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.