July 24th – Hiking in Nyungwe (Knee-ung-gway)

The observant among you may be asking at what point in this trip I am
going to see the Gorillas, given my limited time remaining.
Unfortunately for me, but more poignantly for the Gorillas, a month
ago when I asked for a permit, they told me they were fully booked and
to try again in October. Brutal. Apparently persistent badgering of
the ORTPN office in Kigali can often scare up an extra permit, but
being in Butare, my hands were tied. Next time I guess. I'd have to
settle for chimps, which is why I went to Nyungwe. Apparently for
them, you need your own 4x4 (200$ rental) and you have to stay on the
other side of the forest. Having neither of the above, the chimps also
missed out on my presence. It's like the primates didn't get the memo
that I'd be in the country. Damn dirty apes.

On the up side, at the Kitabi guesthouse, I met a fantastic couple
from Germany, Volker and Corinna, who have been living in the country
for the past year and a half. They were in the forest for hiking and
staying in the same little house as me. I think they took pity on the
rag-taggedness of my travel plans and invited me to come with them to
do a hike the next day. They then offered to drive me back to Butare
to pick up my gear, then maybe even back to Kigali and finally to stay
with them in their house, downtown Kigali. How could I say no?

We went on a 4 hour hike with a guide, Thierry, who was very
knowledgeable and accommodating of my questions. We hiked up, down and
around a few hills to a beautiful little waterfall. Unfortunately
there we saw no primates in the forest, but there were baboons at the
hotel and mountain monkeys on the road, so I was happy. It was a
beautiful jungle hike.

The trip back to Kigali was long but I was thankful for the ride, as
it probably cut 3-4 hours off my journey. Volker and Corinna's house
was beautiful. They live in a walled compound, like most houses in
Kigali, with a security guard 24/7. The house was beautifully
decorated with African furniture and art and my hosts were warm and
welcoming. I am indebted to them for all their hospitality. They also
took me to a place with "The best pizza in Africa", and it didn't
disappoint, although my limited travel experience does not qualify me
for such hyperbole. Theirs does. Tomorrow they offered to give me a
tour of the city, followed by a drop-off at the airport. Either they
really liked me, or I looked really pitiful in Nyungwe. Ha.

July 23rd - Road to Nyungwe

In this post: Travel, Murambi genocide memorial. Read at your own discretion.

I decided that on Friday I would forego the anesthesia learning and
work on some life learning for the day. I had reserved a spot at a
place in Nyungwe forest that night, which is a national park a couple
hours away, and I wanted to see one of the genocide memorials along
the way. I packed up my things from the Credo hotel, a half-decent
establishment that I called home in Butare, and made my way into town
to find a bus. Turned out that it was the day after all secondary
schools had their final day of the term, so the office was
ridiculously packed with students trying to get home. Luckily I'm 6'6"
and white, so I stand out and the people working there expedited the
process. Nonetheless, because of all the students, I had to wait 4
hours for the first bus.

I used the time in Butare to visit the national museum, which is
located there. The museum has a half dozen large rooms that highlight
the cultural history of Rwanda, including exhibits of clothing, tools,
weapons, housing etc… It was alright. I'll admit that it was a bit of
a snooze fest, but I generally feel that way about most historical
museums. Apparently there are some nice places around the country
where these traditional clothes are worn in traditional ceremonies,
dancing and weapon showmanship.

The road to Nyamagabe, where the Murambi genocide memorial is
located, was an hour of winding roads on terraced hills. There are
definitely more than a thousand hills here… ten thousand maybe. In any
case, after arriving at the bus terminal, I hopped on a moto-taxi (the
standard (and almost exclusive) mode of transport apart from the
buses) and rode the 2.5 km to the memorial. I'll talk about the
memorial after relaying the rest of my trip.

There is no direct bus (or at least not one leaving by the time I got
to the terminal) to Kitabi, on the edge of Nyungwe forest. I had to
hop on a smaller bus, a 19 seater, in order to get most of the way
there, then grab another moto-taxi the remaining distance to the
hotel. These were both great experiences in their own right. I arrived
at the hotel just as the sun was setting and the red light on the
countryside was amazing. I've got some great video of the motorcycle
ride. The whole adventure of figuring out how to get across the
country on my own was fantastic, juxtaposed against the gravity of
what I will now describe.

The Murambi memorial is located at what was once a polytechnical
training institute. During the genocide of 1994, 50'000 tutsis
gathered there for protection from the Interhamwe killing squads. Like
many of the supposed safe-havens around the country, as in churches or
hotels, the school only concentrated the victims, making it all the
easier to starve and then murder them. All 50'000 died. Grenades, guns
and machetes were the weapons of choice. Neighbours killed neighbours.
For a full account of the genocide and the events that led up to it,
I'd direct you to any number of books on the subject. I read
Dallaire's book. I've heard 'A Sunday by the pool in Kigali" is also
good.

At Murambi, the bodies were dumped in large mass graves beside the
school, many of which are still present today. Eventually the French
operation Turquoise came into the country and occupied the site,
apparently building a volleyball court on top of one of the graves.
The guide at the memorial blatantly implicated the French as
accomplices to genocide when I asked how they could be so
inconsiderate. This is the most direct accusation I've heard on the
issue, but it may only be one person's opinion. Dallaire certainly
found the French to be less than helpful when they came.

After the genocide, 850 of the dead were exhumed from the graves and
preserved with lyme. They are still there today, in 24 rooms of 30
bodies each. Men, women, babies: indiscriminate slaughter. Their
corpses rest in the positions they were buried in, skulls crushed or
limbs hacked off. They are bleached white and they smell strongly. Not
of decay, but of the lyme. I don't think I'll ever forget the smell.

If my writing is stark and heavy, it is because the memorial is
equally so. The people there want the world to remember the brutality
of the genocide so that it will never happen again. Any visit to this
site etches the reality of the event so deeply in one's head, that it
shall never be forgot. May they rest in peace.

July 21st & 22nd - Rwandan hospitals

I had another couple good days in the ORs this week, and I was able
to do more and take more responsibility during the procedures. It's
nice when you start to get to know to people working in the OR, and
Dr. Alfred, a second year resident in anesthesia, has been very
welcoming and generous with his teaching.

The ORs here are somewhere in between what I've seen at the national
hospital in Muhimbili and the ORs at Ifakara, in terms of equipment
and resources available. There are still things that I see in theatre
that make me cringe, but in general they're doing a pretty good job.
Beyond resource differences, the biggest change for me is in patient
autonomy. The doctoring here is behind the times in allowing the
patient to make their own decisions and is thus very paternalistic:
Doctor knows best. Unfortunately this manifests as a feeling that
doctors don't need to tell patients what the procedure is going to be
or what to expect during and afterwards, or even when they're going to
stick a needle in someone's back. Maybe these are luxuries in our
country? There must be some evidence out there that we achieve better
outcomes if we treat our patients as a member of the health care team
instead of a child who doesn't know any better. The nice thing is that
the training that the anesthesia residents are receiving is starting
to change this attitude.

CASIEF is Canada's Anesthesia society, and they've been sending staff
anesthetists and Canadian residents over to Rwanda to teach for the
past 5 years. During and after the genocide in 2005, only a single
anesthetist remained in Rwanda (I got to work with her for a day:
wonderful woman. The strength she must have is mind boggling). CASIEF
is trying to help by training Rwandan residents to the degree that
they will be able to take on the teaching themselves and become
self-sufficient. I think it is an exemplary program because it follows
the old "Teach a man to fish" adage. When my training is complete,
CASIEF's is the type of program with which I'd like to be involved.

I was lucky enough to see the program in action on Thursday
when Roger, a staff anesthetist from Australia, and Rob, a 4th year
resident at Dalhousie, came down to Butare for two days of teaching. I
had known that Rob was going to be there at the same time and had
briefly met him prior to departing, so it was nice to see a familiar
face half way around the world. They spent the morning in the OR with
the residents doing clinical teaching, the afternoon doing a short
didactic session and then a webcast seminar on pain. I was glad to see
the quality of teaching that CASIEF is putting together and also to
chat about the experience in the hospitals frankly and honestly with
people who share my frame of reference.

Just a couple of short anecdotes: On Wednesday, a little girl of 7
was brought into the OR for a repair of a broken forearm. They sat her
up on the table and starting getting everything ready for the surgery.
However, the anesthetists don't like to put the patient asleep until
they see the surgeon in the room and being the first case of the day,
we were waiting for about 30 minutes that morning (fairly typical wait
time). The little girl was just sitting on the table in the OR,
waiting for her surgery and no one was really talking to her. I pulled
out my pad of paper and a pen and started drawing animals for her. She
came back by drawing a house and a person and then oddly the 5 vowels.
The segue was apparently lost in translation, but we also covered
numbers up to twenty in English, which she was clearly quite proud of.
Dr. Alfred got in on the action and made a latex glove balloon person
to play with. Hopefully it helped take her mind off the scary room and
the throng of doctors with masks on for a few minutes. The nurses were
clearly amused.

On Thursday the surgery was to insert a big metal rod in someone's
fractured femur. The problem was that the rod they had was too long
for the woman's femur, so instead of scratching the surgery, as they
would in Canada no doubt, the large scrub nurse, dressed in sterile
gown and gloves, grabbed a massive pair of bolt cutters and started
going to town on this rod. Then he got out a hammer and started
wailing on the cut end of the rod so that it wasn't as sharp. It was
quite the sight to behold, but far better I think than for the
patient, who was awake with spinal anesthesia but unable to see the
spectacle. I can only imagine what she thought was going on, hearing
the massive crashes of a blacksmith's hammer in the OR.

July 20th - Muraho Rwanda

The trip back to Dar Es Salaam on Saturday was good, but
packed, hot and dusty. We ended up squishing an old man into the two
seats along with Jeff and I, so it was an akwardish ride, because he
didn't even really acknowledge we were there, even when I offered and
he accepted snacks and ice cream I purchased along the way… weird, but
I guess that can be customary here. He redeemed himself by breaking
out a big smile and "Asante" as he was getting off the bus. Ha, I love
old people. Most of the girls on the trip had considerably younger,
but equally as cute charges, as mothers forced to stand in the aisle
hoisted their children onto open laps. I guess this is also customary,
and I had a lot of fun playing games and drawing pictures of African
animals with the little girl sitting on Lauren and Meredith's lap
behind me. The best part though, was when Jeff gave the little girl
one of his ear buds. Jeff only listens to hard metal… like really
really hard death metal. The kid loved it!

The next morning, all my companions went their separate ways early,
before I needed to be up. I had a relaxed breakfast and chatted with
Anna, the maid/server who was nice enough to teach me a little Swahili
every morning over kahawa, ndizi, mpapai na mayai. It's an odd feeling
going out on my own in Africa… partially because I still can't really
believe that I'm in Africa. The flight was good, but it had an
unexpected (for me) stop in Bujumbura, which is east and south of
Rwanda… I haven't looked it up yet, but I'm guessing in Burundi? There
was a big white UN cargo plane on the ground and a couple choppers.
Neat to see.. I wonder what they were doing there?

The flight into Kigali (the capital city of Rwanda) was great… the
hills of Rwanda are beautiful and the agricultural terracing that
covers many of them makes the approach to the airport almost
breathtaking. Kigali airport is located on top of one of those hills,
to the east of the city centre. I hopped on a bus to take me from the
airport to downtown, much to the mild amusement of everyone around of
course, but the driver and fare collector were very friendly and
helpful.

The city of Kigali is perhaps one of the most beautiful cities I've
been to. Period. Forget fancy architecture or feats of engineering or
thousands of years of history of Europe. What Kigali offers is pure
natural beauty. I hate to keep harping on these hills, but everything
here isn't named "Milles Collines" for nothing… there are a lot of
hills, and they are steep hills, with many houses nestled precariously
on their slopes. The terraced fields are evident even in the city
proper, and the valleys tend to be reserved for rice paddies. The
roads are winding and fun to experience on the bus (in addition to
being surprisingly well maintained!). Not much traffic on a Sunday,
and I got to the bus station without a problem and hopped on the next
mini-bus to Butare, a 2.5 hour drive over and around… you guessed it:
more hills! There was just too much beauty to adequately express in
words what I was seeing. I would have taken pictures, but I'm at a
weird ethical place now, where I'm not sure how I feel about taking
pictures of peoples' lives for tourism's sake, nor flashing my
expensive camera around when many people here will never have the
opportunity to own a digital camera. Sorry. I'll get over myself in a
couple days a take some shots to prove how beautiful it is.

My French has really come in handy here, as many Rwandese do
not speak English, the national language being Kinyarwandan. I'm able
to muddle my way through most conversations with the French I'm
dredging up from my high school years and the people here are
incredibly accommodating with my limited vocabulary and strange
accent. Nonetheless, I've managed to have some great conversations
with students and nurses in the hospital about medicine, cultural
differences, just about anything… except maybe what I'm most
interested in (and perhaps you, reader, are most interested in). I
haven't brought up the genocide with anyone. I don't know that it is
my place as an outsider to bluntly ask. I might take a trip to a
memorial on Friday, in which case I wouldn't have as much of this
worry. The genocide is such a chilling and relatively fresh piece of
this country's history that most of the people walking down the
street, or working behind the hotel desk or coming to the hospital
have experience violence or death from it. How does one even go about
addressing that? The government here seems to have done a fairly good
job, and Rwanda is now one of the calmest countries in Eastern Africa.
I might leave more discussion on the genocide for after my trip to the
memorial.

This is sooo long. The hospital has been great so far. Worked
in ICU on Monday and in the ORs today. The anesthetist staff and
residents here are great and have been very welcoming, if somewhat
amused that I am only staying for one week. Nonetheless, I think it
will be a great learning experience… hopefully both ways. I was able
to offer some suggestions both in the ICU yesterday and in the theatre
today that seemed well received and useful. There are a bunch of new
5th year medical students rotating through anesthesia, and I think
that I have a lot to offer them in terms of clinical anesthesia for
the med student, even with my limited exposure thus far. Unfortunately
none of them have aspirations of anesthesia yet, but maybe I can help
light a spark in them.

Alright, you've been tortured enough, and I'm getting hungry.
I went into town the afternoon to a little bakery, but the samosas and
croissants are wearing off. If you've read this far, congratulations.
If you've checked in just to see what people have commented (you know
who you are), don't worry, that's what I do too.

June 12-16th Last week in Ifakara

Pics are shots from the vehicle on the road to Lupiro, trying to
depict typical rural living in Tanzania.

My last week in Ifakara was a nice continuation of what was a
valuable learning experience in the hospital and a further exposure to
the rich Tanzanian rural culture. Clinically, I spent the week with
surgery, paediatrics and internal medicine: doing rounds with the
interns and physicians and attending clinical meetings in the
mornings. Things really slow down here in the afternoons and most of
our afternoons were free to relax or explore the city and the city's
fine establishments for a cold one after work with the interns. I'll
just relate a few particularly telling anecdotes about my experiences
this week.

Surgeries were still cancelled due to a complete lack of
anesthetic drugs. Even emergency C-sections were only receiving
minimal anesthetics, so it was a slow week in surgery and a sad week
to be doing rounds and surgical clinics, having to tell people to
maybe come back in a week or two for a better chance to be treated.
Even sadder when those surgeries that had to be done immediately were
done without anesthetic. I didn't see this personally, but a boy with
40% burns to his body had to undergo surgical debridement (removal of
dead tissue) without even a pain killer. It's hard to believe what can
and will be done when you don't have any other options. However,
perhaps the hardest moral issue I've been faced with has been related
to the cost of medicine here. Everything in the hospital costs money
and must be paid for before receipt of service. This even applies to
the burn patient in ICU mentioned above, who was not receiving any
antibiotics despite septic wounds simply because he could not afford
it. Even a child with a sever complication of diabetes (ketoacidosis)
could not be monitored closely with electrolyte levels because each
electrolyte cost 5$, a price too high for her family. This just
screams "wrong" at me on so many levels that I had a hard time not
pulling out my wallet and paying for the meds or tests myself.

Despite not participating in the theatres for the week, I did
enjoy doing rounds for multiple days and starting to know the patients
and the cases. I felt like I was legitimately able to contribute to
the care of the patients, and felt like my opinions were valued and
respected. As an example, it didn't seem as if many people in the
hospital felt comfortable reading EKGs, so I was able to spend a few
minutes going over the basics with some of the interns in peds. It
felt nice to help out, even in a minor way.

I guess to summarize my experience at St. Francis: I saw that a
resource starved hospital is doing all that it can for its patients,
sometimes against odds that are stacked heavily against them. The
level of care and the nature of the patient-doctor relationship are
markedly different between our country and theirs. I hope that in the
coming years these physicians will not only continue to make
technological advances, but also advances in how patients are treated
once they walk through the doors.

On Wednesday afternoon we managed to take a field trip to Lupiro
Health clinic, and smaller clinic with 20 inpatient beds and 3 staff
physicians. Susan had been there 4 years ago with her group and said
that it was worthwhile seeing a smaller facility. (I actually tracked
down her name in the guestbook they had there! It was a great feeling
to recognize her handwriting and have a little piece of my wife
sitting there in that book, half way around the world.) Lupiro didn't
have many patients when we arrived, but we could see that it has been
well-used for many years. The buildings are all pretty dilapidated and
certainly not a place that would promote healing. There are water
stains in the ceilings and large portions that are just missing
roofing altogether. The beds look uncomfortable, but not necessarily
cramped. There are even dividers between many of the beds, a step up
from muhimbili or St. Francis! The physician in charge graciously
showed us around and explained some of the difficulties he faced. He
also showed us the medication store room, which unfortunately was a
bit of a stretch for all the empty shelves that were inside. We
decided to donate some money and some of our clinical things to Lupiro
once we finished our clinical experience in the hopes that even little
bits would help.

On Friday we went to see the hippos on the river, but alas, the river
was too swollen and the hippos were nowhere to be seen, favouring
smaller rivers where vegetation is presumably easier to get at. We
wanted to go along for the ride anyway, and it turned out to be a
great trip in an old school, 40 year old dug out canoe. We spent an
hour and a half on the river and saw many species of river bird,
including stork, herron, pelican, skimmers, bee-eaters, eagles etc… it
was a nice and relaxing end to the week. Unfortunately I didn't get
any pictures for fear of losing my camera in the green and greasy
Kilombero river.

Kinda sad to say goodbye to Ifakara… It was just starting to feel
like we were settling in nicely. However, we're all excited to be done
the program proper and moving onto to our own separate adventures. I'm
off to Rwanda!! 5 others are going to be climbing Mt. Kilimanjero and
one will be heading to Zanibar.

June 10th and 11th - Internal Conflict

Pic 1 - The game of Bao. This was a dirt version... some boards are
carved ornately into wood.
Pic 2 - The Weaver's shop, with Joyce, our guide.
Pic 3 - An Old man that we met at the Leprosarium. He and his 6
friends were working together to make a little bit of money by selling
small reed brooms. We bought a few from them and threw in a little
extra money.

Sorry for the lack of posts in the past few days: evenings
have been busy with either world cup finals or meet and greet with
other students at the TTCIH. I'll catch you up on the weekend.
This past weekend was a great couple of days for a number of reasons.
The first of which was our visit to the Leprosarium, a complex of
buildings that is only a few minutes' walk from here. We went with
Joyce, who we've got to know really well over all the breakfasts and
dinners we've eaten at her house. She took us to a weaver's shop on
the way there, where the owner took some time to show us how they used
the old fashioned looms to make all sort of fabric for bedding,
curtains, kitchen etc. It was neat to get that feel of local products
being made by hand in the old-fashioned manner. We all bought a few
things to support her business.
The Leprosarium both wrenched and lifted my heart when I saw the
institution. The staff weren't really around, but we were greeted by
an old man with a big toothless smile, two milky white sightless eyes
and a complete lack of fingers or toes. It was a shocking first
exposure to leprosy, but the warmth of his smile was humbling and
great to see. He was happy to chat with us for a couple minutes and
welcome us to the place he now calls his home. We later watched a
group of men afflicted with leprosy play a game of Bao, which is a
confusing array of nuts piled in small cups in a board. We have no
idea how it's played or how you win, but the old men seemed to really
enjoy it. Again, the contrast of emotions was evident, as the old men
had no fingers with which to grip the nuts and had to rely on younger
men to make all their moves for them.
The toughest part of the visit came when we went to see the old
women's dormitory. 7 women, most of whom were blind, were sitting on
the concrete in a small shaded courtyard. None of them had full use of
their hands or feet and most had to crawl on their knees, callused
thickly from too many years on concrete. They have the help of a
nurse, but life must by unimaginably hard for them: I could see it in
the wrinkles and creases of their weathered faces. Perhaps on par with
the cases of polio we've seen here, advanced leprosy seems like a
monstrous disease, slowly and unforgivingly stealing what function
these people have left. Thankfully this center seems to take good care
of these patients and provides them with some dignity in the remaining
months or years of their lives. I'm glad I was able to witness this
center and some of the people it is trying to help.
On the way back to the TTCIH, we passed through a community where 30
children were sitting around watching some girls play basketball,
although the net was only a small reed bent into a circle and tied
onto the top of a wooden pole. We stopped and a few of us even played
around for a few minutes. I totally dominated those kids… they had no
chance. I made them all cry and then brought out the smack talk. Ha.
Nah, it was great, and afterwards Jeff brought out a couple balloons
he had and they went nuts playing with it, then they went nuts when I
brought out a couple Canadiana bouncy balls I had brought for just
such an occasion. Kids are awesome.
Sunday was spent relaxing, doing my jail-house workout with water jugs
(watch out P90 X), swimming in the pool and playing Frisbee. We caught
the final of the World Cup in the bar on the compound with a few other
students. Great weekend.
Pic

June 8th and 9th - more adventures in the hospital

Pic: Guess which one I am.

On Thursday and Friday I was hanging out with the surgeons
again and saw some more surgeries, both minor and major. Of note,
there was a circumcision of a boy who we put under with ketamine.
Circumcisions are still a regular occurrence here, even while in
Canada, they are entirely elective and you have to pay for the
procedure out of pocket. I think it is a matter of hygiene here more
than anything else. In any case, it was a quick procedure, but it is
disconcerting to hear the child cry out in pain, even though they are
probably hallucinating and would never remember the experience. It's
been a rather common experience actually: unless there is a reason to
use a gas anesthetic, quick procedures only receive ketamine, and many
of the patients visibly grimace or try to move their limbs while
under. I guess that with the limitations on drugs, they don't have
much choice, but its hard to see.

More drug woes here today: All the anesthetic drugs are
depleted and elective surgeries have been cancelled. It's only the
C-sections that seem to be going, unless the procedure can be done
with local anesthetic. Maybe by Monday, they say. We'll see.

On Friday I attended the surgical department's meeting and
rounds, which was really interesting for me, because I hadn't seen the
wards in a Tanzanian hospital first hand. We visited many of the
surgical patients in the hospital, including those who were in the ICU
and paediatrics. It was a good exposure, not only to the typical
surgical case here (ortho!) but also to the dynamics of the hospital
(nurses play a different role here and the hierarchy is obvious). It
was also interesting to see the level of the residents here, compared
to Canada. It seems as if they are on par with Muhimbili, so perhaps
not as far along their training as I think we would be in Canada. It
also exposed me to a few cases that we'd never see in Canada: a hippo
bite (broke the skin and fractured the bones of his foot) and Maasai
spear wound (in the back, causing some neurological deficits).

Friday afternoon I spent with an Austrian doctor who is
volunteering his services here for 6 months. We reduced some fractures
and did some casting with plaster of paris. People have to pay for
their casts here… probably about 15$ CDN, a fair amount for many.
X-rays cost 10$, which is often equally prohibitive. They also carry
their own xrays around with them to the hospital and bring them home
with them, as they do with the official drug records and sometimes
even their charts. I find this somewhat bizarre, and I wonder how many
records get misplaced or forgotten about.

July 7th – Monkey falls

We'd heard about an interesting hike from Dr. Pemba in a national
park that is 2 hours back along the road to Dar Es Salaam. Being a national
holiday (they call it saba saba (lit. 7th/7th), we took the
opportunity to visit the Udzungwa Mountains national park for a day hike. Dr.
Pemba was amazing about arranging the experience and even provided the
transport to and from the park (the roomy land rover was much nicer
than the cramped bus on those bumpy roads!). We were planning on a 5
hour hike up the Udzungwa mountains, so we left the center just after
7:00 and were on the trail at 9:30.
We had a great guide with us, David, who's been hiking these trails
for many years and was very knowledgeable about the flora and fauna in
the park. Udzungwa is one of the top 40 biodiversity hotspots in the
world apparently, and includes 2 species of primate that are found
nowhere else on earth. In addition, the trail we were going to hike
would lead us up 600m to a set of three waterfalls, the tallest of which
cascades down a full 170m. We were excited for a great day of hiking.
Right away the guide starting pointing out interesting insects,
spiders and plants: stuff that one would never see in our climate. The
whole time walking up I just wanted to take more and more pictures of
everything I looked at. Well, not the whole way, seeing as it was a
decent ascent at a quick pace… I was breathing pretty hard a lot of
the way! I've include just a sampling of the photos that I took on the
hike, but the trees alone would fill a photo album. The canopy towered
majestically above us, supported by massive trunks and buttresses
below. Large tarzan-type vines hung from branches 100 feet in the air.
The sounds of birds and insects were subdued, but ever-present.
Within 10 minutes of hiking we heard and then saw our first monkeys.
Blue monkeys; not to be confused with the previously mentioned
blue-ball monkeys. There was a family about 50 feet away in a tree,
peering intently at us for a few seconds before going about their
business. Just as we turned to leave, one of the monkeys launched
himself 20 feet down onto an adjacent tree, the whole branch bending
under his weight. It was great. Not 5 mintues later we caught a
glimpse of some black and white colobus monkeys, but they were high up
and not easily viewed.
The rest of the 2 hour hike up to the waterfalls was fantastic, with
many great look-out points, both of the river valley and the
waterfalls. Once we got to the top, at the base of the third and
highest waterfall, the guide told us that we should have a swim. It
was "cold for me, but only cool for Canadians", and after the hike up,
we couldn't say no, despite feeling like we were rolling the dice with
freshwater parasites… I can say that it was legitimately cold, but you'll have to stay tuned for the
parasitic infection. After the swim we had lunch on the rock plateau
that sits just above the 170m waterfall. It was a gorgeous view of the
plains and agricultural fields that surround the area.
The hike down was when we saw most of the action with the primates.
The sun had come out more fully and I think they became more active,
because we saw a small group of Mangabay monkeys on the ground
(endemic to the area) and then as we came to the base of the large
waterfall, we saw a group of 7 red-headed Colobus (unique to this
park) and 5 or 6 black and white Colobus monkeys. These were the
famous monkeys we'd been looking for, and they obliged us by posing
for a few seconds for pictures before scampering off into the canopy.
It was a fantastic sight and one that I won't soon forget: just as I
won't soon forget the whole day. The best Saba Saba holiday I'll ever
experience I think.
The pictures that I've posted are only a sampling of what I wanted to.
I might make an online album later on.

June 7th - Pictures of Udzungwe

Pic 1 - The intrepid group of hikers at base camp.
Pic 2 - Blue Monkey. Female. She has a baby with her, but I didn't get
a good pic
Pic 3 - Some of the buttressed trees, 15 feet around. Hunters used to
hide in these butresses if they got caught out in the jungle at night.
Pic 4 - All of us at the second set of falls. I was obviously feeling
pretty good about myself.
Pic 5 - Self portrait on top of the 170m waterfall, with the
agricultural lands in the background
Pic 6 - Playing around with perspective. Heh
Pic 7 - This is a buffalo spider.. the horns are impressive and
apparently for defense from birds. The unsuspecting group of hikers is
waiting below.
Pic 8 - Red topped Colobus in the tree accross the valley. Amazing
Pic 9 - Me at the base of the big falls. It was awesome
Pic 10 - playing with the super macro on my camera with this
millipede, who was interested in my lens apparently.

July 5th and 6th - Ruraler medicine

Pic 1 - Off to tour the hospital
Pic 2 - An amusing but sad room in the pediatric hospital
Pic 3 - "Mosquito village"

On Monday morning, we had an introductory session with Dr.
Pemba, the director of the institute that we'll call home for the next
two weeks. He had a brief presentation about the training center, the
research institute and the hospital that form a triumvirate of health
care and research in Ifakara. Dr. Pemba seems like a great man, with a
great vision for his institute. He has been a very generous host and
incredibly excited about the partnership between Ifakara and
Dalhousie. He speaks like a proud father about the journey this
institute has gone on since the 70s. After his presentation, we spent
some time touring the hospital and research institute.
The hospital has 370 beds, with all major departments represented
(except mental health, which I don't think gets serious consideration
here). The wards are modest, but each person has their own bed (in
contrast to Muhimbili) and each bed has a mosquito net. The buildings
of the hospital are all linked by covered walkways, which are
typically lined by people waiting to see the doctor. We get a lot of
stares as we walk by, but a few smiles too. An old woman, barely
taller than my navel, wearing massive coke bottle glasses and walking
with a cane a foot taller than her, was so excited to see us and shook
our hands with such abandon that I was worried she'd fall over from
the vibration. It was pretty cute.
Apparently we're coming at a quiet time for the hospital
because many people are currently out in the field harvesting their
crops, or maybe planting their crops; I'm not all that clear on
growing season here. In any case, apparently if faced with the
prospect of harvest and a serious medical problem, people here
typically choose harvest. It's tough to think about how many adults
and children are dying out in the fields as they try to put food in
their bellies.
The research institute here has some great facilities, including
great lab space for molecular biology, immunology, serology,
microbiology etc… They are used by a number of different
investigators, who come to Ifakara to study tropical medicine. We got
a tour of the facilities and then the staff entomologist took us into
the mosquito tents, which are used to breed laboratory strains of
mosquitoes. They have even created a small village within a big mesh
tent, which they use to study mosquito behaviour in a semi-natural
environment. The goal here is to gain a better understanding of the
vector that carries Malaria, the killer of so many in this and other
African countries.
On Tuesday we were in the operating theatre again, although there was
definitely a difference between the national hospital and this site.
There are only 2 ORs and they alternate days for procedures:
Obstetrics and Gynecology on Tues/ Thurs; General surg and Orthopedics
on Mon/Wed/Fri. I got to see the fastest C-sections imaginable (knife
to baby = 1 minute) and another giant ovarian tumour resection.
Anesthesia here is different as well… they don't have anesthetic
machines, so they use the old style bellow ventilator for general
anesthesia, with the old-style draw-over aerosolizer for halothane
delivery. It's all a little technical I know… suffice to say that they
are using old equipment and old drugs, if they even have the drugs at
all. A couple surgeries were postponed because they ran out of
ketamine. (The other night a lady almost died of cerebral malaria
because the hospital ran out of saline! The nurse had to go around the
wards sucking of saline from other people's IV bottles.)
In the afternoons this week and next, we'll be taking part in a
course that the Ifakara institute has piloted here a couple years ago
on childhood illness from tropical disease. The idea is to train every
health care provider, from medical officers in rural areas to
physicians in tertiary centers, how to recognize serious childhood
illness and take steps to refer or treat the child as appropriate. It
is an attempt to standardize care and prevent really sick children
from falling through the cracks in the health care system. It should
be an interesting perspective on home-grown solutions to health care
problems here in Tanzania.
Side note: We found a canteen that serves a massive plate of rice,
meat, beans, fruit and greens for 2000 shillingi (1.50$) for lunch and
dinner. Jackpot. I'm so glad that I like rice, because it is the
definition of a staple food here. Also, we've discovered that 500mL of
beer is about a dollar. It seems criminal.

July 4 - Born again in Ifakara / relaxing Canadian style

The first person we met once we got to the Ifakara institute
was a lovely woman who works the reception and seems like she helps
run the joint. She was very welcoming and a friendly face to greet us
at the door. She has gone out of her way since our arrival to make
sure we are comfortable and have everything that we might need. Since
there are no quick and easily accessible restaurants nearby without
prior arrangements, she also offered to cook us dinner and breakfast
for a few days, which would also help raise some money to send her
daughter to school in the States. She's been a great cook and we've
enjoyed the local fare that she cooks in her small kitchen in the
house she lives in on the compound.

At breakfast, she asked us if we'd like to attend church with her on
that Sunday morning, and she was so nice about it and promised a
unique ultural experience. We all agreed that this would be an
interesting way to spend our Sunday morning in Ifakara. An interesting
cultural experience it certainly was. We all dressed up and went with
her to the church, which was a Born Again Christian church. The church
was modest, but well-kept and large enough to fit the 150-200 people
who attended the service.

We walked in just as they were passing around the microphone to
introduce new visitors, so we had to stand up and introduce ourselves.
I attempted this for the group in Swahili, explaining that we were
from Canada and visiting Ifakara for 2 weeks. I also thanked them for
their hospitality and they were very welcoming. Introductions were
followed by performances by 5 different choirs, complete with dancing.
If you've seen any of the large evangelical Christian ceremonies on
tv, you'll have an idea of the structure and components of this
service, complete with speaking in tongues and an attempt at laying on
the hands, although no one volunteered that their kidneys were in
trouble, as I think the preacher was expecting. Our host was kind
enough to translate much of what was being sung and preached. It was
certainly a culturally eye-opening experience, regardless of my own
views. I think this church serves an important role in many community
members' lives in Ifakara, and it was good for us to get a taste of
the importance of religion to some of the people here. The whole
ceremony was long… about 3.5 to 4 hours, roughly rivalling the sum
total of time that I've been in a church to date. I was happy to be a
part of it and didn't feel much pressure to confess my sins and
promise myself to God when I was there.
In the afternoon we just decided to relax into our new surroundings
and we all got together and played ultimate Frisbee in the field
behind our guest houses. It was a great day for it and we all had a
lot of fun running around and tossing the disc. We're hoping to
convince some of the local children to give up football for ultimate…
ha.

Creepy crawlies in Ifakara

Massive and interesting versions of snails (shelled and not),
dragonflies, bush crickets? maybe cicada? and a praying mantis being
devoured by ants. We have geckos and other lizards in our room at
night to catch the bugs. Apparently the monkey bit someone, so we're
keeping watch when we walk under trees.

Money Shots

Just playing around with some fedha (money).
The currency is the Shillingi. Roughly 1500 per US dollar.

Pictures on the way to Ifakara

Pic 1 - These blurry shots are from the window of a speeding bus, but
these were so close to the road!
Pic 2 - Erin, Steph and I squeezed into the bus from Ifakara
Pic 3 & 4 - Starting to get into the mountainous region. Some
absolutely beautiful scenery on this drive.
Pic 5 - Again, from the window, but this gives you an idea of the
typical rural house that we've been seeing. You can also see the woman
wearing typical tanzanian colourful clothing. The smoke in the
background is from the ubiquitous coal-burning fires everywhere...
it's a wonder everyone doesn't have asthma or lung cancer.
Pic 6 - Our accomodations. Jeff and I are sharing this bed... with
pink sheets... and a mosquito net to make things extra cozy.

July 3 - Peace in Ifakara

I shouldn't get ahead of myself. For my legions of avid
followers, you will, no doubt, have noticed that I didn't write
anything about my adventures on July 2rd. To be honest, there wasn't a
whole lot to relay from my final day in Muhimbili, although I got to
observe a few more surgeries in theatre. The rest of the day was spent
packing and getting things ready for our trip to Ifakara on Saturday.
It has been a whirlwind two and a half weeks in Dar and it feels like
we've seen and done an incredible amount in such a short time. Dar es
Salaam was a great introduction to Tanzanian life, but I think we are
all looking forward to a new experience in the rural setting, away
from exhaust, smoky coal fires, traffic jams and aggressive touts.

The bus ride to Ifakara started with a flourish as we arrived at the
Ubungu bus terminal in Dar at 06:00 amid hundreds of other travellers
all jostling to find the right bus. The buses were decent and were
equivalent to the greyhound or Acadian lines buses back home, except
the seats are much closer together… it was a tight squeeze. All in all
though, the trip was great and took us through diverse cities and
communities and showed us everything from open savannah and dense
tropical forests. It seemed like we were stopping every 15 minutes
though, either for police checks or to pick up more people for the
trip. There were a couple toilet stops, which were just on the side of
the road. It was interesting to see everyone pile off the bus and just
do their business on the side of the road, side by side.

The bus ride also exposed us to much of the rich colour of Tanzanian
culture along the sides of the road in stores and peoples homes.
Beautiful kangas and colourful shirts seem to be the favourite of many
Tanzanians. It is also interesting to see people walking down the
street in tshirts that read "Save lake Tahoe", "Middlebrook Valley
Lions" or, my favourite "Please don't feed the models". These must be
coming as donations from the States and Canada in big shipments,
because we would often see big piles of shirts laid out for sale on
the streets of Dar. Anyway, back to the culture. We saw all sorts of
houses, from crudely constructed mud and palm-leaf shacks to big
mansions on the hillsides. Some communities are barely above
slum-level and some are fully constructed with brick houses, with
simple, but tidy plots. None but the richest have lawns or gardens,
and those are usually walled off in compounds with guards at the gate.

I'm finally getting used to people running up to vehicles when they
are stopped in traffic to sell food or goods. This was especially
apparent on the bus, when at every stop or weigh station, guys would
run up to the bus with oranges, roast corn cobs, bananas, loaves of
bread or rack of fedoras… they seem to have everything. Some people
even get on the bus and walk up and down the aisles selling their
goods for a couple minutes before we push off, making for a very
congested bus. Additionally, the buses here don't function like
Greyhound once they get out into the rural areas. They will often pick
people up, even with a full bus, who may be travelling 5-10 km, and
they'll stand in the aisle, much like a local transit bus. This is
probably because everything is so remote here and public
transportation so scarce, but there ended up being a large mass of
humanity on the bus by the end of the trip. That's enough about
humanity though.

I saw my first wild Giraffe! This was followed closely by a couple
elephants, then some gazelle and finally a whole herd of giraffe right
on the side of the road. We're pretty sure we some lumps in a little
patch of water that looked suspiciously like hippos. No great pictures
unfortunately, because the driver was zooming down the road, but it
was pretty special nonetheless. All the animals were in Mikumi
national park, which is contiguous with Selous NP, the biggest park in
Tanzania (even bigger than Sereghetti).
I can't wait for the safari. It's gonna be amazing.

We arrived at the Tanzanian Training Centre for International Health
in Ifakara and were blown away. It is a beautiful property. Absolutely
gorgeous manicured lawns and clean walkways and buildings. And the
quiet; the loudest thing out here are the crickets, and this is a
welcome relief after Dar and the bus ride. We're staying in beautiful
guest rooms in the compound, although it seems as if we are the only
guests currently. We haven't really got a run down on what this place
is all about, but based on the feel of the place, it seems like an
elite training facility for grad students or professors on sabbatical
who want to study tropical medicine. It makes me think of the fancy
hunting lodges that English gentlemen would come to when they wanted
to hunt big game back in the colonial heyday, but retrofitted for
malaria and HIV research and health care. I am thus pretty conflicted
about staying in such swanky lodging. It feels great, but I worry
about the image that we are portraying to the residents of the city or
even the people who are working here. I think I've decided that the
best thing to do is to show a willingness to learn from the institute
and to try to stay as humble as possible and appreciative as only
Canadians can be. I hope that the people here can understand and
accept the role that we play in this place.

July 1 - happy Birthday Canada!

It took a considerable amount of effort to explain what Canada Day was
and why we were painting our faces with maple leaves today, but we
went out and mixed a little bit of alcohol with a little bit of
malarone and had a good night in Canada's honour. We were also
celebrating Meredith's 22nd birthday, so plenty of reason to
celebrate! Failing a Canadiana bar in Tanzania, we settled for the
next best thing: O'Willie's Irish Pub. Ha. Good times had by all.

Earlier in the day at Muhimbili, I finally got to see the large
mitral valve surgery that had to be pushed back. The patient was a 22
year old man, who, when I looked in the theatre, I swore was no more
than 12. This was another case of 'failure to thrive' and at 22, he
had not yet even gone through puberty because his heart was having to
work so hard to keep him alive. The problem is that the mitral and
tricuspid valves in his heart, which normally keep the blood flowing
in one direction were, in this patient, crippled and almost useless
due to a bacterial infection that triggered Rheumatic heart disease in
his childhood. Rheumatic heart disease is almost unheard of in Canada
because we can treat the bacterial infection so easily, but big heart
repairs like this one are common here, Really common: 90% of cardiac
surgeries are for mitral valve repair secondary to rheumatic heart
disease. In Canada, the majority of a cardiovascular surgeon's time is
spent repairing coronary arteries or grafting on new ones when our own
become clogged with cholesterol. I guess as the saying goes: Out of
the frying-pan and into the fire, or; out of the deep-fat frier and
into the rheumatic fever, burning away the youth of this country.

As a result of the rheumatic fever, all that blood moving in
the wrong directions has numerous consequences, the most striking of
which was to increase the size of his heart: on x-ray, it took up 75%
of the diameter of his chest (normal is 50%). It was massive. His
whole chest pulsated with every erratic beat and sound of blood
rushing the wrong way through one-way valves was clear as day.

The surgery itself was incredible to watch and amazingly
complicated, including cardiovascular bypass (a machine pumps all the
blood around the patient's body for them), a full mitral valve
replacement with a prosthetic metal valve and a tricuspid valve
repair. It was about 7 hours from start to finish and thankfully there
were no major complications, although the bypass was hard to set up
and the patient's blood pressure dropped to 7 / 5 for a couple minutes
while they sorted out the hole in the aorta. There were a few tense
moments where we packed ice around the patient's head to try to
protect his neurons from being damaged.

June 29/30 - How is that even possible?

In this post: Late night on the streets of Dar, You call that a tumour?

The mitral valve repair got bumped this morning: they didn't have
enough blood in the bank for this size of operation. It doesn't happen
too often apparently, but they rely heavily on the patient's relatives
coming in to donate if they are going in for surgery and this time it
didn't work out. I got to sit in on a peripheral venous stasis repair
though, which was interesting. The guy had apparently had a pretty bad
ulcer on his ankle, which someone had put a skin graft on 10 times
before they realized that there was a bigger problem with the veins.
They managed to get him all patched up pretty quickly and I had an
early day.

Later that night, Jeff and I met up with one of the interns
that Jeff had met in the hospital to go to a local bar and watch some
football: Spain v. Portugal. He brought his brother and cousin along
and we had a great time chatting about culture, football and language.
It was very interesting walking back from the bar late at night in
Dar. I felt comfortable because we were with some locals and it was
great because I got to see a side of the streets that I hadn't yet
experienced… quiet. It was almost eerie after the bustle of the day.
There were a few people sleeping out on the street, but they were far
out-numbered by the security guards sleeping in their chairs outside
of almost every business (Econolodge has 2-3 guards with Billy clubs
at night… some guards around the city are sitting around picking their
noses with shotguns. Scary).

On Wednesday we met up with the intern again for breakfast at the
hospital because we wanted us to try cassava. It is the root of a
local plant, that when cooked becomes somewhat sweet. It is served
with a spicy chilli sauce, which is a different experience for me that
early in the morning. It was pretty decent though, and I could
envision becoming accustomed to eating it, just maybe not while eggs
are still an option.

Today I switched to the General Surgery service and got to watch 4 or
5 operations throughout the day. The first was a doozie: She was a 60
year old woman who probably weighed maybe 110 pounds… a full 15 or 20
of which was abdominal tumour. When it came out, it was the size of an
American football. I guess part of the reason that cancer can get so
big here is the lack of screening, coupled with the belief that
traditional healing can reverse the course, added to the fact that so
much of the population is rural. It was unbelievable how fast they got
the thing out though. The majority of the operation was then spent
repairing the abdominal structures that had been compromised by the
tumour. I wish I had a camera, but I doubt many readers would want to
see it anyway. Your stomachs are probably already turning as is.
Sorry.

The rest of the surgeries were a mix bag, ending with an HIV positive
lady with an opportunistic infection that had turned into a large
ulcer on her face that needed to be surgically removed. She was lucky
that she didn't lose her eye but she is currently recovering with a
good chunk of cheek bone exposed to the air. It was a sad case to
witness because her prognosis is so poor.

June 28 - What patient privacy?

In this post: Day one Muhimbili, patient presentation, cardiac surgery

We started in the hospital today, which is associated with the
Muhimbili University of Health and Allied Sciences. It is pretty
central to Dar and a warm 25 minute walk from our hotel in the morning
(warm even at 07:00). There is something nice about stepping into a
university campus from the streets of Dar. It almost feels like an
oasis amongst the chaos of the city, with students working on laptops,
professors strolling the grounds and the feeling of higher learning in
the air. It is Academia I guess, and I think I feel so comfortable
because I've spent all of my adult life in it (having passed my final
med 2 exam, I am now officially in Grade Twenty-two!).
Jeff and I are both doing a surgical elective while at Muhimbili and
we heard that they had a lecture/ teaching session at 7:30 on Mondays,
so we got there bright and early to sit in. We were both pretty
shocked when, in front of 30 doctors and med students, they wheeled in
a patient and laid him out on a gurney that was set up in the corner.
A nervous resident then proceeded to present the patient (in English,
so we had no trouble following along, but the patient probably had no
clue what they were talking about). It then seemed that whenever the
docs in the audience felt like it, they got up to examine the
patient's findings (in this case, jaundice) with a curtain half-drawn
so that we could still see the patient's head. It just felt like a
bizarre show-and-tell at school. The resident then had to field a
number of questions from the docs in the audience in what seemed to be
a formative evaluation. Jeff and I, having just completed that unit in
school, did pretty well. Unfortunately he was having a harder go of
it. Apparently he was an upper year resident, so it was a striking
difference for us about the level of schooling in Canada compared to
here. While I hope that this is only one case in an otherwise
wonderful school, I unfortunately have the feeling that this may
develop into a theme in the days to come.
After the teaching session, I met up with the cardiac surgeon that I
would be spending the next three days with and he took me over to the
operating theatre for the day's case: open ligation of a patent ductus
arteriosus in a 9 year old girl. (For those of you less medically
inclined, the ductus arteriosis is a structure in your heart that is
vital for proper oxygenation of blood in the fetus during pregnancy.
Once the baby starts using its lungs, it doesn't need this structure
and it normally closes off in the first few hours. In this case, the
little girl's ductus arteriosus didn't close, which actually makes
things pretty bad. She was 9, but because her body was never getting
the oxygen it needed and was working so hard to pump blood around her
body, she was the size of someone years younger than she and was
effectively skin and bones.)
The operating room was surprisingly modern (see pictures),
with most of the standard bells and whistles one would find in Canada.
In fact, the whole process seemed very familiar and I immediately felt
at home in their OR and during the procedure. The cardiac surgery
program is a new one at Muhimbili, run by three cardiac/vascular
surgeons who are amazing and very welcoming. The nurses and
perfusionists in the room were also very welcoming and I had much of
the same banter with the nurses here as I normally do in Canada. It
usually starts with one nurse coming up and standing next to me,
marking their height on my arm and then laughing. I usually indulge
and walk around for a little while at their height… it usually gets me
in pretty good with the nurses, which I guess is as important here as
it is in Canada.
There were a few hiccups during the induction procedure
(putting the patient to sleep)(medical note for Patty's interest:
Ketamine to induce, halothane was the gas of choice, although they
also have isoflurane on the cart; no art line; morphine post op with
local costal block before closure), but the rest of the surgery went
amazingly well without complication. It wasn't a 'crack the sternum'
type operation, but a smaller incision with access to the heart
through the left ribs. It was pretty neat to see and a nice feeling to
know that this child will probably start feeling much better almost
immediately. I'm looking forward to tomorrow's procedure, a mitral
valve repair that will need cardiac bypass.