Letter Five from Tanzania


The unreal teal and blue waters of Zanzibar are not looking as inviting to me this afternoon. After arranging the last of the transport for the students, Julius and I headed to the beach at Nungwi to feast on some octopus curry, and enjoy the deep powdery sand of the Zanzibar’s northernmost beach. As it was getting hot, we both headed for the water for a quick swim. Not 10 minutes later, Julius had 10 sea urchin spines embedded in his foot and I had 3 in mine, as well as a jellyfish sting all across my left knee. If that’s not the universe telling you to get out of the water, I don’t know what is.

While I’ve had numerous jellyfish stings over the years, I’ve never been attacked by a sea urchin before – and may I just say that it’s much more painful. As Julius and I limped to shore, one of the security guards who had been seeking shade beneath a pier approached us to ask what was wrong. When we showed him our feet, he told us to stay put, and disappeared. Julius told me that he’d gone for medicine. OK. Now I’m just at TIA as the next person – perhaps more so. But I have to admit I didn’t have a lot of faith in the medical expertise of the security guard. Unaware of my misgivings, the security guard reappeared with two sand-covered local men (Martin and Alli), a papaya, and a bottle of paraffin.

Alli explained to me in broken English that the local treatment for sea urchin puncture wounds is juice from a green papaya, which digests the bacteria and neutralizes the toxin on the spikes. (OK, so he didn’t use the word toxin. Or neutralize. But that’s what he was gesturing. J) And the paraffin? No clue. Nevertheless Alli started on my foot first. He used the cap of the water bottle to remove as much of the spine as possible. Then he used the bottle cap to make little holes in the papaya and dropped papaya juice into the wounds. Finally, he poured the paraffin over the foot. He did the same to Julius explaining that it’s harder to do on African feet because they tend to be tougher skin since they go barefoot more often.

As Alli treated our puncture wounds, Martin ran to the village to find aloe vera for my jellyfish sting. Yes, I know that the true traditional treatment for jellyfish stings is urine. But I was not about to be peed on by Zanzibarian men on the beach in Nungwe. And once Julius dug the 3 additional sea urchin spikes out of my knee, the aloe seemed to be doing the trick. So I’m now sprawled on my bed with a knee full of aloe, and a throbbing foot. Sounded like a good time to let you know what’s been happening the last few days.

When last I left you, the trip was almost over, but we hadn’t yet met all of our goals. The students had requested more clinical observation – and it had been our intention to provide it. But without Maria, who safely had made it to Portland, we weren’t sure how we were going to get the clinical piece done. Fortunately, my longtime friend, Pam, has started working with a group out of Britain called HIPZ, which provides medical care at two of the hospitals on Zanzibar. Pam approved the students to observe in the hospitals. We split the students into two groups, with me leading one, and Elizabeth leading the other. Each group went to one hospital on Tuesday, and the other on Wednesday.

My Tuesday was disturbing. And I’ll warn you that the next few paragraphs may disturb you too. Feel free to skip it. I’m going to write it anyway because I think I need to get it down in print to help me process it.

Kivunge is a ‘cottage’ hospital near Nungwe in the north of Zanzibar. If you drove past and didn’t see the hospital sign, you would never guess that’s a hospital. It’s a collection of run down, dirty, cement buildings. The red dirt that meets the broken cement paths through the buildings is the same color as the dried blood on some of the walls. There are no true doctors at Kivunge, only medical officers with limited training, nursing assistants, and orderlies (who were hired to clean, but clearly aren’t). There’s one properly trained British nurse who is at Kivunge through the HIPZ program.

Our tour of Kivunge began with the emergency room. There we found a 2-year old little girl struggling to survive, barely breathing. She’d been admitted two days prior, and had had two days of antibiotics and anti-worm IVs, not that any tests had been run on her. No one had even taken her temperature or respiration rate. Nor had anyone weighed her. When the ‘doctor’ roughly pulled back the floral scarf that had been used to cover her, it was clear she was starving in addition to whatever else was wrong. This wasn’t a couple of days of not eating – it was months. The ‘doctor’ ordered a malaria test and an HIV test. Why this hadn’t been done previously wasn’t clear. What was also clear was that no one wanted to take responsibility for her care. On her medical chart were the various things that had been administered, but no one had initialed the chart, so the nurse couldn’t follow up with anyone. I’d be surprised if the child survives the week.

We left the emergency room to continue our tour, but a piece of me stayed with that little girl. We continued to the women’s ward, and then pediatrics. The wards are simple cement rooms with 6 donated hospital beds in them, and often nothing else. The women’s and pediatric wards had recently been painted, so they were at least clean.

In peds we ran into another 2-year old, this one had fallen into a fire during Ramadan. The nurse told us that this is the most common reason for a hospital visits this time of year. Since no one eats all day, and all of the cooking is at night, people trip and fall into fires often – especially children. The child had severe burns over her face, chest, and right arm and shoulder. She was up and about, but will likely have those scars permanently. I asked why she hadn’t been transferred to the main Stonetown hospital where they have doctors who can deal with burns. The nurse explained that they are short of medical care there as well, and they’re out of beds. In fact, when they do send patients to Stonetown, the patients often end up lying in a hallway until they die there. So there’s not really a point to transfer them.

The men’s ward had not been renovated. It looked and smelled like an oversized outhouse. Fortunately, there weren’t a lot of sick men. Maternity was the cleanest ward. However, although there were 4 women in the room – all in labor – there were no staff. No one to check on the mamas. No one to deliver a baby. There was an incubator in the delivery room for babies delivered by cesarean section, but no one who could do a c-section. Short staffed doesn’t begin to cover this hospital.

The final insult on my senses was the emergency room. As we went to walk by, the nurse said, “Oh, there’s a surgery happening – you should have a look.” She pushed us into the small concrete room, only to discover a young woman with her right arm amputated, and a barefoot orderly cleaning the wound. Although the orderlies are hired to clean the floors, because the hospital is so short staffed, they do whatever is necessary. In this case, the young man was dealing with an amputation. His only training would have been on the job. He was barefoot because everyone takes off their shoes to go into the operating room – to keep it clean. I struggle to find words for this. I guess I’m grateful that someone was treating the young woman, but her care may end up killing her. And she may have died anyway. Ah, Africa. Why?

The HIPZ NGO has built a new facility that will be the outpatient building when it’s finished. It’s a lovely new building, although the logistics are a little off. The smallest area is the well-baby check up area. Yet that’s the most number of visits the outpatient clinic sees – more than 200 children a week. It’s interesting. People donate what they believe that this neck of the world needs. So, for example, one group insisted on donating a new $18,000 generator for back-up power, even though the hospital already has a new generator for back-up power. Now the new donated generator is sitting beside it, rusting and aging. One of the rooms in the new clinics is entirely filled with wool sweaters for babies knitted by Norwegian women. Piles of wool sweaters at the equator where the temperature range is usually 70-90 degrees.

My western sensibilities were truly challenged at Kivunge. I have visited hospitals and clinics before, and I certainly know the extent of the challenges in this country. However, it bruises my heart every time. Every time. I know that this is why I couldn’t be a physician. I’m too empathetic. And I also recognize the experience as culture shock for me, because my immediate response is to think of very western solutions – even though I know that one of the reasons that they’re in this position is that well-meaning westerners have all tried their own solutions. And while my students were not saying anything, I could only guess that they were also going to process it for themselves at some point. I thought they might be numbing out. So I took the students to lunch and for pistachio ice cream. A little dose of western culture…

The next day was at Makunduchi hospital. HIPZ has been working with this hospital for nearly 10 years now. And the improvement was obvious. The hospital was clean and organized, and the systems were streamlined. Yes, there were still more mosquitoes at Makunduchi than anywhere I’ve seen so far on this trip. And the occasional chicken still roamed through freely. However, the crew at Makunduchi seemed to be a team. The students paired up and went to different places to observe: two to maternity/OB/Gyn, two to one outpatient clinic room, and two to another. I joined Cody and Wes with a ‘doctor’ in the outpatient clinic.

We saw about 15 patients in the 2.5 hours that we observed the ‘doctor.’ The vast majority of cases were high blood pressure, in many cases VERY high. Why is there so much hypertension here? They eat less processed foods than we do in the west. And most of the people with high blood pressure weren’t excessively overweight. Where is it coming from? Maria and I have a theory about how re-using cooking oil again and again is causing trans-fat production. Add the high carb diet and low exercise, and you get hypertension at epidemic levels. When the ‘doctors’ give diet advice to the patients, they tell them to eat less salt. After two weeks of dietary intervention, if their blood pressure isn’t reduced, they put them on meds. All of these patients were on meds. Salt reduction isn’t going to cut it here.

The most interesting case we saw was elephantiasis. This is a symptom of filariasis caused by round worms, and it’s usually contracted through bites of black flies or mosquitoes. The worms can get into the lymph and block flow during one stage of their life cycle. Fibrous tissue forms around the infection and the limb – in this case the left foot and ankle. While the infection can be treated, and eventually goes away, the limb will remain large for the rest of the person’s life, hence the name elephantiasis.

The students really appreciated the clinic days. They felt like they saw places where they fit in should they decide to practice medicine in Tanzania. They felt like it gave their training more meaning. They also saw places where the natural therapies would be far more effective than the drugs that are being given. One student said (to paraphrase) that she could appreciate that humanity is humanity – and we all have our problems and our reasons to celebrate. In the West, we often view African problems as more severe. But problems are just problems. And the people of Tanzania are not unhappy. They’re working through their problems just like we work through ours.

And that was the end of the formal education. From Mowo to Serengeti, Sedaani to Zanzibar, it’s been a whirlwind 3 weeks. We celebrated the last night in the village of Jambiani. The villagers roasted a goat for us, and several mamas made pilau, coconut rice, cabbage salad, greens, and curry for us. Julius and Eliphas thanked the group and reminded everyone that they would be waiting here should any of them decide to come back. They also reminded them to be happy, because why not? The students had toasts – all expressions of gratitude for various things along the way, and people who had made a difference to them. It was really a nice way to finish the trip.

I’m spending today on Zanzibar – heading into Stonetown to have lunch with my friend Pam. And then I’ll spend tomorrow and Sunday with Julius and his family before I fly to Amsterdam to meet Don.

My advice to you, avoid sea urchins.