Pictures from Zanzibar

Not Really a Foodie in Muheza Part 1

Not Really a Foodie in Muheza

I love food.I love traveling and trying new food as part of the cultural enjoyment and discovery. I am fairly convinced that I am not a foodie .Food loving is not food obsessed.I am not limited by my need for rare and expensive ingredients and there are few things I wont eat ( OK I have never had a Tim Horton’s coffee and I don’t eat KD)
A few recent pieces of information have further convinced me that there is another level of foodie out there( extreme foodiism) that I don’t fit into.

A recent Saturday New York Times food section Brought by Leah after her trip to Toronto , included pages about drinking ‘Cocktails”( except for the occasional marguerita and one Manhattan many years ago to celebrate the life at the death bed of a patients of mine’s manhatten loving mother , I don’t drink cocktails). Seems as if it is a generation X, Y or Z pastime.
In the same section there was a wine auction announcement ( I thought there was a terrible economic recession out there) including a case of 1982 Chateau Ausonne MAGNUMS( and although I do love big red Bordeaux and have actually had a bottle of Chateau Ausonne - bought at the vineyard- the thought of a case of magnums is a bit much).
And most recently at the Red Monkey Lodge ( Zanzibar) where we passed our recent Christmas and dined Christmas Eve with Germans and Scandinavians ( their seasonal meal) on Barracuda, octopus,lobster squid,and goat I found a Penguin Book of Food and Drink ( 1996) to add literature to my salivation ( not salvation).

But I thought sharing some of our food experiences with you might be fun.

Although I have a very few cravings ( NOT Fantastico lattes-see below) occasionally cured meat even though there is good bacon here (see later) .If anything , fresh salad greens- very few available and safely washing them without wilting them to death is basically impossible. ( oh ya I forgot English Micro Brew Bitter but I will get that in 2 months)

So I will start today with fluids and will follow with meals and treats at some later point.

Liquids

Water ( Leah would start with coffee), not safe out of the tap, we filter and refrigerate and it tastes fine. Better tasting, cheaper and less polluting than the local bottled water that is everywhere ( as are the plastic bottles).the biggest problem is drinking enough especially if your pre-trip eGFR ( doctor talk) was 52

Coffee , except for a treat in Zanzibar last week no Lattes. Instant coffee from Tanzania available, Different than the few instant coffees I have had ( those of you might remember that I came late to coffee well past the Maxwell House Days)
Coffee is grown in Tanzania and the raw beans are available here in Muheza . bulk can be a bit of a mélange of beans, husks,other plant material and stones but a packaged ‘export quality’ is also available – still needs some going through- less stones-1500 Sh./kilo
( $1.50)
We then roast it in our oven which makes the house like a sauna and watch it closely ( try to) and make some variable blend of dark and medium roast ( with the very occasional hint of burnt). Our neighbours Sally and Ben have a hand grinder and Jay and Sylvia gave us a very intriguing large syringe like filtering system ( they forgot it at our house and kindly turned into a gift) that works perfectly ( if you do not over grind the beans) and tastes wonderfully. 1-2 cups daily

Tea also a Tanzanian crop. Local tea harder to find. A roibus-like Tanzanian tea ( drank with tons of sugar “sukari” or milk “raingi”(coloured) is available .English tea bags abound and we got gifts of these from visiting English guests so we are fine and just to be sure Sally and Rose sent us some Murchie’s #10 Blend for Christmas

Fresh squeezed juices and smoothies- overpriced are rarely bought.
We should squeeze our own more.

Ceres juices (from S. Africa) not really from the 100 mile diet and expensive.

Sodas – mainstream, Coke,Sprite, Fanta orange plus a variety others- fanta passion ,pineapple, black current( don’t see these back home)
Bitter lemon, tonic, sparletta, ginger beer called tanga-wizi and a brand Mirinda ( a pepsi prouct) orange,fruity,lemon-lime. Cold they help break the monotony but the sugar quantity is not insignificant. 40-50 cents for 350 ml bottle. Fortunately a deposit is mandatory , in fact without a return it often is hard to get a bottle,so glass bottles are not part of the litter (same with beer see below)

Milk, local cooperative pasteurized and packaged in plastic for 25 cents for 250 mls. We just today bought some raw, boiled it ( pasteurized) and will drink it and try and make yogurt. I am finishing this entry the next day and am glad to report that milk and yogurt are delish and this will be our new routine

Finally alcohol
Beer is the staple at 70 cents for a 500ml bottle ( again No bottle return No beer to take away) all lagers, but very tasty cold. Most from Tanzania but a few S African ( Castle) and Kenyan ( Tusker ) available.
There is distilled alcohol available and except for a bottle of gin that I think Sally and I split early on we have had none ( I even passed on duty free scotch) and the wine is S.African and expensive and not their best and I am not knowledgeable about them ,so for now cold beer.


Next Week Breakfasts and Lunches

A Simple Comparison

RED MONKEY RESORT (ZANZIBAR)........YELLOW POINT LODGE( LADYSMITH BC)

east coast of zanzibar ..........east coast of Vancouver Island
beautiful sunrises ........... beautiful sunrises
group meals .......... group meals
hot ocean swims ...........hot tub
small simple cabanas ...........small simple beach cabins
chritsmas 2008 .......... annual anniversary celebration
afternoon tea and sweets ...........afternoon AND evening tea and sweets
bike rentals available ( don't do it too hot)...... bike rides
ocean sports-snorkeling, swimming ...........ocean sports kayaking, TOO COLD to SWIM
birding ...........birding
reading, resting, writing ...........reading, writing , resting
cheaper to bring your own alcohol ............cheaper to bring your own alcohol
some interesting people some not so ............ some intersting people some not so
80$ plus meals = aprox.150$/night ..............about 150/ night
no fire place although BBQ for lobster ..............fireplace
long walks on beach .............. long walk in forests
lunches from village-local food ...............Crow and Gate Pub
Cottage industry -growing seaweed and.............. herb farm and Barton Lear Galleries
crafts


41 DEGREES ................. rarely over 25 degrees


MERRY CHRISTMAS to ALL

Hardships (Beefs)

I felt it would be reasonable to discuss the difficult parts of this trip and not just glowing event after event, story after story.

For me (Ambrose) there are 3 issues that can affect my day adversely that are regularly an issue.

These differ from the day to day unpredicted challenges of work and play here in muheza …resource poor, sick people, difficult to make arrangements or the fact that we can’t really understand all that is going on due to language and culture. As a rule I can accept those challenges

1)the heat.. it is sapping and slows you down and makes you walk at a Tanzanian pace. But even though I am down to a daily shower from 3-4/day at the beginning, the heat affects daily events and comfort and nightly sleeps ( even with the fan on full all night0

I sweat through my shirts frequently and even without rain I am soaked

2) my skin…even though we have avoided major or significant illness my skin has been a big bother

bites… mosquitoes here are small and silent . daytime mosquitoes are supposed to be more likely to carry dengue fever( have not heard hide nor hair of dengue fever since we got here) and nighttime mozy’s are supposed to be more likely to carry malaria( a big concern and a significant killer here) for us they itch severely but fortunately for only about 20-30 minutes but usually worse just before bed.

The night mozy’s seem to like the lower altitudes, under tables, under desks and along the floor so sitting up late becomes unappealing and we start our nights itching and even our mosquito nets are not 100% effective. And then there are other itchy persistent bumps and welts and rashes ( causes and vectors unknown) that make me uncomfortable in my skin. Usually ignored or tolerable during the day , they are more obvious or symptomatic at night and if you add 1( above) this sense of persistent dislike of ones body ,this discomfort( not severe pain) can drive one a bit batty and make for irritable comments and restless sleeps

3) computers, computer access, e-mailing ( or the lack there of) , blogging…..

I am not 10 or 13 or 23 ( coincidental ages chosen?? I think not) so computers at the best of time are not my friend.

Now they have become some weird essential part of traveling, yet I think back to trips through Europe, Africa(1982) and south ameica1994 where we traveled well , kept in touch by mail and had NO computer access and managed just fine

I remember going to belize in 1999 with graham and the boys and the internet café becoming an important part of graham’s sanity

Here where power is inconsistent and recently where internet signal access is gone and when available speed ( what is speed???) variable, the whole mood of individuals and the family unit is affected. Our most irritable is when we have to use an internet café rather than hospital access and although cheap 1000 shillings =1$/ hour there is pressure of time and shared access and little time to read blog comments or check world news and SPORTS or follow links friends may have suggested.

Add power outages, water shortages,water rationing and recent water lack ( pump broken) and some days can be more challenging than others

Those are my complaints , I will soon return to the joys of this trip which are many and more important

The Mangoes are Ripe!!!

“The mangoes are ripe !” A welcome reality as I step back into life in Muheza. We are enjoying daily mangoes for pennies and delighting in our ½ km diet (backyard avoes soon to follow). “The mangoes are ripe” can also be a saying (in Swahili of course) that adorns kangas (the brightly coloured rectangular cloth that wraps around the waists of all women here) so its always good to get the translation of the saying on your kanga before strutting around town!

I had fretted more than a bit about sliding back into life and work here; from the cold and grey and ‘luxury’ of Toronto, thinking of Muheza’s heat and sights and hardships and especially the problems at Teule Hospital had made me quite anxious. However, the transition back has been easier than the transition to Canada! In talking with Sally and Rose, I realize this may in fact be forshadowing of things to come for the Marsh-Norgrove reintegration down the road , as S and R have found themselves missing Muheza big time and their African life here, and the transition back to regular life in Victoria harder than expected…

So although power outages, no running water for 3 days, no internet connection, 30-35 degrees, tough clinical cases have characterized my first few days back, I am very quickly feeling “in the fold” of the family (we are a tight unit here !) and engaged back in our journey and work life here. This is a bit of a catch up blog so I hope you have a few minutes open to join me.

It was so good to be part of dad’s recovery phase. By the time I managed to get a flight (thanks Sally for your help) and make the trip (really it took 2 full days door to door) Dad had hit rock bottom of a huge GI bleed and was in the ICU beginning the long road back. It was a crucial time to be with him and to be reminded with fresh eyes of the challenges of being 81 and critically ill in the big machine of a huge state-of-the-art urban hospital (more than 700 beds between Scarborough general and Grace). He received very competent and compassionate care, with a few especially shining stars and fewer low lights. By the time I left, Dad could walk the hallway (with walker) and was beginning to do stairs. I talked with Charline last night (her loving care and support has been a wondrous sight to behold) and hear that he is now days away from discharge. Dad received about 17 units of blood and plasma during his time there….

The contrasts between medicine in Toronto and medicine here could not have been more starkly juxtaposed. I am back where the prompt scoping (the procedure to look beyond his stomach into his small bowel to identify the bleeding and stop it) that Dad received in Toronto (in fact he had it 3 times in all) is not something we can offer here and such a medical situation would quickly turn into a death. Alex (UK doc here) relayed to me a case that ran parallel to my father’s that he had cared for while I was away. Young man, previously well, upper GI bleed, no scope…..blood products very limited (a family member has to donate unit for unit of blood to the blood bank…not always possible , therefore no or very limited blood for a patient) and sadly general apathetic lack of willingness to trial surgery (a poor but possible second best to identify source of bleeding). Needless to say, this man died.

The time in Toronto has solidified a couple of themes on the work front that have been evolving in my mind. One is that part of our internal struggle is the notion that we are weaving palliative care into situations frequently where people ought not to be dying (or wouldn’t be in Canada). I know , I know…. Seems obvious, but it continues to rub in a very uncomfortable way. So often it is young women with children in the prime of life dying of HIV related illness. It feels a lousy second best to be ensuring that the overwhelming headache of her cryptococcal meningitis is relieved and that she is not suffering as she dies, rather than ensuring her survival to raise her children.

Yes, there are ARVs, but there are probably less than ¼ of the treatment options we have for people at home (Chris Fraser help me out here). The reality of ARV’s in a ‘resource poor setting’ is totally different than in Canada. The notion circulated at home is that ARVs turn HIV from a death sentence into a manageable chronic disease. This is not entirely accurate here. Ease of access to ARVs , stigma, nutrition, co-morbidities (TB, other infections, cancers), competing religious/spiritual beliefs regarding the need to stay on ARVs once healthy, all affect adherence to this life-long treatment and survival. Sadly, the introduction of ARVs is not an instant switch to survival but rather a slow evolution, and we are early on in that continuum. Being HIV positive still means high likelihood of death…perhaps months or a year or 2 or 3 later.

And where is the husband of this woman dying of HIV related meningitis ? Perhaps already died…or likely not yet identified as HIV +, not willing to be tested or receive treatment (even though he probably infected her). She was perhaps identified via obligatory pre-natal testing when she had her last child, or voluntarily out of her concern for her children and for her survival to raise them. Anecdotally, three quarters of the patients waiting for ARVs at Diana centre are women and this is a profound curiosity to me. That stigma is so huge, he would rather die than be identified HIV + . Apparently many women attend and don’t even tell their husbands of their status for fear of being abandoned by them.

So the emotions and ethics of building a palliative care program in a setting where many of the deaths feel needless is confusing and distressing. In Canada palliative care providers have the luxury of feeling confident “everything was done that could be done” or at least everything that people chose to pursue was done. Elements of choice and access to lifesaving treatment are not present here in the preamble to a palliative care program. A very profound difference. And yet people continue to die and need comfort and an organization of care services to support them, until the slow wheels of change come around.

The other major reality is the profoundly different experiences we are having at the 2 hospitals in which we are working. At Teule morale is poor; “morning meeting” (daily discussion of critically ill patients and the deaths overnight) is either characterized by non-participation, or more often turns into a mutual accusation-fest. At Teule, if you write an order, the meds are frequently not given to patients or only some doses. Patients may even go for days, critically ill, without being seen due to abject neglect by certain clinicians.

Gratefully, gleefully for us, Bombo is so different. The basics of medicine are functioning. Patients are seen every day, histories taken, patients examined. Orders are carried out, care teams/consultants seem to work collaboratively. The leadership is excellent. There is a sink on each ward to wash your hands, and the wards seem cleaner (nurses are responsible for cleaning !!) We are welcomed and we feel proud and privileged to be mentoring the new palliative care team there and so grateful to be having this contrasting experience, still a ‘resource poor setting’. It has made us understand what a difference leadership and moral and local history make and probably a whole lot of other things we will come to understand over time. It does also feel better to be palliating where, at least we know that everything that could be done here in Tanzania, has been done and usually done well. (Not so at Teule)

An emerging urgent concern is the nationwide shortage of something called paraben, a chemical used to stabilize oral morphine solution. Apparently supplies will run out by January and the order is mysteriously not available from the usual S. Africa. This could mean that morphine will cease to be available to Muheza from Ocean Rd Cancer Institute, just when we are expanding its use dramatically and formally applying for its distribution to Tanga/Bombo. We have begun emailing collegues/pharmacists/neighbouring Uganda to try and urgently secure a supply of paraben. Any ideas from you medical types reading this would be most welcome !

We leave in a week for Christmas in Zanzibar ! Imagine that !! Have been enjoying biscotti from the LeFrank/Neate parcel (thanks Deb) trying to drag Ambrose into the Christmas spirit. He did however manage to arrange for the traditional Christmas puzzle to be here…amazing. I can see the kids are a bit more unsettled without school, and approaching that favorite time of the year without all the normal rhythms and traditions.

We look forward to visits in January from Joel and Paula, and Fiona (my old office partner) and her daughter Haileyy with their friends Stephanie and daughter. In February maybe even Pam and Anneka !

“Wuzungu” (white European) dinner was renamed ‘Wednesday dinner’ as this crop of medical students from London, Eng. are, of course, not white. Griffin continues to be my steady companion for the late afternoon cycles, a cherished time with him where I can hop on my gearless wonder and roam the sisal fields and villages and finally relish the African sun, well past its prime of the day.

A Special Day Now That Leah Is Back

Leah got back almost a week ago.A relief to us to have her back, a relief to her that her father has survived numerous complications( including the need for 16 units of blood) and was back in rehab and improving quickly.

Jet lag ( she talked to me until 3 am the first night and leah is NEVER awake at 3 AM)

Culture shock ( no malls full of Christmas shoppers)

Temperature shock( the weather had moderated while she was gone and now has climbed back to high 20’s and low 30’s) all experienced again for her

She brought us requests ( books, a new rubber spatula, chocolate … very melted and rushed into the fridge) and gifts from , graham , unle bill and auntie shauna, bop and Charlene ,deb lefrank et al including Christmas biscotti and poor imitations of our advent calendar .. but the boys got caught up on the chocolates quickly anyway.

Fortunately for leah and in fact all of us she got home late on a Saturday and the Monday and Tuesday were holidays( muslim eid and national celebration respectively) a chance to get back into it slowly.

I planned a few better meals including Tuscan chicken a la Muheza (ask sally and rose) and newly found feta cheese from Arusha about 200 miles away( oops there goes the 100 mile diet)

Our friends emily and alex joined us for Sunday dinner

On Monday leah convinced me to join her and the boys for a family cycle.

She and the boys have cycled daily to school( the boys managed brilliantly with friends and on their own while leah was gone) and leah and griff have cycled locally for fitness and curiosity

I had cycled occasionally, the bikes are challenging in configuration and the roads are challenging in condition and I have been playing a bit of soccer for my fitness.

But a family ride seemed a great idea

So leah and griff showed us all kinds of sites ( birds nests, sisal factory,villages) rutted routes and ups and downs, some of the downs with crazed speed and laughter.

New birds were sited but really to identify them they need to sit still in an open area (obviously not a normal bird habit)

We brought cold water which is gulped when breaks demand it

And as the sun was setting ( cycling usually occurs at about 430 for an hour or so because of the heat)we headed back only to get caught in a warm drenching rain that we pushed home through anyway.

Smiling, soaking, happy to be together again

Still hard on my knees , but I am sure we will do a few more family rides if only for the memories and laughter they create.

Last Minute Blog Entry Before Cleaning the House Because Leah Gets Home Tomorrow

The size of snails and millipedes in Muheza is astounding
. hopefully we will have a photographic record to share on this subject
. the escargot are to die for if you were French ( or maybe to die of)
the storms are more frequent and intense ( a video clip from such a storm in Dar es Salaam will hopefully get posted)

We have survived 16 sleeps without Leah ( although I honestly did not sleep as well). She is in transit as I type and arrives tomorrow.Ross is slowly recuperating and resuming rehabilitation after a rocky complicated post-op period.
While Leah was gone we were busy. The boys finished their first term of school and had a week on their own( continuing their home schooling- Thank you Eva again),cribbage, blogging, videography ( new video soon to be sent to rose for posting), marbles, cycling and reading voraciously ( another true colattral gain from this trip is the 2 boys have turned into readers and we have all enjoyed reading again) , we have also developed bottle cap Texas Hold ‘Em at present Simon is surprisingly ( except to him) whooping us.

The first w/e leah was gone we went to a local nature reserve –Amani, and camped with Alex and Emily ata curious NGO resort> we were hosted by an American born Brit ( Althea) while the owners were at a craft fair in Dar es Salaam..Walks, reads, Frisbee, at a bit of elevation the nights were actually cool…’where are my socks’. The highligt was a guided night walk with A&E and our Irish teacher friends where we found chameleon,stick bugs, large crickets.astoudind and the chameleons so so unusual..

Leah and I were just ramping up with speaking and educational engagements when she left and I was able to meet all of our commitments here in Muheza as well as in Pongwe, Mgamiani and Tanga. I am sure they all missed Leahs slower and clearer delivery but generally it went well.
During the second week the boys were willing to stay on their own because some of my travel days started at 0530..power outages, water rationing and no local internet access has been that much harder with Leah away.
Even though Rose is gone Catan has continued with the medical students. I even leaked out a victory.

Alex and Emily have somehow motivated the powers that be and got housing on the hospital property, eliminating their daily pre work work out. I is nice to see them almost settled, there was painting last w/e and cleaning and shopping
Big news for us is a new cold bigger fridge!! Not North American in girth but neither am I anymore.
Ilse our roommate is gone to New Orleans (her first time in ‘ America’) and then home to Holland for Christmas so we have the house to ourselves for 3 weeks. Anyone want to visit??

The second w/e we went to dare s Salaam so I could meet with some people about improving the availability of morphine to the region. Moderate success but only time will tell. It was strange to be back with Wazungu (white faced folks) travelers, all with their copy (some translated) of the LPG.Long walks through interesting neighbourhoods especially the textile (katan, Katanga) areg and long cab rides through rainstorms and terrible traffic on my way to meetings. We also found a very good quite expensive (but how could I refuse-see above) English bookstore. The highlight and lowlight was the Africa Cup qualifying Match on Saturday. Tanzania vs. Sudan (how does Sudan have a team?) 3-1 for the home team in a very comfortable half-filled (capacity 60,000) Chinese built new stadium. In our celebratory mood we were led into a funnel of crushing people, scaring Simon and me and then I was pickpocketed but realized at the last moment and was able to scare the perp so he dropped my wallet. Sadly we discovered hours later when buying our return ticket to Muheza that Griff was successfully pick-pocketed from a front zippered pocket in his shorts for money and a mobile phone. He was devastated and I was saddened ( and maddened)that we needed this rude awakening.
We were in the Indo-African part of town and found some great eats and fortunately for Leah and did not bring any barfi back for her (her year in India put her off barfi for life)
During Leah’s time away I did have roasted cassava (good),ugali ( not bad)and jack fruit ( OK).
So we have a 4 day w/e for Leah to settle in (Muslim holiday and a national holiday coincide) the house will be clean she can get used to hot temperatures and humidity again and I will make sure the toilet seat is down again (3 boys can slip into old habits quite quickly)

So we hear of constitutional/political turmoil in that backwoods hamlet called Canada ( not making CNN international news) and that the canucks are doing well at hockey
Snail mail is arriving but I have saved it for leah’s return
Christmas in Zanzibar is the next excitement and teaching right up until then. Tutaonana, baade.

Photo Post From, Ontario!

Hello all,

Graham has finally received passwords and has found 15 mins (admittedly in the middle of class -discussing Western European "catch all parties" is not so riveting on a Monday evening) to post photos!

Hope everyone enjoys.

Another Post (one of very little)

It has been an incredible month of new discoveries, comings and goings of friends and family and visitors. A month of settling into the life here in Muheza. This past week we have hosted “the Anglicans” as they came to be known in our family (10 visitors from a church in Sunningdale, UK with a long history of significant donation to the workings of Hospitali Teule) who were here for less than a week and had a whirlwind exposure to Muheza, the hospital, the Diana Centre (Muheza Hospice Care and HIV Care) and even the boys’ school. It was strange to suddenly be the hosts and be the ones who “knew” and to be showing others about life in Muheza! In a curious way I think it helped us to realize we are settling in and becoming more confident and comfortable in life here and especially for the boys to receive such interest in their school and commending words of support for their adventures in Africa.

The boys are a joy to watch. Griff is back to his pre-mefloquin self and we are so grateful for that. Took about 2 -3 weeks for his confidence and poise to return, and now he is chief market bargainer and probably has the best Swahili of the family. He is super bored in school, but takes his home-schooling math book we brought with us and is working through his own math. During their Swahili, he works on “teach yourself Swahili”. He came forward with the scary experience of seeing his classmates hit (hard with a yardstick to the point of tears) and managed this with remarkable emotion and maturity. Fortunately, Sister Gwynneth has total intolerance of corporal punishment and for the moment the situation has been ’managed’. However, it will likely rear its ugly head again for him or for Simon as it is apparently the norm amongst Tanzanian teachers, despite there being a recent law forbidding corporal punishment in schools.

Simon has been a wonder, especially when I think of how far he has come from his initial huge fears of being the only white kid at school, and of missing out on everything at home. He is making friends, and making thoughtful comments about what he is seeing around him. For a couple of weeks it was really hard for him to go to school, but he seems over the hump of the early days of unbelievable adaptation to everything different. He is with kids a year or 2 older and the math work is actually about where he left off. My sense is that he is thriving with the family time and is pacing himself for the months and adventures ahead. No easy feat for a 10 year old. He has such a keen eye and appreciation for all the birds and insects and reptilious creatures here. We look forward to taking him on a nocturnal ‘camelion walk’ up at Amani Park on one of the upcoming weekends (and of course a safari at some point !)

They are both learning important life lessons such as how to navigate on a gearless bike at top speed the deep unpredictable ruts of the trails to school (especially after a rain when the slippery mud congeals between your tire and your fender), how to win at marbles on the playground (several different complex games) , how to take enough showers and drink enough water to stay alive in 35 degrees, how to sleep through the call to prayer at 4 am and the moaning cow across the road, how to avoid ugali and macheecha (Tanzanian staples) and squat toilets.

Graham ‘dropped’ in for a couple of weeks, in the middle of his university term. He got a good taste of life here although I am sure overwhelming for him and far too short. I am glad that he can now picture where we are and imagine the stories from afar. It was an epic journey for him to pull it off and we are grateful for the effort !

Our bodies feel in a state of suspended animation waiting for the damp cold and rain of a fall in Victoria to begin. Instead it gets hotter and hotter and hotter. Muggy days too with intense humidity that lifts only briefly after short unbelievable deluges of tropical rains. The other day I borrowed Rose’s little thermometer and attached it to the back of my bike as I rode up to the school for the afternoon pickup. We stopped on the way home at the hottest open patch and it read 40 degrees. Yikes! It is good that the kids are off school Dec and first half of January through the “hot season” !!!! It is all very survivable as long as the power is on, and the fans are working. Otherwise (recent outage for 3.5 days) the nights are long sweat-fests. We are all shedding pounds, just from the new rhythm of life, gratefully not from any serious illness.

Tonight we are entertaining Alex and Emily (2 young volunteering docs from UK) and the menu includes chicken on veggies, mashed potatoes, mango/avocado/tomato/red onion salad (your recipe Deb !) all well within the 100 mile diet. We are certainly eating well and enjoying fruit salads of mangoes and pineapple from our backyard, cooking with modified recipes from home.

One of my hopes for this trip was that time would slow down, and balance of life would improve and certainly I am loving the hours we have together, and all the reading aloud and games and discussions. The 6 of us (including Sally and Rose) are reading aloud “The story of the World: History for the Classical Child, Volume 4: the Modern Age”
(Thank you Eva for the suggestion) It is great to fill in our collective significant gaps in history especially around the colonial eras and how they have affected places like Africa.
The boys are becoming voracious readers and finding the joy in curling up with a good book.

On the work front it feels like we are making good progress. There was certainly a real low for a couple of weeks, where a feeling of futility and overwhelm would descend on a regular basis, but that seems to be getting better. We are engaged in a process now and feel significantly less ‘out of the loop’. We are doing consults on the wards pretty regularly and following a group of ever-changing patients, with cancers (always advanced and completely untreated) and HIV and end-stage this and that. We are building relationships with nurses and what are called AMOs and COs (assistant medical officers and clinical officers) and docs. Most of the time we are able to find someone who can translate for us so that we can have a decent exchange with patients and family, but not being able to speak Swahili remains a huge limiting force. The positive flip side of this is that translating for us actually places nurses and docs in the position of ‘role playing’ and practicing moments of information sharing, answering questions and ‘breaking bad news’ etc that are not typically part of care of the dying patient here (more often continued focus on inappropriate active care and/or general neglect of the patient). At the same we continue to be very aware of the different cultural context of illness and death and to tread very respectfully. My guide is the patient and family and try to let them show me what they need and want.

The politics of the ‘divide’ between the hospital and the Diana Centre are becoming clearer as we hear more and more snippets of the history of the last 8 years or so and the complex layers of government, NGOs, funders, egos and at times corruption that has shaped the delivery of first palliative care and then integrated active HIV care in Muheza. We are trying to keep neutral and focus on patients and certainly it is beyond us to maneuver. We have begun some formal teaching (with power point no less !) a series on palliative care that will provide a framework for what one can do in the face of incurable illness, and suffering. It feels like medicine at home, but 30 years ago. Ambrose recalls noticing on rounds as a medical student that the patients with incurable cancer were visited less often and for a shorter time, as death got closer. In fact, palliative care grew out of the gaps and lacking of acute care for these patients. Here palliative care is being born and growing up in response to a totally different context, the HIV epidemic. The definition of PC here is very broad, eg to “look after people with incurable illness, relieving their suffering and supporting them through difficult times”. So it is woven into active HIV care in a very different way than at home. We are learning, learning, learning.

Down the road in Tanga we are beginning the ‘roll-out’ of Palliative care and the use of morphine. We gave our first talk there last week at Bombo Hospital (big regional hospital) and took 20 handouts (based on the response in Muheza) and there was a HUGE audience of over 200 !! The questions were wonderful and the discussion after, more than we ever could have hoped for. They are keen, keen, keen and although the particulars of getting over the morphine access hurdles still need to be worked through, it feels very hopeful, and something we can really sink our teeth into. We will lecture, but more importantly attend ward rounds with the newly forming palliative care team, and teach at the bedside. We are feeling quite optimistic about this chapter….feels unencumbered by the unique history that burdens the development of palliative care in Muheza.

I am continually struck by how things here are both completely different and the same as at home. For example the politics of the hospital: the details are unique to Tanzania, but the heated human emotion feels very familiar. Also the patients: here they are in open wards, dressed differently, being cared for differently, different diseases and disease processes, but really in the end just the same. People are people it seems to me. Not to underestimate the huge importance of culture, language, history…but somehow a comfort to be finding common ground.

Religiosity: “at the same time both extremely important and not important at all” (Rose et al in conversation Oct 20, 2008). We are certainly the oddities here to be white and not Christian. But we are welcomed and not criticized it would appear. Perhaps it is because Christians and Muslims live side by side in complete harmony as do dozens of different tribal cultures. This is the legacy of Nyerere (the first post independence president) who set the tone of nationalism and one language of Swahili, insisting on peaceful co-existence that has been long-sustained.

That’s all for now. Thank to all for keeping in touch. Letters/snailmail very welcome !!
Love all around,
Leah

Contest Winners

The contest winners need to get announced

Our blog title was successfully translated by a number of you but there was definitely an order of receipt

GOLD MEDAL our friends in the highlands THE WENSTOBS/FLEMING

Not sure who of the 4 Kevin, Sarah, Erik or jack should get credit

SILVER MEDAL Bop and Charlene Leah’s dad and Charlene are very wired and resourceful I am sure this was a combined effort


BRONZE MEDAL back to the west coast The Svordal/Scarth family

With 4 very bright children I am not sure the parents should get much credit (except for creating them).


Congratulations to all

And a big congrats to Barack Obama

It is cool to be near his home country.

Finally a post

Rose and I just beat Simon and Graham 2 games straight at cribbage. Now it is time to reflect on our last few weeks.
You have heard from Leah lately and if you are reading the boys blogs you have even more idea of our tales

Got a speeding warning yesterday ( 85 in a 50) initially there was a suggestion of a 20,000 TZ.SH. fine but the more senior officer suggested a warning which garnered a hearty asante sana from me.

At a slower and hotter pace we still have a full life.It does end at 930ish at night although Leah and I watched our first movie ,since flying,the other night and stayed up to 11!
‘The Visitor’ highly recommended.

The ‘full life’ just has other less stressful and usually less time dependent issues. Going to the market to get today’s produce. A small fridge means daily market visits. Or roasting and grinding our own coffee beans. Using jay slater’s traveling coffee press technology we are hardly missing our Café Fantastico lattes (leah says’not’)

At present we are many .Graham is here which makes us whole at 5, Sally and Rose,plus we have daily visits from our new friends Alex and Emily , another couple who are docs here from England for 10 months.
They are staying with the nuns at the guest house at the school where the boys are attending and have lunch with us most days( Juliette’s soup is daily, different and delicious)
Ilse our last roommate( a dutch MD doing pediatric malaria research) has been here variably as her parents are visiting Tanzania for the first time from Holland and she is spending as much time with them as possible.

School for the boys is tolerated as they have other distractions ( Graham) and the courses work is a bit boring ad although lunch is provided.. beans rice and ugale (corn flour porridge) is not very appealing.They cycle with leah both ways every day ( unless a rain storm)This is strenuous and hot( afternoon rides can be up to 34 degrees C.) ,but they are getting fitter and fitter and the hills are flattening out. They started bringing a small lunch today and Leah meets them with a treat and water before their return sweat.

Rose has been teaching introductory IT up at the school to the 3rd through 6th formers with mutual enthusiasm.Sal is helping rose and dabbling in about 3 other projects . I think the boys like have them up at school( very familiar faces)

Much to our dear friend Paul Best’s chagrin we have started talking about Christmas and are making plans to go to Zanzibar.

I have been reading as much as I can both books ( slowly slogging through Paris 1919, embarrassed at my lack of knowledge of events that occurred before July 6 1954)newspapers, economists,walrures brought by Graham are being slowly devoured.

Not real happy about Canadian election results very sad for Brione Penn.
Highland political updates make me wish I was home to help during
the election.US election more promising. We get some info on line when power and internet connection and certain indeterminate stars line up appropriately. also I just found out that I can access CNN at the Diana center on some days

Can someone please lend me $$3.275 trillion or so?
those of you who know Dan Nevin( you should all know Dan.N.) should get a copy of an editorial he sent me ( and others I am sure) about the ‘Banksters”

Soccer a number of days a week is how I get a sweat up. Usually with a bunch of younger friends but once with men Graham’s age ( yes graham is a man) Griff stopped watching after awhile. It was not a pretty sight.After the game a fellow asked me if I would give him my soccer boots, I guess he felt I was wasting them or he realized there were many untapped goals still in them.

Silvia is in France for Paula’s 50th (I am not actually sure of the occasion but I am sure it is not her 60th) with Paula ( really) and joel.I found out our dear friends Suasan and Phillip ( who recently lost their wonderful son David)are meeting them and I seriously considered surprising them but just not enough notice to pull it off.

So for me this week was a perfect example of the wonders of this trip with all its ups and downs

Downs

-Graham left
-Sy not keen on school on Monday
-Long discussion with palliative care leadership( karilyn Collins the english MD who encouraged us to come and who developed much of the palliative care here during her 6 years here is visiting) executives of one of the Sainsbury trusts ( considering some funding). The challenges, the personalities, the politics felt quite overwhelming
-No power for over 50 hours( no fans!!,limited cooking- finally got kerosene cooker up and running for morning coffee)
-sally sick with GI complaints ( no further details necessary ) for 36 hours
-a poorly managed , poorly palliated pediatric death – very troubling and representative

Ups

-boys school routine better every day
-griff invited a new friend home for marbles and xactica( card game)
-10 visiting brits( Anglican donors-don’t usually hang with Anglican donors) brought along with their faith a grand enthusiasm- and another new card game Wizard.we assisted in hosting them even with a candlelight meal their first night here and other meals and times together. If you come and visit we found a great “bar/restaurant” the we call Frankie’s ( after the”Maitre D”). we had dinner there for graham’s last night and had 2 large wasungu dinners there over the last week.good food, cold beer, great conversations
-I finally won at Settlers of Catan.. a slightly hollow victory as simon made a late trade out of sympathy rather than strategy . but for now I will take it
-leah and my biggest highlight this week( after a few tough days in a row) occurred when we prepared ( adapted and improved) our local ( muheza) palliative care power point presentation( introduction to palliative care)it was met here with reasonable interest but low attendance, for presenting in the regional capital Tanga at their large hospital Bombo Regional hospital.We made 20 copies of the presentation , only to walk into a room of over 200 people.the presentation went very well, well received, and good discussion after. We will be following up with further didactic teaching and ward teaching over the next 4 months. It made us feel like we can do as we hoped and improve and help develop a sustainable palliative program in the 2-3 major hospitals in the region
next week is a 5 day workshop that had been previously planned to further develop a palliative care presence and we will be assisting in its presentation. It too is in tanga so there will be logistic issues both for our to and froms and the boys schooling. Fortunately sal and rose can help
-simon has restarted violin practice( with the encouragement of financial support for a dirt jumping bike when he returns…he has also developed quite a skill at playing hearts which was the second ”adult” card game I learned after crib
-and finally a wonderful card ..our first snail mail… sent by our dear friend deb lefrank with messages from a large number of friends congregated for a thanksgiving meal at debbie and dan’s place. Thank you so much deb


sadly this is sally and rose’s last week and we will all say goodbye with heavy hearts and leah and I will have to create a new chapter and routine

I heard this week that my dear friend nou’s father died suddenly( he had been in poor health but his death was unexpected)
It has been a peculiar year for life and death juxtaposition( sadly I believe this is the new stage many of us are in)I miss not being there to support him as has me for so many years.

This an adventure ……life is an adventure

Stay tuned don’t touch that dial……


Ps. Hopefully graham will soon download some pics from his visit onto the blog

PPS leah will soon add her thoughts to the blog.. as I said earlier it is a full life and electronic communication is only one of our
Priorities

a

winners

The contest winners need to get announced

Our blog title was successfully translated by a number of you but there was definitely an order of receipt

GOLD MEDAL our friends in the highlands THE WENSTOBS/FLEMING

Not sure who of the 4 Kevin, Sarah, Erik or jack should get credit

SILVER MEDAL Bop and Charlene Leah’s dad and Charlene are very wired and resourceful I am sure this was a combined effort


BRONZE MEDAL back to the west coast The Svordal/Scarth family

With 4 very bright children I am not sure the parents should get much credit (except for creating them).


Congratulations to all

Update

Rose and I just beat Simon and Graham 2 games straight at cribbage. Now it is time to reflect on our last few weeks.
You have heard from Leah lately and if you are reading the boys blogs you have even more idea of our tales

Got a speeding warning yesterday ( 85 in a 50) initially there was a suggestion of a 20,000 TZ.SH. fine but the more senior officer suggested a warning which garnered a hearty asante sana from me.

At a slower and hotter pace we still have a full life.It does end at 930ish at night although Leah and I watched our first movie ,since flying,the other night and stayed up to 11!
‘The Visitor’ highly recommended.

The ‘full life’ just has other less stressful and usually less time dependent issues. Going to the market to get today’s produce. A small fridge means daily market visits. Or roasting and grinding our own coffee beans. Using jay slater’s traveling coffee press technology we are hardly missing our Café Fantastico lattes (leah says’not’)

At present we are many .Graham is here which makes us whole at 5, Sally and Rose,plus we have daily visits from our new friends Alex and Emily , another couple who are docs here from England for 10 months.
They are staying with the nuns at the guest house at the school where the boys are attending and have lunch with us most days( Juliette’s soup is daily, different and delicious)
Ilse our last roommate( a dutch MD doing pediatric malaria research) has been here variably as her parents are visiting Tanzania for the first time from Holland and she is spending as much time with them as possible.

School for the boys is tolerated as they have other distractions ( Graham) and the courses work is a bit boring ad although lunch is provided.. beans rice and ugale (corn flour porridge) is not very appealing.They cycle with leah both ways every day ( unless a rain storm)This is strenuous and hot( afternoon rides can be up to 34 degrees C.) ,but they are getting fitter and fitter and the hills are flattening out. They started bringing a small lunch today and Leah meets them with a treat and water before their return sweat.

Rose has been teaching introductory IT up at the school to the 3rd through 6th formers with mutual enthusiasm.Sal is helping rose and dabbling in about 3 other projects . I think the boys like have them up at school( very familiar faces)

Much to our dear friend Paul Best’s chagrin we have started talking about Christmas and are making plans to go to Zanzibar.

I have been reading as much as I can both books ( slowly slogging through Paris 1919, embarrassed at my lack of knowledge of events that occurred before July 6 1954)newspapers, economists,walrures brought by Graham are being slowly devoured.

Not real happy about Canadian election results very sad for Brione Penn.
Highland political updates make me wish I was home to help during
the election.US election more promising. We get some info on line when power and internet connection and certain indeterminate stars line up appropriately. also I just found out that I can access CNN at the Diana center on some days

Can someone please lend me $$3.275 trillion or so?
those of you who know Dan Nevin( you should all know Dan.N.) should get a copy of an editorial he sent me ( and others I am sure) about the ‘Banksters”

Soccer a number of days a week is how I get a sweat up. Usually with a bunch of younger friends but once with men Graham’s age ( yes graham is a man) Griff stopped watching after awhile. It was not a pretty sight.After the game a fellow asked me if I would give him my soccer boots, I guess he felt I was wasting them or he realized there were many untapped goals still in them.

Silvia is in France for Paula’s 50th (I am not actually sure of the occasion but I am sure it is not her 60th) with Paula ( really) and joel.I found out our dear friends Suasan and Phillip ( who recently lost their wonderful son David)are meeting them and I seriously considered surprising them but just not enough notice to pull it off.

So for me this week was a perfect example of the wonders of this trip with all its ups and downs

Downs

-Graham left
-Sy not keen on school on Monday
-Long discussion with palliative care leadership( karilyn Collins the english MD who encouraged us to come and who developed much of the palliative care here during her 6 years here is visiting) executives of one of the Sainsbury trusts ( considering some funding). The challenges, the personalities, the politics felt quite overwhelming
-No power for over 50 hours( no fans!!,limited cooking- finally got kerosene cooker up and running for morning coffee)
-sally sick with GI complaints ( no further details necessary ) for 36 hours
-a poorly managed , poorly palliated pediatric death – very troubling and representative

Ups

-boys school routine better every day
-griff invited a new friend home for marbles and xactica( card game)
-10 visiting brits( Anglican donors-don’t usually hang with Anglican donors) brought along with their faith a grand enthusiasm- and another new card game Wizard.we assisted in hosting them even with a candlelight meal their first night here and other meals and times together. If you come and visit we found a great “bar/restaurant” the we call Frankie’s ( after the”Maitre D”). we had dinner there for graham’s last night and had 2 large wasungu dinners there over the last week.good food, cold beer, great conversations
-I finally won at Settlers of Catan.. a slightly hollow victory as simon made a late trade out of sympathy rather than strategy . but for now I will take it
-leah and my biggest highlight this week( after a few tough days in a row) occurred when we prepared ( adapted and improved) our local ( muheza) palliative care power point presentation( introduction to palliative care)it was met here with reasonable interest but low attendance, for presenting in the regional capital Tanga at their large hospital Bombo Regional hospital.We made 20 copies of the presentation , only to walk into a room of over 200 people.the presentation went very well, well received, and good discussion after. We will be following up with further didactic teaching and ward teaching over the next 4 months. It made us feel like we can do as we hoped and improve and help develop a sustainable palliative program in the 2-3 major hospitals in the region
next week is a 5 day workshop that had been previously planned to further develop a palliative care presence and we will be assisting in its presentation. It too is in tanga so there will be logistic issues both for our to and froms and the boys schooling. Fortunately sal and rose can help
-simon has restarted violin practice( with the encouragement of financial support for a dirt jumping bike when he returns…he has also developed quite a skill at playing hearts which was the second ”adult” card game I learned after crib
-and finally a wonderful card ..our first snail mail… sent by our dear friend deb lefrank with messages from a large number of friends congregated for a thanksgiving meal at debbie and dan’s place. Thank you so much deb


sadly this is sally and rose’s last week and we will all say goodbye with heavy hearts and leah and I will have to create a new chapter and routine

I heard this week that my dear friend nou’s father died suddenly( he had been in poor health but his death was unexpected)
It has been a peculiar year for life and death juxtaposition( sadly I believe this is the new stage many of us are in)I miss not being there to support him as has me for so many years.

This an adventure ……life is an adventure

Stay tuned don’t touch that dial……


Ps. Hopefully graham will soon download some pics from his visit onto the blog

PPS leah will soon add her thoughts to the blog.. as I said earlier it is a full life and electronic communication is only one of our
Priorities

a

ughhh....hhh..hhhhh...hhhh

Graham wants to cry this internet is so slow...

Sorry to anyone waiting for email replies.

Lots of sun, rains, and good company...

Graham.... for the family...

My birthday post

Today is my birthday and I keep forgetting as it seems so out of place in this context without all the usual cues and prompts. Birthdates are clearly not as important here and are often unknown. As I write referral letters for patients in Teule to send them to Dar for cancer treatment at the Ocean Road Cancer Institute, there are no birthdates to confirm the identity of someone, only names and approximate ages.

We have been here almost a month and the passage of time feels simultaneously both disturbingly fast and amazingly slow. Fast as day after day passes in the work context with little outward evidence of us doing anything, while a cacophony of discussions and ponderings go on inside my head and out with Ambrose and others as we try to make sense of the medical scene. And painfully slow as we focus on the computer screen waiting for an individual email to be successfully sent (or not) or a webpage to pull up (or not) in the brief hours when we can access a computer and the power is on.

Gratefully, a big theme of our existence here is the bicycle. We have purchased 3 and daily rides have become a wonderful part of our routine. I had worried that we would have no bike fitness leading into the cycle trip, but I think that will not be such an issue! The boys’ school is about half an hour away over some seriously hilly but beautiful and un-trafficked terrain (except for pedestrians and other cyclists). We are a curiosity here for sure, as wazunga’s (white people) don’t usually ride bikes but rather are driven around in big white land rovers. Some folks are getting used to us, and simply greet us as regulars, but usually the ride stimulates some comments and shrieks (usually amused and encouraging) from onlookers. We have been strongly advised that the boys should be accompanied out of concern that they could be stopped and have their bikes stolen. Property security seems to be a very big issue here (you should see all the locks on our doors) but gratefully not personal safety.

Mostly I am riding the boys up in the morning, leaving home around 7:30 and at that time the air is still tolerable. I am back by 8:30 and a quick shower is in order before the work day can possibly begin. The ride home (3 pm pick-up) is more of an epic daily dehydration fest, truly feels like you are exercising in an oven, sweat pouring down all surfaces. We carry loads of water with but never can we seem to be able to drink enough. The bikes are made in China, single-gear clunkers that take me back to my blue CCM bike of childhood, although these are noisy (cheap), heavy (cheap) and feel like driving a shopping cart. We are regularly at the bike fundi (repair person) as bits and pieces rattle loose and drop off and inner-tube valves crumble with attempts at pumping up tires. Repairs always cost 500 Tsh (about 50 cents), so that’s tolerable. However, the initial flurry of problems and repairs seems to have leveled off (now that we have prophylactically removed baskets (cheap) and lights (cheap cheap) and we have had a good week of rides without a peddle falling off.

The boys are having a hoot with the bikes. Simon’s is a blue very comfortable slightly better quality with a cushy back seat for doubling someone. Sometimes a friend (Kevie) rides Griff’s bike home and Griffin and Simon double over the bumpy muddy terrain laughing their heads off (until Sy falls off and the heat catches up). The birds and insects usually show us some new species every day and Simon loves to see all the new creatures and try to identify them. It is a curiosity of timing that Sy was just launched into a serious love of mountain biking and dirt-bike jumping just before we left home. His friends have been sending emails detailing their adventures and new jumps they have built and it is just about killing him to hear of their exploits without him !! Hard to reassure a 10 year old that it will all still be there when he gets back…His bike here and our rides over the deep red earth (and mud post torrential but brief bursts of rain) of Muheza district, are a metaphor for how profoundly different everything is here for him. He is coping (in fact thriving) remarkably well. He said to me yesterday.. “can you believe that a month has already gone by ? Don’t you think its going very fast !! “

Griffin has had to face a few more challenges on the other hand. Chiefly he has had a terrible time the last couple of weeks with mefloquin side-effects, the anti-malarial he was on. What began as nocturnal nausea and vomiting (preceeded by non-specific anxiety and claustrophobia characterized by an intolerance of mosquito nets!) eventually (after a normal week without any problems) lead to full on decompensation complete with hallucinations (crawling ants and monkeys) and a couple of completely sleepless nights fraught with intense anxiety and mental restlessness. Poor kid. He has been a trooper through it all as we discussed the symptoms with others and helplessly watched the thing unfold. (We got out the ativan and curtailed the 3rd night) Sadly, Mefloquin is a long lived medication given weekly, so the final effects are still lingering I would say even though it has been 11 days since his last dose. (Some say it can take weeks to completely wash out !!) We look forward so much to seeing him back to his normal self, as he was the first couple of weeks, venturing to the market, playing soccer with the local kids, and reflecting so competently on his experiences in his writing and blogs. ( I will have a thing or two to say to the travel doc we saw in Canada who confidently told me children never get the neuro-psychiatric side-effects of mefloquin!!)

Otherwise, tummys have been reasonable ok and we are enjoying local market shopping and cooking mostly adapted Canadian meals. Sally and Rose have arrived and it is wonderful to see them. The first few days we kept shaking our heads at the sight of them here with us, but now we are settling into a new expanded family and configuration of routines. Rose has already been up to the school and today she met with Sister Gwynneth (the Welsh nun who runs has built and run the school over the last 6 years) and is preparing to teach the newly developed Tanzanian IT curriculum for forms 3, 4, 5 and 6 (todays late-breaking news!!). Sally has a few tasks dropped in her lap researching the ordering or meds for the hospital, and reproducing charts detailing the patient flow systems for the Diana Centre. I will introduce her to the orphan program folks there this aft and see where that leads her. (see their blog for further details of their safari adventures before they joined us).

We went away last weekend with Sally and Rose (as well as Sally and Ben and kids and Alex and Emily) to Peponi a low end rustic beach resort on the Indian ocean and had a wonderful (except for poor Griffin’s bad night) time swimming in the sea and visiting the sand island (white seashelled beach exposed only during low tide) and snorkeling along the coral reef that runs along much of the local coast. It was fantastic snorkeling with colourful coral, fishies, urchins, starfish and tubular mushy things. It was lovely to get away although the contrast of life in Muheza and the resort was a bit jarring, and perhaps a bit early in our time here. That being said I am sure we will re-visit the coast and enjoy those spectacular beaches many times.

Graham arrives in a couple of days and there is great family excitement anticipating his arrival. He has managed to take a couple of weeks out of life at university and fed ex and we hope this is not too detrimental to his studies. It feels right that he come now and share in the early weeks and be able to picture our adventures better from Ottawa. This will be his first real foray into a ‘resource poor setting’ and I’m sure will feel truly surreal in the middle of his school term.

Work continues to be an unfolding adventure of revelations, ponderings, discussions and tiny planning steps forward. We are learning tons about HIV, TB and malaria. We certainly are helping with consults and direct patient care (endless and could consume all time if we chose to), but understanding the big picture of the troubled forces and resources that fuel patient care and palliative care here is much more complex. Sadly, in Muheza what was a relatively thriving palliative care infrastructure since 2003 ish has largely fallen apart over the last two years due to a complex web of problems. What is worse is that there is bad blood in its dissolution and the hospital is not a wholly receptive environment to palliative care and is strained by extreme human and material resource shortages. Perhaps we are fresh faces who can try to redevelop the palliative care foundation in Teule hospital in a sustainable way, but perhaps the division between Muheza Hospice Care and the hospital is also too deep and complex for our timeframe here. We are more hopeful that we can be of benefit down the road in Tanga where the history is different and the interest to learn about palliative care and pain relief appears keen. Every effort to build even the smallest of capacity here and in Tanga that will persist after our departure, remains our goal. So while Muheza has been absolutely ideal from a family adventure perspective, there are unfortunate extra layers of challenge that encumber the work.

Internet access continues very difficult, often extremely slow, characterized by crashes and power outages. It looks hopeful that we will get our own hook up at the Diana centre, but the schedule for this seems definitely on an African timeframe. This would really help and then we could access more reliably as long as there were power. In the meantime blogs and emails will appear in bits and pieces and we thank you for your patience.
Our snail mail address is

C/o Dr.Leah Norgrove
Hospitali Teule
Private Bag
Muheza, Tanga District
Tanzania

Our first week

We have not yet been here a week and already it feels like we are settling into a rhythm. First impressions reminiscent for me of India: overwhelming cacophony of noise, smells and visuals….In a few short days I already feel a bit desensitized to what is so new and amazingly different. I am amazed as how quickly we adapt.The long journey from London went well without significant problems. The boys were wonderful enjoying the freebies of Air Emirates and the swing of travel. We arrived in Dar immediately smothered by the hot hot air , all bags safely with us and eventually met by Juma the taxi driver (amazingly, via our UK contact to Muheza, Dr. Karilyn, we were able to text Juma from Hereford UK and set up a pick-up in Dar/ hotel and bus tickets for the next morning to Muheza !)Five hour bus ride on “Scandanavia” lines, the ‘better’ bus company, without ANY shocks, unbelievable (SCARY) speeds, but free bottled water, biscuits and juice included in the price. Met by Dr. Sally and immediately we are indebted to this lovely family from the UK who have been here 6 years already and planning for 4 more. Sally is a ob/gyn and Ben doing malarial and pediatric fever illness research. Their 3 boys Zach/Max/Piran (8/4/4 mos) blended with ours in that amazing way that kids instantly do and introduced us to some of the local kids who hang with the Wazungas (white people). They fed us lunch and supper, and walked us around Muheza which is a few crazed streets of tiny shops selling their narrow range of stuff, fantastic open and covered market and mosques alive with Ramadan (Moslem festival we have stepped into the middle of this month of Sept). A far cry from the Lonely Planet guide’s description of Muheza as a ‘scrappy cross roads town’ that could easily be left off the travel itinerary. On the contrary, feels like a perfect size for this Canadian family, and full of unique Tanzanian life for us to explore and find our way.Our house is great, shared with Dutch MD researcher Ilse and we quickly unpack stuff and watch the kids stake out their domains. She has stocked some food so really there isn’t even a scary low of “what will we eat and where do we get it ??” The house known as Hillview, is spacious and obviously built by Wazungas (complete with sit toilet, water filter and shower which wouldn’t be the norm here) and we feel lucky and comfortable. The house comes with ‘house girl’ Juliette who makes us wonderful soup and bread for lunch, washes the clothes and dishes and cleans. Imagine! She is lovely and welcoming and will teach us a lot of Swahili.
The next day Sally and Ben bundled us off to Tanga (larger town down the road) where provisions like cheese and yogurt and safe meat and a bigger market are to be found. We stock up and then spend a lazy afternoon at the Yacht Club (sounds posher than it is) for our first swim in the Indian Ocean. Warm salty water…what a concept.We are greeted in Muheza by a couple of brief power outages which we learn are frequent but usually short events. Uncharacteristically, there is a major outage of a greater magnitude that begins shortly after we arrive involving the hospital, in particular the lab and the hospital based internet which we learn will be our lifeline to the outside world. So for the first few days here access is not easy and we eventually find an internet café on the other side of town with very slow access to get off a few brief hellos to announce that we have landed safely.The power issue is big for Ben and his years of research samples, tiny vials of blood and serum that need to be stored at minus 70 and there are a couple of frantic days as Ben tries to find temporary freezer homes for them. Ultimately, they are shipped off down the road to a different part of Tanzania to another research site.The week settles into the daily jobs of buying a bit of food, figuring out what to make for supper (yes the question follows us across the world), walks, explorations, and gentle introductions to the hospital. We feel very welcomed by all. “Karibu” or Welcome in a million variations. We attend morning rounds (overwhelming reports of deaths in the night, new admissions and unintelligible monotone summaries of critically ill patients). We try to get our ears into English as a second language with Swahili as the first, let alone the Swahili. Sally tours me through the wards which are ‘Nightingale’ style open wards, male or female with 30 beds closely lined up beds with each holding at least one patient if not 2 or 3. No curtains. One or maybe 2 nurses. Although I know it is exactly what I expected and knew to be the reality, it is still hard to absorb.
The Muhueza Hospice is quite separate (called the “Diana Centre” as the monies for its development have predominately come from the Diana foundation) and that is where we will be based. We are learning about the necessary shift of focus of the palliative care team in the last short years (2-3) who now provide ARVs (anti-retroviral treatment) for the HIV patients, rather than simply supporting them as they faced certain death. The two services (active HIV care and palliative care) will separate in the timeframe we are here and that transition will certainly shape our experience. The layers of politics, both Tanzanian and Wazunga will take some time to understand. We will go gently and learn more than we give for quite some time.The boys have already made friends, partly via Zach and Max, but also via the now daily late afternoon game of soccer that has started. Amb and the boys wandered over to a dirt soccer field (generous description) with a ball and were quite instantly surrounded by 10- 15 boys. A couple of kids, they discovered go to the same school our boys will attend, and so there will be familiar faces. Their English is marginal, but better than our Swahili (!) and enough to make a good connection.We all plan and prepare for school next week. Turns out the school they are to attend is about a 45 minute walk out of town, so we decide to buy bikes to make the daily journey more realistic. A couple of days ago we walked up there and despite our best intentions found ourselves walking in the peak of the African sun without enough water (3 bottles was no where near what we needed). We collapsed for the rest of the day and drank drank drank. The boys seem fine with it all, and find humour in the seriously ugly green gingham shirts and green shorted uniforms, rather than despair.We are so proud of how they are doing with all of this. We can see already that they will speak Swahili much better than we will by the end. Muheza is certainly a setting where they will play with and attend school with Tanzanian kids, and that affirms for us our decision to come here, despite the currently indecipherable complexities of the work situation.
Have bought coffee beans in the market and roasted them myself for the morning brew! Ambrose says it is not up to Café Fantastico: I am awaiting the frother when Sally and Rose arrive next week and then we will have lattes.