African House Calls

Kendu Bay

2011-11-06T09:15:00.000-08:00

Discussing our upcoming trip to Kendu Bay.

The final destination and, by happenstance, the birthplace of President Obama's father. We did make the pilgrimage. Apparently he was a troubled man who died quite young.

We met with M.P. Rege on Saturday morning and then toured the Kendu District medical facilities. Our first stop was the newly designated District Hospital. It had been the sub-district hospital but when the district was divided last year, it became the major facility for the area. Not that that changed anything. The funding remained the same and there was nothing available to upgrade nor to add surgery to its capabilities. It is a sad, chaotic, disorganized, poorly run place. There is one physician sent there as part of his government service who has little interest in the place and the work and he freely admitted that. He plans to be there only three days a week and return to Nairobi to build his private practice. There are two Clinical Officers, equivalent to our Physician Assistants, but these two are not well trained and rather poor clinicians. More on that later. Our tour took in the now sub-district hospital and that was wonderful, organized and with a devoted staff. We were most impressed. How well they practice medicine is something we will have to discover. On we went to the rural clinics of which there were four. Two were being constructed and we could obviously not make any judgements. One, which was right on the lake shore in a small fishing village, was a lovely large facility built by the Japanese. Sadly it was staffed by an incompetent nurse but fortunately she saw perhaps 5 patients a day. I did tell them that the clinic should be closed, the nurse retrained and sent where she could be supervised. The final facility was at the opposite end of the district and was busy. It, too, was run by nurses and will require much work but it was needed and could not be abandoned.

We spent the week at the District Hospital and each day it became more discouraging as the practice of medicine was atrocious. Patients wait long hours to be seen which was not necessary. They were sent immediately for the few lab tests that were available and generally were treated for all possible ailments despite negative tests. No attempt was made to obtain a cogent history nor to perform a physical examination. Usually they got treated for malaria, pneumonia and typhoid. It was not surprising that the pharmacy had run out of most medications and did not expect a re-supply for two months. This meant that patients had to purchase the drugs in town if they could be found. The World Health Organization estimates that 25% of drugs in Africa are counterfeit so that adds to the terrible outcomes that occur. Similar circumstances exist on the inpatient units.

The last visit we made was to the Seventh Day Adventist Hospital a few miles out of town. A large complex that had been established over a century ago. It has a close affiliation with Finland ( I will find out more when I go back as to how that came about). An excellently organized facility which has Clinical Officers and Nursing Schools. We were invited to teach there and likely will but our major effort will be at the District Hospital.

Sadly I could not take pictures as my camera battery died and none were available but when I go back in January, I will rectify that so that you can get a better sense of the reality that exists there. It is a very sad sobering thought that there is more equipment in Lewiston-Auburn, Maine than exists in the whole of Kenya, a country of 28 million people.

This will be the last post until I return to Kendu Bay in January. I wish you all a wonderful holiday season and the time to reflect on all the blessings that we have had in our lifetimes.

As I am in the process of establishing a charitable foundation to assist us in our work, I would ask each of you, if you feel it appropriate to share this Blog with friends and relatives.

Ukwala & Matibabu Foundation

2011-10-16T09:26:00.000-07:00

The top picture is of me teaching at the Ukwala Clinic and underneath is me again on the road to Kisumu

Onto the second site-the clinic and soon to opened hospital at Ukwala, a small town north of Kisumu near Lake Victoria. First into their Nairobi office to meet the country director, Daniel Okala, a diminutive man bursting with ideas and enthusiasm. It was impossible not to get caught up in them and imagine phenomenal health care rolling out from this center. A discussion about my possible role and then back to Kenyatta airport to catch the flight to Kisumu and from there the ride to Ukwala. Naturally no one was there to meet me but, whipping out my trusty mobile phone, I was able to contact dear Winnifred and about 30 minutes later, the driver did show up. Seems they were in Kisumu buying water for me. Heading north on a real tarmac road, dodging potholes that threatened to swallow the car, the driver, probably about 20, wanted to overtake anything in his path. After about 90 minutes, we swung off onto a dirt path and followed the same drill. Around dark we got to Ukwala and I was deposited in the Parish House where there were quarters for the volunteer staff. Met and had supper with the area priest, a delightful man with, sadly, severe rheumatoid arthritis. Meanwhile John who had traveled by bus was stuck somewhere and did not make it to Kisumu until midnight and stayed overnight there. Evidently the gendarmes were out in force checking on vehicles to be sure they had the proper inspection and insurance documents and were not overloaded. Since few of them had any of the necessary certificates and most were overloaded, there was a long line of vehicles taking devious circuitous ways around the roadblocks. He did finally get to Ukwala the next day at lunchtime.

Onto the clinic-a good facility and well run. Met the doctor who was frosty. I do believe that she was concerned for her position. I worked with the clinical officer in the morning and there were very interesting patients to care for-malaria, infant with HIV and kwashiorkor, young man with granuloma inguinale. On the walk back to the parish house where John was waiting, I noticed a government clinic across the road. It appeared well staffed. In the afternoon we walked out about 2 kilometers to see the new hospital that was being built. Lovely location in a large field with a good view of the surrounding hills. It was quite large, a cement structure, built in tukal style with a diameter of about 100 meters. It had 10 patients rooms with one bed each but could expand to two beds/room. Each room was being equipped with tv and Internet connection. Two nurses' stations with total visual contact. This is to be a pediatric unit and there are plans to expand to a 200 bed women and children's hospital. Wonderful design and idea but what I believe is a waste of resources for the reality of the area that it was in. You could build a more practical structure at less cost and use the monies to purchase diagnostic equipment and an adequate supply of medication. They have received money from their American sister foundation, Tiba, and the Clinton Foundation as well as Pepfar money. Still, from my experience, those sources tend to dry up and you are, all to often, left with nothing to continue. One year in Darfur we were functioning on $250,000 and the next, we were expected to expand services on $150,000.

Day#2 here in Okwala-back to the clinic and there were only a handful of patients so that we were done by 1100. Across the street the workers at the government clinic were on the veranda reading and chatting as they also had little to do. At lunch John and I decided to leave at it was clear that, at this point in time, they really had no need of us. This was Friday, the 26th of August. Luckily the priest was leaving after lunch to go to Kisumu. We called our contacts there, clambered in Father Fred's car and off to Kisumu to spend the night and move onto Kendu Bay on Saturday. But, like "The Perils of Pauline" that adventure will have to wait until later.

IN THE BEGINNING

2011-09-26T13:35:00.000-07:00

Day#1

The great luxury of the Flora is the ever-ready HOT shower and, after 10 minutes in Nairobi, you need it. The usual buffet breakfast, if one is lucky and I was, has some fried eggs instead of the ever present gruel and wonder bread. John was late and I was restless so I got a cab to take to the first place we were to visit, the Ushirika Clinic in Kibera. I had to get Kenyan schillings (they refer to them colloquially as "bob"). Now what I rather slowly discovered after 4 different ATM stops is that the Kenyan banks abhor MasterCard (which I possessed) and love Visa (which I don't). So by the time I got to the Clinic, there were John and Kennedy Obuya waiting for me. Kennedy is the chief of security for James Rege, the MP whose district includes Kendu Bay. We did tour the clinic and met the personnel (pictures included). and then made plans to visit Kibera itself the following day.

With Kennedy's help, I did get my "bob" and at 95 to the dollar you do feel flush until you actually buy something. Inflation is galloping here in Africa. In Kenya in July and August alone, inflation was over 30%.

Later around 1700 we did met with James Rege and and the mayor of Kendu Bay. We did arrange to tour the medical facilities there with him on Saturday. Then back to the Flora. Supper was over so we took a cab to the local version of Burger King/Kentucky Fried chicken, sipped our beers and discussed the plans for Tuesday.

Day # 2-Tuesday, August 23rd

We met with Kennedy and a Nairobi detective, Lawrence, who lives in Kibera. Kibera (pictures), although physically one huge slum is actually divided into villages and the various tribes congregate together in separate ones. The ones that are allied are closer together and separated from the other non-allied so the Luos are separate from the Kikuyu. These two are the major rivals. But, like brain chemistry, that is a very simplified version and there are many nuances. As you look at the photos, you will see the open sewerage running by and the children playing in and nearby. As for children, you can see how much like the Pied Piper, John truly is. A return to the Clinic for more discussion of their needs and then a visit to a government clinic just at the edge of Kibera. We met there with the"personal assistant to the prime minister" or so his card read and he promised to send us a report on which clinics he felt would be in most need and be most reliable. He never did!

Then back to the Flora. This time we did make it to supper.

Back in the Land of the Round Doorknob

2011-09-19T13:10:00.000-07:00

A long trip and a long goodbye but only for a time and, perhaps, this time it won't be so long. Certainly not four years.

Forty hours on the road. The trip to Portland, a sad "aufwiedersehn" to my dear Gerda. The usual lousy movie on the bus but, if you leave the sound off, it ain't so bad as you can create whatever dialogue that pleases.

The airport, checking-in and taking off the belt, shoes and pockets. Through the body scanner-a bit more radiation to add to the rads that I have accumulated over the decades. A bit like the 1/10% benzoate of soda that now percolates through my vessels. The long flight to Frankfurt, a race through the endless corridors and moving belts to get to the short trip to Zurich. The same at Zurich. I used to get excited to get my passport stamped. Made it to the Nairobi plane with 15 minutes to spare and, mirabili dictu, the flight was only about 1/3 full. The shear joy and comfort of stretching out on two whole seats and actually sleeping.

No mishaps and the long line to get my visa-what a beautiful picture I take. Finally out the door and there were my friends waiting, Dr. John Ott and several others that played such an important role in facilitating this trip.

First though there was Bernard, a student whom Gerda has sponsored for years. Grown up and now beginning his third university year. Then a hand-off of a bag of clothes and books that I had brought.

Then there was Kennedy, an aide to James Rege, member of parliament, and he is very important to this tale.

Two students of John's rounded out the group and, of course, Winnifred, the representative of the Matibabu Foundation whose clinic I had promised to visit during this trip.

Greetings, handshakes all around and then off to the Flora Hostel, a place that Gerda and I stay at when we are in Nairobi. Run by the Carmalite Sisters, it is very tidy and the fee includes all meals. It ain't the Ritz but it quite safe.

Into bed and finally more SLEEP. In the morning we go to Kibera, a huge slum on the outskirts of Nairobi, reputed to be the largest in the world housing over 250,000 people, where we were to see a clinic, Ushirika Clinic, that we might support and work at.

So now I will sleep and then when I can I will continue with the story of this trip. Futher episodes to follow in the amazing adventures of Dr. Stephen.

Reserection

2011-08-19T14:01:00.000-07:00

It begins again. Finally after almost 4 years, I will be on the road again. I leave tomorrow to Kenya where I will be for almost three weeks. This time I will be looking at several clinics around the country. The first will be in Kibera, a huge slum on the outskirts of Nairobi. On Wednesday, I will likely fly to Kisumu, a city on Lake Victoria and visit two clinic/hospitals one about 50 kilometers north and the other the same distance south. I will spend about a week at each to hopefully, decide which one(s) I want to devote my declining years to assisting. I will take pictures of all and post them when I can and I will write of my adventures as I follow Burton and Speke looking for my source of the Nile.

Stephen

still hoping

2011-04-19T14:06:00.000-07:00

I am still negotiating with folks in Kenya and, hopefully, something will happen soo.

WAIT

2011-02-04T13:56:00.000-08:00

I am still waiting for more information about Africa. Hopefully, soon.

Possibilities

2010-09-18T08:58:00.000-07:00

Howdy once again after such a long time.
I continue with the University of New England for now. I almost went back to Sudan but I got word from a good friend there that the program was poorly run and decided not to go. At present I am with a few good colleagues trying to set up our own NGO and start work in Kenya.
I will keep you all informed of our progress.
Stephen

The Visitations

2009-12-12T09:14:00.001-08:00

Two down and one to go! Though the one will only be with a Washington staffer of Senator Snow and that will be on the 18th. Meanwhile Gerda and I have met with Representative Michaud on Sunday, November 29th in his Lewiston office and Senator Collins through a video-link on Monday, December 7th. Both were very attentive though it was a relatively short meeting with Collins as she had other meetings scheduled. Let me detail the encounters individually.

Michaud: Very knowledgeable about the details of the bill and very sceptical about it and without much hope of meaningful change. He does want the government to negotiate with pharmaceutical and insurance companies over costs and does want a vigorous public option. Finally he was very upset about the Stulpak amendment and does not expect that it will stay in the final bill though there likely will some restriction on abortions.

Collins: We did agree on a number of points as cost containment and that the bills as now presented will do little to change that. She did seem surprised to learn about the waste of monies here in Lewiston-Auburn. There was little time for discussion. I have asked for clarification and explanation of one remark that was left dangling-that she was opposed totally to any government plan. So far, no reply.

And that's the update from here in L/A
where the women are strong
the men, good looking
and the children above average.

Stephen & Gerda

Vigorous public option necessary to cure health care problems | Sun Journal

2009-12-08T17:10:00.000-08:00

Vigorous public option necessary to cure health care problems Sun Journal

An Early Holiday Gift for the Big Pharma

2009-11-26T08:01:00.000-08:00

Well it is now the holiday season and we all look forward with gratitude for what we have to a wonderful season with family and friends-the true gifts of this time.
Our friends at "Big Pharma" evidently have been so excited that they could not wait and decided to give themselves an early gift by raising prices this year so far a whopping 8.9% despite the fact that the Consumer Price Index (CPI) has fallen 1.3%.
It would seem that after careful reflection they were very uneasy about the 8 billion dollars that they promised President Obama in yearly price reductions over the next 10 years if the government would not start negotiating prices for medicare or other government programs. A bit like going into the local store when they have those end of year sales-10% off the 25% mark-up.
The usual argument is heard round the corporate tables. If we do not do this, why then research and development (R&D) of those vital lifesaving drugs will stop and we will all suffer unspeakable consequences. Let's take a closer look at this claim, as who would be so selfish and un-American as to want to be responsible for all that misery.
The ten biggest pharmaceutical companies had total sales of 269 billion dollars in 2008. Of this only 42 billion (15%) went for R&D. The vast majority of R&D money comes from the National Institutes of Health, our tax dollars at work. The other 30% comes from foreign laboratories. Additionally the vast majority of these drugs were "me too" products that added nothing to health care. Of the 667 new drugs approved from 2000-2007 only 75 (11%) were either new important additions or a significant improvement on an existing product. "Big Pharma" made 49 billion in profits (18%) in 2008. Now that's good business as the average for all Fortune 500 companies was a paltry 0.9%.
To ensure it's place "in the sun", "Big Pharma" spent 55 billion for lobbying, political contributions, front groups as "patient advocacy"and" independent" think tanks.
Education is a major part of this money. Hundreds of "detailers" scurry around the country to educate doctors that their drug is the best and has the least side effects. As part of this process free meals are given, meetings are sponsored and gifts with the drug name inscribed are distributed. For the consumer ads and free first prescription offers abound on television and on the Internet. While researching this Blog entry, I have bumped into Lipitor at least 5 times.
One of the most fascinating aspects of this (for me) is the creation of new disease entities to expand a particular drug's market. We now have "Social Phobia Disorder" and that can be treated. A few years back, those folks were just shy and considered normal. Up to 7% of American children now have Attention Deficit Hyperactivity Disorder and are medicated with who knows what long term effects. Years back they were considered variations of normal and sent out to the playground to "run of some steam". Interestingly in Great Britain, the estimate is only 1%. We now have children as young as 3-4 being labelled as Bipolar and treated again with unknown long term effects on the developing brain. Turns out that the physician that did the studies was funded by the very pharmaceutical firm that manufactures the medication.
And so in this season of joy and gratitude, we should all reflect on our health care chaos, realizing that all too many of our fellow citizens and other folks that we invited here have no regular means of getting help when they are ill. We must change this. Then this season will have a real meaning.

Stephen

For those who would like references, go to the website of Physicians for a National Health Program--- pnhp.org. There, look up work done by Dr. Marcia Angel, former editor of The New England Journal of Medicine.

THE REPLY

2009-11-18T18:59:00.000-08:00

Dear Senator Collins,
Thank you for your recent response to my concerns about health insurance, the reform process and its impact on health care here in America.I am deeply disappointed by your reply and I do hope that it was written by one of your staff as it shows a complete lack of understanding about this most important issue. Additionally the "non-partisan" Lewin Group that you cite is a subsidiary of United Health Care, a large corporation that sells (would you believe) health insurance. To use them as a resource is disingenuous and only obfuscates discussion on this issue. Obviously you have little knowledge of how the rest of the developed world functions and functions well as opposed to our totally inadequate and grossly unfair system that seems only to penalize the ill and helpless. Are you aware of the number of Americans that die yearly because of a lack of health insurance and thereby a lack of adequate health care, approximately 45,000 and of those close to 3,000 are veterans who served their country. Are you aware that the majority of bankruptcies in America are due to medical bills and the majority (75%) of these folks are working. I have two children with pre-existing conditions who cannot afford insurance. You ignore the fact that a public option does not obligate anyone to give up their present plan if they are content. I do believe that, as drug companies are now rapidly increasing their prices, the insurance industry will simply raise premiums to ensure that their obscene profits continue.
With respect I urge you to examine this with greater care. It is one of the most important issues today. Our system is in great danger of collapse and nothing in the Congressional bills seems to want to recognize that. You are all too beholden to the insurance industry.

Sincerely

The Forces of Darkness and Evil

2009-11-07T12:16:00.000-08:00

"Of all the forms of inequality, injustice in health care is the most shocking and most inhumane"
Rev. Martin Luther King Jr.

This was recognized by Dr. King almost 50 years ago as he engaged in the Civil Rights struggle. Yet we today have been unable to address and correct this glaring inequity.
I spent with Gerda a fascinating day making the rounds of our congressional delegation to try and foster a meaningful dialogue. We was most politely received in all three offices. we spent the most time at Senator Snowe's office where we discussed health care and a range of different but related social issues. I found Mrs. Diane Jackson most attentive and interested and I do thank her for her time. Less time was spent at Senator Collins office but we were shown the same courtesy and interest by David Heidrich Jr. Sadly at Representative Michaud's, it was very different. We were told by the staffer that he could spare us five minutes and, although notes were taken, I felt that there was little interest in what we were saying. We will remember that. Whether the afternoon will make an iota of difference.............. well I do doubt it. Nevertheless it is critical for each of us to continually register our concerns.
I thought that it would also be reasonable in each of these blogs to focus on one particular problem among the myriad in our rapidly crumbling all-American system. Today's will be bankruptcy caused by medical bills. A Harvard study recently published in the prestigious American Journal of Medicine ( August, 2009 ) found that 62.1% of bankruptcies in 2007 ( before the recession ) were significantly contributed to by medical problems. The majority ( 77.9% ) had health insurance at the start of the illness. Of these 60.3% had private coverage. These folks were solidly middle class and were working at the time of their illness. Many lost their jobs and their insurance as a result of the illness. In no other developed nation does this occur. Their medical bills ranged from $17,749-$34,167 depending on the type and chronicity of the illness. As we can learn even the well insured can be devastated by high out-of-pocket costs incurred by co-payments, deductibles and non-covered services. Having two children with pre-existing conditions, we know both how hard it is to find reasonable coverage ( there is none ) and the fear engendered by going without.
And that's the news from Lake Auburn,
where the women are good-looking,
the children above average
and you had better pray that your
insurance is adequate.

Stephen & Gerda

Health Care

2009-07-26T09:11:00.000-07:00

I thought you all might like to see this as it was just published in the Lewiston Sun Journal on Sunday, July26th, 2009.

Inconvenient Truths about Health Care in America

Health care in America is a shambles and will, like a critically ill patient, likely collapse if it is not properly and promptly attended to.

We are told that we have the best health care system in the world, yet when we are ranked by the World Health Organization, we are 37th out of 137 just above Cuba and well below the United Kingdom and Canada both of whom have single payer systems. In the same ranking, we are 32nd in infant mortality, 24th in life expectancy and 54th in fairness.

Almost fifty million Americans are uninsured and a similar number are under-insured, 75% of whom are employed. Thirteen percent of Mainers live below the poverty level and over 9% are without health insurance. A similar number are under-insured. The Institute of Medicine of the National Academy of Sciences has shown that 50 Americans die daily because of lack of health insurance. Imagine if that figure were the casualties of our troops in Iraq and Afghanistan. Yet we expended 17% of our gross national product, 2.4 trillion dollars on health care in 2007, twice as much as any other industrialized nation and achieved significantly lower quality. We are now in the throes of a severe recession and more Americans, as they lose their jobs, lose their health insurance. Medical bills cause sixty percent of bankruptcies and 75% of these folks are insured.

Why? Private insurance companies are driven by profit and expend 16% of their income on overhead and therefore are very stringent about what they will and won’t cover. Most people with underlying common chronic problems as hypertension and diabetes are excluded. In contrast Medicare spends 2.1% and Canada, 1.2% on overhead and there are no exclusions. We spend over $7,000 per person per year while Canada spends $2,500 and achieves better results.

We have been told that free market forces and competition will correct these problems yet, since the inception of the private health insurance sector during WW2, costs have only accelerated. When you have a heart attack or appendicitis, it is very hard to shop around for the best price. These companies are not market driven. They are for profit. Keeping the present system of a myriad of private insurance companies only guarantees the status quo. Remember that the health sector spent in 2007 $450.7 million on lobbying alone and that was not to insure equal access for all. Pharmaceutical companies spent over 14 billion on advertising, not only to doctors but to all of us. Remember the slogan on those TV ads, “Ask your doctor if………” Some of these very drugs are quite hazardous. Hospitals, purporting to exist only for the best care of us, expend enormous amounts in competition for their “market share”. Just check the ads on TV and in the newspapers. Sadly doctors have also joined in.

A single payer system would eliminate many of these inequities by significantly reducing overhead, regulating costs and eliminating much of this frivolous waste. Good examples of excess here at home are the presence of three CT scanners, 2 MRI scanners and a part-time PET scanner, more than in any developing country. We also now have a cardiac surgical unit, which cost millions; while there is one of the best in the country forty miles down the road. A criticism has been long waiting times in such a system. Having had personal experience in Canada and Germany, I can state that no critically ill or urgent patient has been refuse excellent care. Unlike here where over 300,000 yearly are denied access no one is turned away from emergency rooms because of inability to pay.

In 1995 Taiwan changed from a U.S. type system in which only 60% of the people were covered to a single payer system. By 2001 97% were covered will only a minimal increase in cost.

I agree with the “founding fathers” who believed “that all men were created equal” and that we all had “certain unalienable Rights, that among these are Life, Liberty and the Pursuit of Happiness.” Now I wonder how any of these rights are possible to those of us who are sick and cannot get proper care. A single payer system similar to Medicare, which has made a huge impact on the health of the elderly, can achieve these ends and is in keeping with the values that America and Americans espouse. Health care is a right for all and not a commodity for the privileged.

TA-TA

2009-07-11T06:33:00.000-07:00

watch this space for a very important announcement

waiting

2009-03-06T13:02:00.000-08:00

Well I am right now in a waiting mode. Waiting to see where I go next. Please stay tuned.
Stephen

2008-11-02T02:08:00.000-08:00

Do GO and VOTE!!!!!!!!!!!!

I won't tell you who to vote for but, if you vote for Sarah, you are a bit idiotic!

Operation Stephen's Freedom

2008-07-26T08:26:00.000-07:00

July is now ending and my tenure here at Mature Care (great name, eh) will soon be ending. Then it is to be relegated to carrying Gerda's bags as she leads her students back to Berlin for the Fall semester, not that I mind as I do like Berlin. We will stay there through the Holidays and then back here to Lewiston and, finally, I will go out on another assignment. What that will be and where is totally unknown now. We will see what crops up in this chaotic and rather merciless world of ours. Unlike Pip, I do not have "great expectations" for progress. I suppose that is job security but, at my age, it would be wonderful to see a bit of progress after the past disastrous eight years.
Stephen

As time goes by

2008-03-01T10:51:00.000-08:00

We are now in the primary season and, like so much in the US of A, this does just not seem to stop. I do think that either of the Democrats would be fine as president, though I still do believe that a woman would be preferable for this bigoted country. McCain, while a man of courage and conviction (at times), is an anachronism and should serve out his waning days back in the Senate. He is definitely not the person who should be in command. He still is too much of the hostile warrior. We have had enough of that. At least he has served and suffered greatly though it did not have the appropriate impact. As George Patton observed, "War is Hell". That seems to have escaped Senator McCain. We won't talk about the Bush and Chaney combination that have never been in battle but quite easily send others to die or be maimed. Meanwhile the Democrats, like Yassar Arafat, never miss an opportunity to miss an opportunity. Instead of trashing each other, they should emphasize their differences from the Republicans and they are vast. Of course whether anything happens in the next few years to better our lives and world is totally up in the air right now. As the old Crosby, Stills and Nash song goes, "It's always darkest before the dawn." One can only hope so.
That's the way it looks from here.

Stephen

Confusion Has Its Day

2008-01-19T10:19:00.000-08:00

I have now been home for a month and perhaps this is a time to think about my experiences over these days, days that have passed so quickly and that have been rather puzzling.
We are now in the extended presidential race and what I do see, read and hear is so very bizarre. Who knows at this point how many millions have been spent but, at least, it is millions rather than the billions spent on Bush's insanity. I have always maintained that we will have venial people among us. Actually I used the word psychopaths, though he is not that far gone. That epithet belongs to truly EVIL folk as Cheney, Wolfowitz and the other "neo-cons" that have brought us here and who have been responsible for so much death and destruction. Bush is just stupid.
I have learned this week that Iraq has now moved down in importance to the economy in the concerns (fears) of our citizenry. As if the two are not intimately interconnected but the "sub-prime" debacle seems to have claimed that exclusive title. Interesting the way our economy gets "all shook up" every decade by so similar events as rapacious, immoral , supposedly educated idiots who only care about themselves run rampant over our "capitalist ad absurdum" society. There seems to be, in our fretful minds, little concern about the way the poor of this country and the world live. Those that try to find enough food for the next meal, to find shelter, education, health care and safety. Few seem to realize that we are all interconnected. Few seem to believe what Christ and other spiritual thinkers have tried over the ages to teach us. We humans are a sad species. Rife with selfishness, controlled by fear mongers posing as saviors, we forget what life really should teach us. We do so admire in a rather puzzled off handed abstract way the saints among us as Gandhi, Martin Luther King, Mother Theresa and those others that do redeem us. We would rather admire the brute, the greedy, the superficial, the wealthy but we ignore those quiet heroic folk who daily go about their task of caring for those so less fortunate among us, be it family, neighbor or just fellow being. Obama is right we do need change but I do not believe that his view is radical enough to save and redeem us. We need to return to The Sermon on The Mount and understand and follow what Christ was trying to teach us. These lesions are not the purview of Christianity. They are there in every religion that we on this tiny planet live with. How tragic it is that a bit over 60 years since the end of the Holocaust we still allow this slaughter of our fellow creatures to continue and even supply the material to carry on. I do believe that the slogan of this presidency is "Not On My Watch". I guess that like so much else our government says as it mounts on its "moral high ground" is froth designed to make us all feel good at little cost.
As one on of my favorite weatherman here in Maine always says, "That's the way it looks from here".

Stephen

The Long Road Home, Part 2

2007-12-20T05:48:00.000-08:00

The last two days here in Tanzania were spent finishing my exit report and signing out. On Friday I went to see a Christmas Pageant. The daughter of the country director was in the school's annual play. Actually just about everyone was which I thought was wonderful. Later we went back to the Lebanese restaurant for a farewell late lunch as they were traveling that evening back to the US of A for Christmas. Saturday was spent wandering about a relatively fancy shopping area called Slipway just on the Indian Ocean where I managed to get rid of all the Tanzanian schillings that I had left and actually a bit more. That night off to the airport and my Bird home. The flight left and arrived on time and the trip was not bad though long and cramped as usual. I had just a bit more than an hour between connections and was apprehensive but my arrival gate was E2 and my departure gate was E3. So a leisurely stroll over, a bit of standing in the check-in line and onto the next flight. As we left the pilot announced that the snow had begun in Boston. "How wonderful," I thought, "New England is so happy to see me that it is giving a nor'easter in my honor". Then for the next 6 hours nothing further. The movies were so bad that even I, who will watch the lousiest movie on a flight, skipped this one. Finally about an hour before arrival we got the news, not unexpected, that Boston had closed for snow removal. Onto JFK where we refueled and then back in the air to Boston. We got in about 3 hours late but it was a lot better than circling about Boston endlessly. By good fortune the Concord buses were running and I managed to get the 1530 bus up here. It was slow going as the light rain that was then falling in Boston had changed to freezing rain in New Hampshire and then into snow in Maine. Our driver had to stop around Saco to clean the ice from his windshield and while we were sitting there, some poor soul in an SUV slid into us. I felt nothing but heard a noise that I thought was the driver changing gears to start up. A good advertisement for buying the largest vehicle one can instead of these compact cars that I do. Though with gas at three dollars plus, you can't go very far these days. We sat there for an hour until the police came by and then did get into Portland about 2030.
By then the roads were so bad that I spent the night in Portland at the "Clarion" hotel. Used to be the "Doubletree" but now a bit more upscale. Actually it was quite comfortable. The restaurant was surprisingly good and it was not that expensive.
Monday beamed bright and sunny with that beautiful white purity that only a fresh snow can impart. Gerda got plowed out, got down to Portland and took me home where I was able to give a cheery hello to my good friend Jack Daniels who had been patiently waiting such a long time for my return.
Strange feeling now three days later on Thursday morning as I write this. It is almost as if I had never left but I do know that I did and did return. More than "deja vue". Perhaps a new syndrome and we can call it "ne deja vue pas".
And, as the caption at the end of the Loony Tunes and Merry Melodies always said, "That's all, folks".

Stephen

The Long Road Home, Part 1

2007-12-13T03:12:00.000-08:00

It was a dark and stormy night. The wind whistled ominously and the trees branches beat on the window as if they were trying to break in. Now this has absolutely nothing to do with my day yesterday but I did think that it might just get you interested to read a bit more.
Actually the day started out without problem. It had only rained a slight bit on Tuesday so that I thought that the road would not be a real problem. Wednesday morning just as I wandered over to have a bit of breakfast at 0630, a few drops of rain began to fall. Over the next 30 minutes as I finished packing and loading my bags in the car, the rain began to pick up and the low hanging clouds began to cover our hillside. Starting out was no problem even though the rain began to pour down. We had to stop at Nduta to pick up some specimens from the respiratory surveillance program to bring to Dar. I had not been in the camp for almost a week and I was eager to see it again. But what I found was a village under water. There were large puddles of water everywhere and what was not under water was just that cement-like mud that clung and refused to bescaped off. The ditches that channeled the water were torrents of brown water rushing by. People were peering out of their huts watching dejectedly. Occasionally thunder would roar as if a beast had been struck by the lightening that had just proceeded it.
From Nduta we traveled on to Kisulu as we had mail to deliver there. Swaying from side to side, our car tried to avoid the larger puddles and ruts that dominated the road but, though slow, we made it to Kisulu without a real problem. we had two young boys, one of about 5, the other about 7 with us as they were traveling to Kigoma to spend the holidays with their grandmother. The younger, a bit unexpectedly for a child of a staff member, was frightened of me, refused to sit too close and kept staring at me as, if like Michelangelo's Moses, I might grow horns. I didn't. He did relax a bit as we went on because we pick up two more staff at Nduta to take along. So he was forced to crowd close to me and he survived.
At Kisulu, we were greeted by the coordinator, a lovely Kenyan lady that I had medically helped before. We stayed for about an hour for tea and lunch. Ominously she told us that it had been raining very hard for more than 12 hours.It still was coming down heavily and still the clouds were lower. We left Kisulu, about 1230 and drove out of that small dilapidated town through streets that were flooded and drainage ditches that were overflowing with garbage and muddy water. Like the road from Kibondo to Kisulu, it was all packed dirt but, unlike that road, this one was only mud and water. Where the large trucks had passed, it was churned-up mud and ruts. We had enough time to drive even slower and still make it to the plane that was scheduled to leave at 1630. We were assuming that it would not be canceled because of the weather. This was a bit optimistic as we had earlier learned that Dr. Vachagan's flight on Sunday had been canceled for "technical reasons" and, although he made it out the next day, he had missed his connections to get back home to Yerevan. I was a bit more careful as I gave myself a couple of buffer days just for that contingency.
We traveled slowly along dodging back and forth between small lakes, ruts, the ditches, the few people on foot or bicycle. Suddenly ahead of us, as we topped a small hill, was a truck stuck in the road and jackknifed. There was, fortunately, a bit of space near the not to deep side ditch that we were just able to inch by. Shortly after that the road became more hard packed and the mud less slippery. On we went, a bit of calm overcoming my nervousness. Again we climbed a small hill and there in front were a few stopped cars but in front of them about halfway up the hill coming toward us was a huge truck stuck and behind that was a line of about 20 more vehicles of all sizes. People were gathered and chatting as if at a grand fete. There were folks trying to brace the truck. It was a double load with a trailer attached and it really had that resigned look that so clearly said, "I am not going anywhere". Off to one side in the ditch blocking that way was another truck so mired down that it would never more during this rainy season unless "all the king's men and all the king's horses" came along. There was even less room on the other side. I looked at my watch, 1330. I had visions of a long very uncomfortable night. We were out of Codan (radio) range and also mobile telephone service range. One little bright spot, the rain slowly stopped as we got out to walk a bit and watch the proceedings. The truck had started up the hill but because of the weight it was dragging and the slippery mud it was traversing it could not get traction. It had begun to slip backward and in doing so the link between the 2 portions had twisted so that it could not be further backed down. As we watched and silently cursed a bit, actually more than a bit, men were filling in the ditch on the side of the road. After an apprehensive 30 minutes during with I was growing more resigned though not any less annoyed, a Toyota land cruiser from the opposite way managed to get through, a UNHCR car no less. Right after that we too got in place and and went through very very slowly. We were the third car through and that was also fortunate as the ditch was getting chewed up. As we inched along through the ditch very close to the truck looking more and more like a beached whale in my imagination, the car began to tilt ominously until we were at a 30 degree angle and I felt sure that we would tip on our side. Luckily at that point there was a small hillock that blocked further tilting and we scraped along it. As we passed the beached truck we were able to get back to the middle of the road and could easily get by the line of cars and trucks stranded there.
The weather continued to improve and and the road got harder and less muddy as it had not rained so much. So as we got closer to Kigoma it became hard packed again and once we got into the town there was, believe it or not, there was tarmac. We turned off the tarmac road onto a small, almost a path, road to the airport. Bouncing along through the deep ruts, we did without further mishap make it to the dirt strip airport that fortunately the UN also used so that it had been upgraded. We got there at about 1530, stood in the passenger line to squeeze through the narrow door, to have the luggage hand searched and finally check in. The plane had not been canceled though it was an hour late. I was comforted as I saw a Catholic priest among the passengers, thinking God will now definitely not let anything happen to us. Carmen DelRosario who was traveling with me to go back to her family for the holidays, a Catholic, told me that she had had the very same thought. The flight back to Dar was without problem. I was further reassured when I went to the loo and saw that the instruction signs were in English and German indicating that the plane was made in Germany. The only real disappointment was that I missed having enough time to make a pilgramage out to the spot where Stanley met Livingston on the shores of Lake Albert (Tanganika) at Ujiji so tantalizing close by.
A short ride to the hotel, the Markham, the same one I was in when I first got here, a small supper at the new Lebanese restaurant across the way and then to bed after an exhausting day and, like Ishmael, I lived to tell the tale.

Stephen

Last Post from Nduta/Kibondo

2007-12-07T23:16:00.000-08:00

On December 1st, the world, at least some parts of it, noted "World Aids Day" with ceremonies in many places. There was one at our camp, Nduta. Although the mood looks very cheerful, there was, indeed, a very serious message about safety and commitment. Whether the men and it is the men who hold the key to curtailing this scourge paid any attention is up in the air right now. Statistics would suggest that they do not. Statistics from America also suggest that this absolutely fatal incurable disease is now regarded as an annoyance that can be controlled much as hypertension and diabetes are. Incidence rates are rising and this is tragic news.

I had my last day at the camp on Wednesday and have spent the past few days here at the base tidying up the end of mission details that are always there. The major one is the "End of Mission" or Exit Report". It is basically a summery of what I found, what I did and what I think needs further work. On Wednesday, the 12th, I will, early in the morning with another ex-pat from Boston, no less, make the 6 hour drive to Kigoma to catch the flight to Dar es Salaam. Six hours if it is not raining and the roads still are functional. So far the rains have not been that bad and the roads have remained quite reasonable for out here this time of year. I remember when my time to leave Sierra Leone during the height of the rains in August drew close, I would get up every day and check the sky. The road out from Kailahoun to Kenema was 60 kilometers of rut and mud but we did, albeit quite slowly, make it.

That's the latest and the last from out here where

the days are cloudy

the roads muddy

and I am giddy.

Stephen

Short-Timer

2007-12-01T01:12:00.000-08:00

Officially I became a "Short-Timer" this morning as I will leave here (Kibondo) on the 12th to Dar es Salaam and from there on the 15th back to "our fair city". As usual the red-eye special. At least this time it is at midnight rather than the 4 a.m. ones from Khartoum.
Little of note happened this week. Our new technical advisor for this area of the world arrived for a visit. A very nice knowledgeable physician lady from Belgium who has a vast experience working in this part of the world. We took her on a tour of the clinic/hospital facility on Thursday. She agreed with our concerns and, hopefully, we can get some money to improve things out here. That won't happen during my tenure but, at least, there is a chance of it happening.
Now,as I have nothing else to write about, here is a bit about our weather and Thanksgiving.
Yesterday was a return, albeit briefly, to hotter weather. I did enjoy the change but today it is again cloudy and cool. Last night was glorious as a storm slowly came tramping in from the East and slowly spread over the sky. As the sun moved further West and the clouds gave chase, the colors changed dramatically. Streaks of red and bright pink began tickling the bellies of those dark grey-black storm clouds and here and there at the vanguard the clouds piled up as if climbing on each other, just a bit reluctant to pursue the assault against so powerful a foe. As that happened, a bright light illuminated them and they just glistened going from dark black to intense white. Further back bolts of lightening occasionally burst forth and thunder rumbled as if to encourage or perhaps threaten the front line troops to press forward.
We did have our Thanksgiving dinner and it was the same as we had back in Darfur, mainly as we had the same ingredients, tough chicken, potatoes, some stuffing, biscuits and corn muffins. The enjoyable part was that we were really all together for a meal instead of a few drifting in and out which is the usual pattern. The rest of the day I read a bit, put another note on the Blog and answered a few letters. Today I will make up a small protocol on the use of a nebulizer which we found in the storeroom. I am have been waiting for the solution to arrive. Not here yet but, hopefully, this week.
And that's the news from here where
I have become a "short-timer"
And you know you're in trouble
when you can't wait for airplane food.

Stephen

The UN Comes A'Callin!

2007-11-22T23:47:00.000-08:00

Wednesday, November 21st

The UN and all the major donors to them and therefore to us came on a visit that they termed euphemistically the JAM, Joint Assessement Mission. We presented, all the various programs, what was happening in them and then took them about to highlight the myriad problems that we have, what we were trying to do to strengthen the program and why we need additional funds. They did listen but whether this will translate into any supplemental grants is totally unknown. Do not hold your breath. We did also learn that BPRM, an American agency with the full name of Bureau of Population Resettlement and Migration, cut their grant for next year in half by $500,000. And where we are to find replacements for that alone is totally unknown. After that I went to the OPD again until we discovered that there was no one checking on the pediatric ward. So I spent the rest of the day there. I have a CO who is the most faithful and we have spent the most time together. He has changed his habits and I do think that he will continue to do so even when I leave. About the others, I have no such illusions. For example, I gave another training session as I do every Wednesday and he was the only CO there. The rest were all Community Health Workers and nurses. I am grateful that they were there.
That's all there is to report today from here where
The UN and donors came and went
A jam they called it
But who knows if it was heaven sent.

7:57 AM 11/22/2007

A small bit of minutia:
One bit of interest from about a week ago. The ants had disappeared for some time. At least they were not in view and not serepticiously biting. One morning last weekend on the way to breakfast, there was a long column of them, about 10 meters, marching through the drainage ditch of my house. Now they were tramping along two by two in a very long line. Generally they were quite orderly and well mannered. Every so often one here and there would break off and scout about. They were, I am sure, a food finding expedition. As they reached the end of my house, there were still more tramping out from their nest in the walkway. They had evidently dug a tunnel at the side of the walkway and no longer were coming out on top where we galoofed by. Nevertheless I was apprehensive as to their motives and, as I could not speak Antese, I decided that this was an act of blatant aggression. I raced into my house for my "weapon of mass destruction", the can of SUPER DOOM and attacked. A rout and shortly thereafter came a heavy rain and washed the bodies away. So I do believe back at ant headquarters they could only report, "lost, whereabouts unknown".

Sunday, November 18th.
Today I do have to prepare some additional teaching guides for the clinicians so that they might think of ear infection without waiting to see pus draining out from an ear. We have been over this several times before but it just does not seem to percolate through to them.The favorite sequence here, as I have written about, for diagnoses is first and always, Malaria and throw in an antibiotic for a respiratory infection though they have done nothing to prove either. If that does not work, gears are switched and the next diagnosis up is Enteric Fever. Now that is difficult to diagnose but it does have a pattern that tends to be more characteristic. A serological test called the "Widal", named after the good doctor who first described it more than a century ago, is ordered. This test has been abandoned in developed countries as useless as it has little sensitivity nor specificity. You might as well flip a coin. We back in developed countries rely on blood, stool and bone marrow cultures. But the news has yet to reach Africa and no amount of discussion can shake this belief, just like dialogue with fundamentalists. Then chloramphenicol is added and that drug, while cheap and useful out here, has a lot of bad side effects. So part of my next session will be on just that disease. I really do not expect any paradigm shift but I have to try.
And that's the news from out here in Tanzania where
the clinicians can diagnose without examining patients
malaria abounds even with negative tests
and the UN keeps trucking them in.

Stephen

The Weeks Keep On Rolling!

2007-11-17T00:36:00.000-08:00

Today is the 14th of the lovely month of November and one bright spot, as I was walking over to the car to go back to base late in the afternoon, there appeared on a tree peeping at me a gecko with a bright blue face. But, like some of the children here, when he saw me he just scurried up his tree. Not that the children scurry up a tree but they find me so strange with my pale white skin that they hide themselves in their mother's body and periodically peer out and cry in terror. Tonight the black rain clouds are rolling from the north with some thunder and lightening. The clouds spread across the sky like tentacles and leave patches of dusky blue in between with a few stars twinkling through as if to reassure me. So far no rain though.

November 16th.
It rained a lot last night for about 2 hours but this morning was delightfully bright and cool. As usual down at Nduta it was hot but it never gets as bad as in Sudan or in Kakuma. I am working with a new C.O. and he is good. I am still on the adult wards. Now comes a longer tale with an interesting twist at the end. I have for the past two weeks been giving presentations on malaria and yesterday the health coordinator came out to present a survey that he did on our use of anti-malarial drugs. He found, and this was not unexpected from my observations, that 2/3s of the people treated for malaria did not need it according to the tests that were done. I have been trying to tell the clinicians, ad absurdum, that, if the tests are negative, you have to look for other causes of the fever, which they just do not do. They simply diagnose "suspected malaria", put the patient on anti-malarials and throw in an antibiotic just to cover everything possible but are really too lazy to try to make a proper diagnosis. This afternoon, as I was leaving, the Tanzanian doctor said that the COs wanted me to show them how to do a better examination. Instead of saying something sarcastic such as, "What the hell do you think that I have been trying to do for the past 2+ months.", I replied that I would be delighted to. So Monday I will head back to the pediatric outpatient department and try again. I can deal with this as I have but 3 more weeks to go out here and, who knows, something just might stick. I will not get too excited. I had found myself over the past few days getting too exasperated and that just interferes with my ability to make good decisions. It has been building for some time. I keep getting too personally involved. It really did almost come to an explosion yesterday during the training when several of the people there came out with their personal anecdotes of tests being wrong. None of the examples that were cited had anything to do with malaria. Finally I decided to just laugh and said, " OK, lets just get rid of the tests, treat everyone with fever for malaria and buy beer with the money we save." I do think that the message I was trying to give got heard. Sadly, by today's admissions to the adult wards, not everyone was paying attention.
The camp consolidation process goes on and, fortunately, the weather has not been too bad with rain so that people are constructing their shelters. And so far, despite the very harsh conditions, no outbreaks of diarrhea or other problems. And that's the latest from Nduta where
Two camps merge into one
The UN thinks that this is fun
And, mercifully, no one has the runs.

Stephen

Camp Consolidation

2007-11-11T01:04:00.000-08:00

Today the camp consolidation, as it is euphemistically by the UN, started. They are closing Kenembwa as I have written about and the folks are being all moved to Nduta, those that do not want, as yet, to repatriate. I had wanted to go there earlier in the day when the first convoy arrived but there was no vehicle available until late in the day so I went there before heading for Kibondo. You know that I have been questioning my sanity and the purpose of my being here. I guess God, Buddha, The Great Spirit, whatever you would like to call the force that somehow guides this universe of ours got tired of my quengelig mutterings and gave me a very clear answer. I was so overwhelmed by what was taking place that it brought me to tears. I will try to give you an idea of the pictures that I saw. I did have my camera but did not have the ability to use it. I spoke with both the field and health coordinators this evening upon my return and we will go back in the morning to see if there has been any improvement. I arrived there at the "reception center" at about 1630 and it was utter chaos. The center is rather small, perhaps 400 meters square and that is a guesstimate. There were lorries including a container vehicle unloading these poor folks' possessions, mainly wooden objects as doors, window frames and furniture into a large pile in the center. It looked like a pyre that would soon be set on fire to propitiate the Gods. People were scrambling about trying to find what was theirs and cart it off to the shelters. Others were carrying large bags full of clothes, rags and other possessions into the shelters that were only wood frame rectangles covered with plastic sheets with a brick floor. The majority of the bricks were loose and jumbled about.There were no assigned places just the words"men", "women" scrawled on the plastic and people were trying to find spots to sleep. Wandering about were small flocks of chickens and ducks. Outside the wire fence, men were herding about 20 cows and more goats to keep them from wandering off or being stolen. The Nduta inhabitants were all crowded up against the fence trying to see relatives and contact them or just watching the entertainment.There was an NGO, Tanzanian Christian Relief Services (TCRS) that had about 10 people there that were not of any help. A few were at the gate with sticks pushing people back. The rest were just sitting and watching the turmoil, chatting amongst themselves, not trying to assist or control the confusion. Off to one side there was a shelter of about 5 x 10 meters where people were cooking. As they had not taken down the plastic siding, the wood smoke was swirling about in there and it looked like a sauna but the fumes were deadly. No firewood was supplied and they were forbidden to bring any with them so they had to scrounge about and there was precious little. Right in front of these was a large deep pit with a skimpy rail fence around it. the was a garbage pit. The children were playing near and, surely, one will fall in. The water points were adequate but the kids, having little else to do, were playing with them and rivulets were forming and the mud was accumulating. There were only seven toilets for what was reported to be at least 500 and possible up to 800 people. At least that was all that I could find. There were some outside the fence but I was told that the people could not go out there. Now, as I was wandering about asking questions, more trucks kept coming in as the second convoy of the day was arriving. And indeed on the way home here to Kibondo, more trucks went by us. So more goods on top of those already piled up. It would become dark soon about 1900 and there is no electricity to assist unloading. Over the next few days, they will build mud/wattling houses on the plots in the camp that have been assigned to them. The will be given some sisal rope, plastic sheeting, framing posts and a handshake. It rained this weekend. Today was overcast most of the day and there was only a bit of sun late to dry the ground. If it does not clear for the mud to dry then it will just melt right off in the first heavy rain that comes. The next group is slated for Friday and the whole move is supposed to be done by mid-December. So back again tomorrow and, if there has been no significant improvement, we will try to stop the process and get it better organized.I will let you know in Wednesday's letter.

This part was written on Friday, the fifth day of the consolidation process. Refugees keep coming in daily from Kenembwa which is certainly not the way the UNHCR described the move. I went this evening over to the "reception center" which is crammed with people and very unsafe from a health perspective. I won't comment on the social aspects. Construction materials were to be given out on Monday and then there would be three days that were allowed for the men to build their homes and then the next group would be moved in. However convoys arrive daily. For the first time today framing posts were supplied and in very limited quantity but so far no rope and no plastic sheeting. And today is the 5th day that the Monday arrivals have been living in even worse squalor than usual. I went over there again this evening to see so that I could report to our FC (field coordinator) & HC (health coordinator). I can not tell for sure how many are now crowded in there and the UN will not supply us with a list but they claimed earlier in the week that they could safely get up to 1200 refugees in. It certainly looks like that number but it sure ain't safe. Debris still is strewn about. The barnyard animals wander in and out. The shelters are over packed and stuffed with their possessions, enough so that quite a number have to sleep outside. There are not enough blankets, thievery abounds as you might expect in such an unstable condition. And to add those further twists of the screw, there are now two more gathering places with a fourth being constructed. The second is at part of a school and that one is not bad as there are many fewer people, there is more space and the buildings are solid. The newest one opened evidently last evening and consists of four huge WFP (World Food Program) storage tents that are generally used to store food supplies.Now they are supposed to house 100 people each. I have been in each and they will be crowded with 50 as most of the space is taken up by bundles of the refugees' possessions, leaving precious little living space. Some women were cooking inside with charcoal and rather noxious fumes were drifting about. There was only one water point. A second one had not yet been connected and a group of women were digging latrines while the men watched with a casual interest. I was told that even last night, the first night, some had to sleep outside and still daily new refugees keep arriving from Kenembwa. Once again as I was leaving the buses and trucks were rolling in with frustrating regularity. Our FC did write an excellent letter protesting and has been in touch with our country director. The next bit of good news from the UN was that they would give us no additional money to upgrade our hospital/clinic/ outpost complex and we have but a fraction of what we really need to make those critical changes that I have already outlined. That has also draw a strong protest. Whether anything comes of this is totally unknown but I will, of course, let you know.

Stephen

Mirabili Dictu!

2007-11-11T00:04:00.000-08:00

At last I have convinced at least one clinical officer that the use of an inhaler with a spacer is the best way to quickly treat and stabilize an acute asthmatic attack instead of their previous dangerous relatively ineffective use of intravenous aminophyllin. Also please note that he is counting respirations on the child. Yippie!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

My Week at Nduta

2007-11-03T01:15:00.000-07:00

Here are some of my good friends at Nduta that usually wait for me as I make daily rounds on the pediatric.ward and a view of the compound on weekly wash day.
Monday, the start of my week.I should have known what kind of a day it was going to be when it was inaugurated by that ant attack that I wrote about earlier today. At the pediatric ward the chief CO decided to attend and he was a bit better than some but not by much and he was very full of his importance. Rounds started well but then I began picking up the mistakes from the weekend, the undetected pneumonia because some still do not count respirations nor listen to the lungs. so what was on Friday a mild pneumonia by today was very severe and possibly life threatening. I went to the pharmacy to look for some medications and, how unusual, they were out. I asked if they had ordered them.
"Oh yes", came the reply.
"Well were are they?"
"Oh they will come in with the monthly order in 3 days."
"But you are out now!"
Then comes that rather silly smile that I do so hate and that I see all too often. What to do. I must keep remembering that this is a long term task. It really ain't going to change during my tenure. What I can do has been put into place. Pointing out the deficiencies, suggesting ways of correction and starting a reasonable reliable training program. I have also found a fine physician to replace me.
The heat has returned here over the past 2 - 3 days. The sky starts clear in the cool morning but then the puffy fluffy clouds come slowly drifting in as the day heats up. We see the same type of cloud in Maine but they are just so much more energetic. By then I am down in the valley at Nduta where I do recognize that I am very very close to the Equator. But back up here on the hill it does cool off at night and that makes it easier to sleep. We are in what would be the Fall as many leaves are drifting down but they have none of that vivacity of the colors that we are blessed with. They turn a paler shade of green and give up the ghost with a sigh as the rains are too late to save them. They cover the ground to the delight of the goats that wander through the compound, depositing their small pebbles as a thank you. They have begun to make a habit of lying about in the shade outside the pediatric ward where I daily work so that I see them from the window gazing at me when I go over to the hand washing bucket. Today two young males were butting heads to see who could attract the ladies who were not very interested.
TuesdayI did get another CO so that, certainly at this point, the system does seem to be running. Today's was good and he quickly got the idea that counting respirations is a good idea as is the washing of hands. And to my delight the aides and nurses on the ward are beginning to do the same.
We did lose our first baby today that I am aware of since I came. A newborn who after about 30 minutes started having trouble breathing. It was a good sized baby of 3.3 kilo. Looked normal but had a big liver. It was not cyanotic, had no heart murmur and both lungs were receiving air. We suctioned him and gave antibiotics which really was all that we could do. I ask the doctor involved about transferring him to the KIbondo hospital but he felt that they would do nothing which is generally the way they do things there.
Well now another bit of the ongoing ANT WAR. Last night 2 of the lady ex-pats were attacked as I had been earlier in the day. No serious injuries only lost dignity as clothes had to be removed and brushed out and the vicious little creatures removed, rather pulled off. Fortunately there is more than one room in the staff lounge/dining area. So they were able to discreetly run in the other room to do this. And I do mean run. Those guys really hurt. I had found out where they had built their nest, actually there were two colonies. There were two nests side by side, one with big guys and the second with the smaller fire ants, so called as their bites burn. I had decided that if they behaved, I would not bother them. But they broke the truce this morning. As I walked very carefully by I got bitten again. So after breakfast, I took my can of Super Doom and attacked. Right and left I sprayed. Up and down the canister of deadly poison flared. Meanwhile two of the guards appeared to see what was going on as thousands of ants milled about trying to form ranks and counter-attack. I handed over the canister to them, pointing out the entrance to the nests and left them to mop up the battlefield. Tonight I am pleased to report, no ants and the dead have been buried with proper respect.
On the ward today, well I have noticed it over the past week or so. There must have been a sale on jerseys from the Valencia Fussball Klub as there are at least 6 women wearing the same one that says Rinaldinho on the back. It does confuse me as I tend to recognize some of the mothers from their garments. Around noon today, as the kids were getting medication and, at least, a dozen were crying, I was reminded of the word BEDLAM and its origin from the English insane asylum of the same name.
Wednesday was very sad. We did have another death night before last. A one month old that had been discharged 4 days earlier after an episode of what I was convinced was neonatal sepsis. He was treated appropriately and got better, only to suddenly at home have difficulty breathing and high fever. The CO did put him on antibiotics, not the best ones that we have and the child, a few hours later, grew dramatically worse and died. As we have so little to evaluate anyone and as the records are so scanty, it is difficult to put this together. We also have another child that came in forming large blisters on his skin and actually sloughed about 15% on his upper chest and face. I started him on antibiotics believing it was a staphylococcal infection but he did not improve. I then added cortisone on the possibility that it might be pemphigus, usually a disease of older people thought I have seen it in 30 year olds. Anyway it has also been described in children and the child did start getting better. Now sadly I think that he has a bowel infection caused by the antibiotics called Clostridia difficle colitis. Basically the antibiotics kill off the normal flora and this allows the germ to grow as there is now space. This germ secretes toxins that severely damage the colon's wall. There is a good test for the disease but, obviously, it ain't here. So, like I have to do so often, you go with your instincts. What makes it even more difficult is that I have been trying for almost a week to get a good antibacterial cream for him as I consider him as an extensive second degree burn and I finally today got what I wanted. So we shall see but I do not think that he will survive.
Thursday started cloudy but then gradually cleared and about 1300 we got a strong wind and the fine red dust that I so dearly love coated me and everything. I left the camp early as I had to go to a camp consolidation meeting at the UN. I wrote earlier that they were closing Kenembwa and moving the people to Nduta. Well it will start next week when they move the first group. They will go to temporary housing at something called "the reception center", which has always housed new arrivals. Each family will be given building supplies consisting of poles, plastic sheeting and two rolls of sisal rope. They will have but three days to build a shelter and then they will be moved out to make room for the next group. They want to get this done over a month's time. By their estimate that will be about 9000 people. They were given a choice of the move or repatriation back to Burundi and only about 1000 chose to go back. Meanwhile we have only gotten preliminary plans and cost estimates for the renovations that are so necessary. well I do like living with a bit of chaos as you so well know. I have been talking with folks again about my replacement and they appear to now be convinced. I am just waiting for final approval from the country director. Now no ants have been sighted today and no threatening notes have been slide under my door and no bites have been reported by anyone.
Nothing very dramatic today, Friday, as that child that I described yesterday is a bit better. I think I was right about the diarrhea as it is improving today and there are no more new skin lesions. Mother now tells us that another child in the same family had the same illness last year. As there are no reliable records and the story keeps changing, I really do not know what to believe.
Another child we saw with a mild congenital heart problem that is being followed in the regional hospital. The child also has seizures that are not being treated but mother is so focused on the heart that all she can talk about is to go to a Western country to get it fixed. Well I was able to start the child on anti-seizure medication but I so far have not been able to convince mother that the heart has nothing to do with the seizures as she was told that at the regional hospital. She says that she knows some one with the exact same problem who went to Norway and now everything is fixed. Well you know how difficult it to shake something like that. So I will see her again next week.
Well we might be back in the rains. I am not quite sure but today, Friday, at Nduta about 1530 we had a really torrential rain that lasted a good 30 minutes. The kind that causes the drainage ditches to fill like small torrential rivers. The children love it as they then have a new place to play as they go wading through the reddish waters swirling by while mothers look on a bit anxiously lest one of their charges gets washed down stream. The shelters that they live in get rather wet and uncomfortable but they are still so much more stable than the ones back in Darfur. What I find fascinating is the rather narrow swath that these storms seem to take at least at this point. Back at Kibondo there was only a light shower and nothing else. The road is still quite dry and travelable. There are drainage ditches on each side and, every 50 meters or so, there are deep ditches leading from the road to the adjacent fields. So we have not been mired in the mud as yet.
And that has been my week here in Kibondo.

Stephen

Kibondo Visions

2007-11-03T01:07:00.000-07:00

That was the week that was

2007-10-28T01:15:00.000-07:00

Well another week has past out here in Kibondo/Nduta. I have decided to focus all my efforts at Nduta for several reasons. The most important is that, with the exception of one clinical officer, there was essentially no interest in learning or changing poor practice habits and I have gotten a bit too old to keep beating my skull against the trees even though it does feel so good each time I stop. Hated to give that up. Also there will be a move shortly ( always up in the air out here) over to Nduta. And there I can assign other duties to those recalcitrant souls as janitorial until they see that obstreperousness, like crime, does not pay.

Last week at Nduta, there was a definite change in attitude. I had written that I had gotten 3 very interested clinical officers. Now they are all coming. I had a different one each day and all were eager to learn. Four of them were a delight to be with. The fifth on Friday was very difficult. She was extremely slow and had a weak fund of skills. Nevertheless she tried and that is really all that I do require. But I was very happy when the long day finished and, unlike some, I needed more than one day to rest. I can only hope that this effort will continue in the six weeks that are left for me here. There were many good teaching problems. The most important one that I have reiterated ad nauseum is that NOT ALL FEVERS ARE MALARIA. Now that does not seem to be too difficult a concept to incorporate but it is. We are in a holoendemic area with stable year round transmission and that, certainly, has to be always in the foreground of one's thoughts but,when all the tests are negative, it just ain't sensible to diagnose "suspected malaria" and leave it at that. You must do a very diligent search for other causes such as pneumonia which is also so very common here. The most sensitive tool we have is counting the respiratory rate as we have no x-ray. Now that is a concept that, like washing hands after every patient, is finally beginning to take root. YIPPEE!!
The case though that I started to write about was a two year old that was sent into the pediatric ward where I spend my teaching days as they are the most vulnerable. She came in with that all too ubiquitous diagnosis of "suspected malaria" and had the negative tests to prove it. Turns out on a more through examination that what she really had was a large foot abscess with a cellulitis half way up her leg. What she needed was not the quinine that had been prescribed but good old cloxacillin and gentamycin and drainage.
We are seeing more malnutrition now. Not in the refugee population as they have a stable food supply from World Food Program but in the Tanzanians. We care also for any of the local host population that comes into our clinic. We are just at the beginnings of the rains though they, after that first few days two weeks ago, essentially stopped again. The fields are being prepared for planting with that so efficient, time-honored, slash and burn method. Periodically from the veranda of my bungalow, I can see plumes of smoke and hear the crackling of the fires and, as we travel back and forth to the camp, we pass through the acrid stench. But planting has not really started and food is getting more expensive here. This is a very poor area and is neglected by the government as it is the home of different clans and the opposition party. We have now several children with marasmus and kwasiorkor and they are very sick.
So my friends that is the way it looks from out here. I have past the half way mark and I have found an excellent physician that I worked with in Thailand to replace me. Now all that has to happen is that they hire her. In my followup note to them after she wrote that she had, as yet, heard nothing, I wrote, "if you let her get away, you definitely need psychiatric assistance".

Stephen

The Operating Theater and Delivery/Gynecology Room

2007-10-20T01:22:00.001-07:00

The operating room, an excellent facility for this part of the world, at Kibondo camp. This camp is slated for closure over the next two months and we are debating whether to move the theater to Nduta. against the move is lack of money to construct the facility there and the small number of procedures done, predominantly Cesareans. For the move is the fact that refugees and poor Tanzanians are extremely badly treated at Kibondo government hospital and there have been maternal/infant deaths because of mismanagement as these patients have no money to pay. This despite the fact that they are supposed to be cared for free. facts all too commonly seen out here.

Our delivery/gynecology area is also desperately in need of repair and suffers all the same problems as the rest of the hospital.

Our Hospital

2007-10-20T01:02:00.000-07:00

A view of the exterior and interiors of the wards here at Nduta. I have previously described them as decrepit, filthy crumbling, dark. whatever epithet you can think of is appropriate. It is difficult to believe that this could happen even in this setting. Yesterday we went with our logistician and listed what needs to be done. Unfortunately there is not enough money now available so we will do the most critical first and that's a hard decision as everything is so important.

Our Clinic

2007-10-20T00:51:00.000-07:00

Views of the OPD and the vaccination area on a typical early morning. The congestion and chaos are startling and have gone on since time immemorial. We are working on ways as I have previously described to improve this situation

The Camp at Nduta

2007-10-20T00:25:00.000-07:00

These pictures are from the camp and are typical of the shelters that have been erected here. They are somewhat similar to the structures that the refugees build back at home but are very decrepit, dark and poorly kept up. They have been here for years as this camp is now more than 12 years old. There is little encouragement or incentive to repair and refurbish them as there is always talk of return or movement to other places.

2007-10-13T01:08:00.000-07:00

Rainy season has begun though, fortunately, at this point it is not too intense. Generally there is a brief shower that, at times, becomes intense and sometimes it will last up to 30 minutes. Yesterday though we had no rain and today, so far, is lovely with a bright sun and a cool breeze on our hilltop. It is Saturday and so I am at the base and not down in the camps where it is much hotter. On Wednesday, I had started my training session at Nduta when it began to rain, a few drops at first, pinging on the metal roof of the shelter we were at. Then it turned into a downpour. The noise of the water hitting that roof seemed as if a thousand skeletons were doing a fandango on the roof. I couldn't even hear myself speak so we waited for a bit. As soon as it quieted down, I would begin again and shortly the skeletons picked up the beat and off they went again.
We got word this week that there would be another camp consolidation starting in the next week or two. We have two camps here where we are responsible for the health care, Nduta with about 45,000 and Kenembwa with about 13,000. By the end of the year (2007), Kenembwa will be closed with all the people moved to Nduta. There still is repatriation occurring but that is a slow process at this point with only about 100 - 200 a week returning. So many have no place to go back to and those that try find little infrastructure to support themselves. They are given food for three months and medication, if needed, for the same period and about $100 in cash but most still do not want to leave the security of the camps at this time. Fortuitously I had asked just the day before that we all (ex-pats) get together and think out the changes that needed to be made in the clinics not only to make them more efficient but, more importantly, to deliver better care. we had that meeting yesterday afternoon and did come up with a preliminary plan. The major problems leaving aside clinical care are the congestion and intolerable delay at the registration area as well as at the pharmacy. I have started some changes already in those spots. We are now identifying sick children (adults also) that need to be seen quickly. They are given paracetamol (an antipyretic) and fluids and then brought into a clinician. More needs to be done to expedite this, a work in progress as I all too often have to say. At the pharmacy, I have ordered two compartmentalized containers that will hold prepacked medications the dozen or so that we use frequently. This, hopefully, will eliminate the long delay and crowding there while the pharmacy assistants labouriously count out the pills for each prescription. My next project is to establish a better system for educating patients and their caregivers, instructing them on proper use of the prescribed drugs, possible side effects and a bit about the disease they are afflicted with. Meanwhile I will continue with daily mentoring in the hope of changing some of the rather interesting practice habits that some clinicians have developed. Another of my pet projects is hand washing which is minuscule at best now. I have found only one clinician that does it routinely. Of course, first we have to make sure that the wash buckets have water and that there are soap and towels available.
So that is the way it looks from here at this moment where
the clinic is full and chaotic
the soap missing, the buckets empty
and the clinicians diagnose everyone with malaria.

Stephen

Getting to know you, getting to know all about you.

2007-10-12T23:41:00.000-07:00

Out on the trail for a walk, you are greeted by myriads of children, all wanting to touch you. They greet by clenching a fist and touching yours while calling, "tanu, tanu". I startled them initially by clicking my tongue, eliciting bursts of giggling especially among the girls. Now though there is a cultural shift as they have started doing the very same. The real test is how long it will last.

Stephen

Here we go again!

2007-10-06T10:15:00.000-07:00

Well my first complete week at the clinics has passed. I guess I really have a very short attention span or I am just a bit dumb as I seem to quickly forget just how difficult it is to change habits. Evidently there has been little, if any, clinical supervision by an expat physician for a very long time. No one can give me any definition of "a very long time". In my last post I mentioned some of the problems that I came across in my first two days. Working in the pediatric OPD at Nduta, I watch a clinical officer diagnose and prescribe without once examining a patient. A florid case of scabies was diagnosed as a reaction to worms and prescribed the appropriate treatment for helminths but, alas, it won't do much for scabies. When I said that that was the diagnosis, I got an incredulous look and little else.
I did find one clinical officer, retired military, that was eager to learn and became very excited about starting a triage system to identify the very sick children and get them treated quickly with fluids and paracetamol and into a clinician. We actually did set the system up and on Monday, I will return to Nyduta to see if it is working.
At Kenembwa, very little success, in fact the attitude was frankly depressing. Enough so, that I was very happy when my ride back to base showed up in the late afternoon. I will go back and see what their attitude will be next week.
There is a project starting to monitor respiratory illness, part of a surveillance for Avian Influenza. I was asked by the coordinator for this project about the state of infection control awareness at our facilities. Sadly it was a very easy answer, none. Just the idea of hand washing, something so basic, is rarely practiced. I have written about that before. Well if I can get the triage system working and some hands washed, why then, I will have done something.
The high point of the week was a visit to the International Organization for Migration (IOM). What one can accomplish when there is an abundance of money available. Their task is to screen and treat those refugees that are going for resettlement in other, usually Western, countries as America, Australia, Canada, Scandinavia. I had "the tour". A wonderful laboratory, an x-ray unit for chest x-rays but it could take abdominal and bone films. A fully stocked pharmacy that made me drool. The refugees are screened by expat doctors. There are no clinical officers there. We can utilize occasionally their facilities, essentially the x-ray unit and that is helpful as they are close at hand just outside of Kenembwa.
Sunday is now winding down. we did get some thunder and lightening last night and a brief sprinkle this afternoon. Not enough to dampen down the incessant clouds of fine red dust that coat everything but just a taste of what is brewing. We will have a few good dust free days and then mud season begins. Those of us in Maine are familiar with that as it is our Spring.
And that's the way it looks from here in Kibondo where
the dust abounds
the rains threaten
and I hope to get people to wash their hands.

Stephen

The Clinics

2007-09-29T06:19:00.000-07:00

Once again a Saturday and a bit of time to write about the past week though it has been frustrating to try to do this. The Internet is being very temperamental as our services have been cut down by our country director in Dar es Salaam because of supposed excessive use and that curtails everything from the Blog to contacting colleagues, and creating appropriate treatment guidelines. Yet it still works albeit very very slowly. I suppose that I should not really complain though I will. In Darfur, the government would shut us down for days on a whim though usually it was when they were planning to do something stupid. So we always had a pretty good idea of when an attack was coming. Anyhoo our field coordinator hopes to have this resolved next week as he,too, can not get his work done.

I spent Monday and Tuesday, getting my work permit/pass authenticated and then signed in each camp. I was given "The Grand Tour" and introduced to many people so that, hopefully, when I did reappear I would be recognized. I spent 2 days in Nduta which is the busiest and most chaotic with about 40,000 refugees and Friday at Kanembwa, which has only about 13,500 at present. Repatriation is ongoing but the number has dwindled down dramamtically as the earlier returnees pass back messages of no services, lost lands and general instability. There have also been some fighting. It is considered minor but, for me, the appearance of armed people is major whether or not shots are fired.

I got more than I expected on my first few days. At Nduta, we were so busy that I had to do rounds on the pediatric ward and I could not observe anyone. There was sadly the usual crowding with 2 children/bed but, by the end of Thursday, there were enough discharges that we did get down to only one/bed with even a few open spots. At Kenembwa, I made rounds with the physician and then spent a bit of time in the OPD with one of the clinical officers, sort of a P.A. by our definition. The task of trying to change things will be Herculean as there just is so much amiss here from basic handwashing between patients to misuse of antibiotics to a general lack of knowledge of pathophysiology and even appropriate diagnosis. The doctor never washed her hands except at the end of ward rounds even after examining a woman with open Herpetic lesions. AT least she did wear gloves when doing a proceedure though one of the midwives was about to start an IV without them when I intervened. I suppose the most comical really saddest sights was the clinical officer trying to get a blood pressure on an adult patient with a pediatric cuff. It kept popping off as it was just too small. I asked him if he had a bigger size. He replied, "yes" and continued on.

I tried to start a teaching program with a session at each camp. They were used to having one on Wednesday at Nduta and on Friday at Kanembwa. I just could not get them together at either camp as they said they had not been given advanced notice. Well I gave it to them for next week and we will see what happens. Unlike Pip, I do not have "Great Expectations".

Kibondo

2007-09-23T02:34:00.000-07:00

Kibondo

2007-09-23T02:28:00.000-07:00

That was the week that was.

2007-09-19T07:18:00.000-07:00

Once again, a Saturday and the weekend.
Last weekend, my first out here, we went to the UN compound Saturday night to partake of their bar and disco.
My, they do live well here and indeed in all the UN living sites I have been very impressed at the way that they care for themselves. Enough so that I did once inquire about a position. But, as they are mainly administrative, I let that drop.

Sunday we took a long walk to a small mountain called the Mump. Exactly what that denotes, I have to find out. Found out later in the week that it is just a nickname that it got as someone thought that it, sticking up out there, looked like a child with unilateral mumps. Along the way we encountered the usual gaggle of children running out from the little clusters of homes to greet and walk with us as we were the only entertainment about. The children have a unique greeting that I had not seen before. They approach calling "tene, tene" with their fist extended and then touch your fist gently. I startled them by either clicking my tongue when touching or by singing "ding-dong". Soon they were doing it and on the way back they were still doing it. I'll find out this weekend whether I have shifted the culture here.

The rest of the week, I have spent rewriting the outdated treatment protocols. So far diarrhea and respiratory illness have been done and I am now in the midst of malaria. Those are the major causes of morbidity and mortality in all the places that I have been and this is no exception. After that I will start on the less common diseases but I need to get to the clinics to see exactly what is occuring now.

Now another Saturday morning and I did finally get the precious document that will allow me to get my camp pass on Monday after I visit the various offices and officials that abound in every bureaucratic system. With a bit of luck, I might even get into a camp in the afternoon, though I suspect that Tuesday is more likely. As usual I had to threaten to resign to stir things a bit and get this. I had almost gotten in the mindset of knocking on the door at home and surprising Gerda. Not such a good idea at our ages.

I did finish the malaria protocol and now will begin on some others to pass the weekend. Last weekend, I did learn how to use the digital camera that our son, Jan, gave me and to get the pictures onto Snapfish. Now I will try to get them onto this Blog.

That's the way it looks from here.

Stephen

Pictures

2007-09-16T23:15:00.000-07:00

I have posted some pictures on Snapfish. If you have any interest in them, send me an e-mail and I will forward them to you.
Stephen

In The Bush

2007-09-12T07:38:00.000-07:00

I am finally here in Kibondo. We left Dar es Salaam early in the morning on the 12th. First a commercial flight to Mwanza, a city on the southwestern shore of Lake Victoria. From there we took a UNHCR plane, a Caravan, the bush plane. Room enough for 10 and a bit of lugagge. Fortunately there were two no-shows so that we were able to get a bit extra on board. We were supposed to take only 10 kilos each but I had 22 and still left some back in Dar. Getting on that plane rekindelled my excitement about being here in Africa again, especially as we flew over that familiar landscape. This included a good portion of the Lake which is always breathtaking. We landed in Kibondo and then a 20 minute drive to the compound, again through the landscape that I am so fond of.

The compound here is very large and situated on a hill. I have a bungaloo which faces south. The Burundian border is northwest of us, about 10 kilometers distant. A private shower with hot water twice a day. We arrived shortly before lunch which was excellant and we get 3 meals a day every day. So there goes my African diet plan. This is a bit more like Club Med. and a nice change from other places that I have been.

So far my camp pass that allows me into the refugee camps has not arrived. Hopefully that will not be long as I have been granted (so I am told) my medical license and my exemption which allows me to stay in the country for a year. Those two documents are needed and then the camp pass is automatic. Meanwhile I will review the "essential drug" list and be sure it is accurate. Then, evidently, the treatment guidelines are very out of date and need updating and standardizing so that I should have enough to do for the next few days.

Now it is Saturday, the 15th. and so far I have designed forms for the in- and outpatient departments as well as developed a diarrhea protocol. Actually WHO did that and I creatively borrowed much of it. What remains to do are prot9ocls for malaria and respiratory tract infections. There will be more but these are the most important causes of morbidity and mortality in this setting. What is difficult for me to comprehend is that we (IRC) have been here delivering health care for at least 10 years and this has not been kept up to date.

We went into the "big city" of Kibondo today and it is the same as so many rural African cities. This, being dry season, there was a swirl of red dust every time a vehicle past. You learn to gauge the direction of the wind very quickly. We went into the central market where everything is sold and went to the "supermarket". One room but, evidently, the proprietor just got a shipment of goods, the first in three months. All my favorites were there and I did get a few packages of tea biscuits. The ubiquitous cheese, "la vache qui rie". was there. It exists, like coke. in the most remote places. I even saw a small bottle of my buddy, Jack Daniels.

The weather is wonderful. Cool at night and in the morning until about 1100 then it warms up but not that fierce heat that I have experienced in other places. I have taken pictures of the area and our compound and will try to post them. Hopefully I will get my camp pass in the next few days and be able to be more helpful to all.

And that's the way it looks from here.
Stephen

Still Here

2007-09-08T23:58:00.000-07:00

After many perhaps and possibilities, I could not get a flight out to Kibondo as yet. It seems that there is only one airline and one daily plane that holds only 30 people. So I remain ensconced in a rather luxurious hotel. On Friday two more expats came in so I do have company. They will go out to Kibondo with me whenever we can get on the flight.

Saturday we spent droodling about Dar es Salaam (which means, "House of Peace" in Arabic"). We got a tour of the city past the elegant parts where the rich and diplomats live, by the harbor which is lovely, by the fish market though we knew that place about a kilometer away as we were down wind of it and finally through a few of the upscale shopping plazas. We did get to the National Museum which is sad compared to the one in Nairobi. The most interesting parts were the actual skull of Zinjanthropus (Australopithecus Boisei) 1.6 million years old found by Louis Leaky in Olduvai in 1959. Then there were the actual earliest footprints of hominids, 3.6 million years old, found by Mary Leaky at Laetoli. Other bits were a review of Tanzania history from the Neolithic through Independence with the usual panegyrics to the first president, Julius Nyerere. He was a committed socialist who tried to establish collectives though he called them, Cooperatives. That ruined the economy for decades. The idea was excellent but the implementation disastrous. There was also an exhibit of the Duong, a sea mammal somewhat akin to the Manatee that is endangered here. It has the shape of a Manatee but a face more like a pig's. It is evidently the creature that gave rise to the myth of the mermaid not only because of its looks but also as its call is similar to a woman crying.

Our next stop was at the Botanical Garden which was in sad disrepair. The best feature was the myriad peacocks and peahens that were wandering about looking very insouciant. There a bus full of children also visiting and we were more exotic to them than the birds. They were polite and curious except for the one wag, always a bit older and male who would mouth his few words of English, ask for money and then say something in Kiswahili to make the others laugh nervously.

Back at the room at night, I wandered through the 60 or so channels on the TV. Except for ESPN, BBC and would you believe Hallmark Playhouse from decades ago, there were only Bollywood movies, Arabic news and Indian rappers. By happenstance, there was a feature on Stanley's discovery of Livingstone.

Today we will visit something called the Village Museum which has a multitude of traditional living huts as well as music and dancing.

And so the weekend will go and hopefully we can move on tomorrow and start work, the reason I decided to come out here.

Stephen

I have landed

2007-09-06T02:10:00.000-07:00

IT was a dark and stormy night. The wind whistled ominously through the trees as they scratched and thumped on my window as if something out there was trying desperately to get in.
Now this has nothing whatsoever to do with my doings but it seemed to be one way to capture your attention as really today there is little to say.
I did arrive safely after the usual long and tedious flights but, fortunately, nothing unusual happened. The only glitch was waiting at immigration with the several dozen others for close to an hour to get the visa. On the plane, I sat next to a middle-aged Italian man who spoke only Italian and who wanted to chat. So he spoke Italian and I waved my arms about and peppered my English with the few words from different arias and menus that I remembered but they were rather rapidly depleted. Really how many times do risotto and focacchio fit into a conversation.
The plane landed first at Kilimanjaro and most people got off there to climb the mountain and do the safari route. Then another hour and we were here in Dar es Salaam. A drive through the city to the hotel and finally, after 24+ hours, I was able to go horizontal. I did get to see the Indian Ocean this morning on my way to the office and that was, so far, the only highlight. As expected they did not have the permit that allows me to get in the camps. Personnel went over there this morning to try. They have only known about my arrival for 3 months but that is typical wherever I have gone. So I may be here until Monday or Tuesday depending. Then a flight out west to Kigoma and a 200 kilometer drive from there to Kibondo. That can take 4-6 hours during the dry season or a day+ during the rains.
I did see that film, "Away From Her" on the flight and, despite the presence of an older Julie Christie, I was very disappointed as it distorted reality so much. For those who have not seen this film, it is about the deterioration of a woman with Alzheimer's disease and her husband's response to her increasing disability. First she was too highly functional to go to a home unless her husband was truly trying to abandon her as he clearly was not. Then the home's supposed policy of no visitation for 30 days is very difficult to accept. At that point, she had no real idea of who he was and had formed a close relationship with another patient there. There was no mention of possible treatment and when she became extremely depressed, nothing was done to try to help her. It is just too important a subject to present this way.
That's it for now.
Stephen