Living Deep and Wide

We are nearing the end and I haven’t blogged for a while. Hello out there ! Amazingly it feels like there is no time for reflecting in a blog!! How can that be, that we are so busy here even at altered African heat-pace ?

Lots to reflect upon. We had wonderful visitations by friends in January, first by Joel and Paula, overlapping by one night with my previous office partner Fiona Manning and friend Stephanie and their lovely 11 year old daughters. Joel and Paula made the epic journey for just 2 weeks with us, and they were wonderful to be with, such ardent explorers, keenly interested in anything and everything. Made us feel like we were living at the end of the anthropologic rainbow here in Muheza, and like our little family adventure was unparalleled. It was so nice to see Fiona, with whom I have shared so many clinical hours and reflect upon the medicine here with fresh eyes. Stephanie had lived near Mt Kilimanjaro with her family for almost a year, last year, and was now visiting her placement in follow-up and was a wealth of stories for comparing and contrasting our experiences.

Most recently we spent a week “on safari” which was other worldly. We had an amazing time !! We spent 3 full days in the Serengeti, then one each in Ngorongoro Crater and Lake Manyara. These are unbelievable places teeming with wildlife you can hardly imagine. I know I will both date myself and trigger childhood memories for many of you when I mention Mutual of Omaha’s Wild Kingdom on Sunday nights and say that it was surreal to actually see all of these great beasts in action and linger for long minutes and hours just watching. And these are not distant sightings !! We were metres away at times from 4 of the “big 5” (lion, water buffalo, leopard, rhino and elephant). It is like a giant (massive) reverse zoo, where we are the ones in the captivity of the car while the animals wander around us, seemingly quite oblivious to us (of course, simply desensitized to the thousands of vehicles who quietly watch them annually).

We were greeted by huge herds of migrating wildebeests and zebras (who travel together as one has good eyesight complimented by the amazing hearing of the other…have already forgotten which has which), and they were calving so saw lots of wee ones. Huge numbers into the tens of thousands and a real sense of a ‘migration’. Then it all unfolded over the days with multiple sightings of elephants, giraffes (my personal favorite!) tons of different gizelle/impala type creatures, water buffalo, cheetas with vultures post kill, lions (again lazy and satiated post grizzly wildebeest kill) , hippos and crocodiles in the wet pools, wart hogs, hyenas and jackals to name a few ! Ambrose became obsessed with the birds, and our guide Lawrence was highly knowledgeable and we identified over 100 of the 530 species that grace the park. They were the most beautiful colourful and curious of creatures, in all shapes and sizes of bodies, bills and feet. We will need to do a separate slide show just of our safari as it was truly an experience overflowing with the wonders of mother nature. The role and presence of the Massai also another interesting layer of local history and modern age lessons in traditional land use vs conservation (reminds me of first nation issues in Canada).

To think that we had contemplated not doing safari, as we were put off by the intensely unpleasant ‘vicious’ (as one medical student put it) aspects of the Safari business! Fortunately we were able to find a quite painless connection via the husband of a nurse at the hospital and we got a great price and wonderful guide and had the time of our lives. It was wonderful to see the kids so enthralled, especially Simon, who gleefully exclaimed “I could do this forever…”. This was why he came to Tanzania really, and now that the Safari is over he is quite ready to move on…

After Safari we returned to Muheza to no water and no power, and still find some North American ability in us to whine, and moan (it is 35 – 40 degrees after all) despite the fact that no-one in Muheza has water and everywhere we look, the industry of water transport and selling is milling about like activity in an ant hill. I find myself secretly thinking about a hot shower in Cambridge, and the temperature being cold enough to want one. I am also thinking about riding my bike with gears and silence (no clunks) without sweat pouring off and then dried in an uncomfortably itchy crust.

And so we are down to the last 2 weeks of work life here. We still have a few important teaching wrap-up sessions at Bombo, and the nursing school and in fact I am procrastinating on the final power point prep to write this blog ! Just before Safari, Ambrose and I shared the highlight of our time here when we funded a 2 day palliative care workshop (with some of the donor dollars from all of you!!) at Bombo Hospital. ‘So what ?’ you may say….BUT what is important is in the details. I had suggested we do an intro to Palliative Care lecture (thinking of an hour or 2) for the new satellite CTC clinics (the name given for clinics that care for people with HIV) that were opening in the Tanga region. Our little team took the idea and ran with it and before we knew it, it had become 2 days and 23 participants that included not only the new CTCs but also TAWG (Tanga Aids Working Group who do home based care), the Red Cross (home based care) and the head nurses from all the wards at Bombo Hospital. The best part was that several of the sessions (pain assessment, HIV related pain, and communicating bad news ) were delivered in Swahili by our new PC team at Bombo. This was so amazing, to see the confidence and passion that they brought to the teaching and how competently they had taken on the role of being leaders and educators in PC. This was a moment of great pride and satisfaction for Amb and I, and we now feel like a seed has been solidly planted. There is of course lots of next steps, we are discussing with them (more training needed for these leaders, money for a program, and staffing…etc) We will have our fundraising work cut out for us upon our return…However, this work becomes a joy, when we feel such affection for the individuals and have such a positive sense of their caring and their leadership skills.

Dr. Violet Bakari, the leader of the team, continues to reveal her powerful self to us in a quiet understated manner. Just yesterday, she had our family to her house for lunch and we were welcomed in a fully Tanzanian way, and had the opportunity to make a deeper connection and planning for the future. She shared with us her HIV + status (which had escaped our knowing over the last several months) and more about her health history and work accomplishments. She has worked closely with Dr. Mtatifiko over the last 3 years and has developed the Bombo CTC herself into the thriving functional arm of the hospital that it is. She only began her own ARV treatment in 2004 and was very sick prior to that, so this is really a remarkable accomplishment. She is now a picture of good health and is a success story of ARV accessibility. And now she quietly creates the palliative arm for the hospital, competently bringing the right folks together and building capacity in them. Gladly we will be able to work with her from afar over the next months and years as we look to the future.

Things at Teule, however, continue in a sea of politics and dysfunction. Amb has really given it the college try as they say, using his wonderful management and conflict resolution skills, that he brings from being Chief of Staff at SPH. But to date we have not shifted the milleu, and the 2 sides are deeply divided, and when we leave, so will leave the palliative care in the hospital. At Teule Hospitali we ended up doing precisely what we did not want to do, which was to provide direct service (some 80 plus consults between us) but not build capacity in Tanzanians. Those patients I am sure benefited from our presence here but sadly we will leave (unless some miracle happens in the last 2 weeks!!) without a lasting impact on program development. The reasons are complex and educative (of Tanzania, resource poor settings, of tribal traditions, of HIV/AIDS foreign aid sequelae, of religious leadership, of personality and leadership) but too long for a blog entry.

The whole thing of ARV (anti-retroviral) care in Tanzania is mind-boggling. These are complex treatments with side-effects, and need for absolute unwavering adherence to avoid viral resistance. The system of delivery is new since 2005 or so, constantly changing and expanding at an explosive rate to large numbers of people. However, the anthropology of its impact is not simple and completely different from the introduction of ARVs in a place like Canada. We met a young German MD at Bombo, whose partner is in fact a social anthropologist looking at peoples experience of ARVs both from clinician and patient/family perspectives, and I will be keen to stay in touch with them and learn more of this important research. In Canada, introducing treatments like active HIV care is difficult even when the health care delivery in general is advanced and layered and rich. Here, they are grappling with this complex beast when there is no reliable water, or power or basic medicines, shortage of health care professionals, and the majority by a long shot of the populous live in remote rural villages!

But most importantly I have realized, is that it is a completely different starting place in terms of the lay knowledge base around one’s body and health and disease. For example I saw a patient at Bombo who had advanced breast cancer. Her right breast was consumed by a large mass (peau d’orange for the medical folks) visible spread of the cancer along lymph nodes just under the skin one could see as a lumpy track heading for her arm pit, big lump under her right armpit, and swollen right arm, visible enlarged liver full of metastases. My point is that this cancer had been brewing for years unknown to her. She came to hospital because her right arm was swollen and painful. Think how quickly a typical woman in Canada would have been into her doc had she found a breast lump!! By contrast this woman, had no idea anything was wrong with her breast, and had never heard of cancer. This is a single story representative of a very common scenario. So in the HIV context we can not expect any knowledge base around the idea of germs, bacteria or viruses, let alone viral mutation, infections, or disease transmission. Of course this is changing especially now that treatment is available. Sadly, we are seeing a 2nd wave of deaths, because of course people feel well on ARVs and then think they don’t need them anymore, or side-effects (such as appetite stimulation in the context of not having enough food to eat) make it impossible to continue. All of this is a tall order for HIV educators and care providers, like Violet, and we are blown away by their adaptability, and resilience.

Bus crashes have been a terrible recent theme. Traffic/driving here is unbelievable scary. Speeding, reckless passing, poor vehicle conditions ( 5 gallon portable gas tank at our feet in the dala dala…) . By far and away the most risky thing we have done is to travel to Tanga twice a week and take the bus to Arusha for Safari….Terrible fatalities in the last month on our little stretch of highway, both speed related on the part of careless bus drivers, have resulted in dozens of fatalities. I will not miss this aspect at all. Always feels like a terrible leap of faith to get in a car/bus and go somewhere.

Anyways enough heavy stuff. Ambrose and I look at each other on a daily basis and marvel at the time we have shared here. For all the ups and downs, it has exceeded our wildest hopes as an experience for our family. We have been blessed with a safe and fascinating time here, and solid connections to individuals who have touched us and welcomed us despite our lousy Swahili acquisition, and odd Canadian way of being. I am cherishing the last few bike rides with the boys up to school, and my solo weekend rides through the sisal fields (now much more able to identify birds etc post safari). We are dividing up the last of the donor money between funding vulnerable children to school, provisions for palliative care, support for home based care, and a myriad of other little bits here and there. We feel honoured to have been trusted to share this money around, and grateful to have such concrete directly helpful spots to put it. We will prepare a report of all the homes it found.

It has been unbelievable to watch the boys develop and blossom and adapt. As my mother would have said, “my buttons are bursting with pride”. Each in their own way in their own time, they have come, and learned and shared of themselves. They zoom around Muheza on their bikes, competently exchanging the long multiple Swahili greetings, visiting the various fundi, bargaining at the market and generally taking it all in. Since returning to school in January, there is suddenly a young lad named Ally who rides with us to school, and a gaggle of boys have appeared at our house daily after school. Language still a barrier, but they have the commonness of curiosity in each other. I am so glad we persevered with Holy Family Primary School and didn’t bail to the International expat school in tanga.

And to watch my sweetie Ambrose dive into this time in Africa, has been an affirmation of love and wonder. As we all have seen him give, for this and that, and shared in his endless ability to just ‘get stuff done’ and find the time for everyone and everything, so he has given to Tanzania in the same Ambrose style. (Not that I don’t get very tired of being ‘Mrs. Dr. Ambrose’ and quietly accepting my less visible role….) But together we are a good team (it is the first time we have worked together so closely), and have had the gift of a similar way of seeing things, and endless discussions about life and death and HIV , foreign aid and Africa and human-ness and parenting. I will cherish these six months as a rich and wonderful journey. As one friend wrote in an email, a time of ‘living deep and wide’.