Beautiful Africa

Ever since my last trip to Africa eight years ago I had wanted to one day visiting Ngorongoro Crater, which I had not been able to visit on the previous trip. Throughout this stay in Tanzania I had been looking forward to spending several days on safari to cap off the adventure before heading home. Truly the landscape and wildlife in East Africa are awesome, and Serengeti National Park and Ngorongoro Crater did not disappoint. It is quite spectacular to see the sleek form of a cheetah blended into the surrounding grassland as it rests in the cool of the morning.


There is something soothing and yet terrifying about watching a group of hippos lazily floating in a mirky pond and being reminded that this creature is responsible for more human deaths each year than any other African mammal (except perhaps the Cape Buffalo).



But as incredible as the wildlife is and as beautiful as the a sunset over a grove of acacia trees can be, when my hard drive crashed just before heading back home I found myself worrying more than anything that I may have lost some or all of the most beautiful aspects of Tanzania that I had been able to get on film: its people. We in the West hear only of the conflicts and turmoil in Africa through the media. We read about the civil wars and the corruption and international power struggles and because those are the only things we hear and read about Africa remains in our minds "the heart of darkness" populated by savages and run by power-hungry despots. What we don't read about are the millions of powerless and voiceless people who live a daily struggle to survive and do it with dignity and grace. We don't see the women who juggle several small kids and the responsibility of preparing meals and the crops that need to be tended to and still are able to somehow enjoy the simple moments in life that people with more material distractions would fail to notice altogether.




It is true, however, that a life of constant struggle takes its toll on many. Many faces become wrinkled and weathered far before their time in Africa. There is a fatalistic attitude that affects many in the older generation because they have come to realize that no one seems to be for them in their struggles- often times not even their own leaders. The fact that in only several weeks in the Bugando ICU I saw several people admitted in critical condition from suicide attempts is testimony of the fact that the struggles in life for the average person seem at times insurmountable.



Some adults have been beaten down so much that they seem to have lost the zeal for life. But one need not search far to find where that zeal found a place to dwell: Africa's children. To hear the high-pitched laugh and see the beautiful smiling face of a child playing tag in front of the simple mud hut in which he lives is to learn an invaluable lesson: if you can learn to be content with nothing but the most basic necessities in life there is nothing that can defeat you. There is in the eyes of these children a simple joy... and if one looks deep enough he can catch a glimpse of hope that a generation will rise that will not fall into the fatalistic mindset that seems to come with continual trials, that will break the cycle of corruption in leadership, that will have access to education and resources that will help them figure out their own answers (with the global community's help) as to how to overcome the obstacles that keep their people entrenched in poverty and hostage to disease and famine. These are the beautiful eyes of Africa.

A Woman's Life

Several weeks ago I was standing beside a patient bed in the pediatric ward at Biharamulo Hospital and I happened to glance down at the floor. I had become used to the malodorous fragrances ever present in the hospital by this time. It no longer surprised me to see a patient squat on the floor to defecate during patient rounds. The sight of cockroaches scurrying to find cover under a patient's bag of clothes now seemed commonplace. What caught my attention this day were the bare feet of the mother who was silently sitting on the side of her child's bed as the group of white coats discussed the intricacies of the case in a tongue completely unintelligible to her. I did not know anything about this woman and still I don't claim to understand the complexities of her life, but even without her saying a word her feet revealed much about her and her and her way of life.


She lacked shoes...even the $3 red or blue plastic sandals that are ubiquitous here... most likely because with 4 or 8 or even 10 children to provide for, shoes were a luxury that she could not afford. Without protection from earth and elements her soles had become calloused from long treks over gravel roads and uneven footpaths, often baring the load of not only her own body weight but also the weight of the baby strapped to her back and the bundle of firewood or bag of cassava or bucket of water that she balanced gracefully atop her head. Alternate exposure to dry, dusty paths baked by the intense morning sun and then to a myriad of tiny rivers or pools of muddy water that arise within minutes of the first drops of rain from an afternoon downpour in the rainy season had left her toes and heels dry and cracked. Bruises and scrapes in various stages of healing gave witness to the difficulty of traversing even the most well-known paths in the deep black of shadows of a night with no moon and no street lights...indeed no true street...for hundreds of kilometers. The thick musculature of feet and toes were evidence of the long hours she spent trudging barefoot through muddy fields of rice or maize or potatoes in order to provide food for her family... and hopefully enough extra to make a small profit selling the surplus in the market. She probably was ignorant of the fact that the incessant, though not severe, itching of her feet was due to the tiny hookworms in the soil or the schistosomes in the pool of water where she baths and washes her clothes that penetrated her skin en route to their new living quarters in her gastrointestinal or urinary tracts. Hers were the feet of one who has worked tirelessly, and with little fruit to show for it besides her remaining living children, ever since she completed her government-sponsored primary schooling and realized that she would not be able to attend secondary school (high school) because her family only earned the equivalent of twenty dollars a month and could not afford to pay for further schooling (if in fact she even completed primary school). Her feet had carried the weight of a new infant every year since she had been given in marriage because as a woman in her culture she had no liberty to refuse her husband's advances, and because birth control methods were too expensive or not available and even if she had access to them her husband would likely frown upon them because for him more children meant more respect and higher status.


Her feet were the feet of a woman who understood more fully with each new Land Cruiser that sped by her as she traversed the main road leaving her enveloped in a cloud of red dust, and with each copy of Glamour magazine that somehow made it to her village, that her degree of poverty was unimaginable to many people in more developed countries. And yet they were the feet of a woman who was proud...she walked with head held high... and so refined that in addition to all of her other work she somehow found the time and energy to make sure that her dress and sarong were so meticulously cleaned that when she brought her child to the hospital one would think she had just purchased a fine new wardrobe and would never guess that her day had started in an overcrowded, single roomed, mud-brick house in which she slept on a mat on a dirt floor.




These were the feet of a survivor, of one who has had no choice but to be a survivor because she happened to be born in a poor corner of a poor country on a poor continent where climate and microbiology and economics and a long history of international power struggles have left her and millions like her to bare the brunt of the world's burden of poverty and disease and suffering. I have struggled to try to figure out what is my role...if any...in her story and in the story of a hundred men and women like her that I have passed every day while I have been here in Tanzania. My time here has been rewarding and I feel that it has been valuable if for no other reason than to be reminded that there are a multitude of people who are innately just like me whose entire lives are characterized by struggle and suffering. By no means has everything about my experience here been depressing though. I have had the pleasure of seeing people who are suffering smile and laugh and somehow enjoy simple pleasures that I would have overlooked completely. If I close my eyes the sweet laughter emanating from a group of children in tattered clothes playing with a ball made of wrapped twine in a filthy slum is indistinguishable from the sounds of a similar group in the latest fashions playing in a posh playground in Manhattan. In fact when I open my eyes the sound rings even sweeter. In spite of the pain and the tears that abound there is vibrant life here. Even the clothes people where seem to celebrate life and color. When there is occasion to smile people do so unabashedly and with no self-conscious thought of their crooked tooth or their sun-leathered face...and their smiles are the most beautiful you will ever see!




I feel uncomfortable in this place not only because I don't know the language or the cultural nuances but because it makes me confront difficult questions like is it wrong to take this woman's photograph- even with her permission- with a camera that cost more money than her family will make in three years? I make myself feel better by giving her a copy of the picture. She flashes a radiant smile in response to the gift and I am struck by the fact that her beauty would rival that of most models in Europe or America. What does it say about me that I somehow feel proud of myself for having done my part in making her life a bit better by going out of my way to give her this generous gift? The copy cost me twenty cents.

The Front Lines

Biharamulo district is located in the fertile corridor of Tanzania that lies to the west of Lake Victoria and is home to roughly 400,000 people. It is one of the least developed regions in Tanzania. Agriculture (mostly bananas, coffee, cattle, and goats), fishing, and mining are the main industries in the district but a large portion of the population survives by subsistence farming- though some may be able to make a small profit in a local market if the rains make for a good harvest. For many years Biharamulo district hospital was the only hospital for the entire population. There is one medical doctor employed by the hospital, who also serves as the medical director. Due to the overwhelming patient burden, several years ago the responsibility for health care delivery in the district was split between Biharamulo District Hospital and a hospital in a neighboring district so that now the hospital...and the one medical doctor in the district...is responsible for the health of only approximately 200,000 persons. This ratio is, of course, much higher than the average doctor:patient ratio in Tanzania, which is 1 to 25,000. In the United States there is one doctor for every 400 people.

Five assistant medical officers (AMOs) and a handful of medical clerks are responsible for most of the medical diagnoses and treatment plans in the hospital, which has 130 beds though many times more than one patient may be admitted to the same bed. AMOs receive three years of training after secondary school (high school) to become medical clerks. After working for several years in health dispensaries around the country (treating basic medical illnesses like malaria and pneumonia and referring more difficult patients) they can choose to return for two more years of training at one of the teaching hospitals to become an AMO. At Biharamulo and elsewhere they are responsible for just about everything that has to do with patient care. They make diagnoses, decide on treatment plans, perform procedures such as lumbar punctures or pleurocenteses. They run the HIV specialty clinics and do most of the operations in the hospital including cesarean sections, hysterectomies, appendectomies, and even bowel resections. Although he is often pulled in three directions at once due to his administrative duties, the medical doctor makes "major ward rounds" in each of the wards one day a week, during which he sees each of the patients on a given ward, and will help with difficult patients or some major operations whenever the need arises. Medical officers are in short supply, but the nursing shortage is so severe that a ward of almost 70 patients may be staffed for much of the day by only one "assistant nurse" who has had only one or two years of training after secondary school.

Malaria is by far the leading diagnosis in the hospital, followed by severe anemia which is often secondary to malaria. Malaria is so common and complications so severe that it is a national guideline that any child younger than five years old with a fever should be empirically started on antimalarial medication. Because falciparum malaria is the most prevalent species of the parasite in the region "cerebral malaria" is a common complication of malaria in children here and manifests as neurological complications including strokes and swelling of the brain as a result of red blood cells becoming lodged in the small cerebral vessels. Most children who develop this complication do not survive. Pneumonia is another common diagnosis in patients of all age ranges. Diarrhea is a very common complaint and may be simply viral and self-limiting, bacterial and requiring antibiotics, the result of intestinal worms of various sorts that are ubiquitous here, or all-to-commonly the presenting symptom of HIV infection which has a prevalence of about 10% in the region. There are a significant number of patients with TB in the hospital, but surprisingly there were only 98 documented cases of TB in the entire district last year. Meningitis is very common and usually presents very late. In a matter of two weeks I saw three cases of meningococcal meningitis (a very contagious form of the disease) in children, one case of meningitis that presented in such a severe stage that when I did the lumbar puncture to look at the spinal fluid I had to use a syringe to draw the fluid out (usually it flows like water) because it was frank pus, and another child who had presented with such severe meningitis that I had to tell the AMO who was about to do a lumbar puncture that if he did the procedure the child would die right on the table- the child was unconscious and had one blown pupil and one pinpoint pupil which is a sign of severe brain swelling and doing an LP would cause the brain to herniate into the spinal canal due to the pressure gradient. Traffic accidents are extremely common presenting with all types of injuries including complete quadriplegia. Post-partum hemorrhage, hypertensive emergencies, strokes, diabetes were also seen. All too often we had to just give our best guess at a diagnosis because we did not have the lab capabilities to do the tests that would be needed to confirm or deny our hunches.



I was impressed by the scope of the responsibilities held by the medical staff, and I learned much from not only the medical director but many of the AMOs as well, especially about diseases such as malaria and TB and HIV that I have limited exposure to. However it was apparent that the work load was simply overwhelming. In each of the wards (pediatrics, female, male, and surgical) all of the patients are only seen once a week. On other days only the sickest patients are seen. Unfortunately if a nurse is not trained enough to pick out worrying signs or symptoms, or if a parent is unable to differentiate a soundly sleeping child from a child with a decreased level of consciousness, a very ill person may be missed. A number of times when I walked through the wards just to see if there were any sick patients that had been missed I came across florid meningitis or severe malaria that had been missed. At first my frustration was toward the nurses, or the AMOs, or the parents for waiting so long to bring their children to the hospital...but slowly I began to realize that my frustration ought to be directed towards a system as a whole (not just the Tanzanian health system...a system which we are all a part of in some way) that leaves families so poor that even the money it would take to travel to the hospital would mean that they would go without food for a time, a system that only provides one partially trained nurse to care for 70 people, a system that can pay its overworked doctors only $10 dollars a day, a system that provides only one fully trained medical doctor for 200,000 people.

But somehow in all of the overwhelming workload and disease and mournful cries of mothers who just lost yet another child...there were smiles like this one that greeted me every morning when I entered the pediatric ward...and those smiles gave me hope that maybe things will improve for these people who have waited long enough...

Biharamulo

It is only about 150Km as the crow flies from Mwanza to Biharamulo but the exhausting trip takes about 7 hours if everything goes smoothly, which is never something to be counted on. The trip begins just after sunrise at the shore of Lake Victoria, for the first leg of the journey is a 30 minute ferry ride that saves a 3 hour jaunt around a narrow inlet of the lake that extends south for a significant distance. On a clear, calm morning the ride across the lake is absolutely serene...but the serenity is short lived because if you fail to find your seat in one of the buses packed onto the ferry before the vessel reaches its destination on the eastern shore you are sure to have no option but to take the return trip on the ferry. As the boat approaches the bus engines are already running and almost before the ferry even stops each bus driver has his foot heavy on the accelerator and the steel monsters speed off down the uneven, unpaved, pedestrian-filled road eventually splitting to head off towards their individual destinations. The bus is already full, but the two conductors hang half-way out the open door looking for passengers that may be waiting alongside the road for the Zuberi bus, hoping that it did not break down or miss the ferry because if it did their plans to reach their destination will be canceled and they will have to try again tomorrow. As more passengers are picked up the remaining seats are filled and then the open space in the isle is utilized. Some passengers are in for the long haul all the way to Biharamulo. Some just catch the bus for several kilometers. Most have a small suitcase or duffel in their possession. Some have sacks of cassava they are taking to some town's market. One may have some chickens or a mirror or wheel of a bicycle.

At times the ride is relatively smooth. In fact there is even a several kilometer stretch of paved road at one point. I don't know why that particular stretch is paved, but it is very welcome. Most of the ride is over a washboard road and you will think your retinas may detach if there is no relief soon. The driver does his best to pick out the least traumatic line on the road, and since his vehicle is the largest on the road it does not matter if that line is on the right or the left or in the middle of the highway, everything and everyone else must make way for the king of the road. If you are not used to travel in East Africa you had better receive cardiac clearance from your doctor before taking the trip because even a healthy heart will threaten to stop beating a handful of times as the bus comes frighteningly close to colliding with oncoming vehicles or bicyclists that fail to yield right-of-way (which usually means careening headlong into the tall reeds at the edge of the road because the bus driver usually wants to drive with one set of wheels actually on the smooth "shoulder" which is usually on the "wrong" side of the road). At least a time or two along the way you will pass a broken-down vehicle with three sets of legs protruding from under the engine block and at least five people looking on. Occasionally the most talented drivers may display their superior skills of trail blazing and then take a lunch break while many gather to admire his handiwork.


But for the most part the road is remarkably devoid of other vehicles. There is no in-flight movie but neither the talents of Brad Pitt nor Angelina Jolie have the captivating power of the scenes playing across the dusty windows on either side of the vehicle. The rainy season has turned the countryside into fifty shades of green. Birds ornamented with long flowing tail feathers or bright red breasts bounce between the acacia trees. Further down the road groves of banana trees provide shade for small circles of mud huts with a few children playing on an old termite mound in back. All along the way men pushing large banana stalks on bicycles or women carrying buckets of water on their heads or young men herding their cattle with a bamboo rod fill the road and part like the Red Sea at the sound of the oncoming behemoth.



Twice during the trip the bus stops in fairly large towns. Immediately people selling bananas and sodas and roasted goat strips and pineapples encircle the bus and lift their goods up the the windows to advertise for the passengers. There is just enough time to run out and use the toilet...unless you are a Muzungu and you neither know where the toilet is nor how to understand their directions when you ask, "Where is the toilet?" in Swahili. So you hold it or you somehow find the toilet and return to find the conductor, who fortunately noticed that the only white person on the bus was missing, yelling out to you, "This...express bus!"

By mid-afternoon the bus finally pulls into the town of Biharamulo. You step out and stretch your legs and push past all of the people trying to carry your bags for you as you tell them, "No thank you, I can walk..." and make your way to the hospital where you will spend the next few weeks.

Being confronted with human suffering is not new to me. I still remember vividly the desperate wails of a mother in Yemen after we had transported her daughter's lifeless body back to her village. I can still see the woman dying of AIDS in Uganda lying on only a matt on the dirt floor of her hut with a sheet covering her wasted body that revealed the bony outline of each of her ribs. I will still wonder why the young couple in Papua New Guinea who lived their entire lives in poverty had to lose their only son to what started as a simple pneumonia that probably would have been easily treated in the U.S. I have shed tears and wrestled over questions of why... and at times I have seriously questioned whether I can reconcile my faith in the existence of a loving God in light of the seemingly indiscriminate suffering I have seen. I had thought that I had the question of suffering worked out in my mind and that nothing I would see on this sort stint in Mwanza would shake me. I was wrong.

Sayi, a 20 year old girl who came to Bugando the first week I was here, was severely wasted when she came in- I could easily wrap my thumb and index finger around her thighs and upper arms. Her eyes were sunken and bright yellow. Her abdomen was filled with so much fluid that it looked as though she were pregnant. Her liver was 2-3 times the normal size on exam and packed with hard nodules. She came with no records at first and she would not speak, but after some searching we found an old report of an ovarian cancer that had been removed about a year ago. It was obvious now that her cancer had spread to her liver and likely other organs of her body. Ultrasound confirmed diffuse lesions consistent with metastatic cancer. There was nothing we could do for her to treat her condition or even alleviate her discomfort except for drain the fluid from her belly now and then for her to breath more easily.

I had thought Sayi only spoke Swahili or her tribal language, but several days after she arrived she asked me, "What is your name?" It turns out she had been in school when she became sick and hoped to become a doctor. Her English was broken but she was remarkably proficient with a fairly broad vocabulary. She asked me several times if I could help her and I told her that we would try to keep her comfortable but that there was nothing that medicine could do to cure her. At this she turned her head away from me and said softly, "I am suffering."

About a week and a half after Sayi presented, an 11 year old boy named Matiku came in with a long history of shortness of breath and fatigue. He had signs of right heart failure with distended neck veins and a large liver. He was not making much urine. He had an extra heart sound on physical exam and so an ECHO was obtained (I was surprised to see that we had an ECHO machine and a talented echocardiographer to run it) which revealed a large tumor that was almost completely occluding his right atrium. I don't even know how he was still alive because only a trickle of blood was flowing around the mass and allowing his body to get blood and thus oxygen. There was talk of trying to take him to the OR. No heart bypass has ever been done here, though, and so his chances of dying in the OR were about 95%. There was a 100% chance he would die without the operation, however. In the end the surgeon did not want to try the procedure.

Just before I left for my journey someone gave me a book by Francis Macnutt entitled "Healing" that argues that God still can and does heal people through prayer. The author argues that somehow the Christian church has largely adopted a theology that God does not heal because there is somehow more redeeming value, spiritually, in suffering than in health. The result of this shift in theology from the early church's conviction that God regularly healed people through the prayers of the saints has resulted in Christians today no longer even asking for healing. Macnutt's arguments are convincing. Jesus himself pointed out in Matthew 7 that even more than a parent would for his or her child, God the Father desires to give good gifts to his beloved. In John 14 Jesus told the disciples that the miracles they saw Christ perform would not cease with his passing, but rather that "whoever believes in me will also do the works that I do, and greater works than these will he do..." In James 4 we are told that "we do not have because we do not ask".

I am confident that God CAN heal miraculously. I just don't know if He DOES any longer...at least commonly. But I must say that I WANT to believe that He does. Several days after Sayi came in I asked her if I could pray for her, and she said yes. I prayed that God would comfort her and put His hand upon her...but I did not ask that He would heal her. I think I was afraid of the implications on her faith...and on my faith...and on the faith of all of the people in the room looking on...if I asked for God to heal her and healing did not come. Several days later, however, I was completely overwhelmed on rounds by the fact that Sayi had no hope for any relief of her suffering...on this earth at least... apart from divine healing. After rounds I asked her if she would like me to pray for her again, to which she agreed, and this time I specifically asked for God to heal her.

Similarly, when I realized the bleakness of Matiku's future I felt compelled to ask his mother, this time through a translator, if she would like me to pray for him. She said yes. Through the nurse I told her that medicine and doctors were powerless to help her son, but that I believe God is always powerful. I told her that I would ask God to heal Matiku...but that God can choose how He will act. I said that all I know is that God loves Matiku even more than we do...and that Jesus said that those who trust in Him would live...even though they die.

For the few days following my prayers for each patient I went into the hospital hopeful...in fact even expectant...that I would see Matiku and Sayi up and energetic and breathing easily. The more days that passed with their condition unchanged the more I began to doubt. Today I went in to check in on both of them. Both of them died yesterday.

Some would argue that questioning one's faith is a sign of weak faith. Perhaps... but I think that questioning is vital to a healthy faith. I have had two major "crises of faith" in my life as a believer in Christ. The first came in college and the second in medical school and during those two several-month long stretches I questioned everything about what I believe and why. It was incredibly difficult at the time, each time, but I am grateful for having experienced those empty times. And now I have come to believe that it is good for me to occasionally go back and question and re-think what and why I believe.

I will admit that in the past few weeks I have had fleeting thoughts that perhaps everything I have based my faith upon is contrived. When I see indiscriminate suffering it is logical to entertain the possibilities that 1) there is no God, or 2) God exists but either does not care or does not have his hand actively involved in humanity. But I look around me and see His hand in creation itself. I can remember back to my time in anatomy lab and be reminded of how convicted I was that only a powerful and creative force bigger than life itself could have been responsible for what I was seeing. I have decided that I believe the scriptures are in fact God's word made known to man- and if that is the case I can be assured that there is no questioning God's love for humanity, as He spared nothing to redeem His people.

I do not know what I think about whether God still desires to...and in fact does... heal the way he did 2000 years ago. I know that he has our best interests at heart. I am certain that the tears those who suffer cry are seen and probably felt by their creator. I believe also that just as Jesus pleaded in the Garden that "this cup would pass," he cries to the Father at the side of those who suffer on earth now and asks for the same mercy. But I believe that the prayer is concluded the in the same manner that it was 2000 years ago- "but not my will be done, but your will be done." Certainly there is good in relief of suffering. But I have also seen that suffering can enable those once blinded to see that this world is hopelessly in need of a savior.

I have not seen God heal miraculously, but I know that He is alive and actively involved in my life and I am certain that he desires to have an active part in the lives of all who suffer (and all who don't suffer for that matter). I just don't know how that will play out, and of course I could not expect to know the intricacies of how God may choose to act. But I know that He has called me to serve and to love and in so doing be an extension of His hands. I know that He has charged me to ask for good gifts. I know that He has promised hope to those who have no hope and all I can do is trust that as a loving Father He has his children's best interests at heart... much more so than I do.

Worth 1,000 Words...or More

Inside Bugando

A typical day on the internal medicine service at Bugando begins at 8:00 a.m. at morning report. Sitting in the front of a 10x20 ft room filled to capacity with residents, interns, AMOs, medical students, and one or more attendings ("specialists" as they are called here), the intern who was on call the previous night briefly outlines the presenting complaints, physical findings, laboratory results, working diagnoses and treatment plans for the patients he or she admitted during the night. Questions may be asked of the intern regarding thought processes or treatment options and interesting teaching points may be highlighted during this time for the benefit of students and young physicians. After morning report rounds are made in the ICU with Dr. Peck, the resident covering the ICU that day, and any residents and students who are interested in joining rounds. At about 9:45 rounds in the separate medical wards begin. On Mondays and Thursdays all of the patients are seen. On other days only the sickest patients are seen. After rounds the treatment plans agreed upon on rounds are carried out (medications administered, procedures done, tests ordered) and some residents and interns who have to be in clinic leave for those duties. Residents, interns, and AMOs trickle out of the hospital as they finish their duties and the intern and resident on call for the night settle in for the long haul. A typical night is quite busy on the medicine service- often an intern admits twelve or more patients in addition to taking care of issues that may arise with patients already admitted. But if the internal medicine department is busy, the pediatric side is crazy. The average number of admissions is about 15. Several days ago the intern on call admitted 22. I have heard of as many as 27 kids being admitted in one night.

I expected to encounter significant pathology here, and it did not take long for my expectations to be confirmed. On my first day rounding with the ICU team three of the five patients had presented almost identically: 25-35 year-old male with altered mental status. One was a known HIV patient and an x-ray revealed a classic pattern of "miliary tuberculosis" with small nodules scattered throughout the lung fields. Suspicion was that he had developed cryptococcal meningitis, a fungal infection of the fluid around the brain that is common in HIV patients. He was started on an antifungal drug, but as we are seeing with many cases of cryptococcal meningitis he passed away about a week later. The second patient had had a seizure associated with his decreased level of consciousness. I was surprised to find that the hospital has its own CT scanner (though the patients' families have to pay for its use which often precludes us from obtaining CT images) and imaging of this patient's brain showed "ring enhancing lesions" classically associated with toxoplasmosis, another infection of the brain that I had not yet seen but that is fairly commonly seen in HIV infection. We subsequently tested the patient for HIV and his test was positive. He was recently sent home on treatment for his toxoplasmosis and will come back to be started on treatment for his HIV. The final patient with altered mental status had had multiple attempts to obtain spinal fluid to determine whether he had an infection around his brain as well but all attempts to get fluid were unsuccessful. A day later he developed multiple vesicles in his mouth consistent with infection with herpes virus, which gave an indication that he could be suffering from meningitis caused by the same virus. He was started on an antiviral medication and within several days was much better and has since been transferred out of the ICU.

Patients on the general medical wards are not as critically ill, of course, but quite sick just the same. I was shocked at how many of the patients we rounded on the first day had tuberculosis, HIV, or both. My guess would be that approximately 60% of the patients in one ward were HIV positive. Probably half as many had confirmed or suspected tuberculosis. Isolation rooms would be prohibitive in cost and insufficient in number and therefore do not exist here (each ward consists of 4-5 large rooms that hold 10-12 beds each) and so there is no recourse but to have patients with active TB share a room with patients who have HIV with dangerously low CD4+ counts (leaving them particularly susceptible to infections such as TB, certain pneumonias, fungal infections, etc). I have yet to see anyone, patients or health workers, wearing TB masks. Malaria is one of the most common diagnoses made both on the internal medicine and pediatric services. Whether or not the blood slide indicates malarial parasites most people who come in with a fever are treated with quinine or artemether emperically. Indeed, I have never felt so many large spleens before (a common result of chronic malaria). Schistosomiasis is endemic to this area and is an infection of the gastrointestinal or urinary tracts caused by a worm that lives in fresh-water snails (quite common in Lake Victoria) that invades the skin of people who may wade or swim in infested waters before making their way to their body system of choice. The infection often goes unnoticed for years (aside from some itchy skin) before causing liver and spleen congestion, kidney failure, or bladder cancer. In pediatric patients Burkitt's lymphoma (a disease I have never seen in the U.S.) is exceedingly common and, fortunately, quite sensitive to common chemotherapeutic agents.


But not all of the medical problems we encounter are tropical infections that I have no experience dealing with. I have been surprised at the commonality of hypertension, renal insufficiency, congestive heart failure, stroke, and arthritis. Although I spent much of the first several weeks uncertain of the role that I was meant to play at Bugando and feeling that my experience treating the types of diseases commonly seen here was grossly inadequate, I slowly settled in and realized that I was able to contribute to discussions regarding the plan of care for some of our patients who had disease processes that I was familiar with. I am grateful for Dr. David (ward clerk) and Dr. Onesmo (intern) (pictured below- Dr. David on the right) in particular for letting me join them in caring for their patients on ward J5 for the past few weeks and for teaching me about some of the diseases that I am encountering for the first time.

Settling In

Mwanza is a quaint city of 400,000 people (Tanzania's second largest) nestled among the rocky hillsides of Lake Victoria's southern shore. Although bantu tribes have inhabited the area for hundres of years, the settlement of Mwanza was not officially founded until the late 1800s by German cotton farmers. In the early 1900s the British gained control of the town. The discovery of gold and a new railroad made Mwanza an increasingly important center of trade between western Tanzania and the other nations in the lake region and Zanzibar in the East. Today Mwanza remains an important port city on Lake Victoria and there is still a significant amount of mining done in the surrounding region. The fishing industry, as expected, is an important contributor to the Mwanzan economy. Agriculture (bananas, rice, goats) is important in the region. Finally, tourism brings in a considerable amount of foreign currency as many of the game parks in the Serengeti are easily accessible from the city.
The Sukuma comprise the largest ethnic group in the lake region, but there are dozens of different tribes as well. Although most tribes have their own local dialect, Swahili is spoken nearly universally and serves as a unifying factor for most of the country. Christians and Muslims live side-by-side peacefully. It is just as common for a person to seek medical care from a medical doctor as from a traditional healer, and many patients in the hospital bear the signs of their attempts to seek alleviation of their ailments from these traditional healers before coming to the hospital.

Bugando hospital is the third largest referral hospital in Tanzania and is a referral center for all of western Tanzania (approximately 7-12 million people). It was built between 1968 and 1971 and is associated with the Catholic church. It has a capacity of 850 beds (not a good indicator of the number of patients in the hospital because two patients often share on bed) and offers services in internal medicine, pediatrics, surgery, gynecology, and opthalmology. It hosts the Bugando University College of Health Sciences and this year the first graduating class of medical students will matriculate. The hospital is also a training cite for interns, residents, nurses, and assistent medical officers (AMOs). Read more about the hospital at www.bugandomedicalcentre.go.tz .

For several years Bugando Medical Center, Weill Cornell Medical College and the Touch foundation, with the help of generous financial support from Joan and Sandy Weill, have collaborated to try to help Bugando Medical Center improve its capacity to both care for the large number of patients seen at BMC yearly and to train new health care workers to help meet the great need that exists in Tanzania, where there is only one doctor for every 25,000 people. As part of this collaboration two full-time Cornell faculty members, one trained in OB/GYN and one in Medicine/Pediatrics, are now on staff at BMC and each month cornell residents rotate through the internal medicine department to help teach medical students and AMOs and to participate in daily ward rounds in the hospital. A similar collaboration has been established with pediatric residents from Northwestern University and Anesthesia residents from several other institutions.

I did not know what, exactly, my role would be in coming to Bugando. I had med Rob Peck (the Med/Peds physician from Cornell now working at Bugando full-time) several years earlier in Boston and from the little that I had heard about his new position in Tanzania it seemed that joining him for a few months would be an ideal fit for me, as his job seemed to incorporate many of the components that I have developed a passion for over the years. I have long had a passion for traveling and diving into other cultures and since I can remember I have had a desire to practice medicine in resource-poor regions. In recent years I have discovered that I enjoy teaching very much (though I wish I were more gifted at it!). Mentoring relationships have been vitally important in my life and I am certain that I want to be for others what a handful of mentors have been for me. It seemed, at least from the little I had heard about it, that Dr. Peck's job involved all of these things, and I was excited to get a chance to see first-hand what it would be like to be involved in the medical education environment in a region of the world that has long been faced with health problems that far outweighed their health resources. That excitement, however, was tempered by uncertainty of what awaited me and fear that my medical knowledge would be so lacking that I would find myself learning from my Tanzanian colleagues but having nothing to offer in return.
I arrived at Bugando on a Saturday and had the weekend to get settled in before starting on the wards on Monday morning. I spent most of those two days walking around Bugando Hill, at the top of which sits the impressive structure of the hospital. Much about Mwanza seems familiar to me as a result of the time I have spent across the lake in Uganda. The climate is comfortable, as the tropical heat is moderated by the breeze that usually sweeps up the hill from the lake. As in other areas of Africa I have visited, wealth and poverty co-exist with extravagant mansions adorning the hilltops and expanses of impoverished neighborhoods clinging to steep slopes and resting in valleys where waste-water from more privileged people naturally flows. Children entertain themselves with rusted bicycle wheels steered by sticks held in hand and play soccer with anything that even partly resembles a sphere. Women carry everything from water to bananas to sacks of coal on their heads and their babies almost invariably silently enjoy a view of the world strapped tightly to mom's back. Men work as carpenters, fishermen, laborers transporting heavy sacks of grain or coal or cement. Throughout the city new buildings are being erected. Anywhere man has not left his mark, something green and full of life has made its stand and an array of birds has made it their playground. An army of hawks patrols the skies at all times and mavericks regularly spiral heavenward riding invisible currents of air sliding up the lakeside slopes. Songbirds invariably announce the coming of the morning light. Marabou storks populate the treetops- semblances of some prehistoric creature that somehow survived whatever force caused the extinction of the dinosaurs. And at the end of the day God seems to blaze his signature on the canvass that is his latest masterpiece in the form of a sunset that always seems to be more brilliant than the one yesterday.

Mwanza

It did not take me long to be reminded that one cannot put too much stock in making plans in Africa. This is one of the things that most frustrated me when I lived here but at the same time one of the things that made life here an adventure. On the Monday after I arrived in Uganda I went to Port Bell, only a few kilometers from the city on the shore of Lake Victoria, to inquire about taking the ferry to Mwanza, a town on the southern shore of the lake in Tanzania where I would be spending the next few months. Port Bell was once a thriving center of trade. Now it is a sleepy pier with a few old fishing boats with rusted hulls rocking rhythmically on the water and several weathered buildings with broken windows monitoring the goings-on at the port. I was told that there would be a cargo ferry leaving for Mwanza the next Wednesday and that I could catch a ride for about $15. So, on Wednesday I packed up my things and headed for the port...only to arrive and be told that, "The ferry it did not come...you come back tomorrow." And so I returned to Kampala with plans on catching the ferry the next evening. When I arrived the next afternoon I was pleased to see the ferry present and being loaded with coal and banana bunches. However my pleasure was quickly turned to frustration when a sour immigration officer bluntly told me, "The ferry is here but there will be no passengers." After talking to several officials at the dock and calling the ferry manager in Tanzania I was informed that the Tanzanian government had just that day ordered that no passengers could enter Tanzania via ferry from Kenya or Uganda, citing the ebola scare in Uganda and the violence in Kenya as reasons. I had to find another route to Tanzania.

Early the next morning I packed my things and headed downtown to the bus park. The bus park is something you have to experience and cannot accurately describe, but it is like a living organism. Hundreds of buses somehow squeeze into a dirt parking lot which on this rainy day was more like a swamp. Buses traveling to various parts of the country line up in designated areas of the park and coach-line employees call out advertisements of their destinations. The competition to have passengers fill their buses sparks aggressive solicitation. If you are not careful employees may grab your bags off your shoulders and carry them quickly toward their buses. There is no timeline. A bus will leave when it is full. During the wait vendors selling soft drinks, beer, matoke, and hot stew board the bus and squeeze their way up and down the isles seeking customers. You can also buy a nice pair of socks, a shirt, perhaps an iron or any other conceivable good that may very well find its way onto the bus. It is fascinating. It is also uncomfortable and hot and patience is requisite.

Two hours after boarding a bus heading for the Tanzanian border we were finally on the road. After leaving the city limits we made our way speedily over potholed roads through groves of banana trees, then some small areas of jungle growth that have survived being cleared to make farmland, then low-lying swampland and finally, after 7 hours on the bus, to the rolling, cattle covered hills at the Tanzanian border. Here everyone disembarked, grabbed their belongings, and walked across the no-man's land and into Tanzania. Here I caught a local taxi with room for 13 but filled with 20 and spent an extremely uncomfortable 20 minute ride to Bukoba, a town on the shore of Lake Victoria where, I was told, I really could catch a ferry the rest of the way to Mwanza.

The reports were correct. I got to the pier in time to purchase a third class ticket for the 13 hour ferry ride across the lake...and I was overjoyed! I met several very nice Tanzanians who not only gave me good company during the ride but who also gave me pointers about travel on the ferry. We all made our way into the lower hold where we found seats on the rows of old wooden benches with metal luggage racks overhead. The seats were tight, but I was on the ferry and I had no complaints. I knew I was in for a long night, though, seeing as we had 13 hours ahead of us and we were packed in so tightly that there was no way anyone would get any sleep...or so I thought...

Several hours after we left the pier there was some cue that set everyone into a flurry of activity. People began climbing up onto the luggage racks, under the benches, finding space on the floors and spreading out across the benches and settling in for the night's sleep. Before I knew it every inch of space from floor to benches to luggage racks was filled with bodies comfortably prepared for a good nights sleep. The only one, I think, who was not comfortable was me as my sense of personal space kept me sitting upright in my seat for the duration of the journey! Sometime during the night I had slouched in my seat and dozed, and when I awoke someone's head was occupying most of my seat and I was left precariously perched on the forward 5 inches of my seat. The only saving grace was that I was seated next to one of the windows and had a fresh breeze blowing in my face the whole night. As uncomfortable a night as it was...indeed I thought it would never end...I was glad that I had not arrived early enough to have been able to spend the 3 extra dollars to be in a sleeping room as the experience was memorable, and the people I met were a joy to talk to, even through the language barrier.

At about sunrise the next day Mwanza came into view. We slowly made our way past fishermen casting their nets from small canoes, past the unique rock formations that mark the southern shore of Lake Victoria, and finally to the port at Mwanza. Exhausted, I hailed a taxi and made the 5 minute drive up the hill to Bugando Hospital, where I would spend the next month and a half doing...I knew not yet what.

Long Awaited Return

I think I had forgotten how much my experience in Uganda had become a part of who I am until I found myself once again traveling along the road from Entebbe to Kampala. The familiar smell of the humid equatorial air mixed with odors of diesel fuel and dust and smoke from burning piles of trash unlocked a vault containing a flood of memories that had been sealed and pushed aside by four years of medical school, one year of graduate school, nearly three years of residency, and what seems like enough life-changing experiences to have filled up a whole lifetime. I had forgotten that a bicyclist carrying 2 passengers and a sack of flour would even consider cutting off a fully loaded lorrie on a crowded city street... let alone successfully accomplish the feat. I had forgotten my amazement at seeing women step out of dirty, one-roomed houses made of plywood in the middle of filthy slums with finely pressed and brightly colored clothes and immaculately done hair. I had forgotten that two lanes of pot-holed highway was somehow enough space to accommodate two directions of pedestrian traffic, a lane of bicyclists, the occasional wooden wheelbarrow, three or more vehicles of varying sizes squeezed side-by-side and separated by mere inches, and a constant weave of motorized scooters just to make things interesting. I had forgotten that people can seem like ants busily scurrying about their work, diving randomly into hidden road-side passages and appearing just as unexpectedly. I had forgotten that everyone has a cell phone. I had forgotten about the storks that lazily glide above the city and take turns standing watch over heaps of garbage. I had forgotten that 5 roadside shops would exist side-by-side and all sell the same refurbished weed-eaters in all the colors of the rainbow. I had forgotten how quickly one becomes drenched with sweat in the humid tropical air. I had forgotten how much I had missed Kenny and Monica, who had picked me up at the airport with their new son, Seth; and Doug and Destiny, who now have a three year old son and one on the way. I had forgotten that chaos can be beautiful and that "on time" can be relative. I had forgotten that uncertainty makes life exciting and I felt the anxiety that had resurged within me upon landing in Entebbe slowly fade away. I had forgotten how much I love Uganda and the way of life in East Africa- even though I was also remembering how very frustrating life in East Africa can be at the same time. I had forgotten that there is nothing more exciting than walking forward into the unknown with the deep assurance that a loving Father walks beside me, behind me, and before me whether through mountains or valleys, in safety or peril, with companionship or alone.
-Proverbs 3:5-6

Departure

    
For some reason I was significantly more anxious when I set out for Tanzania than I have ever been before when heading overseas. I found myself feeling anxiety over things left undone at home, anxiety over whether my medical skills and knowledge would be adequate now that I was finally going out with skills that could be called upon to significantly impact people's well-being, anxiety over the gaps in logistics of getting to Mwanza, anxiety over what I am going to do about the mountain of student loans that I have accumulated over the years, and anxiety regarding how I have handled certain relationships in my life. To make matters worse, as my departure time neared a large snowstorm bearing down on Chicago promised to add to the number of things I felt compelled to wring my hands over. On the morning of my departure I awoke with a knot in my stomach and all of these worries swirling around in my head... but I found great comfort in coming across Psalms 4 and 5, "In peace I will both lie down and sleep, for You alone make me dwell in safety," and my fear slowly turned to excitement as the words of a Sandra McCracken song sunk in: "In the arms of a good Father, you can go to the deep water where the questions we have left unspoken come out in the open. We will find shelter here. So I lay down what I cannot hold in my hand. Every sorrow and hope springs out of control, here I find sweet resolution comes in letting go..."

       By late afternoon the snow had started coming down heavily, and even though Christina (who graciously braved the storm to give me a ride) and I left for the 30 minute trip to O'Hare 3 hours before my flight time it became apparent that I  was not going to make it in time after having traveled only 2-3 miles in 40 minutes. At the brilliant suggestion of my sister, Christina pulled into a nearby subway station and I grabbed my bags out of the car and headed for the train. A mere 30 minutes later I checked in for my flight with plenty of time to grab a cup of coffee, watch the snow fall outside the window at gate 22, and wonder... now with more anticipation than anxiety... what the next two months would hold.

Introduction

I was in the middle of my internship year as a Med/Peds resident at Vanderbilt when a friend gave me a copy of Henri Nouwen's The Return of the Prodigal Son. At the time I was stuck in a depressive cloud as a result of fatigue combined with intense feelings of inadequacy on multiple fronts in my life. Nouwen's description of his encounter with Rembrandt's painting and his subsequent journey through the biblical story of the prodigal son spoke to me deeply. I came to understand that I, like Nouwen and like the young man in the parable, had long taken the skills and talents God has given me and presented them to the world in search of finding identity and recognition, only to find that when those skills and talents were no longer enough to impress those I sought recognition from I was left standing in a cold, lonely place with a vivid realization that I had labored in vain to seek the approval of men for far too long. The ongoing process of surrendering my pride and returning to the merciful embrace of a loving Father has been a sweet homecoming, though not always easy and not without a persistent and paradoxical tendency to look back longingly at a way of living that I know ultimately promises only emptiness. I am coming to know that I dwell in a sea of grace the depths of which I will never fully comprehend and that promises excitement and wonder and adventure and awe if only I purpose to seek out the treasures it holds rather than dwelling on self and my comparative insignificance in its vast glory.