Mission Accomplished

The first three months are about to come to a close. I head home for a few months and then return to Tanzania in January.

Angus O'Shea, the executive director of the Touch Foundation gave me the following piece of advice after my arrival in Mwanza.

"Try real hard not to get anything done in the first three months." Angus did provide a bit of explanation for that advice, not a lot, a bit.

Mission accomplished.

While meeting with me to discuss a proposal I had submitted for the casualty department, the director general of the hospital shared that an expert from the U.S had made similar suggestions in the past. "But I don't know where she went. The funding must have run out."

It is way early to draw conclusions. Observations must be qualified as "initial".
I am trying to place myself in the shoes of the Tanzanian physicians. The picture is skewed at a teaching hospital with hallways full of medical students, thanks in large part to the Touch Foundation.

But...what must it be like to be one of fifteen hundred m.d.s in a country of thirty seven million people? What must it be like to come to work every day to a place where babies die and surgery is canceled because the elevator is broken or the rains have soaked the surgery linen? What must it be like to wait for donations to equip your department or have an experienced nurse transferred from your understaffed unit to a more understaffed unit? Could I have a long term perspective and continue pushing hard to move three steps forward only to find myself two steps back soon thereafter?

As an outsider seeking to be an agent of change, my goal is to construct that mission of change in a manner that is least dependent on me.

Signs of hope abound in the people I have met such as orthopedic surgeon who approached me with his dream of creating a Trauma Center at BMC. That is where hope best resides, in this Tanzanian orthopedic surgeon, his general surgeon colleague and in the medical students, interns and residents filling the hallways and classrooms at BMC.

Workers

The intern grabbed a sheet which were in short supply as the stretchers and floor space were overflowing with silently bleeding people who were in a bus that overturned on a stormy night. He gently nudged the man laying there bleeding from the nose. There was no response as he whispered "rafiki" and nudged him again. So he placed the sheet over the man and smiled when the patient clumsily tried to move the sheet off his legs.

Words come suddenly and loudly from the medical officer. "Unaumwa nini?" asked briskly as the gray haired, beleaguered woman takes a seat on the stool. More words uttered singularly, with a playful sense of authority. Eventually a smile on her tired face appears slowly like a sunrise.

Handwritten crumpled paper is unfurled as the intern moves to the front of the room and takes a seat at the table. The room is full of white jackets. The white jackets belong to the medical students with notebooks open, prepared to record the presentation. Wound toilet, debridement and wound excision are defined concisely and explained clearly. The orthopedic surgeon, after a brief period of silence, says " Good job".

Worn down. The looks on the faces of the nurses who have worked the night shift. Always, I mean always, an engaging "Habari za nyumbani?" as I walk in each morning.

Sometimes what needs to happen, happens. Sometimes not.
The moments are lived fully. That allows for interruptions that rarely seem unwelcomed. I am unsure how the future is lived in here. I don't think it is counted on. The past seems quickly forgotten as well which can be good and bad.

The conversations here can seem like flying in a small plane through a thick, white cloud. You can't see where you are going or from whence you've come. It is pleasant for the moment actually but there is a foreboding sense of a need to see if you are about to hit the side of a mountain.

Nameless

A friend of mine wrote a blog about his experiences in a developing country health care setting and chose to change the names of the people and places. I think this was a good idea.

It was my original intent to attempt to share these experiences as objectively as possible so the stories would be about this place and its people and not me. I can't seem get out of the way. I also want people to know about BMC and the work that The Touch Foundation is doing in Tanzania. I can only hope that those who see through my eyes will forgive any inaccuracies or misconceptions that may result.

The life expectancy at birth in Tanzania is 46. A perfect storm of HIV, tuberculosis, child and maternal mortality and increasing unintentional injuries from road traffic accidents combine to account for this shortened life expectancy.

There are also cases like the 23 year old who presented to casualty complaining of chest tightness. His blood pressure was 205/120 and he could not lie down on the stretcher. He had crackly noise in all his lung fields but looked comfortable as he calmly shared his symptoms with me. He also had markedly pale eyelid linings. He said his stool color had been black for 2 days. Again the ICU was full and to clear the casualty stretcher, the young man was admitted to a ward. In the meantime, I followed him to x ray after I was told a portable film was not possible. I saw the fluffy white markings in his lungs that indicated fluid was spilling into his air spaces. I walked his tubes of blood to the lab and waited for the result which was a hemoglobin of 4.4(less than 33% of what it should be).Unlucky for him, his blood type was O negative and the hospital once again had no units of the rare(for Mwanza)blood type. I rode with him up the elevator and explained to the resident and charge nurse that he should not be here and to please take him to ICU when a bed cleared. Later that day I saw him sitting on an ICU stretcher eating rice and meat. We smiled at each other and waved a greeting. I relaxed and went home. This morning I went to ICU and discovered that this young man had died at midnight.

You know if it was ethically acceptable I would choose for you to know the names of each of these patients described in my postings. I think it adds to the sadness that they are the only nameless participants in the stories I share.

The Right Thing

A surgery professor was renowned for his simple instruction to surgery residents, "Don't see what you can get away with, do the right thing."

A baby grunts when she is having trouble breathing. It is the same sound Venus and Serena make after a ground stroke, just a whole lot quieter and after every breath. It is a distinctive sound.

That sound was coming from a mother's mbeleko(the patterned scarf that holds the baby to the mother's body) A toddler was slumped to the side on her mother's back. The breathing was rapid and labored.

The nurse shared with me that the 22 month old had swallowed kerosene. This is a not infrequent problem because in the home dangerous liquids are stored within reach in soda bottles or similar containers.

The problem is that vapor and/or liquid reach the child's airways with inflammation and fluid leakage into the lungs as the result.

This baby girl was struggling with every breath. We placed her on oxygen. There are no monitors. The ICUs had no beds. There is no portable x ray.

I talked with the pediatric resident on call to explain the situation and she said to admit the baby to the ward. We had to take the baby off oxygen to get an x ray. There are no portable oxygen cannisters.

Today I went to the ward where the baby was admitted. She was doing fine. We got away with it. There was no right thing to do.

Context

In the telling and hearing of stories, the context is important. What constitutes a context? Why is it important? In my case the context is all new and includes geography, culture, politics and history. My anthropology friends(Can you believe I have more than one?) caution me that my understanding of illness and treatment are different from my patient's understanding and in this culture the differences are more pronounced. I am limited by language and perspective in understanding them.
Politics and history I can read about and my son Luke gave me a depressing but informative book entitled "The State of Africa" which reviews the last 50 years of post-colonial African history. We all make judgments on the basis of our experiences and context is important as it informs your judgment. I have shared with you a number of experiences but I wanted you to know that my context is limited for now.

The Touch Foundation for whom I work has as its objective to address the shortage of health care workers in Tanzania and I refer you to their website for more information. www.touchfoundation.org. Let me share with you one "statistic" that has informed my judgment. I attend 0730 morning surgical rounds and the surgery interns report on their previous day. There are 4 interns. One is on call for the wards and one for the casualty department. On average the intern on the wards reports that there are 300 patients on the surgery service in the hospital. The interns scrub in on theatre cases and attend outpatient clinics. Those of you with a medical background know the relative impossibility facing these young Tanzanian physicians as they perform their daily duties. The overwhelming responsibility of this patient load is but a microcosm of what the country as a whole faces.

Speaking of new experiences I will end with a list of firsts:

To feed a monkey my breakfast buscuit as he jumped beside the hospital walkway on my way to surgery morning report.
To observe a 13 year old girl barely flinch as she sat on a stool having her blood drawn. Her regal bearing was all the more amazing because her hemoglobin returned 2.8(should be 4 times higher)
To watch a mother carry her limp 5 year old son who 2 days earlier had been bitten by a snake on the right foot. His leg was swollen twice its size up to the thigh.
To walk home for a superbly prepared vegetarian lunch every day. Alfan is the cook of my food(that's the way it is expressed in swahili which I prefer to "my cook")
To be left on the side of the city street as my taxi driver negotiated a "fine" with police for pulling out in front of another vehicle.
To sleep inside a mosquito netting every night. Something is a bit more unsettling here about being awakened by the high pitched buzz of a mosquito around your ear.
To watch the sunset over Lake Victoria in the evening.
To discuss with a nurse in Australia about the transfer of a patient to Johannesburg or Nairobi or Sydney

Peasant

What does the word "peasant" bring to mind? Castles, kings and moats.... Just wrote the word over the occupation line of a death certificate.

Sometime this morning a 50 year old man found himself under an overturned oxcart. He was transported to the nearest hospital where note was made of decreased breath sounds in the left chest and air in the skin(it feels crackly for lack of a better descriptive term). Transport was then arranged to BMC. An official stamped referral letter accompanied the patient.

On a stretcher in casualty with two 14 gauge angiocaths in his chest wall and a blood filled endotracheal tube in his trachea, he died.

It is the 21st century and we still write peasant on a death certificate. The life and death for a peasant has probably varied little between the centuries.

In the twenty first century it means your baby dies of malaria and your dad dies in the afternoon when the oxcart falls on him in the morning. It was probably much like that inside and outside the castles in the middle ages. It is still happening outside the castles today.

Blood Warmer

One of the many functions of the human body is to warm the blood. A couple times in casualty my body has warmed someone else's blood.

The first patient was too weak to stand from the wheel chair and his friend could speak enough English to tell me that he had vomited blood. The bottoms of feet are not supposed to be the color of the sheets and when they are it is a bad sign. Not having a blood pressure is another bad sign. Yet anotherbad sign for a system is that this man had waited to be seen long enough for his old record to be on his stretcher. In that old record was evidence that this man had esophageal varices(enlarged veins lining the wall of the esophagus, prone to bleed because they are close to the surface and not designed to carry large volumes of blood). He had schistosomiasis which is a parasitic infection caught from exposure to water(fishermen on Lake Victoria and children who play in infected water) and a subset of people with this infection get scarred livers and abnormal circulation in vessels outside the liver.

I ordered O negative blood immediately for emergent transfusion along with two large bore intravenous lines with saline running wide open. The casualty nursing director worked on this patient along side me and ran to the blood bank for the blood. We transferred him to intensive care where his low blood pressure was causing confusion and he had to be restrained with sheets tieing his limbs to the bed. I stood beside him squeezing the cold blood bag with my warm hands. He is still alive.

The second patient came in today and was too weak to sit or stand. She was on a stretcher between the 4 beds in the women's ward of casualty. Her feet were pointed in the other direction but her eyelid linings were white, her pulse was thready and the nurse had written "unrecordable" where blood pressure numbers are placed on the chart. Her abdomen was tender in the lower half and up the left side. She told us her last period was August 20th. But there are not too many things that present like this in young women. I told the gynecology intern in the department that I thought this patient had an ectopic pregnancy and ordered O negative blood and 2 lines of saline wide open. For the second shift in a row I found myself at a patient bedside squeezing a cool bag of blood. This time the lab had no O negative blood so I had walked to the lab to explain that I needed a rushed blood typing and 2 units of type specific blood along with 4 units of cross matched blood. In the meantime there was some discussion about sending the husband to the pharmacy to purchase a pregnancy test. The second on-call gynecologic surgeon wanted to see the results of this test. I posed the hypothetical question that in a woman who had no bloody vomitus or bloody stool, had a tender abdomen and no blood pressure, what would they do if the pregancy test was negative. I didn't get an answer to my question. A few minutes later the pregancy test came back positive and two and a half hours later this woman was taken to the operating theatre. The intern told me afterwards that there was about three and a half liters of blood in the woman's abdominal cavity.

Both of these patients survived their time in casualty. Each is an example of the lifeboat approach to care to which I have alluded in a previous post. A whole host of questions arise about systems, culture, training and case management as a result of these two cases. Some of these questions I am ill fitted to ask, much less answer. I share these experiences and have not entirely succeeded in withholding judgment in their telling but withhold judgment I must. A greater understanding is required. For now I am a blood warmer.

Responsibility

Captain of the Ship....that pretense is gone. Captain of the Lifeboat is almost gone. The concept that requires rethinking is this whole captain thing. Living in a wealthy country, born of supportive middle class parents, I have had an intellectual appreciation of God's providence. Mostly there has been the illusion that I was in control. Granted there have been profound failures as when my nephew Charlie died after liver transplant surgery. That wasn't supposed to happen. I have seen more death here in three weeks than I saw in a year working back home. What exactly is supposed to happen?

A 3 year old the second day with large, sad eyes strapped on his Mother's back in colorful cloth had swollen lymph nodes all over, a facial mass and diffuse facial and leg swelling. I thought he had Kaposi's sarcoma, an HIV related malignancy. Sure enough, his rapid HIV test was positive but his biopsy was an inadequate specimen. He died before it could be repeated. Yesterday an older woman with abdominal pain transferred to Weill Bugando after being in a referral hospital for 3 days. She was cold, clammy in obvious pain with a firm, tender abdomen. She was tachycardic with a blood pressure of 120 over 90. I ordered IV fluids and x rays and consulted surgery. Today the intern tells me that she" collapsed" on return from x ray and died. The thin man with a swollen neck described in my first post died in the hospital within a day. A tiny 1 month old grunting in his Mother's wrap, another transfer from the same referral hospital died after a few days in the ICU. A 53 year old woman who collapsed complaining of abdominal pain. I could palpate a pulsating mass in her abdomen that was slightly tender. An ultrasound confirmed a large aortic aneurysm. Her family could not afford the cost to transfer her to Nairobi. As far as I know she awaits her fate on a medical ward in the hospital as I write. I could go on....

I have a selection bias in that I am intentionally gravitating toward the patients who appear to me to be the sickest. Amongst these, there have been some remarkable success'....the woman with a tension hydro-pneumo thorax (fluid and air in the chest cavity where there should not be)
presumably from a bronchial fistula secondary to tuberculosis. She got a chest tube and when food particles were noted in the drainage, she was taken to the operating theatre by 2 surgical registrars and a tear in her esophagus was repaired. She is currently alert and walking around the ICU.

It is actually a good thing to relinquish captaincy. I must admit that I knew enough before I arrived to expect a relinquishment. How to relinquish captaincy without relinquishing responsibility is one of the many unanswered questions at this moment in time.

Sounds and Cold Fury

It's the end of week two. Coming as I do from North Carolina, I have slid down Bust Your Fanny Rock into a mountain stream. The shock of that cold water takes your breath away and you find yourself in beyond your depth. You the readers must forgive my first week's thrashing efforts as I attempted coming up for air. The water is still deep and cold but I have begun to tread and my head's occasionally above the surface.

The door bell is on the outside of casualty. People push the bell when they need help moving someone into the casualty area. When this bell is pushed a medley consisting of "Jingle Bells", Rudolph the Red Nosed Reindeer" and "Joy to the World" plays repeatedly.

There are birds here whose call sounds like a cross between the crow's caw and a donkey braying.

Islamic prayers over loud speakers on one side of the hill and Christian hymns on the other side.

"Karibu" "Habari dakta" "Hujambo" "Shikamoo" are some of the ways of being acknowledged or greeted. It is odd however that these greetings generally come after I am 5 yards past the oncoming person. Occasionally these greetings are in English. "Good Morning" no matter the time of day. Some "Give me money" The always popular "How are you" At other times the greeting is Swahili but the words I don't recognize. These are often followed by cackles of laughter. I'll let you know in a few months perhaps, how I've probably been serving as the butt of jokes.

Today at 4 the Jingle Bells medley signalled a 7 year old girl in a car requiring a stretcher. She arrives in the crowded women's and childrens casualty room with blood coming from her left ear and a swollen, deformed left thigh. She had been struck by a vehicle. She is sleepy but talking. Her Mom comes in and quietly takes her hand. The last sound of my work day is the Mother's whispered voice as she leans over her daughter's battered body.

Lost in Translation

My intention was to place a new post weekly but with such an intense first week, I decided to post a bit extra. I am told I will settle-in, which seems unbelievable at this point.
The patients sometimes stay on their casualty stretchers for days and I've had conflicting explanations for this. One morning I walked in to a full house with some familiar faces from the days before.
From one of the doubled-up stretchers a thin young man would periodically moan. I heard these moans on more than one occasion throughout the morning. Quiet moans.
In the afternoon when the stretcher was singly occupied by that same young man, I took a closer look at him. His chart said he was 19 but he looked 13. He was fully dressed but through his partially unbuttoned shirt I could see his ribs. His chart also reflected that he had not been evaluated by a doctor. I examined him quickly and asked someone to help me ask him a few questions. The gist of the story was 3 weeks of cough, fever and loss of appetite. What bothered him most and caused his moans was the pain in his chest when he breathed. He said his father was receiving treatment for TB. His chest x ray was suspicious for tuberculosis and I arranged for his admission.
This morning I looked at the chart of a young boy sitting quietly on a stretcher with someone I presumed to be his father. His father pointed at his left arm. On that arm he had a plaster splint from shoulder to wrist along the back side of his arm wrapped in kling(gauze). I could see the flex of his elbow seemed swollen and blistered and was covered in gentian violet. His father began to speak to me and I now know how to say "I don't understand Kiswahili" in Swahili so I shared this bit of information with him and went on my way. This afternoon I noted the surgery interns taking off the splint while the boy screamed in pain. The interns told me that he had had the splint placed a week ago for a fracture of his proximal radius and ulna(forearm close to the elbow). The skin about the elbow was markedly swollen and bleeding. I could feel what I thought was a faint radial pulse. The intern said he thought the kling had been wrapped too tight. I suggested that a hospital admission might be a good idea and went home for the weekend.
When you are a U.S. E.R. doctor it is crammed in to your head that you are the captain of the ship and responsible for everything that happens in the department. In order to accomplish this task, it is necessary to know what is going on with all the patients.
I have used the language barrier as a rationalization for failing in this task this week. But the moans and the gentian violet covered blisters required no Swahili expertise to understand.
I share this not with the intent of beating myself up.
There are indeed further rationalizations that the half-day waits that each of these suffering patients endured in the casualty bay will not contribute to adverse long term outcomes. TB will respond to treatment in the afternoon as readily as it would have in the morning and the damaged arm had sustained it's damage for many days.
But I can't help but think and feel that these cases are microcosms of the response to suffering in the world. How often do we use similar rationalizations for a failure to respond?

The Obvious

A siren blasted away outside the casualty area. Nothing unusual for me but it was unusual for a hospital in a city with no ambulance service. I watched from inside as the crowd looked out from the open air waiting space in the direction of the noise. This was going to be interesting.
Two nurses wheeled a stretcher into the department with a man lying on his back with an arrow embedded in his right chest.
The arrow was pulsating.
About that time I realized I was the only physician around. Normally not a problem. In fact I knew what obviously needed to be done and NOT done. The man needed to go immediately to the operating theatre to have the arrow removed after his chest had been opened under controlled, visualized conditions.
He came with a set of x rays from a transferring district hospital which also included a picture of his dislocated left elbow. The blood and air in his left chest were adjacent to a barbed arrowhead. Should someone had attempted to remove that arrow, the man probably would have bled to death.
As it was, he had normal vital signs and was responsive though I did not attempt to speak with him. I wouldn't have understood him anyway.
I knew what needed to be done and began with the nurses help to prepare the man for immediate surgery. We however could not locate a surgeon.
BMC is a teaching hospital and is one of 5 consultant hospitals in the country. There is a thoracic surgeon on staff who happened to be out of town. At this time the surgery intern arrived and spoke to the man. He called his senior resident. The decision was made to place a chest tube and schedule an elective thoracotomy for when the thoracic surgeon returned. They were going to leave the arrow in.
Then the intern shared with me that the arrow had already been there two days. Their plan actually made sense.
What seemed so obvious to me doesn't seem so obvious anymore.

New and Old

People everywhere. Lining the roads on the way in from the airport and along the city streets. Lining the hallways and benches of BMC. Mwanza, Tanzania is a city situated on Lake Victoria. It has hillsides lined with rock formations and homes the color of the rock and earth. It's a bit dry here now and the prevailing background is brown though scattered green trees and flowering bushes break up the earthtones. The city's construction is similarly a monotonous color of concrete broken up by some unusually colored pastel structures. The lake is a lovely, deep blue. The lake attracts as many birds as people.
The theme of the day is "I haven't seen this before."
Today was my first day on the job and introductions to some casualty staff were made. I wasn't prepared to take care of patients. Nonetheless, I saw a few of the many. And it gave me pause.
The cachectic(markedly thin) man leaning over the stretcher with the complaint of throat pain. His neck was visibly swollen symetrically and anteriorly above the suprasternal notch and I swear the swollen area felt crepitant. No history of vomiting or procedures is about all the history my language barrier allowed me to gather. This was a very sick man. Quietly he and his friend waited. The surgery staff was evaluating him amongst many others. Eventually he was gone, admitted to the ward. No diagnostic testing or treatment had been performed.
Along side him sat a young teen with draining areas on both legs and left forearm that he volunteered had been present for years. His x rays were markedly abnormal. It had begun as leg stiffness he noted playing futbol. Now both knees were fused in flexion. He seemed otherwise well. The only other patient I saw was a 3 year old girl with sickle cell disease with fever and cough one week out from a hospital stay where she had been treated with antimalarials and antibiotics. Mildly inactive, she was alert and having no respiratory difficulty.
Only 3 patients today on a day I hadn't planned on seeing any. There seemed to be hundreds waiting. All 3 presented diagnostic and treatment dilemnas. I am supposed to be an old, experienced E.D. doc. Why then does it all seem new to me?

Just the Facts Jack

On the last day of the DTMH course the course director had a feedback session. Routinely and yearly he has discovered it necessary to determine if any particular area of the world has been offended by any of the presentations. Commonly those from Africa and the U.S. experience some difficulties for different reasons.
The DTMH is African-centric with no apologies on the basis of the scale of problems and the experience of the LSHTM faculty. During some of the presentations of the problems presented by HIV, tuberculosis, malaria and neglected diseases in an environment that suffers from poverty, the situation can seem overwhelming. My colleagues from Africa shared mixed feelings of sadness, shame and frustration during these presentations. Some expressed that the picture presented left a skewed impression with those not first-hand experienced with their countries.
My take home message was that a presentation of facts is never simply a presentation of facts. There are other messages delivered with one's choice of "facts", methods of presenting the "facts" and messenger of the "facts".
It generates within me a profound sense of caution as I begin the process of sharing the "facts" of my experiences along with my subjective impressions. Nevertheless the story is worth telling, thus this blog. But I have been thinking about the message delivered with the story and I want to be as intentional with that message as I am with the story. So I need a bit more time to think about what I want to say about my first trip to Mwanza and why I want to say it.

Perspectives

Apparently in Northern Nigeria, polio cases are still actively occurring. One of the reasons is that the polio vaccine is suspected of causing harm. Vaccination coverage otherwise is not out of the norm. Why is this? Kebir believes local politicians have benefitted politically by frightening the local population with fears the US is purposely tainting the vaccines to harm Islamic people. I wondered how the US could successfully be suspected of this degree of nastiness. This was not a unique example. A physician from Botswanna told us of his efforts in HIV education when local people held the condoms up in the sunlight and the visible streams of lubricant flowing down were perceived as worms the Americans had placed within. Where does the fault lie for these suspicions? Interestingly, Kebir tends to place responsibility on local, Nigerian politicians. I, on the otherhand, place responsibility on my country for its international activities in recent history. With this perspective I would be cannon fodder in a presidential debate. The truth is somewhere within my and Kebir's perspectives and would be better understood with many other perspectives. It frightens me for our leadership to refrain from international dialogue. There is limited understanding and a markedly diminished understanding of the truth when multiple perspectives are not solicited.

I have made an initial visit to Mwanza, Tanzania to meet with hospital leadership and Touch Foundation folks. I plan on sharing my initial impressions in a posting to follow.

Soapbox

Today was family planning day at the DTM course. Two speakers spent the morning making the case for the need for family planning in the developing world. No argument really. Yes, there is a need. One of the difficulties in speaking about the needs in poverty stricken areas of the world is not so much making the case that the need exists but how you go about making the case. Because the intent should extend beyond educating people to inspiring them to act on the presented need. Our speakers today failed. I have shared the success' of other speakers.
There is a role that individuals play in the creation of the current world situation. It is an art to communicate this role with the appropriate degree of discomfort and personal ownership absent strident blame-mongering. There needs to be some discomfort mixed with inspiration to alter behavior and encourage positive action. Once the data of inequality is presented is the truth of inequity understood? What do we do once we are convinced of the inequity? Hopefully we find little disagreement that we should strive for equity in the world.

Inspiration

August Stitch spoke to our class on Friday February 1st.
A German physician who has worked with Medecins San Frontieres(MSF), he described some of his experiences since graduating from the Diploma Course in Tropical Medicine(DTM).
He combined scientific expertise about schistosomiasis(a common tropical, water-born, parasitic disease afflicting primarily the rural poor in Africa, Asia and parts of South America) with a captivating story of his venture into the Khmer Rouge dominated area of Cambodia to establish a hospital. This followed a time he had spent working with a Trypanosomiasis(tse tse fly carried parasitic disease in Africa) project in central Africa. His multi-media presentation was well organized and masterfully presented. He shared his frustrations with big pharma as some of the few drugs for trypanasomiasis were discontinued from production in the early 2000s for financial reasons until one of the drugs was included in some cosmetic creams for facial hair reduction and deals were struck with these companies, the World Health Organization(WHO) and MSF. He admitted his mistakes in attempting to tackle HIV with the same tactics used in the schistosomiasis effort.
Friday was a day that met my lofty expectations of the DTM.
In medicine and in life, we are inspired by mentors(or heroes, though these individuals might object to this descriptor). Friday I was inspired.

The City

I like London. The humor, the tube, the diversity, the briskness, the futbol, the history, the squares..... My morning reading from Richard Rohr's Daily Meditations seems timely enough to share in its entirety.
"In America we don't have anything even close to Europe's great cities with fountains, cathedrals, promenades and parks. I know we've had two hundred years to work at it, but the point is, Americans don't dream of building a great city. The American dream is having one's own house. In America, we have moved from the Catholic consciousness of the community, of building the city of God, a great people, to taking care of our houses, protecting our neighborhoods, so that handicapped people and people of other skin colors don't move into it and kill property values. We have got to call this what it is: narcissism.
There's a world bigger than our families. The only way we can ultimately protect our family is to create and protect the entire human family."
Well said.
Once again to rail against narcissism on a blog is quite ironic. Nevertheless Father Rohr in a clear and concise way expresses a reason for us to think and feel globally.
And if you are so inclined and practical...
explore ready to use formulas(RTUF) to address malnutrition at validinternational.org and insecticide treated nets(ITN) to address malaria at theglobalfund.org/en/

Initial lessons

KB is my Nigerian housemate. He rents a room in Mrs Finch's house and attends the diploma course in tropical medicine with me. He is primarily interested in malaria because he directs a malaria control project in Nigeria. We have some discussion over breakfast and hit the road walking at 0800 to make our 0900 first class. The weather here is chilly and wet. He normally drives to work at home where he says the roads are hot and dusty. If he is walking, then a countryman will stop and say"Here doctor, please ride with me." We talk about the salaries of doctors in our countries and how much it costs to buy a car or send your children to college.

The day after I arrived, I bought an Oyster card for a month of unlimited travel on London's tube system. But once we'd settled in our routine, I had the card changed to "pay as you go" and placed 50 pounds on my card. About a week after we had been walking, I developed swelling and pain above my left ankle with crepitance(a squeaky feeling when I moved my foot up and down). Pitiful I know. The treatment is rest and anti-inflammatory medicine. I am taking the ibuprofen but I am continuing my 45 minute concrete surfaced, wet and chilly walks. Doesn't seem right somehow to use my oyster card though I'm sure KB wouldn't mind and probably insist I take the tube should I ask him. I doubt he'd allow me to purchase his tube ticket to accompany me though again I've not asked.

Sometimes it's about the "us" not the "me" or the "you". Tiny, trivial but tangible and a bit of a taste of things to come.

Questions

Questions generally begin with a what, why,how, when, where or who? Though I find "why" questions most intriguing and the answers multi-layered, the what questions are the starting point and require clear, concrete explanation. So to answer "What are you doing?"...

Until I complete exams on April 1st 2008, I am attending the diploma in tropical medicine course offered by the London School of Hygiene and Tropical Medicine. Class begins in the morning at 0900 after a brisk and sometimes wet 45 minute walk from north London to the All Souls Clubhouse classroom(temporary housing while construction occurs at the LSHTM). I walk with my housemate Kebir Ibrahim(KB) a Nigerian physician who works at home in a malaria control program. Class ends at 1700 followed by our walk home. To date the quiet evenings have entailed some reading and British TV watching in the room I rent from Mrs Finch.

Wednesdays are spent in discussion of cases or on rounds at London's Hospital of Tropical Medicine. Thursday afternoons are spent in the laboratory peering through microscopes at malaria infected blood smears or parasite cysts.

Perhaps more interesting is the question "What is tropical medicine?" Two professors have had a go at that question. Eldryd Parry co-author of Principles of Medicine in Africa and impressively experienced in the field, founding multiple African medical schools described it as a blend of poverty medicine and the medicine of climate. Tom Doherty, our course director, also emphasized poverty medicine and added that the patient population tended to be young, otherwise healthy people with reversible medical problems, often an infectious disease.

David Hilfiker MD author of Not All of Us are Saints describes his experience working with the poor of Washington DC and offers that his medical training did not specifically address poverty medicine. Though poverty medicine became his specialty as he worked with his homeless patients. He and my professors here emphasize that poverty medicine must consider more than the bio-medical problems. There are political, social and psychological considerations often under emphasized in traditional medical training.

I am fortunate to be learning from experts in the field teaching me poverty medicine.

Day after

After spending a day in Starbucks on the internet, creating this blog and talking about sharing my thoughts and feelings, my Daily Meditations by Richard Rohr included this thought, "We really need to be saved from the tyranny of our own judgments, opinions and feelings about everything...."

When we think of liberation are we talking about simply doing what we want to do, free from the demands of the other? From what do we seek liberation? Christianity speaks to dieing to ourselves and we are our own worst tyrants.

So a blog seems to be a counterintuitive response to this conundrum. Oh well I'm sure you all will help me out. You always have.

First Steps

Arrived in London to attend a three month course in Tropical Medicine at the London School of Hygiene & Tropical Medicine. Thanks to my friends and family for the send off messages. I hope to keep you informed with this blog. I have about forty classmates, fellow physicians from 5 continents(Antarctica and South America are not represented). My head in the books for three months may not lend itself to interesting experiences for blog postings. However I hope to spend this quiet time in reflection. The centering process could result in some thoughts or feelings worth sharing. Let's hope so and I look forward to hearing from you.