Balcony Garden Update

Things were going great guns until about three weeks ago when the beans got some kind of blight from which they have not recovered. We were already fearing the consequences of their going three weeks without water during the looming Christmas vacation back in TN. My homemade watering system using aquarium tubing, valves and a water reservoir will sustain the healthy tomatoes and basil and mint but the speckled butter beans ( my pride and joy) are toast.

We have been surprised at how well this experiment has gone.

The speckled butter beans did not make it.

We are looking forward to the tomatoes though. Not bad for the resources we had for this project!

The Walk to Work - a short movie

This is the height of banality. Nonetheless, I had fun generating this using my iPhone's camera and a photo program that took pictures every 15 seconds. It goes by fast. Blogger is refusing to accept uploaded videos today for some reason so you will have to download the file from a file repository per the link.

The Walk to Work

Muhimbili National Hospital

Hospitals have always fascinated me. I grew up trailing my Dad around Marion County General Hospital. The uniforms, the smells and the sounds are forever embedded in my mind. Muhimbili National Hospital (MNH) has been a significant addition to my mental inventory of hospitals. It is THE national hospital of Tanzania, a country of over 40 M people. There are other at least four other large referral hospitals spread around TZ but Muhimbili occupies a unique place as the only national hospital.

"Welcome to Muhimbili National Hospital" that sits in the middle of the roundabout entrance to both MNH (to the right) and MUHAS (to the left)

There is a roundabout at the entrance to MNH and MUHAS that I walk through every day. It is also a bus (dala-dala) terminal and a taxi stand. It is an incredibly busy and chaotic place. After months I have begun to understand its rhythms. In the morning between 6 and 8 it is an absolute beehive of activity with thousands of people streaming in and out of MNH. Many people who work in our area of Dar (Upanga) come in from distant areas of Dar and get off the buses there to walk to their workplaces from this terminus. 

The Entrance to MNH and MUHAS at 7 AM

The activity level there is overwhelming most days. You see a huge cross section of Tanzanian society converging there every day. Most days it is crazy busy with people streaming in and out of the main gate to MNH to both seek care and take care of relatives on the wards. There are multiple businesses located there as well as a market for fruits and vegetables. Dala-dala hawkers are shouting out the destinations of their buses and people are everywhere.

Main Entrance to Covered Walkways at MNH

For many years Muhimbili National Hospital was the only place in Tanzania that trained doctors and nurses. It was and is the place complex cases landed. What distinguishes it currently is its nursing and medical staff. Other hospitals may have nicer facilities and may be more efficient at providing patient care but MNH has the specialist doctors and the expertise if any place in Tanzania does. Despite its limitations it remains a unique place and occupies a special place in the minds of most Tanzanians. They may love it or hate it but they know about it for sure and have an opinion about the place.

Overhead from Google Maps of the MNH campus

Medical training is a bit different in Tanzania and follows the British model generally. This was a British colony up until the early 1960's when Tanzania won its independence and their influence is still quite evident in many things. Students come to medical school straight from high school after they have done one advanced year and made the grade via a national testing system. The government tells you what your options are based on your past performance. If you are headed to professional school there are no choices except yes or no. Those directed to one profession may not cross over to another in general. It reflects the residual of the 20 year, post-independence Tanzanian socialist experiment.

Sign on the medical student dormitory by my office

First you must complete five years of medical school. Becoming a specialist is then a multi-year process with 6-7 years required post-medical school. You pay for this specialist education and are treated as a student and have classroom time and instruction as well as clinical duties. This is in contrast to the US where residents are paid but were historically worked like dogs. Frankly, the TZ residents do not work nearly as hard as US residents although that gap has closed some with recent limitations on resident work hours. The number of specialists (internist, surgeon, obstetrician, pediatrician) are limited and spots hare highly competitive. 

TZ Medical Super-Specialist Career Pathway (Nephrology in this example)

Most students need money for tuition and living expenses etc. The government "sponsors" you via a grant. It is not at all uncommon for a career to be halted for two years while you await sponsorship. Further specialization to become a cardiologist or pulmonologist etc. requires another 2 plus years. You are awarded a Master of Science degree with that and become a "super-specialist". Muhimbili is the only place in the country offering what we would call fellowships in the US. There are very few super-specialists in the country and most all of them are al Muhimbili. This is the only place where they are trained and the availability of such training is a very recent development in Tanzania.

My counterpart, Professor Magusi, lecturing to newly arrived third year medical students on the MNH campus

Families are responsible for feeding and bathing etc. their relatives daily. The hospital only provides a breakfast of corn meal porridge to its patients. Water, other food and any number of medical supplies that are not in stock are the responsibility of patient families.

Back of the kitchen where large vats of the corn porridge is prepared for patients

Increasingly patients must pay for advanced services such as imaging or unusual antibiotics or oxygen. Outside the hospital there are numerous pharmacies that provide everything from pills to IV fluids to central lines to TPN. If you cannot pay you simply do not get the treatment. Money is tight. A third of Tanzania exists below the poverty line locally and they tend to end up at MNH.

Prices for advanced imaging like CT etc. TZS 100,000 = $57. These are significant sums to the average Tanzanian. Many cannot come up with TZS 100,000. 

Typical walkway scene with family taking their hydrocephalic child to a clinic visit

Families stay outside the grounds and then come in several times a day for visitation. There is no hotel for family members. Patients from all across Tanzania may be in the hospital for months at a time. Family is hugely important to Tanzanians so someone must stay in Dar with the patient the entire time. Getting here from the distant corners of the country is a major undertaking for most (multi-day bus journey while sick) so they stay in the wards until tests come back etc. rather than return for the next phase of an evaluation as is common in the US.

On rounds with Professor Magusi, my counterpart

It is a huge, sprawling complex with five large multi-story (4) wards for OB and Women's Services, Medicine, Surgery, Pediatrics and a mixed services ward. There is also a psych hospital, a TB ward, a very busy Emergency Department and a huge facility called MOI which houses trauma (lots of that due to the proliferation of cheap motorcycles and unskilled young men who get chewed up on them), neurosurgery and orthopedics.

Typical large ward building and manicured grounds

Handwritten note on the walkway to the chapel on campus in the background warning TB patients to stay away. There is a mosque next door to it.

Patients waiting outside one of the outpatient clinics are MNH

Entrance to the Tuberculosis Ward

It is adjacent to MUHAS, the health sciences university to which Laurel and I are attached. Its campus dwarfs that of MUHAS in size. There are untold numbers of smaller speciality buildings which house things like HIV, TB, diabetes and other specialty services. Many are the spawn of past donor grants or the largess of the US PEPFAR program. There are a alliances with other international universities such as Harvard, UCSF, University of Bergen in Norway, the Karolinski Institute in Stockholm and various other universities from around the world.

Outside of an office building at MUHAS. Everything has wrought iron over windows and doors for security and theft deterrence.

It is a government facility and also serves as a major employer in Dar-es-Salaam, the business and governmental heart of Tanzania. It employs a small army of people including nurses, doctors, gardeners, aides, security, maintenance and housekeeping staff. Most significantly it has its own medical staff which is spirit from that of the academic faculty at MUHAS. They previously were all the same.

Incinerator with medical waste being sorted prior to burning. Little is thrown away if it can be re-purposed. All waste is sorted by hand to recover anything of value.

MNH outreach vehicle with Stop TB message

Covered walkways connect all the buildings and provide welcome shade at this time of year and will be invaluable during the rainy season to follow.

It is run by an Executive Director who is a governmental appointee and reports to a Board that is linked to the University of Dar-es-Salaam, Tanzania's premiere educational destination. It is ultimately overseen by the Ministry of Health whereas MUHAS, the university, is overseen by the Ministry of Education. This governance split came about over ten years ago and has resulted in increasing friction between the two entities over time.

Administrative Offices entrance on the second floor of the ED building

MUHAS is currently constructing a new university hospital for itself about 20 miles outside of downtown Dar that it intends to serve as a "teaching" hospital for the training of undergraduate nurses and doctors. Historically that has been the province of MNH. Speciality care will stay at MNH as I understand the plan. The new hospital has become "the straw that broke the camel's back" in terms of the relationship between MUHAS and MNH. MNH is starved for funding and the diversion of governmental monies to support the construction of a new hospital has been a bitter pill for MNH to swallow.

MUHAS Coat of Arms = Education, Treatment and Research

Artist rendering of new MUHAS hospital currently under construction at Mloganzila

Please note that these observations are not externally validated by anyone and represent my personal thoughts rather than those of the Peace Corps or Seed Global Health.

School Begins!

My apologies to all for the prolonged silence but we have been very busy with the return of the nursing and medical students and the resumption of classes. Suddenly there are nearly a thousand students milling around both the MUHAS (university) and MNH (hospital) grounds. White coats abound.

Students Leaving Main Lecture Halls

Laurel is teaching three courses, two graduate level and one undergraduate. She has been extremely busy with getting those off the ground. She is also regularly conducting in-service training for the nurses on the Psych Ward, something new at MNH. Nurses have a more limited role here than in the US. She has taken an educational approach to this problem. She has met with some success in trying to enlarge their role and offer the education needed to support those expanded roles. She is to be commended as driving change at Muhimbili is not an easy task we have both discovered. Like any large complex organization the systems change very slowly.

Faculty of the School of Nursing

Laurel's big news is her new office. For the past three months she has not had one. It is difficult to not have a place on campus from which to operate. However, she ended up in prime real-estate in the School of Nursing offices when she inherited the old office of the new Dean. Not bad...

Laurel in her New Office

As is my usual I am doing everything at the last moment and have been scrambling to catch up on my lesirely two months without students. I have a role in lectures and bedside instruction for both third and fifth year medical students as well as seminars for IM residents. The clinic work and ward rounds continue as before. I have started a weekly course on interpretation of chest x-rays and CT scans for the IM residents that has been fun but a lot of work. I am now making teaching rounds in the ICU and giving some lectures to the nursing staff there. There is no shortage of things of to do for either of us.

The semester started with the "white coat' ceremonies for both nursing and medical students. Then we were off to the races with multiple duties and lectures etc.

White Coat Ceremony

Professor Magusi, my counterpart, lecturing to third year students

Resources are seriously constrained here. The library is dated in terms of its holdings. Most of the materials students use are online or shared .pdf files of texts etc. Once you understand most are struggling with tuition etc you begin to grasp the level of sacrifice it takes to get where they are going. Some have some stipends from the Ministry of Education but most do not. Not everyone has a computer or internet access so their task is difficult. Most live quite a ways from campus without internet access in their hostels. There is free internet access on campus for students but the access points are limited.

Pulmonary Books in the Library. The textbook is 20 years old.

Overall I find them to be quite committed and remarkably good natured about the difficulties they face in acquiring the education many of us take for granted back home. Tanzania is a poor country with a large base of rural, uneducated peasants who survive via subsidence farming. Most lack education. Students from those families rise in the Tanzanian educational system based on merit and access to the most coveted professional training is limited. Freedom of choice does not always exist in that the government may tell bright student they are going to become a pharmacist rather than a business person regardless of personal preference. Not everyone is happy with their destination but all understand that is their only way out of poverty so they embrace the opportunities as they are presented. Most struggle due to their limited financial resources. As a rule they are engaging young people who brighten our days.

Muhimbili Welcome Sign

Muhimbili National Hospital is a huge place with seemingly infinite small buildings and nooks and crannies. I have gradually been discovering new places there as the months roll by. It is a warren of fiefdoms spawned by prior donor grants and the construction those necessitate. The long term problem boils down to this. Donors like building things with their money but frequently do not provide adequate operational expenses for the long haul. Clinical programs end up operating on a shoestring without many of the "consumables" they require to optimally deliver care to patients.  Quality facilities go unused for lack of financial resources to operate as intended.

Main Entrance to Covered Walkways

Often the Tanzanian response is to build your way out of the jam using more grant monies earmarked for construction of new programs and spaces. A new donor comes along offering monies for construction and short term operation of a new facility that partially duplicates what is going unused. You take advantage of the opportunity and build something new because it offers short term relief. Then the problem of sustainability rears its ugly head and you are back where you started but now have an additional facility you cannot operational support. This is often the only option. It is a recurring problem in most developing world settings.

Odds and Ends from Dar Life

CLICK ON ANY PICTURE TO ENLARGE!

Being from a rural hometown I grew up around folks with green thumbs but have never done much in the garden etc. Knowing we would have a balcony I did a bit of research before coming and bought some seeds of vegetables that supposedly would grow well in a tropic climate. Interestingly they came from a seed company in Mississippi. Laurel had also brought along some herb seeds to make sure she had things like basil that she regularly uses. With great trepidation we embarked on a container garden for our westward facing balcony. It gets a ton of hot, hot sun in the afternoons but it is "what we got" as they say.

We started with seeds planted in the bottoms of old water bottles about 6 weeks ago. My expectations were low. That big bottle in the back is my watering can. Coupled with zip ties and 3M Dual-Lock fasteners we are finding there is not much you cannot do with the water bottles which are made of sturdy plastic. We have used them for waste cans, soap holders (Kudos to Laurel on that one), shower caddies and planters. 

About 6 weeks later we have a serious "mess" of bean plants that are thriving and starting to climb the homemade lattice we constructed out of spare nylon twine. Note the 5 gallon buckets they are in. A shopping spree produced these. A casual question to the building manager about where I could buy potting soil produced about 200# of rich Tanzanian soil delivered in old cement bags. In total the soil cost TSZ 10,000 or $7!

I must give a shout out here to my older brother, Bob, because the beans are not just any beans but are speckled butter beans I have planted in his honor. We are gonna be eating lots of butter beans about Christmas time if all goes well! I cannot wait. 

Food continues to be a pleasant discovery in Dar. The notions of major weight loss while here have fallen victim to the reality of an astounding array of fresh fruits and vegetables that you buy from small sellers with roadside carts. They receive fresh produce from the main market every day and simply resell it to residents of the neighborhood. The same guys are at the same spots daily. Laurel loves to shop at the end of our block and has developed a great rapport with these guys. Mostly they teach her Kiswahili. She is a great cook and is slowly teaching me to do simple dishes. I can now shop veggies etc without cutting my fingers! Here are our first homemade pizzas that were quite tasty.

Many of these small projects being described become possible because I brought a ton of little stuff like a Leatherman (given to me by David Stringfield 20 years ago!), rechargeable batteries, good glue, zip ties, stainless steel wire and other goodies. Although my bags were heavy these items have been invaluable. You can get most anything here but finding where it is being sold can be very difficult as there are no WalMart type stores with vast arrays of merchandise. Most of the places we shop range from 50 square ft to 500 square ft in size. Having to walk everywhere or take an expensive taxi serves to discourage casual shopping. 

It took me a month to find silicone caulk. Most of that delay was because I could not adequately describe what I wanted given my lack of fluency in Kiswahili. Simple things like a hardware store are just not easily found. You have to know to go to this small specific shop for that particular item in most cases. We are learning but have found it challenging. Ultimately I found the caulking at a local 100 square ft shop I was regularly walking by without appreciating it had hardware type items. My taxi driver showed me when I tried to get him to take me several miles to a store I thought might have it. Could be I never saw the hardware store because it was located right next to a funeral pallor in a strip of stores! 

This is a "Stoney" Tangawizi, a ginger based cold drink or soda that is a Tanzanian favorite and has won over everyone in our Dar crew. It is delicious and unique! One of my best discoveries has been finding a place to buy these at the hospital. Muhimbili itself will be the subject of my next posting.

A small sampling of the inordinate amount of electronic cords, connectors and general "I am sure I will need this" items I brought with me in place of clothes, medical books or shoes. I am very glad I was so compulsive as we are able to enjoy Netflix, HBO Go, Hulu Plus and other streaming content from the US displayed on our TV. We have never activated the satellite system left to us by our predecessors so we really do not have TV as such. We brought a large trove of recorded movies and TV series like Breaking Bad or Downton Abbey that we play on laptops or on the dormant TV. 

Internet in Dar comes in two flavors, fast but expensive as you pay by the GB, and slow but all you can eat in terms of GB of downloaded data. We are juggling a mixture of these two. Our main link is a DSL line that is slow by US standards (2 Mbps) but has unlimited data and is paid for by the month. It has been worth every penny it costs. This makes our apartment more like home than virtually anything else.  

The device above is my 4G hotspot which has brisk internet speed and great coverage. Unfortunately you pay for the dat you use in bundles. If you exceed the limit it just stops working unless you recharge it with more money. It is used as a backup and to keep me connected at Muhimbili. I have an office computer which is quite old and functional but there is no reliable internet service at work. I share the one wired ethernet jack with my officemate but find it only works about 25% of the time. There is no internet at the hospital itself that I can access. The hotspot helps me look up things online when I am on the wards and makes my wi-fi iPad a usable computer when at work. It is not cheap and you pay for what you eat so you have to pick and choose what you download. I am grateful to have it nonetheless. Many of our colleagues in GHSP in more rural locales are not so fortunate. 

Our other luxury is a washer located on our side balcony. This is highly valued as we have relatively few clothes necessitating our doing frequent laundry loads. It gets a lot of use.

Tried and true - clotheslines for drying. With the breeze pouring off the Indian Ocean a mile away things dry quickly. This is actually a great balcony off our kitchen because of the super breeze it gets. In the morning the breeze is to the east to the ocean and once the sun comes up it changes back to being to the west. If this had a decent view it would be our main hangout. It is a great place to dry off after the hot walk home. The sun here is brutal after about 7 AM. You can feel your head heating up when you momentarily walk out of the shade (if you can find any) on the way to work. It is impressive - you feel like you are under a broiler. As we edge toward hotter weather and the rainy season the only respite will come from going in earlier and earlier in the morning. By2 in the afternoon the 1.5 mile walk home becomes taxing. I am always drenched by arrival at either the hospital or home.

We do not go out much at night because of security and expense. Having to take  cab to and fro is expensive as we are generally discouraged fro walking around after dark except in our immediate neighborhood which is residential. We have found a nice place in our neighborhood called Alliance Française that has a language classes, cultural events and periodic music performances as well as a decent restaurant. We can walk there and back even after dark. 

Last week our fellow Dar volunteers joined us for dinner in our neighborhood followed by a concert at  Alliance Française. These guys are the Black Warriors and are famous Tanzanian musicians. The performance was spirited and enjoyable. It was kind of like seeing a comeback performance of a great rock group. All the leads were in their 60's and now had younger musicians backing them. They still had it going on though. See the video below.

Nice moves!

Today we went to the famous Mwenge woodcarvers market north of town today with our fellow Dar volunteers and shopped for Makonde carvings. They are probably the best known art work produced in Tanzania. This art is produced by the Makonde people of southern Tanzania, and their material of choice is African blackwood, or mpingo. We bought a small "tree of Life" which classically depicts the ancestor and multiple descendants all carved from the same piece of wood.  

This is about 16 inches high. The wood is very dense and naturally a dull brown when sanded. They finish it with black shoe polish t give it the sheen and shine tourists want.

detail view

detail view

Later we had a nice lunch at one of the Mzungu restaurants near by.

From Wikipedia: http://en.wikipedia.org/wiki/Mzungu Mzungu (pronounced [m̩ˈzuŋɡu]) is a Bantu language term used in the African Great Lakes region to refer to people of European descent. It is a commonly used expression among Bantu peoples in Kenya, Tanzania, Malawi, Rwanda, Burundi, Uganda and Zambia. Literally translated it meant "someone who roams around aimlessly" or "aimless wanderer. The term is now used to refer to "someone with white skin" or "white skin".

This post is running quite long so I will throw in a few spectacular balcony sunsets again.

We never tire of these in part because they are followed by one of the most spectacular things I have ever seen, the nightly migration of about 5M African fruit bats. Recently we have noted that the bats have migrated in a much more easterly flight path. Over the past month they have been coming closer and closer to our balcony every night. I cannot describe what a fabulous spectacle this is, particularly with the setting sun in the background.

One of my frustrations has been my inability to capture this with my iPhone or my point and shoot camera. We recently asked our friend, Geoffrey, the guy who took so many fabulous pictures on our safari to come, and capture this recent change of flight path. It begins nightly with the departure of these large blue birds from the stand of palms about 300 yards from our balcony. Invariably, about 10 minutes later the bats and mosquitos start arriving from the north (to our right).

Geoffrey found the challenge daunting...capture close ups of bats flying by quickly in the dying light of day. He shot hundreds of frames with his high end equipment. The most arresting photos are these shillouete images of the bats through his telephoto lens.

Can you say Batman?

The frame that follows in one of my favorites.

Thanks to Geoffrey you have some idea of what we are now experiencing daily. They are actually flying over our heads when we are standing on our bedroom balcony which juts out from the building. It is fascinating to watch.

This is very inadequate movie of what we now experience nightly. These bats are often 30-50 feet in front of us when we stand on our balcony. Two months ago they were so far away we could only see them as distant dots. Now they dodge our building as they fly south and we can see their fur. We have no idea why they now come so close but are loving the spectacle.

Lastly I give you some slow motion captured with my iPhone. The quality is marginal but I hope you well appreciate the effect. Sorry to go on and on about the bats but words are not enough nor are the images I can offer you.