Jonathan’s Blog

Island Life

4/8I spent the morning in the clinic. Overall it was a slow day. We saw a man with dysentery who came in writhing in pain. His stool sample showed giardia under the microscope. We also had another women with diarrhea who had both giardia and schisto eggs. Giardia is endemic here from poor hygiene. Later that afternoon I would see first-hand some of the practices that make this nasty parasite so ubiquitous. At 3 o’clock Bob, Dorothy, and I set out for the nearby fishing village of Lushongo. As missionaries they do a once weekly bible discussion with some villagers there. To get to Lushongo we descended down into the jungle where, unlike the cool breeze at the top of the hill, the air is stagnant and humid. The winding dirt path took us past a herd of cows, a couple of gray parrots, stray goats, and a chicken followed by her baby chicks. After about 20 minutes we had descended to the level of the lake, still about a mile or so from Lushongo. As we continued on we passed a serious of mud brick homes with grass roofs. Each house had a plot of land cleared of forest and planted with some crop. We saw sweet potatoes, sugar cane, papaya, mango, cassava, and bananas. Almost everyone has a banana tree. I get the feeling just about anything could grow here. Unlike in Ohio, the individual crops are planted in dirt mounds so that the roots can more easily get water. I would think this would predispose the land to erosion. A couple times children from inside the house or along the paths would get very excited when they saw us, yelling “wzungu”. They would then ask me to take their picture. I manged to get a good picture of a couple of boys playing with a soccer ball made from plastic bags tied together tightly with string. We came upon a stream crossing the main path where the kids bathed. Without plumbing and with any number of animals roaming freely it is easy to see why giardia is such a problem. Everyday children and adults pick up this parasite as well as ascaris larvae, hookworm, and schistosomiasis. We knew were close to Lushongo with the scent of rotting fish wafting through the air. Previously I mentioned that the main species of fish in Lake Victoria are Tilapia and Nile Perch. Well there is a third: Dagaa. Dagaa is a fish the size of a minnow, which despite its rancid odor is a mainstay of life on the island. Every night the Lake below us lights up like a city with hundreds of lanterns on boats. The fisherman use the light to attract insects which in turn attract the Dagaa which they then trap in their large nets. In the morning the nets are emptied of tens of thousands of minnows onto the beach where they essentially rot under the equatorial sun. Acres and acres of land is set aside solely for the drying of Dagaa. After they are crispy and sufficiently smelly they are raked up into piles and sold in the market. Traditionally Dagaa are eaten with Ugali (a starch made of cassava root). So we passed the Dagaa rakers and the makeshift fishing cabins and entered the village of Lushongo. Unlike the more rural homes, the homes in Lushongo are built of tin, wood, and other scrap materials. The homes and storefronts are joined together to form narrow alleys that lead through the village. There are also pool halls (pool tables under tarps) where the people gather to play and listen to soccer games on the radio. Swahili rap music blared from a large PA speaker above one of the homes. The stores mostly sell fruit, coca cola, and pirated DVDs. My favorite was “Prison Break Season 10”. That show was cancelled after four seasons. The only electricity comes from diesel generators, car batteries, and the occasional solar panel. For those that do have electricity, charging cell phones is a lucrative business. There is also no plumbing and the smell of Dagaa mixes with the scent of burning wood and other unsavory odors. The people here are definitely less friendly than in the country, and I’m told that HIV, prostitution, and alcoholism are problems in Lushongo. Alcohol incidentally is consumed in the form of vodka contained in small plastic packets slightly larger than a ketchup packet. The packets litter the street. Fermented bananas are also popular. In the last couple days the fishermen have come to the island in droves as the moon begins to wane. When it is darker the lanterns attract more fish. Bob tells me we should expect to see a corresponding increase of STDs in the clinic. Just as in Kahunda we manage to attract the village drunk who insists on joining Bob and Dorothy’s bible study. I could tell they were getting frustrated. That night the clinic guard showed up at our house armed with bow and arrow around 10 pm, just as we were finishing up our Scrabble game. He told us that a woman who thought she was in labor arrived at the clinic with her stepmother. Since Flora the maternity nurse was away on the mainland for a meeting we would be responsible for taking care of here. We walked to the clinic and confirmed that she was dilated to 2 cm. She probably could have gone home, but since she lived an hour and a half away we told her to stay in the ward. We instructed the guard to get us during the night if she went into labor. Only hours later we were hit with the largest storm since I’ve been on Bumbire. We were hit around 1 am, and for a solid 3 hours were buffeted by wind, rain, thunder, and lightning. Combined with my nightly malarone-induced dreams it was a frightening experience. The tin roof magnified every gust of wind and rain drop many times over. I could only think about how those grass huts outside of Lushongo were holding up, not to mention the catamarans out on the lake. I wonder what was going through the head of the pregnant woman and her stepmother alone in the clinic. Even if they yelled I doubt anyone could hear them.4/9Friday morning the sky was clear. We walked down to the clinic relieved to see that the woman had not given birth. She was now dilated to 5 cm. It was a pretty typical day in the clinic. We did some prenatal testing for HIV and syphilis since Flora was absent. We also dia couple of blood smears for malaria, but nothing turned up. Just as Bob predicted a couple of fishermen came by for HIV testing and STD treatment. After clinic our patient was still not ready for labor, so Ester the pastor’s wife who runs a nearby tea shop, invited us to her home for lunch. Bob and I sat in James’ (the pastor) and Ester’s living room while he explained with a calculator how he is able to afford send his kids off to school on the mainland. In addition to being a pastor James is an entrepreneur of sors. He sells bananas, does some carpentry, and charges cell phones for villagers at 500 shillingi a battery (that’s about 40 cents.) The living room was decorated with crayon colored pictures from biblical coloring books and photos of puppies torn from American magazines. The room was small (maybe 10’ x 10’) and completely filled with furniture–so much so that you would have to walk on a couch to get from one end to the other. Smaller bedrooms adjoined the main room. Ester cooked in a nearby brick building resembling a chimney which served as their kitchen. Food is cooked on a fire so having a kitchen in the home would create too much smoke. We were served Ugali (cassava dough), Nile Perch, bananas, corn bread muffins and fresh passion fruit juice. Ugali is the mainstay starch of most meals here and is prepared by soaking the root (to remove the cyanide!), draying it, grinding it into flour and combining it with water to form a Play-Doh like ball which is placed at the center of the table. We each sliced ourselves a piece of Ugali and with our hands dipped it in the fish sauce. It’s basically flavorless, but very filling. I was fortunate Dagaa was not served because I spotted some drying on a tarp behind the house. We thanked Ester and headed back up the hill where our patient (who was minutes from labor at this point) was pacing around the outside of the clinic. This is without the comfort of an epidural or any other analgesic mind you. I’m told that births here are usually devoid of expression on the part of the Mother. Stoicism during birth is a learned behavior, which is passed down and expected. True to form at 3:15, without more than a couple grunts, she gave birth to a healthy 3 1/4 kg baby boy. Bob clamped the cord, I weighed it, wrapped it in a kanga, and gave it to Mom. In accordance with another tradition that is I’m sure welcomed by foreign doctors, the new grandmother and great-grandmother were responsible for cleaning up.

The Clinic

4/5 - 4/6  I have finally fallen into a routine here on Bumbire. As far as 4th year electives go, I can’t complain. The day usually starts with breakfast around 7:30 am. At 8:30 we walk down the hill ( about a 5 min walk) to the clinic building to begin work. The clinic is a modest brick building with an office/patient room/lab for Bob and I, a waiting room, an office for the maternal/child health nurse, a delivery room, and a ward with two beds.  The walls of the office are covered with public health posters and geckos, and there are always chickens strutting around the perimeter of the building. No one I have asked seems to know who the chickens belong to. All of the patients for the day have to check in by 9 o’clock and hen we see them on a first-come first-serve basis. There are only walk-ins and Bob says they haven’t quite figured out the concept of triage. Although Bob is the physician, the clinic is run by the nurse, Flora. She speak only Swahili which makes for interesting charting since the official medical language of TZ is English. Over the first couple days the complaints have been mostly ordinary: headache, fever, abdominal pain, and diarrhea. While the symptoms aren’t so exotic the differential diagnoses here are very different. For any child presenting with headache, fever, and myalgias for example, malaria is a distinct possibility. Malaria, as in much of Sub-Saharan Africa, is a big problem here and the predominant strain is resistant to many medications. While I have ben taking daily prophylaxis and sleeping under a mosquito net, many of the locals do not take such precautions and are therefore vulnerable to infection. It is not uncommon for some people to be infected with malaria several times in a year. It is particularly dangerous for children and pregnant women. I have learned how to prepare thick and thin blood smears and to examine the slides under the microscope for parasites. I enjoy actually putting the microscope to practical use. Of course in the U.S. lab tests done in the office are either not reimbursed or too time consuming. What I find particularly interesting are the improvisations that must be made with limited resources. Yesterday we had to give a man with an otitis externa oral and ophthalmic antibiotics because we ran out of ear drops. As you can see we also serve as the pharmacy. Bob tells me that being the only physician he is also responsible for general dentistry (which just amounts to pulling teeth). As you can imagine, dental hygeine here is very poor.  I’ll have more to say about the clinic in future posts. We’re usually done seeing patients by 1 o’clock and then I will have the rest of the day off. After lunch I will read for a while about tropical diseases and then do something interesting on the island. Today I walked with Dorothy to the see the ruins of a 19th century Catholic church in the jungle. On our way we were frequently stopped by locals who asked us many questions. They mostly want to talk about their lives on the island, their families, and invariably Barack Obama. Sometimes they talk about visiting the U.S. Unfortunately many survive on less then $50 a month and such a trip would be analagous to me chartering a rocket to space. At night we have dinner (tonight it was avocado salad) and play scrabble while we watch a movie on the portable DVD player. Sometimes I get internet, sometimes not. Then bed…then clinic in the morning. 

On a boat…and in Church

Sat 4/3 Awoke this AM and had French toast at the South African missionary’s home. She had a Swahili-speaking African Grey Parrot that greeted me with “salama”—the Swahili equivalent of “shalom”. At 8am we undertook our journey (saferi) to Bumpire island. An aside about Bumpire: The island is actually a chain of 4 islands. Ours is the largest and measures about 12×4 miles. There about 10,000 residents—mostly fishermen and farmers. Their ethnicity would be described as Uhaya and many speak the language Kihaya in addition to Kiswahili. Almost none speak English. The American journalist/explorer Henry Morton Stanley referred to Bumpire as the “island of death” due to his not so pleasant encounter with the natives. We were pleasantly surprised to learn that we would be given the motor boat for our trip which cut our time in half. The two guides loaded our luggage and we set out due North along the Western edge of Lake Victoria. Victoria named by a 19th century British explorer is the second largest freshwater lake in the world (second to Superior). It is shared by Kenya and Uganda and provides water, energy, and employment for millions of people. Much of the world prizes its Tilapia and Perch. Unfortunately the Lake is also infested with schistosomiasis which is endemic here. Despite the weather being clear the trip was quite rocky. It was scenic though. We passed Rubondo game reserve and innumerable islands with lush forests and dotted with fishing villages. I also spooted fisherman in boats with trash bags used for sails. In all the trip took 3 1/2 hours. On arrival to Bumpire we were greeted by several men who helped us carry our supplies up into the Jungle and to the top of a hill were the Matthews home is located. As soon as we had settled the sky let out a torrential down pour so were very fortunate not to be on the boat. The house is about a year old and brick with a tin roof. It is powered by solar energy and there is an extensive system for the collection of rain water. The front porch has a view of the rolling hills of the adjacent Kitua Island, a nature preserve. They also have a garden in the back where they grow bananas, pineapple, broccoli, peppers, tomatoes, avocado, cabbage, cassava, etc., etc. After unpacking we ate lunch and I started reading an account of the journeys of Livingstone and Stanley. Sun 4/3 No clinic today as it is Sunday. Dorothy prepared bacon and pancakes for breakfast and we made our way to the nearby Church for Easter services. Many of the people on the island would call themselves Christians or Roma (for Roman Catholic) but in reality their beliefs are a hybrid of local traditions as well as Western ideas. There are also many Muslims on the island but there is no mosque. On this particular Easter Sunday the pastor was already there when Bob, Dorothy, and I arrived. Despite our being the only attendees, the service began promptly at 10. Over the next 30 min or so about 25 more congregants filtered in and took their seats (men on one side and women on the other). Bob tells me that when it rains people are set back quite a while. The women wore colorful congas and dresses and the men wore button down shirts and slacks. The church itself is a small mud brick building one story tall with a tin roof. It is about 15 rows deep, and open at one end where it overlooks the Lake and the neighboring islands. Where there would be windows there are only holes in the wall. The interior was decorated with colorful doilies which hang from the windows, local flora, and white sheets with Kiswahili bible verses sewn on. Despite not understanding the service (it was in all Kiswahili), I was entertained when the pastor had to yell over the sound of the rain on the tin roof. The service was also halted when the rain came through the holes in the wall and the women had to move to the other side and join the men. At one point I was introduced to the congregants as the medical student, and after the two hour service concluded each member greeted one another while the pastor sang. My Swahili is getting to the point that I can do a basic greeting, say “thank you”, and “I don’t speak Swahili”. The language was formed centuries ago from a combination of local Bantu and Arabic. Apparently “hakuna mtata” does mean “no worries”, but is not often said. I am trying to learn more but it is very difficult. There is no work today so I will read and hopefully update my blog. Unfortunately there has been no internet access for the past two days. First day of clinic tomorrow.

Off to Bumbire

Thurs 4/1

 Not too much sleep last night due to jet lag and the many interesting sounds that wandered through my window: bull frogs, gulls, crows, Muslim prayer call, African church choir practice, howling dogs, and the rooster which started crowing at 4 am. For breakfast had bananas and mangos from the market. The bananas here look different and are less sweet then their genetically modified cousins. Another thing that I have noticed is that grass here is cut by sickle. I noticed this both in Dar and here in Mwanza. Apparently the motorless lawn mower is not very popular. What I find surprising is that almost everyone, no matter his lot in life, has a cell phone.

Friday 4/2

 We left Mwanza early this morning in the Land Cruiser and took the ferry across the Mwanza gulf to the village of Kamanga. The ferry must have been several times beyond capacity with pedestrians and villagers on bikes, and yet the staff managed to guide us onto the boat. The ride was only an hour, but provided for spectacular views of the Lake and the rock formations for which Mwanza is known. From there we drove for about 3 hours on a dirt road which was partially washed away by rain. A couple times we had to ford through areas where the road was completely flooded. The ride was my first exposure to the rural Tanzanian landscape complete with mud brick huts with grass roofs. Bob pointed out the “witch-doctor” dwellings which are round with a pointed top. The road was actually very busy with villagers transporting fruit, rice, and other items by bike. The children would become very excited at seeing us and wave yelling “wzungu” or “white people” which are not often seen in these parts.

 Our final destination was the village of Kahunda where a group of missionaries have established a little community in the Jungle on the bank of Lake Victoria. The houses are all built of cement with tin roofs and are powered by solar panels. The water is pumped by windmill. The flora is incredible and the trees are full of Vervet monkeys which steal all the mangos. I also saw some Maribu storks. I’m told there have been crocodile, hippo, python, and black mamba sightings in this area.

 After arriving we took a walk into the nearby fishing village where we saw homes like those we saw on the road, but up close. Out front men were playing checkers with bottle caps and bao (a traditional African game with stones). I also saw two men carrying the monstrous Nile Perch (an invasive species) strung up by a stick. We also happened upon a soccer game which took place on a field set up in the middle of the village. Although there were no nets between the uprights and the ball occasionally got stuck in the mud, the players were actually very good. For the most past the villagers were very friendly towards us.

           Tomorrow we depart for Bumbire island (our final destination) by motorized canoe I am told the trip can take anywhere from 3-8 hours depending on the weather and which motor is available. I will be loading up on dramamine.

***There won’t be any pictures which is unfortunate because I have some great ones. The internet is just too finicky. I will post them all at the end when I get back to the States. 

Day 1-3

Wed 3/31

This is my first access to the Internet, so I have a bit of catching up to do. As you know I left Dayton on Sunday and flew to NYC where I stayed overnight at a hotel by the airport. On Monday morning was when I really began my journey, traveling about 17 hours by plane only stopping briefly in Dubai. I finally arrived Tuesday afternoon (7 hours ahead of EST) in Dar Es Salaam. The first thing I noticed when exiting the plane was just how hot and humid the air was. The captain said it was 30 degrees Celsius but it felt a lot warmer. As soon as I went through customs I was swarmed by cab drivers. I took a cab to a hotel in the City Centre which was nice despite the AC not working. The driving habits of Tanzanians is something I will have to get used to. There was only one street light on my way to the city from the airport and it might as well have not been there.  Early the next morning I took a domestic flight on a small African airline to the city of Mwanza which is the second largest city in Tanzania and lies on the northwest corner of the country adjacent to Lake Victoria. I met up with Dr. Bob and Dorothy from the African Inland Mission who will be my hosts. We had a bite to eat at a small restaurant outside the airport and went into the city to do some shopping. Bob took me through the busy market where people were selling all sorts of local goods: cloth, fruits, vegetables, fish, live chicken, etc. As far as I know we were the only Americans—and really stood out. For lunch I had fried Tilapia and chips which were excellent and a large glass bottle of coca-cola (which is everywhere). We then went back to a house in Mwanza owned by the church. We will stay there until Friday. The house has a nice view of the Lake and there are mango, avocado, orange, and lemon trees in the yard. Unfortunately none were ripe. We did grab some mangos at the market though. I caught up on some sleep, and then for dinner we met up with some of Bob and Dorothy’s missionary friends and we had dinner at a “Japanese style” restaurant. We sampled a multi-course dinner consisting of potato pancakes, talapia, chicken, calamari, shrimp, and beef topped off with ice cream for desert. All in all I have eaten pretty well, though I’m told things will be different on Bumpire (where the clinic is). I am determined to learn some Swahili before I get there. Not being able to communicate is very frustrating. That’s all for now. Hopefully I will be able to get some pictures up some time soon.

Stay Tuned

I depart tomorrow. Stay tuned.