Photos and Faces of Idunda

Departure?

After hugs all around, the big group has gone.  Gary, Carol, their daughter Jennifer and her friend Julie took the Land Cruiser and the luggage and left with Dennis driving.  Peter drove the Cruiser with only Don and Eunice, but the group will swell to 14 when the other travelers are picked up at Chilinze.  The new arrivals left Arusha where they were stranded because of the explosions here in Dar.  Their plane will arrive here about 10 PM (without them), mine about an hour later, still more or less on schedule, only 25 minutes behind last I checked.

Joseph will be picking me and another woman up at 8:30 PM to go to the airport.  He will pick up Kelsey in the morning for her 9:30 AM ferryboat ride to Zanzibar.  She will meet Amy Schulz and her two friends in Zanzibar for a little end-of-the-trip R&R.  For us, this marks the end of the medical adventure.  Kelsey and I spent some time debriefing the experience.  I think it is safe to summarize saying we both loved it, adventures and all!  She has some thoughtful comments on future rotations, which we will use.  I have great hope for our developing connections with St. Kate’s, IMER and Concordia.

For lunch we all went to “Steer.”  The receipts have “Magic Kingdom” written on them.  But I do not know if it is a subsidiary of Disney or not.  Could be!  The place is a collection of fast food restaurants in an American style.  There was an Asian one, a MacDonald’s style burger place, a bakery and a pizza place in this building.  On the outside were the usual street vendors.  Inside US, outside TZ.

The traffic was bad; no, horrific is more accurate.  It took 2 and ½ hours to get to the place.  We dropped Dennis off first at Wama.  I have no idea what that means.  The name of the business, I think.  It is where BkB buys their vehicles.  Two congregations have bought motorbikes for their partners and Dennis was hoping to get them shipped by truck to Iringa.  Unfortunately, they were buried far back in the container and will take several men to unload enough to get at them.  He felt thwarted. 

Dennis has been our steady pillar.  He is reassuring when we need it, confident when we need it, always wise, smart as a whip and widely experienced.  Dennis was adopted by Benjamin Ngede when Benjamin married Dennis’ mother Sarah.  I deeply respected and admired Benjamin Ngede and no less his son.

It is now 5:40 PM our time, 8:40 AM yours.  I am not sure just how much if anymore I will be able to write before I get home.  It has been fun keeping a little record of this month-long adventure!  I look at the ground below my feet, then at the palm trees here at FPCT and the Indian Ocean and realize I am very far away from home.  Very far.  It is a surreal experience, life changing in so many ways.  It isn’t just me that wants to share the stories.  My experience is that everyone who comes here wants to do the same.  The stories are endless, many tragic and heartrending.  Others are heartwarming and hopeful.  I can’t help but think I am a better person for having been here.  I hope you will come and see for yourself!

For me, departure tonight now seems highly likely.  In the mean time, follow Amy and friends and Kelsey at http://safarinjema2011.blogspot.com/

Ken

Update

Some good news.  The seminarians are found, alive and well, but wandering around aimlessly near Arusha, not knowing what to do with themselves and totally unfamiliar with Africa....

Nope.  They are a resourceful group and reached Jo at the Lutheran Center, who contacted Don.  Now bus travel is being arranged to meet the Tantanca bus at Chalinze, half way to Iringa.  Our group will leave to meet them at the rendezvous.

It is now 1:50 PM here.  The airport has re-opened.  I will go there tonight and hope my flight will actually take off.  Last night's flight will get in at 9:55 PM and should have left about 8:30 AM.  The KLM site doesn't list the actual departure. 

My flight is still scheduled and has left Amsterdam.  It is 25 minutes late, but I will suffer through that without complaint if that is the extent of it.  There was another blast this afternoon, but our understanding is that it was a scheduled detonation of a remaining bomb.  The tweets and news wires say there were 32 people who died in the blasts.  Reuters has a little story and says 20 are dead.

We are all well.  The Iringa folk will be leaving soon for a wait at Chalinze until the Augustana people arrive.  More breaking news as it happens!

Ken

Dar Mall of Tanzania

Bombs Away!

We are safe and sound in Dar.  It is around 9 PM.  However, there have been explosions for the last hour at a munitions dump about 2 km from the airport.  It is now closed and Don’ seminary classmates are stranded in Kili likely until tomorrow’s flight to Dar.  Of course, I hope things are back to normal by then since that will be the flight I take back to Amsterdam.  Apparently the government had been warned to move this explosive dump, but failed to do so.  One report said the fire that started this was from a thunderstorm.  Not so.  There is not a cloud in the sky.  The first couple explosions were really loud like thunder claps close by, but I immediately noticed they were not preceded by lightening.  It took a short time for me to realize the moon is almost full and there is not a cloud in the sky.  From some areas the eerie orange glow of the exploding bombs could be seen.  We are on the outskirts of the 10 K (6 mile) radius they have evacuated.  There have been some exceptionally loud explosions, but many, many less substantial ones.  Much of the info we have learned by watching “tweets” on the internet.  Instant news.

Regardless, now at about 10:30 PM, the explosions have been fewer and further between in the last 15 minutes, but still not finished.

It is now 12:30 AM, Feb 17.  There are no further explosions and the tweets have slowed.  I am not finding any new news on the web.

It’s morning.  The group stepped into my office for an update on the flight, the airport and the explosions.  We found this website: http://tinyurl.com/4c2rolu that tells the story, photo and all.

My office, you ask?  The wireless does not reach to my room, so my office is a chair on the sidewalk in line of sight of the office where the wireless originates.  I charge astronomical rates for my consultations, absolutely outrageous!  But hey, I have a captive audience.  Unfortunately, everyone has paid on credit for Tsh, so I am not holding my breath.  “The check is in the mail.”

I may write more about the pleasant day we had yesterday, but it pales in comparison to last night’s fireworks.  After breakfast we went to a shopping center.  Not quite the Mall of America, but big competition for the Burnsville Center.  We got a flat screen TV for the Lutheran Center, a new phone for Don, a pair of steam irons and more!  Lunch and shopping at Slipway were high-lights, and a very good dinner at a Thai place in the New Africa Hotel.  We did have a great time, but how can that compete with explosions?

I am hoping I have a ride to Dar airport when we go to pick up the classmates. We'll see how that coordinates.  By the time you wake up in seven or eight hours, much will have been determined and likely I will be at the airport waiting for my flight.  I can only hope!

Ken

The view from Idunda

Goats

The car doesn't tell the story. The view does!

Sunday in Idunda

 We awoke to the sounds of morning, roosters crowing and dogs barking - and a radio blaring.  The plan was to get up, go to the dispensary for a tour of it and the unfinished nurses’ residence and to deliver the medicines and supplies we had brought.  Next we would eat breakfast then go to church.  After church we would have our partnership meeting with the elders and leave promptly by 1:45 PM.  This way, we could stop at the secondary school where the Idunda students St. James supports attend.  Dennis said the way he came was faster and the road was better.  We would go home that way.  Unfortunately, this would preclude going to the school.  I had hoped to deliver the 80 letters our confirmation students had written to their contemporaries at Lutangilo Secondary School.  It was not to be.  There were another 25 letters or so written to the people of the Idunda congregation by adults and younger kids.  Many of the kids drew pictures to express their love and messages to our partner congregation.  The adults told about themselves and their lives at St. James.  I settled on giving the Lutangilo letters to the District pastor who could deliver them.  The other letters and the one from Pastors Walt and Will to the congregation I gave to Deacon Letson Chusi.

Before we went to the dispensary, Dr. Saga took me out to see the parsonage/guesthouse wall.  One end of the building had collapsed.  For those who have been there, it was the end facing the church, not the one with “St. James Idunda” inscribed on it.

The visit to the dispensary went well. There are two beds in small but separate rooms and a gurney in the main room.  The town fathers had been using one room for an office, but had moved out.  Nurse Annaliese had full control of the space.  All appreciated the medicines and supplies we brought.  We walked down to the residence, ample for two nurses.  Unfortunately, it was unfinished.  The roof and trusses had been kept and the mud walls had been removed, brick walls replacing the mud.  It still needs its outer coats of cement and all the interior work before it can be used.  The outdoor kitchen was a shell, awaiting the traditional mud wall treatment.  Progress had been made in the last two years, but minimal.  It will take 3.5 million Tsh (about $2500 USD) to finish it.  One alarming construction defect abounds and was obvious in Idunda.  Contractors might be told to make the ratio of cement to sand 1:6 (US would be 1:4), however, sometimes the contractor skimps on the cement to increase the profit and may use 1:10 or 1:12.  This cement quickly crumbles, as evidenced by the wall of the pastor’s house.  Dr. Saga impressed on them how important it is to monitor the construction of the building process so this doesn’t happen.  The floor in the church is crumbling too due to the same construction flaw.  It was poured in 2006 before Leann and Eric Benson were married there.  I told them in our partnership meeting that a floor done properly should last a hundred years.  I saw they understood my disappointment in their use of gifted resources.  In their defense, if it was done intentionally to stretch their resources, you can understand their desire to stretch the capital as far as possible.  I hope they have learned this is a false economy.

Church started 45 minutes later than we had planned, but for no reason that I could perceive.  This is Tanzania.  Once again, the choirs were stellar.  There was dancing.  You simply must be there to appreciate this marvel!   At first the choir nearly outnumbered the rest of the congregation.  As the liturgy began, people trickled in.  This week, all four preaching points came to the main church.  When it began to rain, the numbers swelled to standing room only.  I counted about 80 kids up in front sitting on the floor.  Total capacity is about 250.  I am certain there were twice that many.

And it did rain.  At times, the rain was so loud on the metal roof it was impossible to hear the pastor who was nearly yelling.  It continued to rain.   I could not help but think about our upcoming travel back to Iringa.  The rain did not bode well for us.

Near the end of the service, after we had introduced ourselves we gave our gifts and received gifts in return.  I offered the books Holly and Miriam had put together, the crosses from Bob and the shirt from Pastors Will and Walt.  We received beautiful kangas and lovely small baskets, not to mention four chickens and a huge bunch of bananas.

All four of the preaching points had brought goods for the post-service auction.  With the downpour the auction was not going to be held outside!  So an auctioneer from each preaching point began.  One of the very talented auctioneers danced as he worked the crowd.  I got a couple more baskets. 

Before the service, the pastor’s wife had offered an array of baskets for me to choose from.  We like Idunda baskets.  We probably have enough of our own.  Oh well.  So I said, “Mama will be very unhappy if I fail to bring her this basket,” pointing to the largest of the array.  “And my daughter will be very unhappy if I don’t bring her this one.  And my daughter-in-law needs this one.”  So I bought the whole bunch.  Then I had Msigwa translate this: “If mama is not happy, no one is happy.”  The pastor’s wife smiled broadly.  (Sorry Sweetheart.  It was humor at your expense.)

Unfortunately, as we were about to leave some other baskets appeared, but we simply did not have time to deal with them.  When we come back to Idunda, I propose we ask the women to make baskets for us to buy, so they know in advance we are interested.

Eunice said this was the largest auction she had seen after a church service.  Like the service, it went on for a long time.  Ultimately, we chose to leave before the end of the auction.  We still had lunch and a partnership meeting to attend.  While we were eating, I managed to print some of the photos I had taken.  The little printer I brought was a worthwhile gadget.

The partnership meeting was fine.  We reviewed the projects, the dispensary, the cement quality.  The pastor did say this.  “We thank you for the five bicycles you gave us.  We asked you for eight, but the five you gave us are working well.”   Hmmm.  I felt a little twinge of something at this apparent ingratitude.  I said, “So tell me about the motorbike St. James gave you.”  There was a brief silence as the turn-about-is-fair-play kicked in.  I didn’t mean to be vindictive.  “We still own it,” he replied.  Hmmm, I thought, still ”own it”?  “It is very old, six years.” Hmmm, I thought again.  I didn’t think that was very old.  “It isn’t working,” he said.  Then Msigwa said, “I still have the letter requesting 800,000 Tsh ($560 USD) for repairs.”  They had not been maintaining the motorbike since it was brought to them.  Understand that Idunda is a long way from anywhere, not so many kilometers, but winding, slippery, hilly roads.  Still, there is a reason to get things maintained.  This is not resolved for them. I don’t know what will happen at this point. 

Finally, we were ready to go.  Still raining and over an hour later than our scheduled departure.

Since you are reading this, you can assume we are all well.  You should know the trip home was harrowing.  Don eventually got used to the chorus of “Go slow, go slow,” especially from the Tanzanians who knew about the steep and slippery curves just ahead.  They are so polite though you could barely hear them.  I was white-knuckled much of the time.  We did get stuck three times, twice on uphill slopes, once in the drainage ditch.  Once I slipped getting out to help and got muddy head to toe.  Nothing hurt, uh, except maybe my pride.  Naaaah.

We arrived home, safe and sound, and with great relief.  Trish Bloomquist prepared another of her several tasty meals for us.  We recounted our thrills and went to bed.  The next day, we spent a long while cleaning up Gary’s Toyota Land Cruiser and prepared for our departure to Dar tomorrow morning. 

Idunda and Dennis the Hero!

Saturday

It was touch and go even yesterday, but the sunshine broke though on a beautiful Saturday morning.   What could go wrong?

First off, it rained all night.  The area needs rain.  It’s a blessing, but another day or two of dryness would not be disastrous for the crops and environment.

Second, Dr. Saga’s meeting, scheduled to start at 9 AM and end at 10, did not.  He was specific and adamant that it should, but the others involved arrived at 9:30, despite his admonitions.  Dr. Saga is an Assistant to the General Secretary of the Diocese.  This is an important position.  The fact that those others were late is more a cultural matter than one of disrespect.  He had said if they needed work on, he would leave the meeting in charge of someone else, which he did.  Our departure was to be 10:30 sharp and we did get going about 11 AM.  Not bad!

We were loaded!  That is, the vehicle was loaded.  We were all high on life.  We stopped at Ipogoro, a small village on the outskirts of Iringa.  Consider it a suburb.  The schedule was to stop at Lulanzi, photograph the dispensary being built, lunch at Idete and on to Idunda.  The paved road ends abruptly outside Ipogoro and from there, except for a 2 km stretch which is paved for some reason, the road is gravel or less….

We got to Lulanzi and took photos.  The original footings still showed the error.  The contractor had made them about double the expected square footage, if I got this detail correct.  Inside, Dr. Saga noticed one of the doorways was out of square and ordered it to be repaired.  He is an astute man, well versed in many things.  He served as general contractor (and bird-dog) on his own home.  (He is also an excellent physician, for whom I have deep respect.)

To our surprise, dark clouds were sneaking up on us from behind.  We got in the car, but rain quickly followed.   The road to Idete is “hapa, hapa,” which I believe is Kihehe for “bouncy, bouncy.”  The rain picked up.  We know we would get to Idete, but that would be a decision point.  We arrived at Idete about 2 PM, no problem.  Lunch was waiting, rice, chicken, beef, sauce or “soup” and ugali if I remember correctly.  Eating is always preceded by hand washing.   One of the women pours warm water on the hands over a pan.  It’s always drip-dry. Dr. Saga and I paid attention to the recommendations I made in my brief talk on diabetes.  We ate less rice and less in general.  Good for us!  The rain shower stopped and the sun shined.  We picked up District Pastor Patson Lubawa and started out again

The road to Idunda, well, road is a huge exaggeration, is long, winding, muddy, steep and not all that much fun, especially in rainy season.  We got stuck in the mud twice.  Both times, we got out with a little pushing.  Some parts of the, uh "road" are covered with grass, with barely visible trails.  Going was slow.  Even so, in one grassy area, the trail disappeared for a moment.  Suddenly, we found ourselves sliding off the bank and hung up on the steepest slope you can imagine.  An inch in either direction would have determined whether we noticed nothing and kept on moving or instead toppling down the mountain slope, end over end, rolling about 15 times.  This happened so fast, I didn’t even see my life flash before me.  Of course, I’m old, so that takes awhile.  Thanks to Don, we remained safe.  We got out.  The angle of the tippage was frightening.  We were completely unable to move the vehicle.  To our advantage, we had a winch.  Also, there was a strategic tree to anchor the winch hook.  (Don calls this serendipity a "God thing."  Be thankful for God things.)  Unfortunately, even with the winch we were stuck.  The truck was overheating, so we wisely shut it off.  Unfortunately, we could not get it started again.

As it happened, late the night before, the General Secretary, Chavala, called and canceled on us.  We were supposed to have two vehicles since there were so many scheduled to go.  We would have had five and four in each vehicle, instead we had seven in one vehicle. 

We were stranded.  There was no cell service where we were, several km from the nearest village.  Lubawa headed off to the village with Msigwa when it was clear we needed help to get out of our predicament.  Crazy wazungu!  We sat for an hour.  In the mean time, we had another shower, so we climbed back in the car.  About 6:15, Eunice was tired of waiting so she walked down the road to try her cell.  Amazingly, she got Gary!  (Consider it another God thing.)  Gary called Dennis, Dennis returned the call and said he would leave in fifteen minutes.   He did.  He said he would fly.  He did.  We knew it would be 3 and 1/2 hours.  Msigwa returned first with some boards we could use to dig away at the dirt we thought was the key to escape.  We needed a hoe or a spade.  Eventually, about 18 men and several young onlookers arrived to help, with hoes at least.  They dug away.  It looked helpful.  We needed a battery charge; the battery having been drained with the winch did not have the power to turn the diesel over fast enough to start.  Someone on a piki piki (motorbike) retrieved a six-volt battery, which did not work.  I think we were all crestfallen. 

To our surprise, Dennis arrived at 8:20.  After three more hours of digging and fussing with the batteries, it looked like we were ready to try pulling the vehicle out.  Finally, after several false starts, we were able to pull the vehicle from its one-foot-in-the-grave status without rolling it down the hill, potentially end over end.  Of course, it still needed resuscitation.  A tow chain was hooked to it and we pulled it to get it started.  Whew!  What a relief when the lights came on and we could hear it roar! 

By now it was midnight.  Don led the way with Dennis following.  It was winding, steep, muddy, slippery and treacherous.  We arrived in Idunda to the cheers of many, including the inhabitants of the two vehicles, at 1:30 AM.  We were bushed.  Even before we got out of the vehicles, one of the pastors prayed a prayer of thanks.  Naturally, he had prayed for our safety before each leg of our journey.  Members of the congregation danced and sang.  We ate silently.  We all slept in our clothes.

Last Night and Today

Leaving Ilula

It is Thursday evening here, 9 PM.  The guests have gone home and I should be packing.  But I will write for a bit first.

Kelsey and I found a new watering hole since the Peace Garden has not been open since the big group left.  It is called Namanga Grocery, after a region bordering Kenya and Tanzania. I know the gang would have liked it too.  We first went there with Dr. Mango and found the store is owned by one of the nurses at the hospital, Georgiana.  Somehow we told her about guacamole, one of the few recipes I know by heart, and told her we would make it for her.  We gathered the ingredients with the help of an acquaintance of Anna’s, our caterer.  Esther came running out to greet us, so for the price of a soda, she and her son Dominic helped us make the correct purchases.  We invited them, Anna, Tura and Lucy, the housekeepers, to our guacamole party.  We also ran into Dr. Mango at Georgiana’s Namanga Grocery.  Of course out of politeness we joined him for a beer.  He informed us that Georgiana was out of town, laying the permanent gravestone for her father, a custom to signify the end of 40 days of mourning.  She was to be the guest of honor!  So we invited our friend Dr. Mango instead.  Why stand on ceremony? 

The guacamole was excellent and most liked it (not Esther).  I brutalized myself when I sliced my finger fighting with an unripe avocado.  I hate it when I do that! The other doctor, Kelsey, repaired it with plastic surgery technique.  (A steri-strip from my first aid kit.  I didn’t need the morphine.)  I have a dirty bandage on it with tomato stains (no blood).  In the morning I will trade the bulky bandage for a BandAid, supplied by Anna, my own supply decimated by other minor emergencies over the years and never replaced.  Wow!  That sounds like Africa!

We had a great time.  Sadly, we will miss Anna, charming, attractive and a good cook.

Tomorrow we will say our formal goodbyes at devotions and morning report.  Sometime before noon, we will go to Iringa and spend the night.  We will leave for Idunda in the morning with a big troupe.  (As I write this, we had a big lightening strike and the power momentarily went out.  I think Idunda may still be questionable.)

Kelsey and I were chuckling about how we have adapted.  This morning I said to her, “Now there’s something you won’t see in the hospital at home.”  It was a chicken walking around the hospital wards.  The walls need patching and paint.  There are no screens on the windows, some of which have broken glass.  The only imaging equipment available to us is ultrasound.  Thankfully, Dr. Saga reads them well.  There is an x-ray, but simple as it would be to flash the film, it is not legal without a certified technician.  We have no hemoglobin reagent (coming tomorrow?), so our clinical assessment must suffice, crude as it may be.  We can test for HIV and malaria, contenders for diagnoses 1 and 2 in incidence.  We use syndromic patterns for most diagnoses, like Typhoid and acute watery diarrhea.

Friday afternoon at Neema

We have left Ilula.  We had many goodbyes this morning, several repeated several times.  All the people at Ilula were gracious and helpful, tolerant of our lack of Kihehe and Kiswahili, the local languages.

The drive to Iringa is beautiful.  We arrived safely.  At one of the phamacies, Kelsey and I put in an order for drugs we are taking to Idunda in the morning and cabbed the two big boxes back to the NSSF apartments.  

Tonight it is Roger Bloomquist's birthday and 11 are going out to dinner with him.  We still won't match any Tanzanian choir in our "Happy Birthday" song.  Our present to Roger (and Trish) is our presence at their apartment over night and Monday.

I am planning on having Monday in Iringa to do a little shopping, for what I am not quite sure.  Then Tuesday already we are tagging along to Dar es Salaam and the final leg of our trip.  Kelsey will be meeting Amy and friends to spend a few days in Zanzibar and me, home.

If you have read this far, you surely saw the photo of Kelsey dangling off Gangalonga, but don't worry Gail and Vance, you also probably guessed we rescued her!  Of course, it was a cliffhanger, as you can plainly see.  To know she is well, simply look at the Isimila photo, taken after Gangalonga.

It is now raining a torrent.  This is much needed, but only tomorrow will we know if we can get beyond Idete.  (This is a lot like the end-of-the-season shows on TV isn't it?  So stay tuned....)

Cliffhanger

In Ilula, February 6-9

Sunday Feb 6

The last several nights we have been without electricity for several hours.  It goes out about dusk or before and comes back on around 11 PM.  I believe these are planned outages.  Tanzania relies on hydroelectric power and without rain, no rivers, no electricity.  So this way they conserve.  All of TZ is in the same time zone, so there is no rolling across the country.  I do not know if all the cities are treated the same, e.g. whether or not Iringa goes out to at the same time Ilula does.  Last night was unusual.  Off at dusk, yes, but off all night.  This is not good at a hospital.  Currently, no pun intended, the hospital generator is offline.  It has been sent to Iringa for repair and should be back in a day or two.  I understand that the hospital will get another electric line to satisfy the growing need for power on campus.  That will be good, but not without emergency back-up.

We watched Jeremy Rifkin on my MacBook, downloaded last spring, if I remember.  It was very interesting, indirectly answering the question, “Why are we here?”  Not the existential question, but just why in Africa doing what we are doing.  It has to do with empathy, but read the book or watch the video on iTunes (Jeremy Rifkin, “The Age of Empathy”).  It is worth an hour. 

One of his over-arching ideas is that we (the world) need to have distributed energy instead of the centralized carbon-based energy sources we have.  Of course that means solar, geothermal, maybe wind in our backyards.  It would solve the problems in the poor countries, since development of a grid could proceed and isolated places like Idunda and even Ilula would be less dependent on the wait for the power grid. 

Sunday

What does a Tanzanian do for fun on a Sunday afternoon?  In general, have no idea.  But I know what we did today.  Kelsey and I skipped rounds this morning because I had promised to take photos and offer a greeting at the 8:30 service.  I have promised that I will take the message back to their partner congregation, Chisago Lakes.  My understanding is that no one from Chisago Lakes has visited Ilula.  They support one student, Felix, a nephew of Pastor Muyenze.  Felix just passed his Form Four.  Many, many students did not, especially at the public schools.  As an aside, a criticism of American teachers teaching here is that students are taught "to the test."  Profs teaching at Tumaini U report the inability of students to think critically, a consequence of teaching to the test.  Sounds like a criticism we hear from teachers at home.

The Ilula Lutheran Church wants their companion to know about them (and visit).  They have plans to enlarge their church and finish the pastor’s residence (100 bags of cement for the house).

But the big deal this Sunday was that their youth choir was having a fundraiser to buy guitars, an amp and a mixer, 2,000,000 Tsh (about $1350 USD).  At 2 PM we went to the District Office, near the hospital and the church for this celebration.  The choir sang many songs and there was a featured guest speaker.  She is a professional singer, I think originally from the church.  Then there was an opportunity to contribute.  After that, an auction for a special cake.  Between the two, I emptied my wallet.  I still didn’t win the cake.  (Don’t worry Sweetheart, there wasn’t that much in my wallet at the time.)  The woman who did win, Rita, a nurse at the hospital, donated it to the party and everyone had a little taste. 

We were served lunch.  This is the way in Tanzania.  By about 6 PM, the party was over.  Our caterer, Anna, found a locked door at lunchtime since we were gone, which meant she had to make a second trip, which she did without complaint.  I know she likes us, but she is gracious to a fault!

Tomorrow we have visitors from BKB so we will accompany these wazungu to Image school.

Monday

I have a haunting image to share.  But I have decided not to upload the photo of a baby with end-stage HIV.  The mom brought the baby to clinic with profound malnutrition and deadly dehydration.  If the baby has HIV, so does the mother.  The infection may be passed in utero, but also in mother’s milk.  So she needs drugs during pregnancy and after if possible, if the baby is to survive.  Sharing the photo would be an effort to bring to you the reality of this devastating disease, but you will need to take my word for it on this one.  The infant died about two hours after admission to the hospital.  Can you imagine the anguish of the parents?  First the emaciation, then profound suffering and finally death.

On a happy note, the wazungu arrived.  The first stop is always the administrator’s office for a history of Ilula District Hospital.  Dr. Mango is always gracious and hospitable.  Next I got to lead a tour of the hospital campus.  Despite being a small group, I gave them the full load. Pastor Marty Ericson had several along from Como Park Lutheran and others from Immanuel or friends of Immanuel: Dick, Jim, Barb, Phyllis, Terry, Al and Sue.  I think I got everyone’s first names.  Friends, pole sana about your last names.  (At least two who were planning on coming were rerouted from Cairo to Europe, then back  to the US.)  We had box lunches they were kind enough to bring and Kelsey and I accompanied them to Image School.  Terry stayed with Dr. Saga.  She is a nurse who practices healing touch.

We had great conversation on the bus to and from Image.  They dropped us off and were on their way to River Camp near Iringa for dinner.  Speaking from experience, they will enjoy it!  Thanks for coming to Ilula folks!

Wednesday, February 9

Yesterday it rained all afternoon.  It REALLY rained.  None of this brief little shower business.  The 5 gallon pails the staff collects rainwater in to boil for coffee were filled in minutes.  Of course that’s run-off from a roof, but it rained hard.  The rain is badly needed for the crops.  I am thankful for the rain, but it raises a cognitive dissonance.  If there is rain in Idunda, we may be unable to go.  It is simply too dangerous.  The mountain roads and sheer slopes can swallow a vehicle.  When we were in Idunda in 2006, we had some wet roads and even got stuck on the way home. We simply need to be prepared not to go if they have had rain for three days before or if they have one rainstorm like we had here.  It means the medicines and gifts may have to wait.  The pastor at Idunda called Dr. Saga this morning to report the roads are good, but I am quite sure Dr. Saga was not convinced.  We will see what the weather brings us in the next two days.  Both Kelsey and I would truly miss the opportunity, but there is real danger.

The bishop was here for a meeting yesterday (lasted several hours), but had no need to greet the wazungu.  I think the Bibis (my mom and Nona, the Bibis) were the main reason we had audience with him in 2008.

This morning I delivered a short lecture presentation about Diabetes 1 and 2.  I made the Power Point from memory (I was glad to realize I know some stuff after feeling so lost the past couple weeks).

The Tanzanians were certainly engaged and asked good questions at the end of the talk.  It was very fun.  Today rounds went well with Dr. Sevelo, who is a good teacher and patient with the wazungu.  I delivered a short bedside treatise on a common fungal infection.  I couldn’t help myself.  I finally knew about something!  (Ok, it isn’t quite that bad.)

Early this afternoon, Kelsey and I walked into town.  A woman named Esther, who I thought was all of 16, recognized us and introduced her son of about that age.  For the price of a Coke, they helped us find the makings for guacamole, a recipe I know by heart, but the Tanzanians are unfamiliar with.  It was to be a demo for one person, but now we will invite a few others to try it out.  It will be close to a wazungu party.  An African party would surely include music and dancing.

Isimila Stone Age Park

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