The Bats

Every night about dusk 4-5 million bats take to the air in the northern reaches of Dar-es-Salaam and fly south to overnight in a warren of caves to the south. This occurs like clockwork. Most are several miles away from our balcony but many are quite close. This is a video clip of their flight, brief but illustrative. It is a .mp4 file which plays with all Macs and on PCs with QuickTime.

These are fruit bats with an average wingspan of 3 ft. As awe inspiring as this migration is there is some poignancy to it currently. Fruit bats are THE natural reservoir of the Ebola virus that is currently slowly working it's way across the heart of Africa from west to east. In Dar we are at the terminus of this migration. This was the genesis of the awareness seminar presented this week and mentioned in the last post. We are hopeful that day does not ever arrive.

A Day in the Life in Pictures

Nothing profound here, just some views from the day to day routine of going to work and back with a few comments. Hope this gives you some idea of the physical environment.

Morning balcony view with Upanga high-rises in the distance

The walk to work is about a mile on dirt (a very fine sandy mix) sidewalks

I pass the Aga Khan Exhibition Hall which currently has Chinese brand merchandise (appliances etc) being demonstrated. China is a major trade partner. I venture no comment when queried about the quality of said goods.

Traffic at a major intersection is chaotic with no lights or stop signs. You just kinda ease your vehicle into the intersection and play chicken with other motorists. The right of way seems to go to the bigger vehicle all the time. Size matters!

Needless to say, being a pedestrian crossing this road is no fun. Getting run over is actually the biggest cause of injury for PC volunteers in Tanzania, not malaria or other diseases!!!

Soon I hit a real sidewalk along this major road. It is swept by hand every day by an older woman and is kept spotless. Often even the dirt itself is swept so as to be neat.

Once I get to my office (pictured below) I try to cool off for a minute or two using my AC and fan (highly prized) and then don my white coat replete with the Peace Corps emblem sewn on by hand and the Seed Global Health lapel pin which we received in Washington.

My office with computer that is not connected to the internet at present.

The desk of my office mate with another highly prized item...a printer.

Unfortunately I often arrive drenched with sweat after this modest 1.5 mile walk. The idea of putting on a white ocoat is repellant. Guess what? This is the cool dry season. I am not optimistic about my fate in the hot, humid, rainy season!

Off to the wards I go for rounds on the chest service patients to be described in another post. This is a picture of the families gathered outside the entrance to the medical ward around lunch time. Visiting hours are limited and strictly enforced. During visiting hours the families have to both feed and bathe and otherwise provide care for their loved ones. This is not the role of nursing in the hospitals here. More on this at a later date.

This is a simple flower bed outside my office which is hoed and raked daily. For me it represents the Tanzanian focus on things being clean and orderly. Of note the hoes are about 3 feet long so this represents back-breaking work wherever you see it.

This was a scene I stumbled across yesterday leaving the clinic. The covered walkway you see stretches across the campus of most of Muhimbili National Hospital (MNH) which has multiple buildings spread overs large campus. Since patients are transported outside and since it will rain like crazy in the wet season these are very utilitarian.

The scene was one of about 100 young men with motorcycles who had congregated outside a particular building and were obviously waiting for something to happen. Most every young male here wants or has a motorcycle. These are generally Indian made 125 cc motorcycles that are used for transportation and revenue generation.  They are also responsible for an epidemic of accidents and injuries which one of the local orthopedists described to us at Dar orientation. Amputees begging at crossroads are not an uncommon sight. 

Shortly after this picture was taken a coffin bearing the remains of a young man, a motorcyclist, who was killed in a traffic accident was wheeled out of a building on the far side of the picture. A huge outpouring of expressed grief followed as these young men mobbed the coffin and escorted it down the road. I  was very impressed. This appeared to be the African equivalent of a Hells Angels type sendoff. I am overdramatizing this to make a point. These young men are a community and this was a shared tragedy. As a motorcyclist myself, it was a moving scene to witness.

OOCOM!

Two days ago I had the opportunity to attend a lecture on Ebola organized by the ED Department at Muhimbili. The focus was on preparation for receiving unconfirmed but suspected Ebola cases. There was great interest amongst the faulty of MUHAS and the staff of the Muhimbili National Hospital. The presenter is the head of the ED. Of note, the presentation was in Kiswahili until the professor next to me spoke up and asked the presenter to speak in English after pointing to me. I was quite grateful for this kindness. More on Ebola later....

Attendees

After the three hour presentation I went for lunch at the cafeteria adjacent to my office. This is typical lunch fare...beans, rice with a vegetable sauce, spinach, baked green bananas, and a cabbage. the fare is the same every day. The price is $3.00 or TZS 5,000.

Back home later in the day we had a grilled cheese, rice, carrot and chips supper complete with ice water and a spot of wine. Laurel is teaching me to cook!

She has every right to ask "Is this safe to eat?"

You Are In the Army Now

We completed our Peace Crops training about eight days ago after two days of meetings with our local counterparts most of whom travelled to Dodoma from our future sites for the sessions. Language training wound down and it was time to be sworn in to the Peace Corps in a low key ceremony at our hotel/retreat.

Training session

Swearing In Ceremony

Cutting the cake for our reception!

The group split up the next day and Laurel and I were off to Dar with the other four volunteers who posted in Dar with us. It was another bus trip through Morogoro to Dar. 

Cloud covered mountains outside Morogoro

Laurel has already posted pictures of our apartment in the blog post before this one. We have sent most of the last week getting settled in both here and at Muhimbili University and the adjacent Muhimbili National Hospital. The campuses are large and about a mile away so we are walking to work daily. 

Clinical Ward building at Muhimbili

We have observed that Tanzanians keep things quite tidy and neat. They even sweep the dirt daily. Everyone is friendly and responds when greeted. Although we see few foreigners on our daily trips we feel pretty comfortable in this warm and welcoming society. That said, Dar is still a big city with significant petty crime necessitating caution and situational awareness when one is out and about.

Harbor view from the steps of the St Joseph's Cathedral downtown

We are delighted to be settled in our own place following our own schedules and cooking our own meals. We have much to learn about our environment, but are becoming more comfortable and savvy at shopping as we learn more about our locale.

Bill cooking fried okra. Mississippians unite!

Looming sunset seen from our apartment balcony facing west

Settling in Dar es Salaam

 Least anyone think we are roughing it grassroots-Peace Corps style; we are not. A few photos of our apartment in  Dar es Salaam which is provided to us by Muhimbili University (not the Peace Corp) where we are both visiting faculty members. We are within walking distance (10-15 minutes) of the University and accompanying Muhimbili National Hospital, the country's  National Referral Hospital and University Teaching Hospital with a 900 bed facility, attending 1,000 to 1,200 outpatients per day.

The view from our living room balcony

Sunset over the sky line

Bill on the balcony, taking it all in.

Master bedroom

Living room with aforementioned balcony through the sliding glass doors. And, yes, that is a flat screen TV.

Dining room

Our huge kitchen w/utility balcony visible through the window

Our LG refrigerator complete with family photos

Mtitaa - a trip into the countryside!

Yesterday we ventured to Mtitaa - community of about 10,000 people 60 km from Dodoma. The trip as made by small bus (a daladala). Every seat was full but it was still at only 50% of its usual capacity since these things are usually packed to the gills.

 Bill

Villagers filling water canisters at well head

Back of the bus

After a long and dusty ride (dry season here so it is quite dry and cool) we arrived. We met with the village officials in their tiny town hall and all introduced ourselves in Swahili, a fairly humbling experience for all of us. It was another example of the importance of greetings in Tanzanian culture. It would be unthinkable for us to just show up and start looking around etc.

 Being introduced to the Village's Officials in the town hall

Community Vital Statistics on the wall of the town hall building/room

Our hostess, Deanna, a Peace Corps volunteer, who has lived here for the last two years, took us on a tour of the town's medical facility, a regional health centre in the Tanzanian parlance. It was spartan but highly functional.

Deanna

The clinic and hospital are headed by Dr Anna, an AMO, or Assistant Medical Officer. She has had 5 years of training after high school but in not a doctor per se. She can perform surgery but does not operate at this facility. She has a two year commitment to serve as the cost of her education. She does treat major illness here like severe malaria, pneumonia, TB and HIV as well as providing all maternal and obstetrical care. There is an ambulance if patients need to be transported to Dodoma such as for a C section.

AMO Office and Exam Room

TB Treatment Guidelines Posted in Office

Top 10 list for the Health Centre

The community is quite spread out. They are anticipating the arrival of electricity in the next year so many of the older wooden roofed structures are being replaced by metal roofed modern houses which can be wired safely for electricity. The clinic and one ward hospital does not electricity. Vaccines are kept in a propane powered refrigerator. Vaccination is free.

Our next stop was a local primary school where Deanna has been helping to build toilets. The kids were very excited to see us. The classrooms were packed.

Classroom with children

Classroom

Same classroom when empty

Next we went to Deanna's house to get a sense of how the two year volunteers live. 

We found it to be quite spartan as she has neither electricity nor running water.

House

Bedroom with Mosquito Net

With those sights behind us we returned to our hotel in Dodoma. I was grateful to be in a large city with the promise of some of the amenities of modern life!

Field Trip to the Regional Hospital in Dodoma

Tanzania has both a public national national health system and a much smaller private system. The public system was designed to meet the needs of the populace from a small village to a regional metropolis. This week we saw two of these, the district hospital in Dodoma (a step below Muhimbili) and a Health Centre (one step above the smallest facilities know as dispensaries) in Mtiti, a community of 10,000 about an hour from Dodoma. Both were fascinating and worthy of a post. As you will see we are beginning to get a better feel for what the phrase "resource poor environment" actually means.

Outpatient meds for HIV are generally free as PEPFAR provides these. PEPFAR is the Presidents Emergency Program for AIDS Relief and was established by George W Bush. It provides millions of dollars annually for AIDS and has been judged as successful although any program of that size has worthy critics. Of note, PEPFAR provides almost all the funding for GHSP, our Peace Corp program. Seed Global Health, the Boston NGO behind GHSP, raises money independently which largely goes to tuition debt relief for GSHP volunteers. For those of us who are older and debt-free there is no support per se. The younger members of our cohort however cite the tuition relief as a major factor in their GHSP participation.

Dodoma's facility was not open for outpatients the day we end since it was Eid, the end of Ramadan and thus a national holiday. Although we missed seeing the bustle of the place the absence of all but inpatients made touring the facility much easier. All public health facilities charges modest fees for their services. Remember, this is the premiere facility in the nation's capital.

Welcome Sign at Dodoma Hospital Entrance

Prices are: Dental Extraction $1.50; Minor Surgery $3.50; Major Surgery $25

Insurance is available via government subsidy or on the private market. In some of the pictures you will see prices posted for services. At current exchange rates the sixteen hundred Tanzania schillings equal one US dollar (TZS1600 = $1).
Our visit to the Dodoma facility was eye opening.  It was very sparse. Patients being seen in the Emergency wait outside on wooden benches.

Our group outside entrance to OPD (Outpatient Department)

Outpatient Waiting Area

Admission Fees range from $7 to $2. An X-ray costs $2. 

Hospital Sheets on the line

Inpatients are in common wards with 24 beds/ward.  Separate buildings house different type patients sorted by type (medical, surgical, OB etc). These wards had patients in metal frame beds with mosquito nets and not much else. The laundry hangs outside on lines. I have no pictures since patients were in the beds.

Laundry Washing Station in background 

List of the Top 10 Conditions in the Surgical ward.

Many of these conditions require major surgery. Prostatectomy for $25! 

One of our number is a retired Indian-American surgeon who described the surgical theater as being comparable to "rural India in the 60's".  I missed the laboratory but was told by my group there were many modern diagnostic analyzers donated by Abbott. They had signs on them saying "unable to use since 2012 due to lack of reagents". 

This is an all to common problem in Africa - donations of high tech equipment that prove worthless over time because they are either not maintained or not used due to lack of training or lack of long term funding. The term for this is "Dead Aid". Sustainability is all important. GHSP addresses this by training human resources. Keeping doctors and nurses in Africa after educating them is ongoing issue. Many leave for a better life elsewhere, the "brain drain" phenomenon.

Ward Buildings 

I toured the ICU and noted one monitor, one oximeter, one suction apparatus, one oxygen concentrator and one mechanical ventilator for a four bed unit. All were quite worn and tired in appearance. 

The nursing staff were proud of their wards which were unfailingly clean but threadbare.

Much to my delight I discovered preferential "Doctor's Parking" (RMO=Regional Medical Officer) is world-wide! Hopefully the RHS drives a narrow car.