I arrived in Mvumi today. As I have spent the last two weeks or so travelling, it’s nice to know that I will be in the same place for a while. Because I haven’t written for a bit there’s a lot to say, so I apologise if this post is a little less organised than previous ones.

 Of my last two weeks, I spent one in Nairobi visiting some friends there. One of the first people I met with was my friend Benson, who I, and a few of my friends, have been helping with his university fees. He is doing well, and managed to get back to school last semester, but he is still struggling to earn enough for his studies. He spends his evenings working a police watchman, and his days studying at Kenyatta University. He took me there to show me the campus. It was good to see his place of study. We also went to the medical school there, which has opened only a few years back. I managed to convince the staff to give us a tour of their facilities. They had a histology lab that struggled to get specimens, but their anatomy lab was well stocked (it benefited from there being a funeral home connected to the university – the sign was strange: “Medical School and Funeral Home”, and surely mustn’t instil much confidence in their future doctors). I guess it hit me throughout the day how many sacrifices my friend was making to study. Even with the limited resources the university had to offer him. It impressed on me the value of education in his eyes. I respected it, and I hope it brings him everything that he believes it will.

I also managed to meet with a friend who was working with the microfinance organisation I spent some time with last trip. He now is doing other things, but it was good to see him. He told me of the some horrendous events that happened in December last year. Thousands of houses in the community that he lives in west Nairobi were demolished without adequately consulting the courts or the community. When they fought back, truckloads of heavily armed police where brought in, and they, literally, raped and pillaged those living there. There has been no avenue of redress for these crimes. A lawyer working for the community has been receiving death threats, the local police station refused to accept claims of assault and rape by the police, and a MP speaking on behalf of the community was briefly arrested, and his cries of injustice have fell on death ears in the parliament. All this weighs on my friend (and me) heavily. I’ve managed to document it all, and so if you have any suggestions of who we can forward this information to that’d be great. I really feel that something must be done to set right this tragic and deep injustice.

While in Nairobi I staying with our family friend’s: the Mbuka family. I first met Gideon Mbuka when I was around five years old. He worked with World Vision then, and so stayed with our family (my father also works for World Vision) when he visited Melbourne. But I really came to know their family best when I lived in Kenya during 2006. They looked after me in a tough time, after an unhappy experience at an NGO there. Last time I saw him he told me of a memory he has of me of a very young child praying earnestly for those who were starving in the famines in his country. He told me he has known ever since of my desire to help those in need. They were very good to me, and helped me to deal with some of the most difficult cultural adjustments I had to make. He was a person who I admired deeply. It was with great sorrow that I found out he had died last November in complications that followed what should have been a rather simple surgery. Given this, the idea of visiting Nairobi was largely to see his family, and to visit his retirement home where he is now permanently resting.

He has left five kids and a wife, and a lasting impact on the lives of many of the poorest in Kenya. As evidence of this impact, two thousand people attended his funeral. His son told me that the funeral had happened how he would’ve wanted. Things ran smoothly, in an ordered and timely fashion – something that Gideon had always taken care to ensure at such events. His son told me that would’ve pleased him. When we went to his retirement home, I saw the beautiful place he had built for him and his wife to spend out his days. His son told me that he was sad that he hadn’t had the chance to enjoy those days. He said he’d been too busy caring for others. It was good for me to see the place, and to see his grave. It was also good to go with his sons so that they could explain some of what the place had meant to their father. I will miss him. I remember him as an understated, caring, loving, and unique man. I will not be alone in any of these sentiments.

On my return to Dar es Salaam I had a few days off. I met a friend there and just went to the beach a lot, and movies, and too many Indian restaurants. (We were actually trying to re-find an Indian place I’d been previously, but without success). Most of the time was lovely. But I had a horrible day at Kipepeo beach, one of Dar es Salaam’s nicest beaches. We were there swimming, and had had a lovely day. But by late afternoon as we sat around waiting on a beer, I saw a crowd of people around something a little down the beach from where we were sitting. I started to walk down the beach toward the crowd to investigate. When I got a bit closer I recognised the object of interest as a body. I started to run. I reached the body and saw a boy of around 15 years of age. He wasn’t breathing. He had been swimming and had drowned. No one was doing anything but looking at him, so I started CPR. After a few moments with no response I yelled at the bystanders to call an ambulance. They responded that they didn’t know the number. I yelled at them more, but then just resumed CPR. The chest compressions where very similar to the models I had practiced on. The bellowing effect brought out foamed up seawater from his lungs. I cleared the airway and resumed. A few moments later, he vomited in my mouth, and I stopped, gagged, and then vomited myself. I glanced back expecting this event to mark him regaining consciousness. It did not.  He lay motionless. Dejected, I gave up, only a few minutes after having started. But knowing that no help was coming, and that he hadn’t been readily resuscitable, I felt the exercise was futile and stopped.

I am still struggling to come to grips with this. I really wish it had occurred with someone else more experienced than me to take over, or to tell me what I had done wrong and right. But it was just me, and the crowd, on the beach. When I stopped, a man told me to walk to the beach and wash my mouth out. And my friend did her best to care for me afterward. This helped, but I really wished the first death I had experienced so close up had been easier than this.

These are really interesting comments, Steve, I’ve really liked reading them!

Katie :)

Mvumi is a two-hour bus ride south of Dodoma. It is quite a large township that is divided into two parts, the main township and the mission. Mvumi mission is easily distinguishable from the township in two ways: its buildings are substantive, compared with the rather flimsy 3 ft high mud huts that populates the town, and it occupies a place on the side of nearby hill, overlooking the town. It reminds me a little of the townships that surround some of the castles I saw in Germany. Like a castle, the mission claims the role of protector and provider by its position, and its solid construction.

The mission has a district hospital, a high school, a nurse training college, a medical officer training college, and a lab technician training college. This may sound impressive. It impressed me on paper. But seeing it in reality revealed that things are done to a very different standard that what these things had conjured up in my mind. Just to put one of my first misunderstandings to rest: the hospital’s current highest training level of its staff is that of clinical officer (a one year course-refer to previous post); while the last visiting western Doctor left over year ago (2009).

A theme has certainly developed in my time in Tanzania. The unprofessional behaviour of staff, a lack of training, and the simplicity of the equipment and medicine available means that often the hospital in Tanzania seems more like a place to die, than a place of healing. I’ve seen some pretty appalling things in my brief time here. Nonetheless, I think my point is not to be overly critical – although that too is probably somewhat justified – but more to highlight the difference between the way we use words like “hospital”, “doctor”, “school” and “teacher”, and the meanings they have here. Because by learning a closer approximation of what these words mean I’ve got a much better idea of why people still die of preventable diseases, or fail to be treated for simple injuries and illnesses. Language had previously masked these differences.

Anyway, putting the philosophy of it all aside for one moment, I will give you a run down of what I saw today at Mvumi Hospital. Despite the simple training by staff, the hospital does a remarkable range of things, many of them quite complex. Its general wards are filled with patients who mostly either have malaria or HIV (and its associated diseases), or both. It has a surgical ward that is (like Dodoma and Dar es Salaam) full of men with broken fibulas and tibias, and also a few older men who had problems with urine retention. The women’s ward was more interesting, and also more distressing.

The most interesting was probably a woman who had been trepanized in the local village. Trepanation is the act of boring a hole into a skull to do an operation. This is something that I assumed had stopped 40 years ago. It’s a brutal and reckless operation performed by traditional medicine men here. But again words hide the reality of what an “operation” looks like here. This video captures what is hard to explain in words. Her post surgery presentation wasn’t as bad as the woman in the film, but she still had an open wound on her head like the video shows. She also had old scars on her feet, and was in complete daze when I tried to talk to her. It’s hard to know the full story, but the story I made up in my mind was that she had been trepanized to deal with mental illness (the old scars on the feet from walking round in a state). But maybe it was for something else?

The most upsetting case of the day was a woman with severe ascites. She was in cardiac failure, and on frusemide, but still retaining enormous amounts of fluid. It just felt very unnecessary because, while her death was probably imminent now, she was quite young and she probably had deteriorated to this point without any intervention. Even now, there was no information on what was her underlying problem. This wasn’t the only upsetting case today, but it all sort of hit me by the time I saw her. I’d also seen an old man with malaria who couldn’t afford treatment, a whole swathe of AIDS patients on their last legs, and a lot of very smashed up car accident victims.

However, this wasn’t very different from the other places I’ve been. But still something about this hospital was more raw than the other experiences had been. Perhaps it was the poverty. Perhaps the seriousness of the cases. Perhaps the futility of the treatment options. Or perhaps it was just the tiring bus journey. Regardless I found that it all hit me with this woman in cardiac failure. It was cutting. When she cheerfully replied to my greeting and responded by giving her blessing to me, “and when I return, my family back home”, I was really struggling to keep it together.

These things aside, the day was really productive for setting up my research project. I met a guy working in the HIV department who does patient follow-up in the community. I thought then that this is exactly the sort of person I need to partner with, and so arranged a meeting in the evening. We met after dinner and discussed ideas well into the night (a darkness which was felt more acutely as we had a black out for most of the evening). He was very interested in the idea of research into the way systems of health care run here. I think he shared the interest in my research idea, so that’s exciting.

I’ve basically got to get approval from the local district, and then I am allowed to do my research. So I am going to write that letter today. Once we’ve got approval, I am going to move out here for two weeks – from mid to late Jan. The idea is then that we will use the mission as a base and go into the surrounding town where people are very poor, and have low levels of education. And using the currency of soda, organise small town gatherings to discuss their experiences of healthcare. I’ve got some questions organised but hopefully with some help can get them in a form that people will be willing to answer.

I’m not aware of any relevant studies! Nevertheless it’s exciting to hear about your studies/travels and I hope that your time in Tanzania is fruitful.

The University where I am staying also has a health clinic. It’s a small and simple building. It has a pharmacy room, a consultation room, a very basic lab and two small wards (again, one male and one female) that are now rarely used. The clinic used to be busier as it previously provided cover to all students; now it only covers Government employees (which have a Government healthcare insurance package) and the few that can afford to pay.

The staff at the clinic have a range of experience levels. A cheerful old man acts as the way gate to the clinic’s services. He checks for patient records and insurance forms with frequent consultations to a shy girl in the records office. Patients then wait on a wooden pew outside the doctor’s consultation room. The doctor is a friendly woman who used to run the University stationary shop (she has good organisation skills and apparently ran it well) but has subsequently taken the one year diploma course required to be called a Doctor in Tanzania (there are two levels of doctor; she is the first, which is known as a clinical officer, and the second, the medical officer, requires 5 years of training, and is a closer approximation to what we would consider an appropriate level of training to be considered a Medical doctor).

Next in the chain is the lab scientist, he is frequently called upon as the vast majority of cases are presumed malaria and bloods are requested. The laboratory scientist has an expansive knowledge of parasites and firm grasp of the simple tools afforded him: a microscope (invaluable), a narrow variety of stains, a broken haemoglobin reader (it read 18g/L for a rather malnourished looking young woman), a few urinalysis strips, and a blood glucose counter. Upon lab (or clinical) diagnosis, there is a small pharmacy where a wide-ish range of antimalarials, antibiotics and other anti-parasitics are kept – outside of these drugs, there is precious little.

I’ve mainly spent my time in the consultation room with the doctor. She’s a warm lady with too high a view of my fluency in Swahili. I usually bumble a few questions in Swahili, or offer a comment of some sort. She then replies rapidly to whatever I have said, often in somewhat extended form, but mostly ending with her own question and an expectant look. I rarely answer with anything intelligible. Nonetheless, I get by, in that I usually get the diagnosis and a few key features out of our discussions. My opinion is valued too, a somewhat worrying state of affairs for me. The doctor tends to be willing to order more tests or change her drug prescription based on a brief discussion of this or that. The things I have questioned most is the diagnosis of malaria for things that are a bit of stretch (ie. not a single classic malaria symptom and a few other things that fit another diagnosis). Still, malaria fits most cases. And is a wise suspicion in many others.

If malaria is suspected then I duck next door to the lab with the patient and do the blood film for the malaria stain. Malaria is so common here in blood films that a positive test requires not just the presence of malarial parasites but a number over a certain threshold. In addition to malarial screening, a Widal test is also occasionally done, for those suspected of Typhoid fever. Other possibilities that can be tested for are a blood sugar count, a urinalysis, or the completely pointless, haemoglobin count (as the machine is fickle with the numbers it prints out each time).  The lab technician is equally friendly to the doctor but has a more realistic understanding of my Swahili.

Last Wednesday the doctor was planning to be away for a day and was adamant that I take over her role while she was away. She spent a while explaining how to use her prescription books. I carefully explained how I was unqualified for such responsibilities. She countered that I had a years training, and that was equal to her. I questioned the legality of the matter. She laughed. I looked worried. She looked at me hopefully. I declined. She was unfazed.

So last Thursday I went into the clinic with a measure of trepidation. Luckily the lab technician had also stepped into the role and all I had to do was co-doctor with him. A chair was brought, and we shared the position of authority behind the doctor’s desk. In reality, (and quite fine by me) he took most of the role’s responsibility. The only case where I stepped in was in a 3 year old who had a few signs of pneumonia. The original diagnosis was malaria and I thought that listening to his chest and antibiotics would be a good addition to the screen. This was somewhat confirmed when auscultating his lungs revealed crackles and his blood came back negative for malaria. He was sent home with amoxicillin and paracetamol. I felt fairly sure that was the right diagnosis, and I thought that I did the right thing adding my two cents to what the technician had said. But nonetheless I found the experience daunting of acting above my Australian training level.

Yesterday I went to Dodoma Central Hospital to visit and have a look around. I’ve actually been there three times now, but each day I’ve been told that people are too busy to show me around. And rather than getting a text or a call to say showing me around today won’t work, I have to go in. Even then it takes around an hour before I find out if the Head of Nursing is occupied (getting her daughter into boarding school – which seems to take days of her time), or if she will be able to show me around. I’d been beginning to wonder if it was ever going to work, or if instead, this was a subtle hint that I should stop trying, as I wasn’t welcome.

So really I was quite pleased to be finally told: “Okay. Today works. Which ward would you like to see first?” The wait was over – I smiled a little and replied, “Can we go see the General Medical ward, the Orthopaedic ward, and then the Surgical ward.” She replied by striding rather rapidly (at least for a Tanzanian) toward a building nearby. When we entered, she announced that this was the waiting area where outpatients and first presentations waited to be seen by the consultation rooms.

There were around 20 rooms, and probably over 100 people waiting. A young rather shabbily dressed man walked out of one of the rooms with his hand in bandage. By looking at him (he was covered in cement dust) presumably an injury sustained while working at a construction site. A young boy came hobbling out with his leg in a cast. Another man lay in the throes of fever. Malaria sprung to mind, and I took a wider berth as if he were contagious by mere proximity (I also considered that I should be taking my anti-malarial tablets). We entered one of the consultation rooms. The room was small, and instead of containing one patient had two; one was being examined by a nurse behind a curtain in the corner (the examination area was the size of the smallest of change rooms), and the other was talking with a doctor at a table placed in the centre of the room.

After greeting the Doctor there (he didn’t actually seem keen to talk), we went on to the Orthopaedic ward. I had asked to see the Orthopaedic ward, as I was keen to note the differences between it and Muhimbili. Like Muhimbili, the wards were divided by gender – presumably a sign of the levels of gendered violence, seeing privacy was certainly not a consideration in these hospitals. The ward was less packed than Muhimbili but just as basic. Patients lay in simple beds with stained sheets (the sheets looked like they only got washed very infrequently). I talked with a few patients. However, people were less keen to talk than Muhimbili (I wondered if their mode was a reflection on the quality of care they were receiving). Most injuries were sustained from motorcycle accidents, but a few of the younger patients had sustained their injuries playing at home (falling out of trees, or slipping off a plank over a hole). Again the injuries that led to admission were largely femur and tibial fractures. The worst patients again had general MVA trauma and head injuries – but unlike Muhimbili, they seemed to get little additional care to the treatment of their broken bones (no Neurosurgeon here – in fact Dr Kong, is one of three Neurosurgeons in the country – a ratio of 1:12 million people, much worse than the WHO recommendation of 1:75,000). Anyway, I should not decry the standards too much. It did seem that bones were getting set properly, and this was a formidable improvement in a country where you can see a person hobbling with a deformed leg on nearly every street in the every major city (due to bones not getting properly set).

Next was a female ward for septic wounds post-surgery. It was a small ward, only six patients, and we had to disturb the sister in charge from a nap to get shown around. She had been asleep on a black leather examination bed when we woke her. She was definitely thoroughly asleep as it took her nearly a full minute to begin to formulate complete words. When she did she explained to us the histories of a few patients. One was particularly touching. It was that of young woman who had had a home abortion. She had stayed in bed for weeks afterwards and developed terrible bedsores. They had subsequently become infected, and she had been admitted needing antibiotics. She lay there gaunt and sad, and replied meekly when I greeted her. I wondered about depression. It’s unlikely that she had been given much support if it was – another giant crack in the healthcare system that many must fall through.

We skipped the surgical ward and went straight on to the General Medical ward. I was keenest to see the infectious disease cases. Here I tagged along with a ward round with a senior doctor and a few interns. Their Swahili was fast and technical. I understood little, and made all the more difficult as the case they were discussing was complex. It was a man who presented with weight loss and paralysis. His diagnosis was an oesophageal cancer that had spread to the brain and was causing epileptic-like symptoms. They treated with anti-epileptics, but chemotherapy was unavailable. And the hospital where it was available was in another city at was prohibitively expensive. He would not be able to afford it. Phenobarbitone was prescribed. He would get some palliative care, but he would die here – possibly in the next few days judging by his feverish and emaciated appearance.

I left the General Medicine ward without seeing any malaria patients. It had decreased my chances that most cases are dealt with at clinics (or in the home) and only referrals of complicated cases end up in the hospital here. We did however end up going to an equally interesting ward to finish up the day: the HIV/AIDS clinic. The clinic was a major centre for diagnosis in the region. It performed testing on concerned people, and then in those that were found to be HIV positive it provided some basic counselling. For patients that had already travelled down the inevitable road towards AIDS it provided anti-retroviral therapy (in which the were very well stocked – I was shown a room that had 1,000s of boxes of ARVs). The clinic had around 5,500 patients that it interacted with per year. According to a Western nurse who has worked in the region for decades this is just the ice cube on the tip of the iceberg. She mentioned that when they used to test pregnant women in the hospital a few years back the figure reached had been close to 30% (word is that they stopped screening when such appalling figures were uncovered).

So my three original research ideas for this trip were:

1) Looking at parasite load via something simple like giving anti-parasitics then enumerating them from stool samples, and then measuring levels in a few different communities for comparison. Maybe even trying to look at this longitudinally to get a grasp of how quickly the same kids will get reinfected with the same parasites.

2) Looking at triage processes in the small University clinic that I will be at. Just to see how resources are allocated, and maybe seeing if I can work with someone to try and get processes that do occur written down (whether they be good or bad, just so there can be discussion about how triage is done).

3) Maybe some sort of simple discussion about health of urban poor vs rural poor by selecting a few families that might be somewhat characteristic of the two different communities and running a semi-structured interview (I guess sort of very basic ethnographic research). Comparing things such as access to services, disease experience, disease outcomes, how often people fall sick, etc. just from a few families.

The first option may not be feasible as fun as it sounds to sift through locals’ poo for worms. (I guess I can always do that one next time). Regarding the second option: I am yet to visit the local clinic, and I will keep that avenue open, but it does seem the local dispensary is not really a foci of activity. So it might have only a few records. The local hospital in Dodoma will have more data, but I’ve also been in there three times already and failed to get even a tour achieve – so the prospect of trying to do something more complex may be too much to ask (and be a bit of a headache).

So those are the setbacks that stop the other two of the three ideas from looking like they will work. But what’s pushing me towards the third idea is that a few contacts are already looking like the will be able to assist in that sort of a project, and just as importantly as being able to achieve the research, it genuinely looks like an important research question. (One reason why I think research into “healthcare experience” is important is related to some of the questions around professionalism that have arisen from my experience at Muhimibili – where it seems that low expectations of staff behaviour helps to perpetuate poor levels of healthcare as much as, or more than, lower levels of training or equipment.)

The third idea is starting to get refined into something manageable. Rather than tackling multiple communities, I will aim for just one, and a rural community. One community it might be possible to do the study in might be a community about 40km (?) to the south of Dodoma. I’ve spoken with a former nurse whose got contacts there and she’s suggested that it might be best to start in that hospital out there as it is used to visitors. From there I might be able to make some contacts to help with the research.

The questions I want to ask are about what services people use, and when. I might also add in some questions of how they find services when they use them. I’ve heard that people may be reluctant to talk about things in an open or critical way. Therefore, to get good answers to these questions will take tact, and cultural awareness. I generally lack these, and my measly Swahili will do little to bridge the gaps in thinking, and behaviours. (Relying on locals to assist will be very helpful, but is still no substitute for me having a proper knowledge of the community being studied.) Nonetheless I am interested to attempt the project even if it ends up that it fails. I think the endeavour will be useful for giving me a sense of what difficulties lie ahead for any future research. I guess we all have to start somewhere.

Ethics is something that is looming in the back of my head too. For my ILA I was meant to declare if I was intending to do any research involving people. I did not declare that I was. But now I think that I am. So I may need to make this research something separate to my ILA so I haven’t broken any guidelines for they assignment. Apart from this practical concern, I also have the concern of whether the project is appropriate, justified and basically, well, ‘ethical’.  While I am going to go through the local channels for a research project, I know that I would have to go through a much lengthier process to get it approved in Australia. The process in Australia would involve a body that would give guidance on the ethical dimensions of research involving people. Here there probably won’t be that (there will however be stamps and lots of officialdom I am pretty sure).

So I guess I am going ahead with the project tentatively. Hippocratic oath and all that. (Actually I will try not to be that flippant about not doing harm). One issue I have for now is getting a reasonable set of questions, or something maybe less rigid, but still able to act as a bit of a direction for the interviews. I just don’t want to go in for conversation blank as I think that it might be a less effective use of time. If you are aware of any study that might have a set of questions that seems to fit at all with what I’ve mentioned here, then please do send me an email or post a comment up here.

This morning I went to the Muhimibili Orthopaedic Institute to meet a friend of a friend, Dr Kong, who is a Neurosurgeon there. MOI is a part of the larger Muhimbili Hospital which is the largest hospital here in Dar es Salaam. It is a public teaching hospital and has at least a few hundred beds. MOI was set up by the work of Tanzanian Orthopaedic surgeon and a Swiss benefactor back in the 1990’s. Its main focus is Orthopaedics but there are also operating rooms for cardiac and neurosurgery, and a pathology lab for cancer staging. 

Dr Kong kindly organised for me to go around the wards in the morning with one of the staff and to see what happens at MOI. MOI divides its in patients into female and male wards. There was one female ward and two male wards. (I am not sure if this reflects the number of presentations but I presume so because most patients were admitted with injuries from car accidents, and there are definitely many more male drivers in and around Dar). Most of the patients were there for orthopaedic surgery, and had sustained injuries of broken humerus’, or broken tibia and fibula that needed fixation via pins or external bracing. There were also a few that had head injuries or brain tumours and were there to be operated on by Dr Kong.

So all up I saw around 100 or so in-patients between the three wards. The male wards were particularly cramped with mattresses strewn on the near entirety of floor making it hard to actually make your way through the ward. The wards were pretty clean, and the staff seemed friendly and competent however it did seem that the facilities were basic and this may have caused issues.

Over in emergency there was probably as many if not more outpatients waiting to be seen. They were squished into the corridors of the place. It stunk of body odour, and the mood was somewhat unhappier. In the in-patient wards I had been able to chat patients and they seemed only too eager to show me there fractures or internally rotated legs, or whatever had befallen them. I guess that the patients who had been seen were glad that they had managed to get access to the healthcare system. The many who queued out in the halls of the emergency weren’t certain they would have the opportunity.

After seeing the emergency department we went over and saw the X-ray department. The quality of the images seemed pretty good, and the only complaint I heard from the staff was that the room they had to work from was very small – chumba ni kidogo. The woman taking me around explained that they also had CT and MRI at the hospital, not bad for one of the poorest countries in the world. (That said, later on I did see some of the images from the CT, and they were pretty low resolution).

In addition to the public beds, and emergency department there are also a few private beds. These were rooms were beds actually looked like normal hospital beds (you could set the level on them and they looked sturdy enough to hold a person cf. the public wards). In comparison they costed around 35,000 ($22) a day as opposed to the public beds that costed around 20,000 ($14) for the entire stay. Still they were shared rooms, and they had four or so patients per room, without the privacy that curtains would provide. Next door to the private beds were a few rooms for the ICU. Most patients here had sustained their injuries, again, from car accidents.

After visiting the wards I went back to Dr Kong’s office for a little while. We chatted and he explained his interest in coming to Australia to work. I told him that he was very much needed in Tanzania where he is pretty much the only person qualified to do the kinds of surgery he does. He acknowledged that point but still didn’t seem dissuaded. After chatting for a little while he got a call from the operating rooms saying they were ready for him to operate. He was again very kind to me and allowed me to scrub in and assist (sort of, but mainly just watch) with the surgery.

The patient Dr Kong operated on was a 13-year-old boy with a pituitary cancer. (Although it wasn’t clear to the last minute who the patient was going to be as there were three boys waiting outside the OR, and it seemed just luck of the draw which one ended up getting prepped for the surgery.) I chatted briefly to the boy before the surgery, and noticed that he had the inward gaze that we learnt can happen when increased cranial pressure impairs the function of the abducens nerve.

I thought that Dr Kong might have operated via the sphenoid sinus as that is what I had heard in our course was the best way of accessing the pituitary. Dr Kong however explained that they didn’t have the tools required for such surgery, and furthermore the CT showed that tumour was too large for such a procedure (I wondered if tumours tend to take longer to get picked up here, and so surgeons have the more difficult task of dealing with large tumours rather than less advanced ones). Instead of via the sphenoid sinus the tumour was accessed via the pterygoid fossa.

It was quite an impressive procedure as the boy’s temple was slowly cut away layer by layer. It took Dr Kong at least 30 minutes to cut through the layers of the scalp and thoroughly oblate the vessels to prevent bleeding. It was easy to see each of the five layers of the scalp as he went – first the skin, and connective tissue was cut a reflected and, then the masseter muscle was cut and reflected, and then the aponeurotic layer and loose connective tissue was burnt through, and then likewise were reflected. Finally leaving just the exposed bone ready for the drill and jigsaw to cut and bore through.

This is where problems arose. The electric drill piece wasn’t sharp enough to pierce the bone. Dr Kong also struggled with the old drill’s size in his rather petite hands. After around 30 minutes of attempting to get the first drill to work, and then finding a second drill bit and having the same problems the electric drill was given up on. Instead a hand drill was brought, and was used to do the job that the electric drill hadn’t been able to do. The bone slowly was bored into, and then once the hole had been made the jigsaw like piece was attached to the electric drill. This was more successful than drill piece had been, but it was still a messy task, and the cutting had to be finished again by hand tools that slowly clipped away at the bone until a piece of bone about the size of jam jar lid was cut out and removed.

This exposed the meninges, the protective layer that supplies nutrients to the brain. Again this had to be carefully cut through and reflected. (I was struck by how many layers you have to cut through and carefully reflect before you finally get to the brain.) At last the brain was exposed, at which point I had a weird conversation where I asked in Swahili, “what’s that thing called?”, they replied, “ubongo”. I had spent the day before at the market doing the same thing with fruit to learn their names, I never thought I would learn the Swahili word for brain by being able to point at it directly and asked for the translation. Nonetheless it was there in all its glory, and it allowed for that truly weird experience of being able to look directly at the organ that animates another being.

This is where I had assumed the neurosurgery would begin. I hadn’t realised it was such a painstaking task to get through to the brain. But Dr Kong was here now and he began slowly layering it gause so that he would be able to leaver up the temporal lobe so that he could see deep into where the pituitary was. He allowed me to help him in this part a little by helping hold the temporal lobe back as he worked deeper and deeper into the brain. He had also to stop to remove some more of the sphenoid bone so that he could get better access to the pituitary cancer.

However, again another important tool was not available. This time it was something called the “nibbler”, that is used for slowly removing chunks of bone. This meant that he couldn’t remove more of the frontal bone and so the tumour couldn’t be accessed from in front, but instead had to be worked at down a narrow space about the size of a ten cent piece. Through this small chasm you could see the right optic nerve, and then sitting between that and the left optic nerve was the tumour. Dr Kong said a few times that he might have to give up, because the space was too narrow. He clearly was frustrated by the lack of adequate equipment. However finally he went ahead with the surgery, slowly burning away the cancerous tissue and removing with something akin to a small ice cream scoop.

After much tissue was burnt  away (you could smell the burning flesh), and many ice-cream scoops of cancer were removed, the task was at last complete. Dr Kong then deftly sowed up the meninges, sealing it almost completely with a number of stitches. He stopped one short of the last stitch and filled the cavity many times with saline so that there wouldn’t be any gas left in the CNS fluid. And then the slow task of sowing back each of the layers where they had been was started. The fragment of bone was also replaced (although it now had a few sizable chunks cut out of it thanks to the drill and the saw). And that was pretty much the operation.

Overall I was very impressed by the tenaciousness of Dr. Kong. It seemed to be pretty frustrating for him when tools weren’t working, especially after he had just spent the last hour or so carefully retracting the layers of the scalp. Numerous times the equipment had failed (other things that went wrong included the bed adjuster not working, and many of the tools being the wrong size) or just not been available. However he persisted, and without too much fuss, and I generally thought that was reasonably admirable of him. His skill was also pretty evident throughout the operation, especially when he sowed the dura mater back together like an expert tailor.

Overall the day was interesting, and full of surprises. The level of skill in the doctors I saw today was very high. Instead of training or procedures being the issue, it seems that the biggest problems lie with the quality of the equipment available. However, it was mentioned to me a few times today that this hospital is where there is the highest level of skill in Tanzania, and that most other hospitals don’t offer the level of expertise seen at MOI. I will be interested to see how this suggestions will fit with the experiences I have of other hospitals.

Language:

Swahili is the language of Tanzania. It is spoken universally, and in Dar es Salaam it is heard nearly continuously no matter where you are, as the cries of hawkers, shop-owners and city drivers navigating the pedestrians echo up from the bustling streets.

Many people say it is an easy language. Walking around and seeing the wide variety of people that have arrived here and quickly learnt it, you would be inclined to agree. These visitors have also dragged a world of ideas with them. And as a result, Swahili is replete with a rich mixture of the words from Arabic, Urdu, and local languages. These words are not recent additions. They instead reflect the centuries of trade in culture, ideas, and goods that has occurred along the East African coast. As such they have been fitted carefully into the structure of the language and tend to smoothly slide into existing noun classes and such.

English is only spoken by a minority of people in Tanzania, and in most situations you will be hard pressed to get more than a few words of English out of locals. This is quite different from my experiences of Kenya. In Kenya it is considered a nicety for you to be able to say a few words in Swahili but you can always resort to doing your business in the Colonial tongue. Here, in Tanzania, it is a near necessity to know Swahili, and especially so if you wish to venture anywhere outside the tourist locales. This is something I can anticipate may cause issues for any research opportunities I try to pursue here as although I am pleased with how much Swahili I’ve learnt I am by no means proficient enough to reliable do even the most basic of communication in Swahili.

Tanzanians pride themselves on their Swahili. I’ve had a few conversations where I’ve been asked where I learnt (the little) Swahili I know. I tell them Kenya. There is an awkward moment where the questioner has a half-grin, and shyly looks left and then looks right. Then I diffuse the situation by explaining that I understand that Kenyan Swahili is of poor quality, and is completely unlike the mastery Tanzanians show of the language. This sets them at ease, and allows there half-grin to grow into a chuckle. Even the Kenyans I’ve met here will recognise that Kenyan Swahili of a lesser standard. However they are quick to point out that this is somewhat due to a trade-off for English.

I can think of two reasons for this difference between the two countries. First, that Tanzanians spend the first nine years of their schooling being taught only in Swahili. In Kenya, schools teach in English and Swahili from the beginning, and so more time is spent teaching English to the detriment of Swahili. Second, Swahili is the language that Julius Nyerere used after Tanzania’s independence to unite the country. It featured as an integral part of a indigenous socialism. In Kenya, Kenyatta’s rule was marked by tribalism. He largely favoured only his people group, and therefore had less interest in endeavours such as the development of a national language. He was also relatively more disinclined to break from the British past and perhaps this is another reason why English has also retained a greater presence in Kenya.

Culture:

Dar Es Salaam is an old metropolis, much older than its European counterparts. Well before European cities saw neighbourhoods of Turks, Africans, and Asians, Dar es Salaam was already a city of many colours. The Arabs were the first to arrive on the grey sandy beaches of Dar es Salaam, followed by the Portuguese, then the Germans, and finally the British, and with the British came the Indians. Interestingly the city is largely unaffected by its Europeans visitors. Perhaps they came less in a spirit of exchange and more in one of capitalisation.

However even the exchange of cultures with the non-Europeans has not always been peaceful. Centuries of slave trade happened along the East African coast before the British ban led to its dismantlement. Much of this trade was based in Zanzibar and therefore reliant on Dar es Salaam and other ports to ship the indentured to the island. Hundreds of thousands of Africans saw the cells of the slave market of Zanzibar before it was finally shut and concealed by the building of an Anglican Cathedral.

The word for race in Swahili still reflects this history of inequality between peoples. It literally means “type” and according to my Swahili teacher in the US it indicates that there are three “types” of people: the enslaved (Africans), the enslavers (Arabs) and the free (Europeans). Still, the little experience I’ve had of the city so far is that these old wounds have healed somewhat, and that black-Africans live alongside arab-Africans and indian-Africans in harmony, without making the distinction that I just have.

I spoke with a local about the more recent history of the city. He pointed out to me the four storey housing estates that line the inner city. A relic of Nyerere’s socialism they look dilapidated but still stand as monuments to an egalitarianism I didn’t find evident in Nairobi. Nairobi’s city has many large offices, and is full of skyscrapers that tower with glitz and spectacle. Here, in Dar es Salaam, the urban poor used to inhabit the housing throughout the CBD, and now even after having been displaced by shop owners, are still present as the traders of small things like fruit, pens, mobile phone credit, and repair services. In Nairobi, the inner city is constantly being emptied of these people, displaced by the city council which evicts these workers from its hub (I remember being present as this happened, the city council workers showed up and started upsetting the mounds of fruit set up by the ladies who sell them, this caused a backlash as the younger men responded to the brutality of the city workers by rioting. I saw a few shop fronts get broken and some of the council vehicles get overturned).

Medical Care:

This is really the thing I should be most interested in. But I don’t have much to say about the level of medical care in Tanzania basically because I haven’t seen any (I’ve only been here two days though). That will soon change. Tomorrow morning I will go to Moi Orthopaedic and something Centre which is part of the Mohimbili Hospital, I think it is the largest public hospital here in Dar es Salaam. I will be meeting a Chinese Neurosurgeon there called Dr Kong, and he is part of a surgical team that is funded by the Chinese government. I’m intrigued to see how the hospital compares with what I’ve seen in Australia. I am curious what things will be available. I hope to be pleasantly surprised. And to be honest I’m already a little surprised that there is a Neurosurgery unit at the public hospital here.

Other than that there’s a reasonable looking free medical clinic nearby that is funded by one of the local Islamic communities. It has an ambulance and the waiting room looked pretty swish. I may check the place out next time I am in Dar es Salaam. I also quickly spoke to a woman who is the PA to the head of the Clinton Foundation (Bill Clinton? I don’t think so). She was saying that they are involved in setting up affordable clinics in the area too. So I figure there are at least a few around.

Nonetheless, I think that these sorts of programs that provide free medical care are probably only a very small part of the picture. The buzzword in health is very much “multifactorial”, and rightly so. Most people in Dar es Salaam live a pretty hard existence, with work that exhausts the body, unsanitary living environments that potentially exposes them to infections, food and water that is also another source of infection (and as its availability and fat content increases also raises the issues of obesity-related diseases), and reasonably high, and increasing, levels of pollution. A brief conversation I had the other night with a local upper-middle-class woman added another edge to this point. She was commenting that people here only tend to go to the doctor after they have become very sick. Although anecdotal it also suggests that more doctors and health services, especially in inner city areas, might not actually lead to increased levels of accessibility of health services – due to certain expectation of when health services should, or even, can, be accessed.