Bittersweet Memories

Note: This post was written and intended to be posted on February 7th, but I had some technical difficulties. Enjoy!

Today was our last day in Ilula. Tomorrow morning, we (myself, Adrianne, Aneudy, and Cole) jump in Kulwa’s Land Cruiser to head back to Dar es Salaam where we’ll meet up with Elizabeth and Bri who have been spending a couple of days in Zanzibar. We’ll stay overnight at Wista’s, have some free time to roam in Dar es Salaam on Friday, and then fly out late on Friday night. I’d have to say, this experience was much different compared to last year in many ways, but our mission to strengthen relationships and work alongside our Tanzanian partners was ever present. When I came back from this experience last year, I had only been in Tanzania for barely three weeks (compared to a full four this year), was just starting my clinical rotations for PA school, and had one day of recovery before moving on. This year, I’ll have six weeks to unwind, think about the experience, and prepare for my new job as a PA-C which starts at the end of March. Just like last year, though, there will be many times when I think back to Tanzania and recall the great memories we created as a group. Since I came with the second half of the group on January 14^th, we started with the Ilula-Minnesota Health Conference followed by our visit to Tungamalenga and safari in Ruaha National Park before heading back to Ilula to round in the wards for the last 2.5 weeks. I’ll remember when those attending the conference asked great questions during the presentations and the horrific, jaw-clenching sound the legs of the metal chairs made when they scraped across the poor, clean, freshly-installed tile floor. I’ll remember when we went to Tungamalenga and Barnabus showed us his immaculate dispensary and the children surrounded us during church. I’ll remember seeing Godfrey again (one of our safari guides from last year) and immediately jumping into his safari vehicle and when we got stuck in the mud near some lions after many failed attempts to rescue another safari vehicle which was also stuck in the mud (let it be known that their vehicle was stuck first). Luckily, after quite some time, we were both able to get unstuck. But most of all, I’ll remember the many faces of Tanzania; the old friends and new friends, patients and providers, children and families, and our eager group members. I know Tanzania will always hold a place in my heart and I look forward to the next time I can go back.

Last day in TZ

We are on our final leg of the trip and arrived yesterday in Dar Es Salaam after a long bus ride in a Land-cruiser. We spent the first part of the day at the Woodcarvers market where we were harassed/ambushed for 15-20 minutes by whole families of merchants (mostly men). As Dr. Ken put it, it’s like Masai market on steroids (Masai market, in Iringa, is a flea market where local crafts/goods are bargained for).

Kulwa, our skillful, thoughtful, and irreplaceable driver, has guided us through the chaos on the streets of Dar Es Salaam (mainly Toyota automobiles of various kinds). He seems to know every local in the southern half of TZ.

For lunch we went to “Slipway”, a market along the coast with various shops, food, and art. I met up with an old friend, Adilly, who I had met on a previous visit to TZ and who is now in his final year of medical training in Dar Es Salaam. He has an incredible life story, is a pleasant person, and plans on returning to Ilula after completing his training. He is a close friend of Dr Benjamin Chota, a  physician at Ilula Lutheran Hospital I had the pleasure of working alongside but who is regrettably an Arsenal fan. His studies are being supported financially by Bega Kwa Bega.

For dinner we went to Sea-Cliff Hotel and Casino where there is a beautiful restaurant/bar that sits on a cliff overlooking the Indian Ocean. The food was amazing and now we are heading to the airport before departing shortly before midnight.

Earlier this trip we visited Tungamalenga, a small town on the way from Iringa to Ruaha National Park. One of our tasks was to provide bi-annual medications and medical supplies to the village’s Dispensary provided by one of the Lutheran Churches in the Twin Cities. In TZ a Dispensary provides very basic healthcare where vaginal deliveries are performed and uncomplicated outpatient maladies are treated. Those patients requiring over 12 hours of observation are transferred to the next level of care called a Health Care Center. Thereafter, if needing over 24 hours observation patients are transferred to a District Hospital (such as Ilula Lutheran Hospital), which can perform basic/common surgeries, C-sections, and administer more diverse medications/antiinfectives. Further elevation of care includes a Regional Hospital (for Ilula this would be in Iringa) and the most complicated healthcare involving various specialty services occurs mainly in Dar Es Salaam.

Tungamalenga was incredibly clean and organized; it also had evidence of great documentation and record keeping. This brings up complicated questions regarding lula Lutheran Hospital and whom (if anyone) takes ownership for the state of the hospital. At first glance Tungamalenga Dispensary appear to be doing more with less, however, it is a complicated picture and there are many variables involved. I may talk more about this at a different time.

We are arriving to airport with plenty of time to spare, approximately 5.0 hours early.

Another little adventure

About an hour ago, Anna came running in to say her son Samson was "sick."  All IO could do was to put that statement into the context of my GI complaints a week or so ago.

She went to the hospital to be with him.

Concern and curiosity got the better of me and shortly, I followed.

I walked through the narrow hallway past the dental office and into the waiting area whose benches lining the walls were full of patients. It was a busy day.  Anna was at the payment window, but she pointed to a strapping 13 year-old near me.  Apparently, although details are sketchy, Samson was in some type of altercation - with a chair. Not sure if other humans were involved or not. He did not say much. I have met him before, but I have no idea if he knew who I was.

I watched the repair, certainly adequate, by Dr. Mariana I think. Interestingly, she used chromic. I don't know if it was because nylon was not available or some other reason.  The technique and repair were certainly satisfactory. They shaved the eyebrow, but the wound came together well, though I cringed at not having it available as a landmark. He did not cringe in the least getting the lignocaine injection.

Anna did NOT want to see the wound. She was scared, but maintained her composure as well as Samson did. Samson went to the pharmacy, but I am not sure what was prescribed. It was big, 3 cm, and deep into the subcutaneous fat, but he will do well.  I may have some simple supplies that she can have for the wound.

What is the adage? "Into every life a little rain must fall." Well, it is the rainy season in Tanzania!
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Leaving Ilula

The last of our intrepid group just left, 8:07 AM, Adrianne, Aneudy, Cole and Lisa. They will meet the Zanzibarians at Wista's Inn tonight, tour Dar es Salaam some more tomorrow and leave late tomorrow evening.  Briana and Lisa are evidently having a good time in Zanzibar. I entrust them to our favorite driver, Kulwa.

I am alone here at the hospital with still plenty to do besides packing up my own stuff.  I remain in a quandary about the X-ray stuff, in part because we have a chance to get funding assistance from Rotary, in part, because though slightly different, the two bids we have are at least comparable.

I await a response from the Ministry of Health so we can get some issues resolved, but though a long time in coming, I have faith it will happen.

Anna, Cole, Lisa, Adrianne, Kulwa and Aneudy

Sunday: The Day of “Rest”

Each day we have been taking an afternoon stroll around town, trying to get some exercise and enjoy the weather before we head back to the arctic circle (aka Minnesnowda). As we were driving to Iringa on our way out of town on Saturday, we saw a mountain at the edge of town that looked like a doable hike. So at 9am, four of us packed up our waters and headed up the mountain. Two more from our group came for moral support and made sure we got to at least the bottom of the mountain, and turned around to spend, one of the hottest days since we’ve been here, inside. 

As we headed up the mountain, we met a couple kids so spoke the tiniest bit of English. They pointed us to a path and we headed that way. They decided to come with us and lead the way. Up one of the steepest parts of the mountain, we hiked up with these kids who were in flip flops. Another kid about 5 years old joined us as well without any shoes. As I forced the group to take a break (one of many), these kids were hardly breaking a sweat. 

When we got to a platform, a couple guys met up with us and told us we were taking the hard way up and they could lead us the rest of the way. We happily agreed and said goodbye to the children. I will spare you the details of the hike up, but I am not a hiker and the other group members were convinced that they would have to carry me the rest of the way. We made it to the top (without me fainting)! 

The way down was much easier. I talked with one of the guides, Abraham. He is a carpenter from town, and we talked about the importance of education and about Tanzania and about all the hard workers we’ve seen and met. It was a great experience. Yousef was the other guide and cut the way for us. He was at the front of the group (obviously not where I was) and even though this wasn’t their job, they were happy to help us. At the bottom we thanked them and went on our way. 

On our way back, we were stopped by another guy telling us that if we needed a guide, he would take us up again. I happily told him I had enough mountain climbing for one trip

So even though it may not be Kilimanjaro, I can happily say that I hiked over 7 miles up 1200 feet in elevation in 4.5 hours. I met some great people and became closer with the group. Even though we are here for the medicine, it is nice to be able to learn from others during all aspects of the trip. 

When I'm Sixty-four

...or perhaps a little older....

We threw a soda party for the staff yesterday afternoon.  That means we provided a couple of sodas or water for anyone who wanted to participate. This went over well last year and likewise this year!

Now the Nursing School Dining Hall has been remodeled slightly so it easily accommodated all who came. All staff were invited, All the students. Many came!  

The wazungu each gave a short speech telling of our gratitude and appreciation for our new friends' acceptance.

The birthday part was a coincidence, In fact, I had intended to be gone from the hospital. Then I learned there was a board meeting that I should try to attend. Oh well. I opted to stay.

It was great fun, even learning a traditional way that Tanzanians honor the persons birth by reminding the person they were born wet.  So, I shared the wet hair with others by shaking like dogs I have seen.

There was dancing including a circle dance.  No one did a specific Hehe dance. One of the staff set up a sound system. 

I did proclaim this to be the best birthday party ever. I hope to be forgiven if I use the phrase in the future due to my short memory. No question it was right up there!

After glow. Sorry Aneudy!

Ch-Ch-Changes

 Change is in the air at Ilula Lutheran Hospital (ILH). I will try to outline a few things as best I understand them. I expect that the Tanzanians have been aware of the coming changes for some time.

The Administrator, Kikoti and the Doctor in Charge spent the last couple days in a planning meeting for the Kilolo District.

Starting in April, ILH will no longer be the Kilolo Council designated hospital.  The government has built a new hospital at Kilolo which will have that designation. I thought they were going to split this very large district, but that is not what will happen. 

Now there will be two hospitals sharing the same amount of the Kilolo District budget. Formerly, ILH received about 20% of the total district budget; in the future ILH will get only 10%. I do not know how much this amounts to. Regardless, it will make everything tighter here.

They use ICD-10 for coding here as we do in the US. And just as in the US, if coding is incorrect or missing, it is not reimbursed.  A volunteer doctor, not yet assigned has been working here reviewing all the outpatient visit coding. He is paid out of the money he saves the hospital, which happens at home too. We have coders.  Of course, it is important for the doctors to learn how to code correctly and the Tanzanians have not been taught.  And this really only affects the patients who have insurance. The plan is for all Tanzanians to be covered by insurance by sometime in 2020. We should be so lucky in the US!

Although the budgetary changes will have substantial impact. Assuming that coding is done correctly, it could be a boon for ILH to get paid for services delivered. 

The new Kilolo Hospital is a long way from Ilula, so essentially the catchment population will stay the same. Patients who want to try out the new hospital will need to pay for transportation to get there, likely needing lodging too, and food. The Kilolo Hospital may siphon some patients away from the Regional Hospital, but that will be to the benefit of the Regional Hospital. It is imperative that Ilula patients like (love) Ilula Lutheran Hospital, however.

I think that ILH staff morale is a big consideration in making our patients happy. The staff are loyal despite being paid less than at government hospitals. Sovelo and Kikoti are working on the morale, but this is not easy when they are underpaid and there is no money available to improve wages. I do not know the answer.

Earlier in the month, Dr. Moody and Dr. Tessmer-Tuck, et al, had a tour of the Regional Hospital and I did also last week. It is a sprawling place. Most buildings are single story. It has 377 active beds if I have got the number correct, so for ILH’s 70 – 100 beds, it is nearly 4 – 5 times Ilula’s size. They average 14 deliveries per day; ILH averages 6 – 7 births per day, 2400 per year.  They do have a pretty nice L&D unit, pretty open and not cramped.

While there we looked at the commercial-size washer(s) they use.  They have three new looking 16-kg capacity washers. The parentheses above are because currently, only one works.  I am not sure how many horsepower these are, I just know that ILH washers are hand-power.

Tanzania uses a “Star Rating” system of one to five stars for its hospitals. Ilula gets three stars.  Although the rating document is long, there are three major items that keep us from getting five stars.

1.     No X-Ray. OK, we are working on that, but still only about half-way.

2.     No canteen. This would provide food paid for and served by families for their loved ones in the hospital and would ensure nutritious and safe food.

3.     No mortuary, the bane of our fund-raising. OK, the other things first.  How does someone generate enthusiasm for building a mortuary? Do you suppose our mortuary companies at home would be interested?  Maybe that is worth a shot!  Anyone know a wealthy undertaker?