Ilula

Feb 1

 It is evening.  I am sitting on the Guesthouse porch, looking out across the savannah to the very old mountains. It is warm here, about 85 F. The clouds have been rolling in, there is thunder in the distance too, but this has happened several times the past two weeks without bringing the rains.  I have developed a favorite mountain, though I am sure to the mountain it hardly matters.  There are gray clouds above it that earlier blended with the mountaintop.  This time of night, nearly dusk, that mountain looks like a blue screen with the mountain projected onto it.  It’s north and the road to Image school and village heads toward it.  In the west, the clouds have mostly cleared, but the sun sets far enough south that the view of the sunset is blocked.  It has been hot today and just now cooling a bit.  In the air is the scent of burning grass.  I don’t think it presents any danger.  The view is spectacular.  The only thing marring the view is the satellite TV dish directly in front of me.  Africa is a place of contrasts and contradictions.

Earlier, Tura and Lucy, the housekeepers, who speak mostly Kihehe and Kiswahili, were watching a Spanish soap opera dubbed in English.  They were rapt.  I didn’t laugh but seeing this over-done soap performance I found quite comical.

Kelsey and I walked to Anna’s café to buy some water.  She had a couple of singles, but knew we needed a couple boxes.  She walked us to the duka that had the water, we paid for it and she insisted on carrying one of the boxes – on her head of course.  So I tried my, uh, head at it too.  I needed both hands.  Then she called to one of her young friends.  I think she has daughters the same age.  The girl, form 4 in school, is named Esther (hi mom!).  Of course, she grabbed the box, deftly hoisting it to her head.  They walked us all the way back to the Guesthouse.  There is no arguing with beautiful Anna.  She and Esther left, so I thought it was safe to wash my handkerchiefs and my sandals.  Nevertheless, I felt guilty and hoped I would not be caught!

The contrasts and contradictions do not stop with the ancient and the modern.  Dr. Saga went to Iringa today, so Kelsey and I made rounds with Yunfwa Sovelo, MD.  He apparently is finishing his internship and today was his last day at Ilula for nine months, if I have the details correct.  I think he was sponsored in medical school, so the hope and contract (unenforceable) is that he will return.  He is highly knowledgeable and a great teacher.  I hope he sees the light and will spend a few years here.

Today we saw pellagra, a vitamin B3 deficiency that causes dementia, diarrhea and a terrible skin condition.  The elderly man had lived on pombe too long.  We saw Kwashiokor in a child about nine months, with a swollen round face, swollen legs and deteriorating skin.  Yunfwa said this could be corrected in three weeks with proper nutrition, which the child will get here in the hospital, but will take three months if his mom can afford the formula and uses it, since he will be discharged before he is better. 

We saw a very old man actively dying.  His devastated son asked Kelsey if there was something we could give him to ease his pain.  They have morphine here, which is what we would give him at home.  The situation is subject to the “double effect.”  That means that in giving him enough to make him comfortable, we might give him enough to suppress his respirations.  I do not yet know what the cultural norm is here.  We will ask Dr. Saga.  At home, this creates terrible cognitive dissonance.  Doctors often fail to give enough morphine to alleviate the suffering for fear of legal repercussions.  Think of the fear mongering surrounding “death panels,” so feared by some.

Kelsey saw a normal vaginal delivery, but the umbilical cord stump was swollen and hemorrhagic.  Was it simple cord trauma?  This happens.  Or was it a sign of intrauterine infection?  We started antibiotics.

We were worried about a 12 year old with peritonitis.  As it happens, she was too sick for the surgery she would have gotten in the US.  She died today.  It’s complicated.  No malaria smear, highly unusual.  No hemoglobin – ran out of reagent to perform the test.  We suspect she somehow had a perforated bowel.  This could happen with appendicitis or a parasite and even typhoid.

Now in the quiet, we reflect on the above cases, intellectually, pragmatically, compassionately.  Never forget that despite the terrible stories we write about, these are caring people, doing the best they can with what they have.  We can best help by working shoulder to shoulder, helping with incremental improvements.  Above all, be thankful for what we have at home. 

Ken

Feb 2, my birthday

And memorable it was, too.  After all, I am in Africa!  Of course we did rounds this morning.  In fact, it was consultation rounds with Dr. Kawono, Dr. Ndipisi and Dr. Saga.  We have been pondering a 48 year-old woman with ascites (fluid in the abdomen).  Unlike the Pellagra man, she does not imbibe, a common cause of ascites in the US.  The main other differential point would be cancer at home.  There are heart causes and liver causes too, but they are not in this picture.  TB is, however.  She is already treated with standard antibiotics, so it likely is not Typhoid.  Now a dilemma.  We have no tests to determine what she has.  Even doing an open biopsy won’t help, since the nearest pathologist is in Dar.  We cannot culture, we cannot image.  She cannot afford to go to Dar.  Ultimately, she was committed to a course of anti-tuberculosis drugs.  They are toxic to liver, but it seemed the best choice.  The only choice for her.

Dr. Mango, DDS, MPH, and his dental staff did a nice presentation on complications of pulling teeth.  They are doing a week-long series on dental problems for the medical staff.

Birdie spilled the beans about my birthday and Don Fultz called to wish me and sing me happy birthday.  He has a good voice.

Later Dr. Mango kindly brought me his last week’s worth of English papers.  He took Kelsey and me to get today’s edition and then bought us a beer.  His family is in Dar and he only sees them every two months.  So we had a party of four.  Georgiana, one of the nurses also runs a little duka, which supplied the beer.  This time, Kelsey, the only one I had told, spilled the beans about my b-day.  So they sang happy birthday to me for the second time today.  No cake though.  I think I will ask for a chocolate devil’s food cake with Bunny’s boiled chocolate frosting when I get home.

Feb 3

The porch again.  I napped nearly an hour and a half this afternoon.  My favorite blue-screen mountain is back today.  We did get a little rain yesterday.  It wasn’t an all-dayer unfortunately, just a teaser, but real rain, not just sprinkles.  Kelsey was reading, trying to figure out a patient from rounds.  I joined her and read a couple hours from “Tropical Infectious Diseases.”  Interesting reading, but there is definitely stuff the average person doesn’t want to know.  It’s fascinating reading about things we are seeing daily here that I literally haven’t thought about since med school.  On rounds, Dr. Christopher Mbata asked me how long I had been practicing medicine.  “Thirty-six years,” I answered.  “But I am a baby in tropical medicine.” 

There are many questions we do not ask.  They fall into several categories: 1) questions we cannot ask because we do not have the equipment or tests (gee, I wish we could get a CT scan), 2) questions of curiosity where we won’t use the information in treatment (at home it’s “Doc, should we get an MRI?”), and 3) questions we do not want to know the answer to.  A version of this last question is nevertheless asked frequently, “PITC” or Provider Initiated Testing and Counseling: Rapid HIV test.  The docs are very careful about this test.  You can infer it is ordered surreptitiously.  Important as it is clinically, it is also stigmatizing.  Unlike the US, where we give information very directly, as Dr. Saga says, here the results are given obtusely.  The HIV positive patients are members of the CTC Clinic (Counseling and Treatment Clinic), where they receive education and Anti-HIV medicines, provided free by the government.  The ratio of M:F is 1:1.4 overall, but in 15 – 25 year olds, it is about 20 times more prevalent in women.  Some of those young men get around!  It is 95% heterosexual transmission if you are curious.

A huge concern is that possibly 35% of Tanzanians are HIV positive.  It is important to see HIV as a chronic illness that can be controlled.

Kelsey and I fretted about a child with pneumonia and wheezing.  They do not have the inhaled meds we use routinely at home.  They still us aminophylline, which we essentially abandoned 30 years ago, due to narrow therapeutic range (toxicity) and low effectiveness.  In general, with some obvious exceptions like this one, the national Tanzanian formulary has most drugs equivalent to drugs we have, just not the massive variety the US has.

We finished rounds and attended the dental education session being held daily this week.  After the conference, we attended the Perinatal Mortality Committee meeting, where every maternal and newborn death is discussed, with attention to what could be done in the future to avoid similar problems.  As an example, on infant died after mother’s uterus ruptured.  She had had a C-section for her first baby.  She went into labor and did not come to the hospital as she had been instructed.  In the US, we do many vaginal deliveries after C-section, but they all must be in the hospital and observed closely to avoid this problem.  She likely would not have lost the baby had she come to the hospital.  The Ilula staff is very capable at doing C-sections.

Ken