Finally, I am posting "Same Part 2". . . Many of you know that one of the more challenging things for me about my new job is how frequently I move from one clinic and district to another. As soon as I get to a new place, I long to stay for longer than a week. Sometimes the desire to stay longer comes from the fact that there is so much work to do and there are fantastic nurses and clinicians with whom to do it. Other times I want to stay longer because it is such a beautiful place and I want to be surrounded by the beauty for awhile. Sometimes it is for both reasons, which was the case with Same.
Same is a tiny, quiet, friendly, easy-going town nestled at the base of the southern Pare (pah-ray) mountains. It is about 90 km southeast of Moshi. I arrived on Monday morning, and I was greeted like a long-lost relative by a woman named Habiba Mmaraba. Habiba is a nurse I had met in July at one of our mentoring trainings. Right before I arrived I learned that the coordinator of the CTC (HIV) Clinic, who was supposed to be my host for the week, left to go to a computer training without telling anyone. It was too late to re-schedule, and Habiba agreed to coordinate things, so I decided to stay and do the work. Habiba is an experienced nurse, who is so delightful and fun to work with. We laughed all week long. When she laughs, it is a full belly laugh, head flung back, nice and loud. There is a photo on the previous post of Habiba laughing.
The first thing I always have to do when I arrive to a new district is to meet with the District Medical Officer (DMO). The DMO controls the entire budget for the district hospital as well as any health-related activities that happen in the district. It is a highly political position. This person is usually a man, in fact usually a "big man", as Tanzanians say. A "big man" or a "benzi" (a newer slang term I recently heard that alludes to a Mercedes Benz) is wealthier man, who either works high up in the government or is a super-successful businessman. The terms conjure an image of a well-dressed man with a big belly (and 9 times out of 10 he does have a big belly). Meeting with the DMO is one of my least favorite things to do. He sits behind a massive desk in a throne-like chair, with us peons lined up in chairs on the other side of the desk. The DMO can make or break a mentoring week. In fact, The DMO can make or break a district's HIV treatment program. For our program's purposes, he has the power to allow or not allow a district vehicle to take us to the village clinics to mentor the staff (which is the reason I am in TZ). Even though EGPAF (our funder) awards each district funds to provide transport, some DMOs don't release the funds when we need them to. Most DMOs are supportive, but some are most definitely not. I've worked with both. So these meetings are about sucking up and explaining in a polite, graveling manner why it is important to have transport. Sometimes I have to do a mini-teaching session on what clinical mentoring is. While I was in Same, the DMO (who I hear is supportive) was away, so our meeting was with the acting DMO. He did promise transport for two days (that is what we ask for), but in the end, he canceled the second trip TWICE. Transport is the source for one of the biggest frustrations of doing this work.
The hotel I stayed in was about a km from the hospital, so I walked to and from every day. Habiba's house was along the way, so the first day going home, she showed me her shortcut on winding dirt paths, through people's homes and compounds, past the well where everyone fetched their water, across the town football (soccer) field. Every morning, I took this route on my own, soaking in the tremendous beauty of the sky, the mountains, the people. The dirt is red, the mountains are green and lush and giant. I have become accustomed to people in Moshi and Arusha following me, asking me to buy things or hire them as a guide or to marry them, that it was such a relief for people to be simply curious, and kind and genuinely interested in what the heck I was doing in Same, where they rarely see a white person. Since my last UCSF colleague left a few weeks ago, I find myself immersing myself more in the Tanzanian way of life, practicing my Kiswahili more, just taking it all in more. I do miss having my colleagues to talk things through with, but I love being on my own, too. It reminds me of my Peace Corps experience, which was very positive.
One of my most rewarding things with a patient happened during my week in Same. It is rare for me to be able to follow a patient over time, and to see them get better. There was a 32 yr old woman who came in on Monday, yet another case of TB-HIV co-infection. She had wasting syndrome (weighed about 70 lbs), so weak she couldn't speak above a whisper, dehydrated, coughing, carried in by a family member. She was admitted to the ward and started on TB treatment and also got IV fluids. I visitied with her each day with the clinician I was mentoring on the ward. It was amazing how much she improved in five days. Certainly not 100%, but well on her way to recovery. Amazing what a little TB medicine can do! By the end of the week, she was sitting up on her own, eating and talking. She will start antiretrovirals in another 2-ish weeks, and it is likely to be a happy ending for her and her family.
On Tuesday of my week in Same, Habiba and I took a road trip up into the mountains to a village clinic called Ndungu. We rode in a rattling pick up truck for almost 2 hours on a red dirt and pot-holed road. But wao, was it beautiful! Surrounded on all sides by green mountains, palm trees, banana trees, sisal fields, purple-flowering jacaranda trees, mud homes. The CTC Clinic was in one tiny room, the size of a walk in closet. The clinician saw patients there and the nurses set up outside the door, right next to all the other waiting patients, to do adherence counseling and uncomplicated follow up visits (so much for confidentiality--a different concept here than in the states). Nurses are the lifeblood of these clinics. There are so many patients, there is no way they can all be seen without the nurses seeing a large number of them. Unfortunately, though, they aren't supported institutionally to do this, they are just told to do it out of necessity. They don't get any formal training. So I do spend a lot of my time working to build capacity among the nurses to conduct these visits in a quality way. We saw 44 patients in 4 hours (too many). LOTS of children. Whew. It was a great, but exhausting, day! The rest of the week I spent in the hospital clinic, working with different nurses and clinicians. Such a great week, despite my host bailing at the last minute, and despite the DMO sabotaging our trip to the second village. We ended the week with a case-based teaching session that I had put together based on the knowledge gaps I had noted during the week. It was well attended, very interactive, and lots of fun.
Habiba. . .such a generous soul she is. She is Muslim, so she was fasting until sundown all week long for Ramadan. That did not stop her, though, from inviting me to her home twice during the week, introducing me to her family, and feeding me delicious food (beans with coconut and homemade chapatis--yum!). Such a lovely person she is. When we said good by at the end of the week, we did this kind of hug they do here. Kind of like they do in France, a hug and a kiss in the air on one side of the body and then the other. But she didn't want to stop the hug, she kept doing it over and over, pulling me close and kissing the air on each side of my face, until she finally stopped by giving me a quick kiss on the mouth! It was very sweet and felt so sincere.
Haven't quite figured out how to make photo captions, so here are some explanations of the photos above:
#1 On my way to work. That is Same Town nestled at the base of the mountains.
#2 HIV clinician Mmari and nurse Bulili.
#3 Habiba (on right) and her best friend Mary (also a nurse)
#4 Children having fun at the well, on my way to work
