with a few potholes. This was just enough off the beaten path that it was going to be perfect for a few days of relaxation. We spent Christmas strolling the beach, enjoying a beautiful view of the Indian Ocean, and having dinner in a grassy courtyard under the African stars.

The Mafia Island Marine Park is the only National Park on the eastern coast of Africa and is well known for scuba diving. Since my mother wasn’t certified for scuba diving, I would enjoy snorkeling with her. The next day, we headed out on a traditional, wooden dhow boat for a morning of snorkeling. The colorful fish and displays of coral were absolutely amazing. After eating a late lunch on a small deserted island, we sailed home on the traditional wooden dhow boat.

Sailing in the dhow quickly became my favorite activity. The boat is made of wood from the mango tree, and it typically takes three men several months to craft a boat by hand. The final product is hardly anything resembling good engineering. Later, I would be able to see men constructing a dhow with functional imprecision. A dhow has a central mast, but it doesn’t hold the main sail as would a modern sailboat. Instead there is a boom that can be raised about 20 feet to the top of the mast. The main sail is attached to the boom and the anchor point of the sail is latched to the dhow’s stern. Since the boom is attached to the mast at only one point, it can pivot. The boom usually ends up making a 45-degree angle to the mast and the triangular sail hangs out over the water. While this design may not be the most efficient model, a dhow sails just fine and it’s slow pace is quite comfortable.

The following day, I went on two scuba dives with Cathy. While the scuba diving was amazing and like nowhere else, my mother had the more interesting day. In an adventurous spirit, she had signed up to go swimming with the whale sharks. Yes, not only are they sharks! but they are also the largest sharks! - up to 13 tons large! These sharks feed by opening their large mouths and taking in whatever may be in their path. Therefore, so long as you are not in front of the whale shark, then technically they should be a danger. This would also the first time my mother would be out of my immediate purview, so I was more than a little nervous.

The guide was giving instruction to the boat’s passengers on how and when to jump in the water. “Have your mask and snorkel ready and when I tell you to jump in the water, you jump!” Upon hearing this my mother thought that was the signal to jump, and was quickly in the water. When she came back up she realized she was the only one in the water. She climbed back into the boat and apologized for missing the signal. But hey, what’s wrong with a little practice?

Shortly after this, the guide spotted the whale shark, and he gave the first real signal to jump in the water. My mother wanted to be in fast and she was quick to get in the water. In the ensuing excitement she caught her flipper on the edge of the boat as she leaped into the water. Her flipped was knocked off her foot and was now slowly sinking in the water. Instead of diving down to get it, she looked up at the guide and said, “My flipper is sinking!”

“So dive down and get it!” the guide naturally replied. She refused. The guide jumped in and dove down 10 feet to retrieve the sinking flipper. During this commotion, the whale shark had already swum past and this cost the group their first real opportunity to swim with a whale shark.

Then, there was a second opportunity to swim with a whale shark. She was excited as the guide gave the signal to enter the water. She eagerly jumped in and this time with all of her gear intact. However, by the time she entered the water and looked around, it was already too late. She discovered that the sharks had already swum by, so she clamored back into the dhow.

There was a third and final opportunity to swim with a shark. At this opportunity my mother decided to hang up her fins and observe from the boat. Yes, I could have simply said that my mother swam with sharks, but that wasn’t the full picture. We all shared some laughs that night as she told and retold us her comedy of errors.

The next day, my mother and I went back to snorkeling. Then, another day later, we headed back to Dar es Salaam. Of course, my mother sat in the co-pilot’s seat again.

She and Sophia had only one day to see Dar es Salaam before flying home, and they wanted to visit the hospital. It was a Friday morning, the day I attend the major ward rounds. On the drive up to the hospital I was motioned to pull over by the traffic police. ‘Great, of all the days’, I thought. He saw an expired insurance sticker on the front windshield and he smiled as he realized I was busted. I negotiated him down to about $2 (from $10), handed him the cash and we were on our way.

We arrived outside the Medicine ward and she appeared to be in shock as she looked around. This environment outside the ward is striking. The hospital is a complex and it feels like a walled in compound. The Emergency Department sits across the road. Above the Emergency entrance is a sign reading ‘Casualty’, which I still think is ironic. There were people being wheeled around on gurneys, adults hobbling on crutches, and sick-looking patients wandering about. The buildings are run down and there is trash in the street. There is also abundant activity of people and stretchers with people are being pushed down a dirt sidewalk in the sun

We walked up to the ward on the second floor and stop at the front of the long hall. I see the large group of physicians I would have been with this morning. They are hovering over a patient trying to ‘first, do no harm’. We continue stand at the head of the ward near the nurses’ station. There are no patients in this area, so it allowed them time to digest the scene. It is a lot to take in.

I explain the general situation of the floor and she asks some questions. Sister Kilama says hello. I introduce my mother and she welcomes my mother with a big smile and a friendly greeting in English. I continue to explain lack of resources at the hospital and the situation with the striking interns.

After giving the time to realize that the ward is a safe place, I ask her to walk with me down the long row of beds and patients. She hesitantly agrees.

“This woman is just so thin, does she have HIV?” Sophia asks.

“She is a new patient, so I don’t know her case. She may have HIV. HIV can cause something called ‘Wasting Syndrome’. In fact, my research here is about weight loss, nutrition, and HIV.”

My mother asks how the patient’s acquire food while in the hospital. I tell her that if the patients live within a certain radius of the city, then they must rely on a family member or friend. If they live outside the radium, which is quite large, then the hospital can help them. After I explained this she said, “well, I guess I’ll never complain about hospital cafeteria food again.”

Before I left for vacation, we were in the process of deciding what to do with two young girls with rheumatic heart disease. They will both need cardiac surgery in the next couple of years. However, cardiac surgery can’t be done in Tanzania and their poor families cant’ afford to fly them to India. I wanted to listen to their heart and lungs to see if their conditions had changed. I grabbed my stethoscope and indicated for my mother to follow.

I said hello, introduced my mother, and listening to their little bodies making noises that shouldn’t exist. My mother said, “Would I be able to give them some crayons and coloring books? They are just out in the car.”

“Sure,” I said handing her the keys. She came back in with several coloring books and packages of crayons. I stood off to the side and watched her distribute the materials to the child patients in the area. She is a natural with children. Being an elementary art teacher, she showed them what to do with the crayons and books. I watched the kids as their faces light up with life and excitement. The 5 children in the area started coloring immediately.

I stood back and watched her communicate with these children and their mothers without any common verbal language. But, she didn’t have to say anything at all. I had been seeing most of these children with their mothers for the past month or so, and they had become used to me. It was a special moment to see these children and their mothers warm so quickly to my mother.

Later that night, my mother flew back to the States, and I can only imagine the stories she would tell, and what exaggerations she may use in retelling her stories.

Saturday, November 26, 2005

Clinical Journal

The strike among the interns and residents had been going on for 5 days. This day, they had planned to do a large demonstration and march from the hospital to downtown about 3 miles away. Four days ago, there was no qualified physician to see the patients for the ward rounds, and i had run the rounds with the medical students.

As Jeff and i were walking to the hospital, i said, “i have the feeling this is going to be a very interested day. i don’t know what will happen, but it will certainly be interesting”.

We arrived for the grand rounds presentation shortly before 8 am, and the door to the conference room was gated and locked. Certainly, no one had entered this morning.

“do you think we should see if anyone is up on the ward?”, jeff asked.

“sure, let’s go check it out”. we walked up to the second floor ward and said hello to the head nurse. she told us that indeed the interns and residents were still on strike. I asked if she thought anyone would show up today. She said she there may be someone coming to see the patients around 9 am. I started having visions of seeing the patients by myself, with the head nurse. I didn’t feel too comfortable with that. Given what was about to come, those feelings were justified.

Jeff and i had about an hour. we went to the little cafe next to the hospital building. I had a Sprite and a little donought. it reminded me of being on call in the states. there is always the morning after being on call. i would wake up all groggy and need something to put in my system to get it going again. i felt a little groggy this morning.

For the first few minutes, i just sat there, going over different scenarios in my head. Jeff started asking questions about our fellowship. he asked if he should forward an article about ‘brain drain’ to the larger fellowship group. “sure”, i said, “i think some people will find it interesting and it’s an issue that affects all the countries we are working in”.

Then, i saw a man selling newspapers at the front of the cafe. Here, newspapers are sold by people walking around the streets. No need for a newspaper box, when there is someone to walk around and deliver it to you. so i bought a paper.

The front page had the headline, “Muhimibi doctors end strike”. i read the article and it described how the residents agreed to a salary increase for nearly $200 per month to almost $380 a month. The increase was almost 80%. This is great i thougt, but clearly contradicted what i had just heard from the nurse. Originally, the interns and residents were asking for 1.2 million shillings a month, which is a little over $1,000 per month. A doubling of the salary seems more than generous.

After an hour, I went back to the floor and Jeff left for the office. Again, it was just me and the head nurse. I was ready to ask her what she wanted to do, and just then two attending physicians walked onto the floor. I was relieved.

Jeff had just sent me a text that said, “strike not over. paper wrong”. A few minutes earlier i had told the attending physicians that the paper reported that the strike had ended. they said, ‘oh, that is wrong. that was a statement made by the Ministry of Health. they are publishing their offer and the residents haven’t agreed to anything. the strike is still on.’

We started seeing the patients.

Most of the patients, despite not having care for the last 3-4 days, were doing remarkably well. “we have to discharge as much as possible”, Dr. I said. There were some typical patients, hypertension, diabetes, TB.

Then, we arrived at a patient half way down the long wall when the director of internal medicine for the hospital walked onto the floor. He is a very pleasant, well demeanored man who smiles a lot, and that just makes me smile. We had already been discussing the patient before us, about 16 years old and HIV positive. We were planning to discharge the patient and ask her to follow-up at the outpatient HIV clinic. I felt that if she could get home, then she would have more people to take care of her and she could receive her care on an outpatient basis. The director informed us that she hadn’t been told about her HIV status and that he wanted us to counsel her as well as her parents. This sounded reasonable, but i didn’t know when these replacement docs would have time for counseling. So we kept the patient on the floor.

Soon after, the director left the floor, and we continued seeing patients. Another patient that had been on the floor for awhile had a very distended abdomen. She had a lot of fluid in her abdomen, called ascites. I’ve looked up ascites in my Western medical books. About 80% of cases are due to liver cirrhosis, which is common in the US, given the high prevalence of drinking alcohol. There is no mention of Tuberculosis in my books.

In Tanzania, it is believed that most cases of ascites are due to Tuberculosis, called ‘TB peritonitis’. It is something that i have never seen in the US, and is quite rare. Here about 80% of ascites is due to TB and the other 20% may be liver cirrhosis, heart failure and other causes.

We had to take some fluid off this woman’s abdomen. She we did a procedure called a paracentesis. Basically, we stick a needle into the abdominal cavity and set up a small tubing that drains the fluid to a large bag sitting on the floor. We did this for the patient and her fluid was draining nicely. The procedure took us about 20 minutes and was a clear interruption of all the previous patients who didn’t require procedures.

The next patient we came to on the floor had an almost identical condition. Her belly was just as large, and immediately Dr. I and I knew we had to do another paracentesis.

Dr. I decided to hear the next patient’s problem. She clearly wanted a break. The next patient had a headache for 9 months, some confusion, and vision problems. I remembered seeing this patient with the medical students on Friday. We had requested a CT of her head. She now had the films but no radiology report. We clearly needed to serve as the radiologist and review the films with the patient’s chart.

“Let’s go sit down and review this patient’s chart”, she said.

We walked up to the front of the hall and she sat at the desk. There is only one desk and one chair. I was fine standing and declined her offer to have the chair. She kicked off her shoes, and took a breather. She didn’t look at the chart for a minute or two. She said, “can you do a venipuncture and a paracentesis?”.

“sure, i just need the supplies”. I waited for the nurse to get the supplies, since i didn’t know where anything was located.

I had unrolled the CT scan and was looking at a huge ‘space occupying lesion’ on the middle right side of this patients brain. We discussed it and couldn’t tell if is was filled with fluid or was solid in nature. She said a neurologist would have to look at it and take a biopsy.

Shortly thereafter, Dr. I rose from her chair, grabbed her purse and said, “come with me”. She motioned for me to come quickly and appeared hurried. I didn’t know what was happening, but i followed her and the other physician.

She grabbed a key and we left the ward through the office door. We walked into a small consultation room in the center of the building, between the two wards, and locked the door behind us.

I felt rushed and a bit uncomfortable, but i wasn’t sure why. I looked out the window and saw some workers. It appeared to be normal activity. “What is going on?”, i said.

“just be quiet”, Dr. I said. Then sat in chairs as quiet as a mouse, and i stood along the side wall.

After about 30 seconds, there were loud chants and a large gathering of people had entered the floor.

These people were the residents and interns! They wanted to ferret out anyone who was still seeing patients!

Almost immediately, they had arrived at our door. They turned the handle and tried with a great deal of force to open it. It was locked. My heart started racing.

I had now idea what would happen if they got the door open. Was this an angry mob? Would they attack us for undermining the efforts of their strike? Would they beat us for crossing the picket line?

They rattled and shook the door. They turned and turned the handle. The lock was holding.

Then, we realized there was an window above the door. The window had metal grating in one inch squares. We knew they couldn’t climb in, but they could certainly see in, if someone rose up above the door. So, we cowered up against the door. The two doctors were on either side of the door and i was crunched in the corner.

We watched the handle as they kept turning it and trying to open the door. They were shouting just outside the door. “they are in here”, one of them said.

Many of these residents and interns must be within internal medicine, i thought. These are the same people i had spent much of the last three months working alongside and building a relationship. We had clearly come into opposing forces. I was clearly angry at them for abandoning the patients on the floor. Now, they were clearly angry with me for seeing patients during their strike.

The key started to turn. ‘Were they able to manipulate the key with something’, i thought. One of the doctors turned the key back into place. We never took the key out for fear it would make too much noise. They continued to push and pull the door. The key would occasionally turn about half way and we would put it back in place.

The door was a cheap, frail East African door. Someone can easily knock this down with a good shoulder. Furthermore, the lock is cheap and no doubt being held into the wall by a couple of small, cheap screws. If someone really wanted to get in here they could.

We heard one say, “there are three doctors, two Tanzanian and one ‘muzungo’ (white person)”.

I realized i had left my bag on the main table of the ward. I wondered if they would take it as a punishment for seeing patients while they are striking. Damn, i left my nice digital camera in my bag. I really hoped it was still in there.

I started to look at the window as an option. The window had several glass panes, which could be rotated similar to venetian blinds, except there was no way to pull up the glass panes. We would have to remove several glass panes if we were to get out. Furthermore, we are up on the second floor, about 20 feet from the ground and we have nothing in the room to lower ourselves to the ground.

My heart was still racing. The handle was still being turned vigorously and the door was shaking on it’s hinges. There were many people talking just outside our door, and i couldn’t understand what they were saying.

I sent Jeff a text that said, “we locked ourselves in a room. r okay”.

he wrote back, “need help?”.

“no”, i replied.

After about 10 minutes of this activity, a note was passed under the door. It was written on a patient treatment form and said, “Habari zetu. Karibu, hata kama mnapata millioni msijifiche. Tumewaona. Tunawajua. Karibuni.” This means, “greetings. welcome, even if you earn millions, do not hide. we have seen you. We know you. You are welcome.”

A few minutes later the noise and commotion started to die down. They were leaving the floor and building. We just had to make sure they were really gone before opening the door and stepping into the hallway. We waited about 5 minutes and it sounded like all the activity was gone. Slowly, we opened the door and cautiously stepped into the exposed hallway.

Realizing the immediate danger was gone. We walked back down to the medical ward and walked through the double doors. Most of the patients were out of their beds and standing up watching us walk in. All eyes were on us three as we reentered at the head of the ward. They chatted among themselves and everyone seemed curious to see if anything happened. They also seemed anxious.

We went over and talked to the two nurses. One nurse described how she got into a bed with the patient and pulled the blanket over both of them.

They other nurse was more defiant. She said, “I just sat here. I told them i am in charge of the patients on this floor and i’m not leaving.” She seemed proud, as well she should. She told us, “they said, ‘okay mama, we understand’”. I felt a little compassion for the protestors, but then that quickly subsided when i reminded myself of their neglect of patient for money.

I then thought about my camera and bag. I went over and looked on the table where i had left it. It was gone! ‘SHIT!’, i think i may have said aloud. I can’t believe they took my bag! I started looking around. Then, i spotted it in the corner behind where the defiant head nurse was sitting. Ah, relief!

I asked her if it was okay, and she said she moved it for me and no one touched it.

I finally had a chance to ask them what had happened. Dr. I said, “i heard them outside and saw them coming through the open window. Then the head nurse said ‘they are coming’. So i knew we needed to hide.” The demonstrators wanted doctors to stop seeing patients and wanted people to join their protest.

After we quickly shared our stories, I thought we should get back to completing the ward rounds. After all, i had a venipuncture and a paracentesis to do. We also had about 10 other patients that still hadn’t been seen.

Dr. I grabbed her purse and said in the typical polite Tanzanian way, “okay, so maybe we will see you tomorrow. I’m going to go home to rest.” Before i had much of a chance to answer, she was out the door. Gone!

I thought, there is no way in hell i’m coming tomorrow morning. I’ll be lucky to come back on my scheduled friday morning if the strike is still occurring. Even if the strike has ended and i have to face the interns and residents, i’ll still be bit nervous.

I talked with the head nurse a little more before leaving. She was clearly staying on the floor. I asked her when she thought the strike would end. She said she didn’t know, but hoped it would be soon. She was clearly concerned with the patients, and my respect for her was growing quickly.

As i grabbed my bag and was leaving the ward, she said, “so how much fluid do you want to take off?”, referring to the women who just received the drain in her belly.

“Two liters”, i said.

I left the ward realizing we never finished our morning and didn’t even see about 10 patients. I didn’t feel good about it, but i was still scared.

Outside the building i saw one another attending physician. i went over to talk with him. He was treating patients on the same ward earlier this morning. He told me he was back in his office when they came. “i just locked my door”, but i could hear them out in the hallway.

he was rather calm and i asked him about the strike. “well, they currently make about $200 a month, and i think $400 a month is reasonable. They were asking for an increase of 600% and their salary would be doubled with this offer”. he said, “the interns don’t want the doctors to see patients”.

I agreed. After a little more chit chat i wished him a good day and started walking to the front entrance of the hospital.

I walked through the long outside corridor. As i approached the entrance i saw the crowd and some television cameras. I remembered i was walking past the administrative building. The large crowd seemed to be gathered around the admnistrative building, which was next to the main entrance. The crowd was rather large.

Upon seeing the size of the crowd i quickly realized i didn’t want to take the front entrance. I was carrying my white coat, a sure give away. I immediately made a U-turn and ducked into the main lab building. I walked through the building and it led me towards one of the back entrances. I saw several policemen dressed in full riot gear in the back of a truck.

i walked quickly and within ten minutes was at the back gate. I walked through the gate, breathed a sigh of relief and walked to the office from there.

I went straight to the office. i knew jeff would be in there and a bit concerned. I opened to the door to the office, smiled, and said, “i told you it was going to be an interesting day”.

We left to go have lunch and i told him the story.