made it to june

31/5/12 Made it to June!!

Power off 95% of the time this week. The worst I have seen. As usual, it is not me who is bringing change . It is Africa that is changing me. I have no answer for the lack of diesel and the lack of electricity. So like everyone else here you adapt to living in a blackout.But not everyone can adapt. Particularly the very sick and young. More deaths this week because no lighting, no refrigeration (read Blood Bank), no lab work, no x-ray. At night it’s one nurse, 30pts per ward with one anemic flashlight. Walking the wards at Biharamulo Hospital at night when there is no electricity is a memory air hammered into my brain that I will never forget. People are literally calling out in the dark. There is complete darkness. It is stinky and dirty. My iphone “torch” (flashlight) and headlamp are the brightest things around and I mean around as in the whole hospital. At this point, after 2 months, its “hakuna matata “or you’ll go out of your mind. Given the chance, I will change to cooking with charcoal ( like most do). Forget about electric lights and computers and the internet. Hubristic western thinking shrinks here over time. Appliances are nice but Kagera is not ready for them yet. So why spend your few dollars on something that might not work and if it breaks, like in a power surge, there is no one or way to get it fixed. This is just one of the million reasons things are not changing here like they did in Asia. Poor infrastructure, poor service, no money. and disbelief in change.

I always want to start singing “don’t stop thinking about tomorrow, it will soon be here, it will be here, better then before, yesterdays gone, yesterdays gone”. But yesterday and today are here ,they are strong, they are in your face and they are safer then gambling on the uncertain , broken future known as tomorrow.

Impressions this week:

1) no pillows…anywhere. Anesthetist folds your arm under your head to prop up your head after surgery.

2) No clocks in this hospital, O.R, offices or wards. Clocks break, electricity stops. Want to know the time?? Look out the window.

3) Tape? You want tape? Forget that, just cut a strip of bandage and tie the bandage to the wound

4) the 12ish year old peasant kid who had never seen a glove!!! I am not kidding!!

5) Live chickens, tied together, at the alter in mass……we ate them later. Not to be confused with the consecration/transfiguration,

6) Strong families take care of the patient and live under the bed. There is no going to work when someone in the family is sick. Chores divided up, somebody gets the food and brings it to the bedside, somebody washes the clothes and sheets…..OK, maybe no sheets, kangas, somebody takes the kids. Job?, work? that is so secondary. I have never been asked to write an absence from work note to an employer.

7) Scary impression of this week: Typhoid fever on the rise here.

Rainy season is ending, the hot dry season is coming. The sun is in the north, shadows are a little longer as equatorial “winter” comes and The Southern Cross beams bright in the sky every night.

I will be leaving here in 2 weeks( or so) with mixed feelings. A love for Africa a paranoid mistrust for the World Bank and a beat up GI tract. Will continue to TRY to post at barbaraandlarry.blogspot.com Whether you know it or not I have, at some time this past year , leaned on everyone of you. Thanks for that. July in New England sounds like heaven. L.

She was Beautiful

Ngorongoro Crater 5/15/12

Beautiful Bukoba

Last weekend I made my second trip to Bukoba. It is one of my favorite places to go in Kagera . Remote and full of history, Bukoba is beautiful, enchanting and alluring and at the same time dangerous. Despite or maybe on account of its beauty bad things have happened here. Because it is a port town on Lake Victoria and near the border of Uganda and Rwanda and The Congo it has mix of cultures, religions and desperate people that have liked staying off the grid and below the radar before either term was invented.

The happy story, and it is a story, is that this place is the true source of the Nile. Since Lake Victoria is the source of the Nile and since the Bukoba River is the source for Lake Victoria. The argument goes that The Bukoba River is the true source of the Nile. Of course you could continue the logic and say the true source of the Nile is a raindrop being formed over the Indian Ocean or maybe that mythical butterfly flapping its wings in India...

The dark side of Bukoba, not shown in the first picture, goes back to 1978,79, the famous Tanzanian - Ugandan War, Idi Amin and the explosion of HIV/AIDS. All very bad things. At that time Bukoba, was a run down, lawless, out the way place. There where refugees fleeing Amin and his sadistic atrocities. There were breakaway elements from his his Ugandan army itching to cross back over the border an overthrow him. There was a loose collition of Congolese and other African nationals, mercenaries, arms dealers and agents all smelling the lucrative market of a coming war. Best of all there were 30,000 Tanzanian soldiers waiting for the command to head north, attack Uganda and get rid of their evil neighbor Idi Amin. Since Bukoba is the last big town before the Ugandan border it became the perfect staging area. As it turns out it also supplied the perfect environment for the rapid proliferation of a disease that turned into a pandemic by a virus that, at that time, had no name. If viri live to spread then the HIV virus won the jackpot when 30,000 0r so desperately sex starved males in their 20's got stationed here with money, free time,battle anxiety and who knows how may prostitutes brought in across neighboring borders to serve the troops. The virus had been here for ever. Over time it morphed, evolved and made the jump from primates to humans. ( not the way you think... people do eat and butcher raw monkey meat here). And people had been dying of a "wasting disease" here for decades or more. Post mortem exams and so called coroners cases are not a big item in Kagera. Cause of death is not on peoples minds in rural Africa and Death Certificates are still not used to this day. But the disease never had the conditions to spread in rural Africa. Now suddenly conditions became supercharged and the virus jumped from an out break to an epidemic to a full blown pandemic. And it got its kickstart in Bukoba. After the relatively short war, short enough so that carriers didn't have time to get get sick or die. Infected soldiers and others returned home to Rwanda, Tanzania and the Congo or even better got on jets to international capitals and served as perfect rapid vectors to disseminate the virus worldwide. .

The rest is, of course, history. The story caught up to me in 1981-2 when my mother in law, then a nurse at Sloan Kettering in NYC told me about a disease that was killing young men in her hospital and no one knew what was causing it or how to treat it. At the time I was as a surgical PA intern in NYC at Montefiore Hospital and Medical Center. I was on a surgical trauma team at the time and would return home every few days with under wear and socks "starched" with dried blood of trauma victims. We were a reckless, macho, aggressive bunch and never worried much about gloves or gowns in the heat of trauma resusitation. My favorite event was gunshot or stab wounds wounds to the chest. Always plenty of that ,thanks my new friends in the South Bronx and always plenty of blood. Anyway my mother in laws message was be careful about exposing yourself to other peoples blood and "wear gloves all the time". I kinda blew her off at the time. But since then I have learned always listen to your mother in law. How right she was and wow, how medicine and the world has changed since then. The cause for those changes started, in part, right here. And don't I wish I had invested in a medical glove manufacturing company back then.

The story isn't without controversy. Even though no one denies the fact that the first case of HIV/AIDS in Tanzaia was diagnosed in Bukoba, many argue to this day that the documented high incidenc rate of HIV/AIDS in Bukoba at the time and through out the 80's and 90's is an example of western biasness.

Some have written that the early HIV/ AIDs tests were inaccurate creating false positives from people who simply had TB. Other writers talk about the African immune system is weak because of malnutrition and repeated exposure to insect vectored parasites and this created more false positives. And still others point out that HIV virus a has always been here. This last point is true. HIV testing on old stored tissues and blood samples here as well as in the US show evidence of different strains of HIV virus infection dating back to the 1950’s and 60's and even earlier.

But the fact remains Bukoba was a fire storm. . Every virus's day dream is a epidemiologist nightmare. And if you want a model of how to create a sexually transmitted disease that becomes a pandemic and kills millions and brings out the reactionary ignorant fear in humans than Bukoba is your place to visit.

shikamoo

When walking by people in Tanzania you have to acknowledge and greet just about everyone. Its demeaning if not. And since I am a mzungo I have to be a polite diplomat for not only Americans but white people in general.

Most of the time its “Habari” ( whats the news, but really”hello’) or Habari gani . Habari za leo ( whats new today?) Jambo ( greeting), mambo( hows things). And if you’re trending toward Islam its”Salamu” or Asalama alekum. Then there is ‘vipi” (whats up)?and then there is all sorts of other local slang which I hope and assume, is friendly. This can go on for ever with many kinds of hand shaking which is an art form in itself.

The simple hand shake( like what we do) is formal and really just not enough here. If your friendly, know the person, had a few beers or jut in a good mood the hand shake is a 3 part process. Part 1: orthodox had shake, 2) change to the “brother” handshake then 3) back to the orthodox handshake. This often followed by some other contact, slapping, fist bonking, wrist clinking all the while exchanging greetings and news. Then it is OK to hold hands and be lead somewhere to show something near by. This part was really cringy for meat first, just too uncomfortable. But now its OK to hold hands with a man as you walk, I get it, nothing intimate just genuine friends. But not in the United States thank you.

When I met the Bishop here for the first time in a casual setting (not church) , I did the routine orthodox western handshake and he immediately continued on to the 3 part shake. I knew he was cool and I was “OK” . We are bro’s.

There is another greeting which I have totally missed and it has mystified me until today. Since this is my 3^rd trip here I guess that qualifies me as a slow learner or maybe I am just in denial. Often when I walk out in the country a mile or so ( the only exercise I get) to another village or “neighbor hood” I pass people who have never seen me and so the greeting is different. Young children are fearless, uninhibited and curous and they usual run up to within 5 meters and point and say “mzungu”. After a few words or a petcha ( picture) they are all over you.

Older kids, teenagers, women stay away and either say nothing or say something that I have never been able to figure out. It sound like “shh” or “shiiiit” or maybe “sheek”. I just reply nzuri( good, fine) and keep going. They know they shouldn’t mess with strangers specially white men strangers and I am not going to mess with any women….in a strange village.

Guys, guys are different. They may be friendly ( as above), neutral or out right mean street, bad ass hostile. Some guys just look bad ass, and know it. But even lots of guys, mean or not, say ‘shhh”or something that sound like “Shiiit or” shiik” or “sheek”. So this has been going on for a long time I just chalk it up to another thing I have to learn..someday.

Yesterday I walked to a new village maybe 2 mi. north. No white people there at all. I am alone, a little uncomfortable “entering town” like in a western. New guy in town. New WHITE guy in town. The town is just a bunch of shacks, really stalls with tin roofs, it was hot and smart people ( every one but me) is in the shade. The men are always hanging, sitting not really doing anything. The women are out getting food, water, preparing. This is standard procedure. No cars, couple of abused Chinese motorcycles, dirt road. The backround color for all of this is poverty. You get it.

So one guy says “shhh”, I wave and say “nzuri” ( good) but really unsure what this means. I pass by a few mid age guys ( in there 30’s here) and I hear “shiiit”. Now I am nervous. Like, I am in Harlem, it’s 1969 and the brothers look at me a say”shiit man , whats whitey doing here?” I mean I could be disposed of here and no one would ever find a single piece of me….ever. Anyway I say “nzuri” “vipi” and walk tall with kind of a strut – bop…just so they know.

Then a cool ,older “dude” comes up to me, right there on Main Street and says “sheek” Then in fractured English says “that is a greeting. People are greeting you. you should respond”. He says “SHIKAmo”. It means respectful greetings to an elder” Respectful greetings TO AN ELDER?? ELDER? are they respectfully greeting me because I am an elder? OK, this is an issue with me. Me, an elder.? My mental self image is I am everybody else’s age. I know I have this inflated self image that in my mind that I am forty…AT THE MOST! How can it be so obvious to all these people that I am older then them? All of them? Do I really look that old? In my delusion of denial I just assume I am everyone else’s age. Then I don’t have to deal with the reality of my age.

Well, look that way or not, I am older then 90% or more of the people here. In Kagera the young look younger then their stated age and the old look older then their stated age. This is because of malnutrition in the former and hard living in the later group. Life expectancy here is about 55. I should be long gone.

The dude tells me the response to shiikamoo is “marahaba” ( thank you for your respectful greeting). So suddenly the fear, the anxiety, the chopping me up into little un- findable pieces is gone. These people, living in such incredible conditions of poverty are so respectful, so graceful. I am so embaressed by my ignorance. Later that night I learned that “shikamoo” literally means “ I touch your feet” Blown away by my western paronoia and prejudicial bias, I am the one who is humbled and should be touching their feet. Al of this proves once again that most fear is based on misunderstading. And using symmetrical logic, most misunderstanding is based on fear.

A good lesson for the world to learn. Shikamoo

Did the neck exploration ( Ludwigs angina, google that) today. Every thing is like the first time here. Kinda funny if your not tired. Anyway, I asked Andrew, the best anesthetist here to do the case. Explained the threat to his airway, ketamine. It was a bit of a flail, really gross, really stinky...maybe anaerobes. Got A LOT of pus!! Transverse incision at base of his neck, R. side, big cavity. Stuck my finger along his trachea up to the mandible and then down onto the supraclavicular fossa. Couln’t get behind the trachea where I thought the tract might go. Swept over to the L. side, not so much. No tonsil sucker, just a big thick black tube connected to weak sxn but it worked and sucked pus. I then made another incision at the supra sternal notch, watching out for the plexus of veins that is always there, With no bovie and no good sucker that would have been scary. Looked for a cavity behind the sternum: none. 2 drains and packed open. Waking up was crazy. We moved to the "minor theater" as a recovery room. He was bucking, coughing pus, had low sats for a while( yes have oximerter!) and hallucinating. Bottom line: right now he is better, but I am afraid there is more and I'm sure he is bacteremic. On Ceftriaxone( max dose 2gr q 12) and Flagyl. Want Clinda but there is none. I'm afraid the family will run out of $$ soon, Tomorrow: CXR to look for air fluid levels, collections. I know, why wait???....because "sababu tech anakwanda nyumbani" (tech went home).

Worried. Never see this in the US.

Best of all I went and got the dental tech( Barnabis is gone) who sent this pt home with H2O2. last week. He said " he looks better!! Ha!!

I told him the pt. was going to die from a preventable infection that never should have happened.. meaning :"you screwed up Bub". I don't think he got it.

More to come.....

always get a good dentist

in the old days

hello Larry, goodbye Tex

I  had a dream about my shower at home . I know that’s worrisome and maybe a little strange but I haven’t had a shower in a while and my shower at home is such a nice thing. Its new, shiny with glass walls and a shower head that is adjustable  with the option of holding it in your hand…like European showers. Barbara did all the ordering. I just inherited it.  As  they say you don’t what you got till its gone and I really miss my shower. Anyway, in my dream, I was in the shower and got out and stood on the green stone tile floor ( it might be marble, Barbara  ordered it)  it felt clean and safe  and there was nothing to worry about  and then I just got right back in the shower. It was warm and clean and safe and I think I stayed there a long time. It’s hard to tell time in a dream. But then I woke up and went to my “bathroom” here and I knew I wasn’t dreaming any more, but maybe in a nightmare.  In my bathroom there is no bath. there is a shower but it doesn't work. There is a toilet and even though it is "manual" ( you have to fill the tank by hand) its OK. I had the toilet seat delivered here from Mwanza in 2008. Since  the shower doesn't work I am very good with bucket baths, that is the standard here and that is just the way it is.

  The problem is I share my bathroom with others. They don’t care about the things I do, like cleanliness. Among the "others" that I can see one is a lizard/salamander/chameleon. He is really pretty cute. I know he is good because he eats other bugs and things  that I don't see. The less of us in here the better. I call him Larry but he doesn't respond to his name. Another one  is Tex. I call him Tex because he’s bigger then Texas. He is an NFL sized cockroach. He likes to hang out under my  toilet seat but I think he lives in the drain.Tex is not only big, he is fast. Really perfect NFL material. I am trying to be Buddhist about Tex but I don’t think it’s going to work out. Peaceful co- existence is not an option.  Not in my bathroom here and  not in the bathroom of my dreams. I think its going to be hello Larry, goodbye Tex.

Easter Sunday Morning Lake Victoria 2012

My Dedication

When I first came to tanzania in 2008 I was a different person and my world was a different place. I was married to a marvelous women. It was more then married, we actually felt star crossed. I mean we met hitchhiking in Vermont, I was 20, she was 18. And it really was a done deal at " hi where are you going?".

We were sure we were the luckiest people we knew but being human we didn't jump up and down and shout it to the world everyday. In addition to a life together,we made 2 trips to NW Tanzania, educated ourselves to what world poverty is, educated others, saved a life or two and planned to keep coming back because...well because we could. It really is that simple. Maybe it was a payback for our good fortune but really? what are you suppose to do here? We are here to make things better for ourselves and others . In that order, I assume.....

Anyway in Oct 2010 the bottom dropped out, the wheels fell off, the dream ended. Barbara died from untreatable triple negative breast cancer just 9 months after diagnosis and I found myself kicked out of the luckiest people in the world club. Traumatized, trunkated and eviscerated, for the first time in my life I felt old and very mortal.

I received lots of help and support but the best words that clicked with me where what my friend Jerry Doherty just sort of spontaneously blurted out in mid paragraph one day: " hey we are all just renters here man".

It has not slipped by me that it is 9 months since Barabara died and that it was 9 months between her diagnosis and her death. There is symmetry in life ....and death. Will I close the loop? Pick up my guts? Pack them back in, heal my wounds,stand up and walk, and be left with my scars? This is my story.

I dedicate this journey of healing to Barbara. The journey will not just be the next 3 months in NW Tanzania, it will be the rest of my life. How long is that? Who knows? Some times measurement of time is meaningless. Maybe I will take it in 9 month segments. After all we are just renters here.

Diving In....in slow motion or, karibu Tanzania

Sometimes when people come back from assignments over seas or deployments to different cultures they reenter slowly and with support and guidance. What is sometimes called re-immersion therapy. Maybe to prevent or treat post traumatic culture shock. I am initiating a new preemptive treatment called

PRE -IMMERSION culture shock therapy. Its really quite simple. Go to the country your are about to be immersed in and just sit there. Don't do anything, just be with the new culture and its people. Forget your schedule, your appointments, your expectations. Just be there,in the now, in the moment. If its really a different place( like Tanzania) you will stand out and people , being universally inquisitive by nature, will be drawn to you. I did my first session in Dar esa Salaam( like Jerusalam) airport the other day on my way to Mwanza. My flight was repeatedly delayed and I spent 11 hrs just sitting in the departure terminal.We were never told why; its all part of the therapy. It's not a comfortable place, its noisy, hot and stinky and and there is no first class lounge or club and that is all part of the unproven therapeutic effect. People stare a little, little kids stare a lot and come up to you and sat" mzugu" Later on, around 10pm when all the other flights had left and there were only passingers on my flight left and the lights kept going off and on, we all bonded no matter what our race and culture and entered sort of a survivor mode. By this time the only lights working in the terminal were those soft yellow sodium lamps they use in the parking lots in places like Newark Airport. It created sort of a surreal sepia environment. When I am in that light for a while something happens to me and I enter sort of a slow motion world, as if I was traveling in hyperspace and time itself actually slows down ( try to figure that one out). Again, this is all part of the therapy. I, for one, was convinced we were never going to get out of there that night. I wasn't alone and as the minutes and hrs ticked by and the sepia sunk in we started little conversations and became a survivor tribe....an airport survivor tribe.

We finally took off into the African night in a twin engine propeller plane for a 2 hrs flight thru thunder storms, fear and doubt to Mwanza. When we landed we felt like we had survived together, no matter what your backround, race, creed, color or culture. After a total of 13 hours of "therapy" the last thing on my mind as I picked up my bags in Mwanza was culture shock. I, along with my new tribe, were aware of only the strong desires to get off our butts, get horizontal and fall asleep. See, I knew this would work......its all part of the the therapy.

Karibu (welcome to) Tanzania.