Sugar, soap and snails

With the arrival of Christmas in Ndanda comes some lovely hospital traditions.  I made a rare visit to church this week in order to see the nursing students re-enact the story of Christmas.  I have no idea what they were saying as the rain was pelting down on the roof so hard it was impossible to hear anything.  However, this didn't actually matter too much as a) I do kind of know the general gist of the story and b) I really only went to see the sheep who stole the show last year and did not disappoint this year either.  The students given the role of sheep make the most of having their identity hidden by a sheet over their head as part of their costume and thus their movement up the aisle is accompanied by some fairly loud and alarming sheep noises, a lot of jostling and at one point what appeared to be a fight between two sheep that had risen up onto their hindquarters and were butting each other.  The shepherds also took their role quite seriously and used their sticks liberally to try to keep their classmates/sheep in order.

Another hospital tradition is the giving of gifts to all patients who will be admitted over Christmas.  Apparently in the past the gifts were pretty extravagant and came in large containers from America and Europe.  Unfortunately the containers have ceased to come and hospital funds are tight so each patient now gets a bag of sugar and a bar of soap.  However, whilst the gifts may be less exciting, the gesture is still lovely.   The wards are all decorated with leaves and bright flowers and the nursing students accompany the doctors and senior nursing staff through each ward singing and beating drums.  It's like nothing you could ever imagine happening in England and whilst the pictures don't really capture the atmosphere they may at least give an idea of the scale of the event.

My ward - all flowery and clean

Singing and dancing in the rain

In less Christmassy-related news, the recent rains have heralded the arrival of the giant snails once more to Ndanda.  Having passed many of these fantastic creatures when running recently, I decided to set off on a walk today together with a camera and the objective of getting the perfect black and white picture of a snail.  This was admittedly quite a specific task and after walking for a long time it started to seem like the snails were deliberately hiding just to spite me.  However, just as I'd given up hope and started to head home there he was, the size of a guinea pig slithering across the road.  I have no doubt that the locals thought I was even more crazy than usual as I crouched down and moved around him trying to work out how best to capture him but it was well worth it in my opinion.  I have included two pictures as one is clearly insufficient to capture his awesomeness. 

I hope anyone reading this has a lovely Christmas.  I will be mostly eating Christmas pudding and being on-call.

Diabetes and Dar

This week I’ve decided to return home a little earlier than planned which means I have just over a month left in Tanzania and a bit of time to mull over my time here.  When I first decided to come out to Africa for a year, it seemed like a long time – as a junior doctor in the UK I changed jobs every four months so twelve months working in one place seemed like ages.  Fifteen months have passed and now I totally understand what people were saying when they told me that a year is not long enough and that you need to live somewhere for several years if you have any hope of ‘making a difference.’  I didn’t have any grand ambitions of ‘making a difference’ when I came out here so I didn’t really listen to them!  In fact, I can’t really remember what my motivation was for coming, it was just something I’d always planned to do.  I think I mostly just wanted to live somewhere different, experience a different way of life and see some interesting medicine.   As it turns out, it is very difficult to live here, to see just how unfair life can be, and not want to change things.  It then becomes difficult not to feel frustrated/angry/upset when it becomes apparent just how difficult this can be.  On the other hand when progress is made, no matter how minimal, you start to think that if you stayed longer maybe the impossible would become possible. 

Just before I left Ndanda this week to come to Dar for a meeting I decided to discharge two diabetic patients from my ward.  These are young women who need insulin and in the UK would be offered all manner of support to help them understand and manage their condition.  Here they are usually just given some insulin and sent away with little explanation about the disease, no follow up, no way to check their blood sugars at home and no explanation of what to do if they become unwell.  We therefore decided to have a counselling session with these girls and their relatives before they left and so myself and two nurses from my ward sat down and tried to explain a bit more about the disease.  It was amazing – probably one of the best things I have seen since I’ve been here!  I hardly had to say anything (which is for the best as I would have likely confused the situation more with my dubious Swahili) as the two nurses took over proceedings and did a fantastic job of explaining and answering questions, advising about diet and managing hypoglycaemic episodes.  The patients and relatives actually asked questions (this is a VERY rare occurrence here) and were so incredibly grateful at the end that they all left grinning and shaking hands vigorously with me and the nurses, wishing us all a good day.  It turns out that one of the relatives was convinced the patient had HIV as she had lost so much weight and had thus been hiding her at home in case the neighbours started to talk!  They have promised me faithfully to come back for follow up and I really hope they do (going on past experience of managing chronic diseases here, I won’t be holding my breath).  They still have a terrible prognosis, with no means to test sugars at home they will likely develop complications of the disease much earlier than they would in the UK and they could easily die from a hypoglycaemic coma if the family fail to recognise the problem and act quickly enough.  However, when they left the ward I felt happier than I have for a long time, partly because they were so happy but mostly because it was so lovely to see how well the nurses managed the situation.

Mtwara airport - I think the sign may have been put up a little prematurely!

Someone asked me how big the airport is - not big as this picture is taken from the departure lounge

I’m now back in Dar staying in a massive conference centre run by nuns (they really do get everywhere) which means proper meals for the whole week and the chance to catch up with volunteers from all over Tanzania.  Dar is not my favourite place in the world – big cities not really being my thing, but it does seem to get undeservedly bad press from many quarters.  We receive various emails warning us of the dangers of travel around Dar and the training we receive on arrival in Tanzania is pretty intimidating to say the least.  Yesterday the Tanzanian receptionist warned us that walking around near where we are staying was totally unsafe with muggers and kidnappers lurking on every street corner.  This luckily turned out not to be the case and I had a very pleasant walk along the nearby railway line with one of the other volunteers, joined occasionally by a children who greeted us not with the usual ‘mzungu’ (white person) but with shouts of ‘mchina’ (Chinese person).  This was surprising since neither myself or my friend look even remotely Chinese, but since it is virtually impossible to go anywhere in Tanzania without children (and often adults) feeling the need to remind you loudly and quite insistently of your skin colour, the new word made a welcome change.  I’m not quite sure what has led to the confusion but I suspect there must be some Chinese workers somewhere nearby building a road.  I haven’t had to spent that long in Dar while I’ve been living in Tanzania and have only ever needed to go to a limited number of places (mostly those that sell ice-cream).  This means my knowledge of the Dar public transport system and geography of Dar in general is fairly limited.  However, so far this has not been a problem as people are usually helpful when it comes to directions and I suspect a passable level of Swahili does make things a fair bit easier.  Today as I tried to negotiate the daladalas to meet up with a friend I was taken by the man sitting next to me on the first dala to get the next dala – a walk of ten minutes or so (and as far as I could tell quite out of his way), warned about the dangers of thieves and then, after various enquiries to different drivers, put in a dala to the right place with instructions given to the conductor of where to tell me to get off.  This guy didn’t seem to expect anything in return for his help and I was annoyed with myself that this surprised me so much – I guess I believe the bad press more than I care to admit and had half expected to find myself lacking my camera and wallet at the end of our journey!  Unfortunately I’m not quite brave enough to risk taking my camera out too often when I’m in Dar so I only have a few pictures to show what it’s like.       

Fairly typical housing on the outskirts of Dar

The only train I've seen in Tanzania

Sunset over Dar taken from my hostel

The view from Slipway - basically a little bit of Europe dumped in the middle of Tanzania (including ice-cream parlour)

Being back

I had suspected that going home so near the end of my time in Tanzania probably wasn't going to be the best idea.  The trip home was unavoidable though as I really, really wanted the job and thus had to attend the interview.  Luckily I got the job AND got to see lots of family and friends AND ate a lot of amazing food AND got to enjoy not being stared at all the time and not having to translate everything I wanted to say into swahili.  That being said it has made coming back to Tanzania a little difficult - not least because at least three people have now told me I'm looking nice and fat after my trip home.  I blame the GU desserts and maybe the goats cheese and possibly the wine and cocktails.....

Dar es Salaam actually looking quite nice in the evening sun

However, I am going to try to keep the gloomy and doomy thoughts at bay and write about the nice things that have happened while I've been gone.  Most importantly the mango season has started which means there are mangoes literally everywhere and the flame trees are in flower - I have so far failed to get a picture that does them justice but will keep trying as they are stunning.  On that note, I have bought myself an exciting new camera to play with in celebration of getting an awesome new job.  I have no idea how to use it but will need to learn before I leave for South Georgia if I am going the get the perfect picture of a penguin on an iceberg.  In view of the fact I will be going home fairly soon and the fact I have a new camera and the fact I don't have much exciting to write about, this blog will be mostly picture-based and will hopefully give people a bit of an idea about what Ndanda is like.

Flame tree in front of Ndanda Secondary School

Ndanda Abbey - not entirely in-keeping with the local architectural style

As I have mentioned before, the Benedictines build stuff everywhere - cross on a hill overlooking Ndanda.

Nice clouds over the hospital

I thought I would also share a particularly disgusting image as I have the impression that when I complain about the ants people are not really getting just how many we're talking about.  I have therefore included a picture of my fridge just prior to me attacking in with a can of 'HIT.'  I went out to dinner and came back to find them literally everywhere.  Don't know where they came from.  Don't know where they were going.  Don't know what on earth they wanted from my fridge.  Unpleasant.  Very unpleasant.  I also thought I'd include a picture of my house (mostly because I wanted to use my new fish-eye lens but partly to show off my awesome 70s furniture).  If anyone who has lived with me is reading this they will I'm sure realise that some swift tidying was done prior to the shot (mostly involving shoving a large amount of clothing from the floor into the bottom of the wardrobe where it will no doubt remain for a while).

Ants...A LOT of ants

My lounge/bedroom all fish-eyed up

Tomorrow I will be mostly baking tropical fruit crumble since the main ingredient is now available.  I have so far avoided cooking anything other than spagetti with chilli ketchup since coming back from the UK so this will be a big step forward!

The drugs are available...

“So where did the ALU (antimalarial drug) go?”

“I don’t know”

“Because we got it from pharmacy yesterday but the patients haven’t had any doses...”

“Uh huh”

“Did you take the drugs home?”

“The drugs are available.”

“Will the drugs be available on the ward by the time the patients need their next dose?”

“They will be available.”

“Right.  And this won’t happen again?”

“The drugs will be available.”

“Ok, so would you like some tea?”

The isolation ward with cholera patient - it is as bad as it looks unfortunately

One of the very good and very competent nurses on my ward (not one of those mentioned below!)

The wonderful saying about accepting the things you can’t change and changing the things you can’t accept is a lovely idea.  However, having now been in Tanzania for a while, the number of things I can’t accept are decreasing as I learn that accepting my own limitations is sometimes more important.  It’s not been a bad couple of weeks, but as can be seen from the above discussion with one of the nurses on my ward, it’s not been ideal either.  I have also had to speak with another nurse about turning up to work drunk.... every night this week!  This is an ongoing problem and whilst I am under no illusion that things will change completely, I am hopeful that maybe the timing of alcohol intake can be altered a little so that it has less impact on patient care.  A low point (and reason for the discussion) came when I had to ask a patient’s relative (who is also a nurse not just a random person who turned up on the ward) to draw up and give the injection I had prescribed for her relative.  Having had a confused conversation with the nurse on duty, where even with my limited Kiswahili I could tell she was slurring words and repeating herself multiple times, I realised the chance of the patient getting the correct drug at the correct dose by the correct route was small.  These are not easy conversations to have as a foreigner in a different language – they wouldn’t even be easy in England in English but I am hoping some kind of mutual understanding has been reached....

There have also been some lovely moments this week with patients on my ward.  Occasionally we get patients coming from Mozambique and, whilst my Kiswahili is limited, my Kimakua is non-existent making communication difficult.  Luckily (since none of the nurses on my ward speak kimakua either) the patient in the next bed has been translating for me and, when my Mozambique patient had to go and see the gynaecologist, she simply got a wheelchair for the other patient (who has a dodgy knee amongst other problems) and took her along.  Luckily people are less concerned about confidentiality here and less phased by the thought of having intimate examinations with a stranger in the room!  I may have kept the translating patient admitted for a little longer than was strictly necessary to avoid the need for mime in order to communicate with the lady from Mozambique. 

In other news I have made it home.  It’s cold.  And dark.  But, I’ve met up with my parents, I’ve had a bath for the first time in 7 months, I’ve had sausages with cheesy mashed potato and I am extremely happy.  The journey home was wonderfully uneventful and the road was dry so it only took 9 hours to escape the south and get myself to Dar (see picture above to see what happens to the road when the rains come).  I had a short moment of confusion in UK passport control where, after standing in a long non-moving line for a while, it occurred to me that being the only white person in the near vicinity probably wasn’t normal anymore and should have alerted me sooner to the fact I was in the wrong queue.  So today I am off to buy some more climate-appropriate clothes – a pretty stressful prospect as it will involve tackling Brighton shops on a Saturday afternoon.

I love monkeys

MONKEYS!!!   Ever since I moved here I’ve been hearing about monkeys living nearby but I’d never actually seen them.......until today!  This may be the motivation I need to continue running despite the fact it’s now up to 40^oC on some days (not that I’m attempting to go running at midday but it’s still pretty warm in the evenings).  Another motivating factor is the fact that my Tanzanian friend Edina told me I’m looking “lovely and fat at the moment.”  Without a doubt she meant this as a compliment, but there are many aspects of Tanzanian culture I know I will never get used to, and I have started the morning yoga sessions again as a result of her well-meaning comment!  I have also decided to vary my running route a little and rather than just running up a big hill every day to catch the sunset, I am now making it up to the swimming lake a few times a week too.  It’s probably best to make the most of the lake now as, once the rains come, the water turns a chocolate-brown colour and swimming becomes a much less appealing prospect.  Right now though the water is cool and blue and I am joined on my evening swims by swallows swooping down to catch insects or have a drink.  The resident monitor lizards are often to be seen hanging about on rocks enjoying the beautiful evening sun and, despite all that may have happened during the day, it’s easy to remember the good things about living here.

Edina and her youngest son playing bao outside my house

Ndanda swimming lake

This week I had my first experience of the corruption that is allegedly rife in some of the government-run hospitals, as a patient tried to slip me a 10,000 shilling note (about £4 - but to put it in perspective that’s an eighth of the monthly minimum wage here).  Due to a rather extravagant month of spending on my part the money would have been quite useful but I am happy to report my principles remain intact and the money remains firmly in the patient’s possession.  Having not worked in any other hospitals in Tanzania I can only go on hearsay, but it does seem that in many it is standard policy for both doctors and nurses to expect patients to pay them directly for any services provided.  I guess coming from the UK, the idea of accepting hard cash from a patient for just doing my job is a very alien concept; on the other hand I’ve never had a problem accepting the odd box of chocolates from patients  – I'm pretty sure this is different though.   Anyway, I have no idea whether this happens here in Ndanda as the volunteers are generally out of the loop when it comes to the shadier goings on of the hospital.  Despite trying very hard to eavesdrop, my level of Kiswahili is definitely not such that I can follow high-speed gossiping between the nursing staff on my ward!  However, I’ve certainly never seen it happen and I’ve never heard any of the patients complaining about it (though as a general rule Tanzanians don’t complain).    

Makonde plateau

We have also run out of tuberculosis drugs AGAIN this week in the hospital which is very bad news.  This seems to be happening with increasing frequency and will no doubt lead to some frighteningly resistant strains of TB developing for which we will have no treatment whatsoever.  The drugs should be free to all and are provided by the government as part of the National Tuberculosis and Leprosy Programme.  Unfortunately, the logistics of getting these drugs to where they are needed seems to be something of a disaster.  As one of my colleagues pointed out, it is possible to get the latest Harry Potter book delivered to the most remote bookshops in Europe in time for the release date, but getting life-saving drugs to rural hospitals in Africa before stocks run out is seemingly impossible.  I don’t know where the problem lies, whether it is merely a matter of disorganised transport policy or whether there is a more sinister reason involving black markets and people getting rich selling drugs that should be free – it’s not something I am ever likely to know, but it’s made this week fairly awful for both me and several of my patients.

Road to Newala with Makonde plateau in background

Luckily there is a light at the end of the tunnel as the working week is over and tonight we are off to drown our sorrows with 50p bottles of beer and chip omelettes in the local bar – happy days indeed!  This bar just happens to be run by nuns – an unexpected combination in my opinion and something that still makes me smile a little every time I go. 

A nun running a pub

Sunshine, swimming and cornflakes

Having just enjoyed the culinary masterpiece that was chapattis with strawberry jam, I feel ready to give an update on life in Ndanda.  Since the strawberry jam is likely to be the only thing resembling one of my 5-a-day that I eat today I have washed it down with a multivitamin in an attempt to avoid scurvy.  I actually have good intentions of cooking something healthy later in the week and have bought a pumpkin in preparation for this momentous occasion.  However, it will probably take me a few days of looking at said pumpkin before I can summon the energy to attack it with a bread knife or smash it on the concrete floor (depending on how thick the skin turns out to be) and make it into soup (which I will then be able to eat for at least 5 or 6 days).  

I have just returned from a long weekend in Mtwara with several of the volunteers working in nearby hospitals.  Mtwara is a quiet town on the coast and thanks to the fact the Benedictine missionaries build stuff everywhere there is a house that we can stay at for a small fee as a reward for working in one of their hospitals.  The house is literally on the beach and with turquoise water, snorkelling and with the promise of red wine, prawns and cornflakes, these trips are one of my most favourite parts of life here.  The only slight problem is the 4-5 hour daladala ride to get there, which involves taking your life in your hands as the conductor attempts to squeeze as many adults, children and chickens as possible into a bus that isn’t actually designed to have anyone standing.  I think at the worst point there were probably around 45 people squeezed into something the size of a minibus and I spent my time trying not to think too much about what would happen if the bus decided to part company with the road – especially in a country where there is no emergency service.  I may get a little frustrated and ranty with the increasing number of crazy rules and regulations invented in response to the looming threat of litigation in the UK, but I have to admit there are occasions where a few strongly enforced rules might not be such a bad thing.  Hopefully the pictures will help you picture the paradise that is Mtwara.

Work continues to be interesting and frustrating in approximately equal measures.  Last week I was again faced with the difficult situation of relatives requesting discharge when treatment has failed and the patient is quite obviously not going to survive.  It’s not that people shouldn't have the right to die where they want but more that in the UK this decision is taken because the patient feels more comfortable in their own home, whereas here it is usually financial because transport of a dead body costs a lot more than that of a live one.  The luxuries of palliative care teams, Macmillan nurses and social services don’t exist here and quite how these patients make it home at all is usually beyond me.  However, since the only painkillers at my disposal are paracetamol and diclofenac (morphine being unavailable in Tanzania) I can’t exactly offer any kind of effective palliative care, even if they stay in the hospital, which makes the decision to send them home a little easier.  On a more positive note the new nurses on my ward are still wonderful, with one of them even trying to swap his shifts in order to help me with some procedures tomorrow.  It would also seem that my twittering has not been entirely wasted as he not only identified a pleural effusion from an x-ray but also listed possible causes and told me how examining the fluid would help to decide whether it is likely due to TB!  (I realise this last bit will only really make sense to the more medically minded readers but it made me so incredibly happy I had to mention it).

Sunset over Ndanda

I think that is enough for now and my newly acquired copy of the Dead Poets Society is calling me.  On the subject of films though, it would seem American English is not actually the same as normal English - who'd have thought it?  This I discovered while showing Take the Lead to one of the nursing students when she came round for dinner (yes I did actually cook her something – pizza in fact which was awesome).  Anyway, surprisingly enough there is no direct translation for 'punk ass' into Kiswahili and really no way of explaining what it means at all – this term was used A LOT in the film!  I’m going to have to be more careful with my choice next time.

Trip home and the end of the Nutella

So this week has been pretty good.  This may be in part because I know I will be going home for a couple of weeks next month and have been getting excited about all the food and wine I will be able to consume.  Surprisingly, when there is no possibility of wine, chocolate and roast lamb I don't actually miss it all that much, but as soon as it becomes a real possibility, my mind has gone into overdrive imagining going out for dinner somewhere that serves food other than chicken and chips or chip omelette (don't knock it til you've tried it).  It will also be lovely to see the family and friends who I occasionally see via the wonderful medium of skype or get emails and packages from (or, in the case of my grandma, speak to briefly on the phone but have to explain each time that yes, unfortunately I am still in Tanzania and that no, I will not be coming home just yet).

Work has been comparatively wonderful recently as the newly graduated nurses have just started on the wards which means that a) we actually have enough staff and b) the staff we have are pretty keen.  I have surprisingly few patients on my ward, giving me more time to try to understand their more complicated complaints.  Unfortunately this doesn't always help with diagnosis - it would seem I missed the lecture on pain that starts in the right big toe goes up the leg, across the abdomen (where it feels like an animal moving under the skin) and up to the left temporal area where it causes hearing problems.  When this was first explained to me in Swahili I have to admit I gave up trying to understand the finer details and when it was again explained to me in English today (by one of the amazing new nurses that have been allocated to my ward) I decided that multivitamins were probably the drug of choice - I will see on Monday how this has worked out!  When I first came out here I found the uncertainty of everything very unsettling but now I guess I have come to terms with it ...... to a certain extent at least.  Coming from working in UK hospitals where results are available within minutes (ok, so not always minutes but still pretty quick) and x-rays, ECGs and CT scans can be requested at the drop of a hat, rural Tanzania is .......different.  Since patients have to pay extra for x-rays and ECGs (and many of them can barely afford the admission fee) it makes you think really hard before ordering these tests.  This often means that rather than doing the test you give the patient drugs to treat the most likely problem and then wait and see.  It is inconceivable that in the UK you would treat a patient complaining of palpitations without looking at an ECG first or tell a patient they have cancer because they have lost a lot of weight and you're pretty sure that the liver feels a bit lumpy.  Unfortunately this is often the reality here and although I am more used to it now, it's still not exactly easy.

Besides working I have been getting out running most days, though as the weather heats up in preparation for the rains it is getting harder to summon up the energy to do this.  The heat also means that even after being back for 2 hours, having had a long, tepid shower, I am still bright red and sweaty and looking somewhat worse for wear.  However, I clearly remember that this time last year when people were asking me if I wanted to go running I thought they were completely crazy to be going out in this heat so I guess I've acclimatised a bit.  I'm not sure this is going to make England in November an entirely pleasant experience though.

To end on a sad note, the jar of nutella that was brought out to me at the start of the month by a very wonderful friend is no more.  This means I am going to have to revert to peanut butter for dinner on the (many) days when cooking just seems like too much effort.  It was amazing while it lasted though and it is a shame that due to my greediness (and laziness when it comes to cooking) it did not last longer!

A tentative move into the world of blogging

So I've been in Tanzania for a while and since I've forgotten nearly everything that has happened to me so far I have decided to start a blog rather than relying on my somewhat dubious memory.  It may also be nice to let friends and family know what I've been up to while not working hard for the NHS, as I'm not always so great at keeping in touch!  Just to set the scene, for the past year I have been working in a hospital in the south of Tanzania which can just be seen in the distance on the photo above.  The village is called Ndanda and is as beautiful as it appears in the picture.  I should probably also point out that this blog is unlikely to have much to do with embroidery and to be honest little to do with fluffy kittens - unless of course I find myself an orphaned leopard cub which would make me extremely happy and would certainly be worth blogging about.