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Out of Africa

Well my time in Africa has come to an end (that is if my flight plans work out). Tomorrow morning I will be leaving for Dar es Salaam, then Dubai, then NYC, then Atlanta, and then Dayton. For the last few days I have been in Mwanza mostly eating at restaurants (enough to get traveler’s diarrhea as a going away present) and shopping. On Tuesday I was fortunate enough to make the trip to Serengetti National Park. The trip probably warrants a post, and I could say that writing about it wouldn’t do it justice (which is probably true), but mostly I just dropped the ball. It really is an amazing experience, and I hope I can talk to some of you about it. But pictures will have to do. Thanks to those of you who have followed along with me on my travels. I have tried as best I could to put into words both the indescribable beauty and poverty I’ve encountered while at the same time making it at least slightly enjoyable to read. I also wanted to write a final sprawling reflection of my experience here. But there just isn’t any time, and I don’t think I’m ready for that yet. Like I said in the beginning, I will try to put up pictures on this blog when I get back. I will probably also post them on facebook. So if we’re not facebook friends, maybe we should be.  Kwaherini! 

Maisome Part III

Only in retrospect do I realize how smooth the clinic in Bumbire actually ran. The Maisome clinic on the other hand is a heart-breaking example of rural African medicine. The clinic itself is a well constructed building whose design shows real forethought into the needs of the community. There is a large outdoor waiting area, a registration counter, the doctor’s office, the lab, and a pharmacy counter all organized to promote the efficient flow of people. Wooden panels in the walls connect each of the rooms, so presumably charts and specimens would be passed back and forth. That is, at least, if there were a staff. Unfortunately, only 6 months after the clinic was built, the health care officer and nurse in charge stripped the building of its pipes and shelves and took off in the night. Now there is no running water (despite the massive tanks beside the clinic), and the beds in the ward are without mattresses. And now this shell of imagined greatness is run only by a staff of two: a part time nurse and Mgupta, the health care officer. Mgupta is a friendly, short, bald man who wears an oversized black suit and gives off an unmistakable used-car salesman vibe. As a health care officer, he has more training than Flora back on Bumbire—or at least just enough to blurt out phrases like “compleecations of diabetes” at inappropriate times. Bob comes to Maisome for three days out of the month, but for the rest of the time the clinic is run by Mgupta armed only with a monocular microscope and a manual centrifuge. When Bob would ask for amoxicillin to treat a urinary tract infection, Mguptu is quick to yell out from behind the pharmacy desk “out of stock”. Mguptu orders all of the clinic;s medicines and as supplies would indicate, only believes in injectable penicillin. Once again we had to go into the Bumbire stockpile.

Because I know so little Swahili, and the clinic was very busy, I had the honor of using the newly purchased microscope to look at blood, and stool specimens. Since there is no electricity I use a flashlight as the light source. Mgupta uses a mirror, which is nearly impossible.  I ruled over the lab. The microscope was at the end of a long counter next to which was an assembly line of patients’ charts, each topped with a small bottle of urine, a match-box (or in some cases a leaf) with a sample of stool, and sometimes a blood smear. Some patients preemptively bring a stool specimen, apparently knowing how much Mgupta likes to use his microscope. The patients at Maisome have been far more interesting than those on Bumbire—probably because they’re all waiting to see Bob. Yesterday we saw a guy with 6 months of hemiplegia (presumably from a stroke) who was adamant that someone had placed a hex on him. He had cuts all down the paralyzed arm and leg where the witch doctor had set to reverse the curse. The man said he paid a goat for the service. We spent a good hour examining this guy, but by the time it came time for him to pay us the equivalent of 4 dollars he said he didn’t have any money. The AIC can’t convince Mgupta to collect before services are rendered. We also saw a 3 year old with malaria so severe he had a hemoglobin of 4 and his urine had turned black (a true case of “blackwater fever”). Mgupta doesn’t have the equipment for a transfursion, so we could only give him malaria meds and refer him on to the closest hospital on the mainland.

For me the most gratifying experience is to find a parasite in the blood or stool and being able to give a simple, affordable medicine to treat it. Unfortunately most of the time we just don’t have the capabilities to either diagnose or treat what afflicts these people. Some wait hours or even days to be seen, so we make sure that everybody, no matter the complaint, leaves with something, even if only a placebo. In this way I suppose the clinic in Maisome is a lot like those in the U.S. 

Maisome Part II

Part II

Wednesday through Saturday we lived with the pastor Zacharia, his wife Joyce, and their nephew Ema. Their house is a traditional rural Tanzanian home, but is actually a bit nicer because it is built of cement and has a reservoir to collect rain water from the roof. There is one large living/dining room surrounded by 4 smaller bedrooms. My room was a cement cell with two windows and a single mattress above which hung a mosquito net. They have three chickens and a rooster which have the run of the yard (but sleep in the house at night to protect them from wild animals) and a kitten named Tom. Meals are prepared outside in the dirt yard between the house and the smaller kitchen, which is separate from the house and largely serves to store rice, veggies, pots and pans. There is also a separate building which is a combination outhouse/bathhouse. The bathroom side is simply a hole in the ground. No seat. This is actually the case throughout Tanzania, but until this point I had managed to avoid using them. I imagine Africans must have toned quadriceps. There is a cover to place over the hole to prevent bats from flying in. There isn’t much you can do about bugs though—or the smell. The bath side has enough room only for a basin of water just wide enough to stand in. Joyce heats up water over coals in the yard, and when it is bath time pours it in the basin so we can have warm water. On my first try at the bucket bath it was already after dusk, and a bat flew in and encircled me twice before leaving. Joyce prepared for us three meals a day: midmorning tea, dinner, and supper. Tea was served with chipati (flat bread), but all of the other meals were pretty much the same and consisted of rice, beans, bananas, and tomatoes with okra. The made us rice only because they know that we don’t like ugali (cassava root). Occasionally there was fried perch. Morning tea was always awkward because it was served only a couple hours into our work at the clinic. Joyce would walk over and tell us that tea was ready, and we would just drop whatever we were doing to walk over to the house and eat. The way the clinic is set up we would have to walk past all of the sick people waiting to be seen. But this is apparently accepted culture. Nowhere in Tanzania does there ever seem to be a sense of urgency. After clinic Joyce will heat up water for our bucket baths. I spent the rest of my time either reading, watching the Vervet monkeys venture  from the tree tops to the ground to scavenge for fruit, or playing soccer with Ema and the other local kids (including Jame’s son who apparently lives and goes to secondary school on Maisome). We eat supper by lamp light, and when we’re done it’s just about time for bed. It’s funny that I would consider the way I lived for those three days to be camping. And without electricity or running water, really rough camping at that. And yet this is the way they live every day of their lives. 

Maisome Part I

The Trip: Wednesday morning began with us carrying all of our things through the jungle to the area where the missionary boats are docked. We loaded our luggage onto a wooden fishing boat and said our goodbyes to Flora and some of the others who had helped us carry our things. Joining us on the boat were James, another woman who needed a ride to the mainland, and the driver, Boni who just so happened to be wearing a belt buckle with an Obama hologram. Our first stop would be the missionary base in Kahunda where we could drop off many of our things before continuing on to Maisome. We set off at 8:40 in good spirits. The sky was clear and the water was calm. We were only 500 feet from the dock when Bob spotted a hippo sticking its head out of the water near the shoreline.  We all turned too look (including the driver), when we suddenly noticed that off the port side of the boat was a man struggling to stay afloat. Man overboard? No, he wasn’t on our boat. Then it occurred to us that our boat had run over this fisherman. In front of our boat was the fisherman’s raft—the size of a twin bed mattress in every dimension and constructed from styrofoam covered with bamboo. We pulled the man into our boat and then grabbed a hold of his raft and his other various belongings that were floating around us. We were fortunate that he was not hurt, and also fortunate that he didn’t seem to mind all that much. In the United States such an incident would be mulled over in the courts for the some months. Despite the inauspicious beginning the next 3 hours of the ride were very smooth, but would have been more pleasant had James not decided not to act out stories from Genesis in Swahili.         Around hour 4 the wind started to pick up and so did the waves. Whitecaps formed on the surface of the Lake and as we hit the crests water would fly up and over the side of the boat and into the hull. Boni covered our bags with a tarp and began to pour out water that collected in the bottom of the boat with a bucket. I was getting soaked, and James offered me his puffy winter jacket—which until this time I had privately made fun of for being completely unnecessary in Africa. Well, it did the job. Then conditions got worse. Coming up on hour 5, no more than a couple miles away dark clouds began to collect and beneath them emit a solid sheet of rain. We were still a good hour and half from Kahunda and slowly but surely the storm approached us until, still dry, I could see the ripples created by the raindrops on the water only 10 feet or so away. At this point we all covered ourselves with a second tarp, sitting on the edges so that water could not leak in (think giant parachute from grade school gym class). As soon as we did the sky emptied a deluge upon us. The boat began to rock to the point that the water was less than a foot from entering the hull. There we were, huddled under a tarp beaten by wind and rain, rocking violently from side to side, when suddenly the motor turned off. Then we began to rock even more. We were under the tarp, so we had no idea why Boni had turned off the motor. Was he even still in the boat? It would have been nearly impossible to get out from under the tarp at this point. If there were ever a time to panic this was it. Here we were in a wooden boat, in the middle of a storm, in Lake Victoria. I’m sure I would have been sea sick if I had not been so focused on staying inside of the boat. Then only a couple minutes later (but for what seemed like an eternity) the rain lightened, the motor started back up, and we continued on. I emerged from beneath the tarp, and the boat continued on with relative ease for another hour or so. I had arrived in Kahunda intact. We unloaded our things, and after a quick lunch got back on the boat for the 1 hour ride to Maisome where we would spend the next 3 days.

Bumbire Cup

I have had the opportunity to come to know several locals during my time here, but perhaps none better than Masambuko. I met the man on my first day on Bumbire when he came by to welcome Bob and Dorothy back to the island. Bob and Masambuko have a mutually beneficial friendship whereby he teaches Bob Swahili, and Bob teaches him English. Masambuko is very friendly and it is probably his intact, pearly smile which makes him look much younger than his 40 years. He stands about 5’5’’, with both a soul patch and Hitler mustache, and he is always well dressed. Despite the fact that we have seen each other many times over the past 2 weeks, he still speaks to me in Swahili as if my vocabulary of roughly 10 words has given way to fluency. I always answer him with “Hakuna Mtata” which he finds funny because he has never heard that expression before. In addition to being a farmer, Masambuko is a VIP of sorts on Bumbire, where he has over the last few years organized a soccer league. There are now several teams on the island, and he is their de facto commissioner. Even more importantly, as commissioner he takes it upon himself to tell Bob who should and should not receive the soccer balls which have been donated to the Clinic. Earlier in the week when he came by for his weekly English lesion, Masambuko said that he would try to get me into one of this soccer games on Sunday (yesterday). I told him that I was not very good, but he said everyone would just be excited to have an American playing with them. So yesterday when Bob, Masambuko, and I (fully dressed to play) were walking to the soccer field, I was surprised to hear him casually mention that this was actually the league Finals. Bob laughed. Typical Masambuko. At least I wouldn’t have to play. I was badly out of shape, which would only be compounded by playing at an altitude of 3,000 feet. I wouldn’t have to embarrass myself and more importantly my country in front of a group of people who would probably never see another American play. I was sure that decades later the people of Bumbire would be telling their children of America’s athletic inferiority as demonstrated in the Championship game of 2010. So I dodged a bullet there. The field was in the vicinity of the Lushongo fishing village and in view of the Lake. When we arrived there was not a person in sight. Just an empty field swarming with dragonflies, and soaring above them the black kites hunting their late afternoon snack. Before I could ask the commissioner whether we missed the game, he pulled a whistle out of his front pocket and blew. Within seconds dozens of people emerged from the jungle on all sides in groups of four of five. Each group had a hand held radio, and they were all listening to a Tanzanian soccer match between two teams from Dar Es Salaam: “Simba” and another team whose name I can’t remember but means “yellow”. The game on Bumbire was between Lushongo (the home team) and Maasi who had made the long walk up the hill. For 30 minutes the players stood around suiting up—the Maasi players in their knock-off purple Arsenal jerseys and the rag-tag Lushongo players in whatever they could find to put on. Some wore shoes, most didn’t. Then the ball arrived. Balls are scarce on the island, and I was worried we might have to walk back and retrieve one from Bob’s secret stash. The net-less goals were assembled at either end of the field, and after the players were brought to the center of the field for a quick talk by the commissioner, the game began. I hesitate to say that the players weren’t good, because they are far more talented than I am, but the play resembled the kind of foot shuffling and juggling I saw the kids do with their makeshift balls in the villages. It was like watching “And-One” Basketball on ESPN and thinking, if they had ever once tried to run a play they might be somewhat decent. There were no shots taken outside of 20 feet of the goal, and the passing was abysmal. I took several pictures, but tried to keep this to a minimum because each time I took out the camera, every child under the age of 10 huddled behind me to see the screen on the back of the camera. This would cause Masambuko to pick up a stick and shoo them away. As if Bob and I didn’t stand out enough already, the commissioner made sure to secure for us two wooden and place them at midfield so that we could watch the game in comfort. Nobody else had a seat. It was embarrassing. I only hoped that the players thought that I was some kind of MLS scout scouring the continent for hidden talent. Masambuko had his own motives, as earlier on our walk to the field he hinted that now that I was rafiki (friend; also the monkey in Lion King), I  might send him a television when I am back in America so he can watch the games. The match went the full 90 minutes, punctuated by three goals from Maasi to Lushongo’s two. Maasi had won the Bumbire Cup, and the children who had made the 30 minute walk to support the visiting team went wild. Several of the players shook my hands after the game was over. “Sorry”, I told them. “You’re just not Arsenal material”. Tomorrow we’ll be leaving Bumbire by boat for Maisome Island. We will stay there for four days and work at their clinic. I’m told it is more rustic and that I won’t have internet access. When I get to Mwanza next weekend I will post what are sure to be good stories. 

The Road to Maasi

4/17Saturday afternoon’s entertainment was a hike to the East end of the island and the village of Maasi. Because it’s such a long hike, Bob and Dorothy had been there only one other time in their two years here. In all it’s probably no more than 2 miles, but it is a very difficult 2 miles. There are several steep inclines both up and down, and at several places the trail disappears entirely into fields of 8 foot high grasses where we would have to go back to find our way. And when there was a trail it could be even more difficult because the earth has been packed down from the near nightly rains to form a substance as slick as ice, so that every step must be deliberate. On the way I probably slipped 4 or 5 times, but caught myself on each occasion. First we walked up the hill just behind the house, and at the top found the same herd of cattle we passed on the way to Lashonga, only this time they were huddled together in a corral made of tree braches and fastened together like Lincoln Logs. There were also a couple of pigs. I can’t imagine what just a couple of pigs are good for here except for maybe a long term investment like a dowry. I have not once seen pork served. A little further down the road and at the top of the hill the trail flattened out and we could see the Lake surrounding us on all sides. A couple of boys, no older than 10 and 12, were walking ahead, frequently looking back at us. Each was carrying a hoe and a large recycled plastic container for water. The older boy had a radio, and when we caught up I noticed it was playing Madonna’s Like a Prayer. I pointed out to them (in English) that I knew this song. That it was Madonna. They just looked back and laughed, but kept walking until they turned off of the path to a cassava field where their day’s work lie ahead.After another 40 minutes or so of struggling to find our path (with the cell tower as our only bearing),we climbed over some igneous rocks harkening back to Bumbire’s volcanic origins and came upon the island’s only elementary school. The building was one story concrete structure, no larger than a trailer, and at one time painted with a solid coat of blue paint which was now mostly faded. There were two classrooms inside, each with conjoined wooden desks—enough to hold 50 or so students at most. Outside of the nearest classroom door hung from a rope attached to the tin roof a rusted-out tire rim. This must be their bell. Some of the local kids who easily spotted the Wzungu (which by the way literally means “people who go in circles”) had stopped by to have their pictures taken. I did. And in return they gave us a tour of the classrooms. The children here must think that every white person they meet has camera on them at any given time. Of the wzungu they’ve seen, they’re probably right. Polaroids would be a big hit here. Inside the classroom the wall almost almost blends in with the scratched surface of the blackboard. The equations on the board looked to be permanently there, as if any attempt to erase the board might cause it to crumble to dust. The kids then led us outside the school where there was a well maintained field framed at either end by soccer goals fashioned from tree branches. It only now realized the harsh reality of how inaccessible this school was to the vast majority of children, not only on this island, but on the chain of islands that make up Bumbire. I imagine that most kids instead get their education working in the fields like the two boys we ran into earlier. We continued on a ways and passed the humming monstrosity that is the cell phone tower, protected by barbed wire fencing and outside of that a guard seated beneath a grass hut. On Bumbire there is really nothing that can compare to the tower either with respect to size or impact on the lives of the people. While every other technology over the last 75 years seems to have passed the island’s inhabitants by, cell phones have taken a foothold. Even the women, who don’t have pockets in their Kangas, carry phones in a case which hangs by a string around their neck. Baby in back, phone in front. I’m told that nightly entertainment on the island often consists of games built into the phone. I imagine the whole family huddled around the 2 inch screen watching Dad go for the high score in Snake. I could also envision a devoted group of islanders erecting a shrine at the base of the imposing structure and praying to ward off dropped calls: Church of the Cell Phone Tower. “Though shall not call during dinner”. After another 10 minutes were at the top of a steep hill looking down over a jungle at the base of a cliff and next to it the Lake. We carefully descended down the rocky trail the missionaries refer to as “Jacob’s Ladder” and into the jungle below. We were now out of the hot sun and under a canopy of banana leaves and other subtropical trees with their hanging vines. We were in Maasi. Here the plant life was so dense that the houses were hidden and barely visible from either side of the path that lead through town. Those that did appear looked more permanent than those on the other side of the island, and were constructed of brick and cement. I imagine generations of people have lived in this village relatively unchanged and untouched by outside influence (except of course cell phones). We crossed a small brook and came upon a brick house which out front had a green flag hanging limply from a 20 foot bamboo pole. A man spotted us and beckoned us to his front yard where the rest of his family was seated on the straw surface. There he set out chairs for each of us. He told us he was the Berazi (ambassardor), as signified by the green flag, and presided over 10 family units. In all there were 90 households in Maasi. Being a good ambassador, he gave his guests a tour of the village. He took us down to the Lake shore and pointed out the much smaller island across the way where he can buy medical supplies. He knew Flora from her trips to the mobile clinic there, and although he said he was Roma, he also knew James. He took us past the house of the Chairman who was in charge of the nine Belazi. The cement house was in the center of town, and unlike any other I’d seen in that it was painted on the outside with a blue and yellow floral pattern. He then escorted us to the edge of the village where he gave us his contact info. There we also ran into a man from Lashongo selling on a mobile wooden easel various items: belt buckles, girls’ dresses, men’s shirts, coats, etc. He followed us back up Jacob’s ladder and turned off at the road to Lashongo on his daily round trip of the island.After another 2 hours and a quick detour by the vast pineapple plantation we were back. We each enjoyed a well-earned ice cold coca-cola followed by grilled cheese and tomato soup. I was exhausted and turned in around 9 o’clock.

What’s in a name?

4/17

We had been called into the clinic at night on only three other occasions. The first time for the woman in labor, several days ago for a boy with a laceration of his nose, two nights ago for some run-of-the-mill dysenteric cramping. But last night was the first true emergency. I had just played the opening Scrabble move when Bob got a text from Flora that “She needed someone that took poison”. Intoxication—a subject about which, despite four years of medical school, I still know very little. When I am the intern on call in just a few short months and am presented with a poisoned patient I will not hesitate to call the poison control hotline. But alas there is no poison control hotline on Bumbire.

         So it was already dark and we grabbed our flashlights and walked down the dirt path to the clinic. The ward is lit only be a lantern and on the bed I could make out a woman, 19 years old, moaning incoherently and occasionally retching, being held by some man—perhaps her husband. Four or five other people stood in the corners of the room obscured by shadow. Bob tried to get the story from the man, but it was clear that he only understood some of the story. He says that his Swahili is worse at night. He thinks because he cannot read the expressions on people’s faces as they listen. From what he could make out (and I was proud that I could make it out as well), the woman had ingested 20 tylenol and an unknown quantity of home-distilled alcohol (I didn’t make out the home-distilled part). Only she didn’t smell of alcohol and nobody had witness the event. Obtaining a history in this kind of situation is hard enough when you speak the same language. Here it was nearly impossible to discern exactly what happened. But regardless, here we were with a nearly comatose woman, who despite her stable vitals, seemed anything but okay. To make matters worse we did not have N-acetylcysteine (the antidote to a Tylenol overdose) to prevent liver damage. At least she picked a toxidrome I remembered. And if we did have the antidote, we would have no idea how much she really took, when she took it, or even if she took it. She took something though; there was no doubt about that. Supportive care was really all we could offer.

So Flora made a phone calls to the higher-ups in Nairobi, and arrangements were made to have the woman evacuated by boat to the nearest hospital—a long and treacherous journey by night. Even after they would arrive at the mainland in Bukoba at best an hour later, they would still have to track down and pay for a Dala Dala (an overstuffed van-sized taxi) to get to the hospital. The prevailing opinion was that it was unlikely the hospital had the antidote either. But at least they could, at least theoretically, get a couple blood chemistries and place an IV. We also could have placed an IV, but Flora was not comfortable with it.

In preparation for their journey, Bob had to write a letter addressed to “Doctor in Charge” explaining his assessment and treatment plan. He pointed out to me the patient’s eerily appropriate name “Aiba”, which means “Shame” in Swahili. Apparently such names are not uncommon. For every “Grace” and “Patience” there is a “Misfortune”, or a “Hatred”. Did she ever have a chance?

We walked back over for a final assessment before they set off. It’s lucky we checked in when we did because one of the family members who emerged from the shadows (let’s call her “Trouble”) was trying to pour milk down the throat of the semiconscious woman. “Hapana maziwa!” “No milk!” Or water for that matter. The family was incredulous that this was not good medicine, and Bob grew more stern at repeated attempts by the well-intentioned woman to drown the patient. After the confrontation was over, we wished them a safari njema and they were off.

As Bob and I walked back up the hill to resume our Scrabble game I noted that the sky was completely clear and that I had only seen so many stars during summers on the Outer Banks. Only I was sure that the constellations were different in the Northern Hemisphere. He pointed out the Southern Cross and the upside-down Big Dipper. Off to the West I spotted Orion, turned on his side, and pointing his arrow into the middle of the Lake.

Zahanati

4/15

Previously I said that I would write more about the clinic. This post will probably be drier than the others, but I think it is worth posting considering it is after all the reason I am here and where I spend every morning. A bit of background on the organizational structure: The clinic (zahanati) itself is run by the African Inland Church (AIC), a private, nondenominational organization spread throughout much of Africa and whose focuses include health care, agriculture, refugee camps, and yes, Christian evangelism. The AIC is run by Africans as opposed to the African Inland Mission (AIM) which is run by missionaries and fund much of the AIC’s projects. The two organizations are historically and practically linked. Much of the funding for the AIC’s health clinics come through donations from private organizations and believe it or not from the Canadian government. 

The clinic on Bumbire, Maisome (a neighboring island), and Kahunda (the closest mainland town) are largely managed by so called “community health evangelicals” or CHE workers (actually pronounced “Chay”).  They are local Africans who administer vaccines, do much of the testing, and provide home care in the villages. They also instruct people on sanitary practices and provide basic health education. The qualifications to be a CHE worker however and minimal, and their understanding of disease in many ways is less than the lay person’s in the U.S.

In addition to socioeconomic barriers to health care, there are many cultural barriers that exist here as well. For one, the clinic is seen by many people here as second-line only when traditional healers’ remedies do not work. On several occasions I have noticed scars left from cuts made along the abdomen of patients where I’m told the healer has placed various herbs and elixirs.

Many people also do not understand the concept of a chronic disease. Here disease is seen as something that can be cured with a specific remedy. The idea that something like say, asthma, needs to be constantly controlled with inhalers and other medications is foreign. So an endless cycle of taking meds, feeling better, stopping meds, getting sick, etc. continues. This is where frustrations sets in on our part. There is also no understanding of the difference between “clean” and “sterile”. Generally speaking though, nothing here is truly sterile. I’ve learned to be happy with clean.

The clinic somehow manages to cover the cost of the salaries of the CHE workers through donations and the nominal fees it charges its patients. The idea is to be self-sufficient. The charge for a single visit (which includes any medications given) is 4000 shillingi or 5000 shillingi for procedures. This is about $4-5 dollars. Or for the price of just 10,000 shillingi (or about $9 dollars) a family of 6 can buy insurance for 6 months. This covers all expenses for all visits and meds dispensed within that time frame. No co-pay, no limits, no extra charge for preexisting conditions. As in the rest of TZ, treatment for HIV patients is free (their equivalent to Medicare). The cost of an entire pregnancy including prenatal visits and delivery is also 10,000 shillingi.

So yeah, it’s a pretty good deal. But if you’re thinking “well, you get what you pay for”, then you’re partly right. As far as diagnostic tests go, we’re limited to urine dip, urine pregnancy, syphilis, HIV, HepB, malaria, and whatever we can see under the microscope. And all of the above depend on availability. We have a variety of the most basic antibiotics, Tylenol, ibuprofen, steroids, albuterol inhalers and other essentials. We can suture lacerations, splint and cast, pull teeth (though probably not very well), and deliver babies. But we’re obviously not suited for any obstetric emergences, or any other emergencies for that matter. If you need an appendix taken out you better get on the next boat.

 All that being said though about the shortcomings of the care provided, there are certainly bright spots. Immunization of children on the island is fairly widespread. Also, a recent effort by the government to spray homes with insecticides has resulted in a steep fall in the cases of malaria on Bumbire. But it’s not the expensive diagnostic tests and treatments that would make such a large difference in the types of diseases people face here, but the widespread implementation of seemingly simple but practically difficult measures such as water sanitation, hygiene, and nutrition education. Over and over again I see the same things: schistosomiasis, round worm, giardia, etc. Wearing shoes, using the toilet, washing hands, boiling water before drinking–these are the measures that will really improve lives. Easier said then done. I suspect that with more advanced technology we would probably run into diagnoses that would require only more expensive treatments that we don’t have. On the other hand, an ultrasound machine would be fun to play with.

Hey, why not ask for more?

4/11 There is no clinic on Sunday so I was able to sleep in until about 9 o’clock. It was also the first evening in several days where was no rain, and so I slept throughout the night. Church once again started promptly at 10. This time however, there were more than a few people there. I also noticed that the pastor had conspicuously placed a clock on the wall behind him on the pulpit. This Sunday he was wearing a collar (despite this being a non-denominational protestant church) with a purple shirt and a grey suit coat. After sitting through 2 hours of incomprehensible praying I went home for lunch and spent most of the rest of the day reading. I have probably read more during this trip than I have at any other time in my life. During my idle time I have also become adept at singling out the many birds on the island and their distinct calls: The whistle of the black kite, the insect-like call of the red-collared widowbird, the chirps of the pin-tailed whydah, the two toned laugh of the pied crow, and those tantalizing explosions from the grey parrots who always fly over but never stop by. At about 5 o’clock Bob and I decided to do some exploring on the island. We first descended into the banana forest below us stopping to talk with the people as we passed their homes along the way. More than once we were solicited for money or other more extravagant requests. I think there is a cultural divide between America and Tanzania when it comes to charity. In America soliciting strangers for money is often seen as an annoyance and has certain connotations as being a shameful act. Here however, such requests are commonplace and done with nonchalance. The requests are also on a much grander scale. Rather than asking for spare change we were asked by a man to “pay for his children’s school tuition”. We had never met this person.  Upon taking a picture you might hear a stranger ask you in a completely non-threatening way if they could have your camera.”No, sorry. I need it”.”Okay”. ”You’re going to Mwanza? They have motorcycles there. Will you bring me one?”.Another: “You’re from America? My grandfather lived in Europe. Will you help me get there”.The request is always cordial and there isn’t the sting of rejection. It’s as if they’re thinking” “well, you can always say ‘no’, but maybe, just maybe, you’ll say ‘yes’. So what’s the harm in me asking.”In one of the villages in the valley we ran into a throng of children playing soccer with a makeshift ball. Slowly the group of children snowballed to about 30 as they crept out of the woods to surround us. They were quiet until their precocious leader asked us for a new soccer ball. The rest of them laughed. I took their picture, which was enough to satisfy most of them and Bob and I continued on. About 10 of the children, their leader at the front, followed us for a quarter mile or so. I have noticed Tanzania has a very young population. There are children everywhere. Whereas the U.S. is growing older, TZ seems to be growing younger. Much of it I’m sure is due a shorter life expectancy and an absence of birth control. The procession came to an end when we climbed up the hill on the other side of the island. At the top was a narrow strip of tall grass and boulders on which from either side we could see Lake Victoria. Just north of us was Uganda and less than 100 miles to the West was Rwanda. The sun was beginning to set and it was quite a spectacle. We descended back into the jungle so we would could get back before it got dark. We got lost along the way (we made a right at the cassava farm where we should have made a left). With some help from a local we got back just in time to see the lanterns light up on the Lake for the night catch.