#12 Reflections on Beauty

This weekend we returned to Lubwe village in Nyakyusa country and visited our friend, Pastor Mwangoka. It was lovely to see him and his family again. On Saturday we enjoyed walking with him to the neighboring village. The following day we drove 50km of dirt road to one of the churches under his care, a tiny village called Mbigili. The setting was beautiful, high up in the hills, surrounded by volcanic mountains and lush vegetation. A tiny mud built church with dirt floor and tin roof lay surrounded by wild flowers and banana plants. Butterflies of many colours and shapes were fluttering all around, hornbills and sunbirds flying overhead. There were fields of neatly planted tea plants; potatoes, coffee and yams also flourish there.

I was thinking how wonderful it would be to live in such a place. As soon as that thought came to me, I began musing on the problems of healthcare and education. I thought about the 2-3+ hours it would take to access a basic hospital and all the worry that would bring with our own children to care for.

I really enjoyed speaking to the children we met on the way and watching them play with Lydia and Aaron. Meeting little ones in remote, or even not so remote, villages often makes me wonder about aspirations. With little exposure to the outside world what do they dream of? What do they long for in life? What will they get? Is any of it fair?

These beautiful and lively children, who give such thoughtful answers and who are keen to talk about many things. What will they get and where will they go in life? Working in the health service here I know how the story can end. No matter how many times I see a little one, or a young woman, or a 24 year old man, whose life has been broken by a preventable illness such as HIV, or by a treatable illness that only came to get help when it was already too late, I hope that it never stops hurting. I hope that I never loose the ability to feel and to cry for them.

Great beauty has enormous capacity to move us greatly, even to tears; it might be in a poem, in nature, or in the faces of people, in their eyes, or else the stories that lie behind the eyes. There is abundant beauty here in Tanzania. Beautiful places, and animals and flowers of course, but mainly people and their beautiful acts of love. I see it in a patient sharing what little food she has with her neighbour in the next bed who has even less. I see it in the eyes of family as they search my face for  news of their loved one’s progress.

I hope that seeing daily all this beauty gives us the motivation and energy to confront all that seeks to tear it down and to break it. Sadly, too often that is not enough. Complacency easily creeps in when we reflect on the enormity of the task before us, when we see the sheer cliff-face of poverty and disease and step back from the attempt to scale it. We need to ward off that complacency, to squash it and dare to hope.
 


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#10 People working

Ibada - patients praying
Ibada - patients praying

There are often wonderful moments of closeness to colleagues and patients at Mbalizi hospital. I have recently been reflecting on the richness of these experiences, and wondering if the equivalent is available in larger hospitals such as those in the UK. 

 

Whenever a member of staff or one of their family members is sick, needs surgery, or is in labour, they usually come to my ward. This means that I am often treating colleagues (almost daily). It's a privilege, though not without its challenges. Inevitably, I am present when a colleague’s relative dies. I cared for the terminally-ill mother of a nurse; the warmth and tenderness I sense from her now, after her mother's death, continues to surprise and challenge me.

 

When a colleague dies (sadly we have lost several nurses to road accidents) we are together in mourning. If the funeral takes place in the hospital chapel, we all go together, all of us pay our respects to the body, one by one in a long file. If it is further away we share cars and all pile in together.

 

Then there's the experience of being crammed into a small room for our 'ibada', a biweekly evening service in the chapel for our patients. There is always a guest choir, and so a great deal of dancing and loud music. If they can't walk, they simply come in wheelchairs or are carried in on stretchers. The smells of the African night air mingle with those of wounds and disinfectant. Seeing the raw expressions of despair, searching, hope, joy and pain in the faces of many sick of all ages is one of those experiences from which it is hard to detach oneself.

 

There are gifts too. I have recently received tomatoes, cucumbers, cabbages and a pumpkin from kind subsistence-farming patients. Even when out in the market shopping I have been given extra peppers by a patient whom I had cared for during her pregnancy. Their gratitude can be hard to take when one feels one has contributed so little. 

 

Tea break in the morning about 10am is really more like breakfast. Here in one room, nurses, admin staff, ground staff, our carpenter and electrician, and doctors all eat together. Chat is lively and everyone invests time in keeping work relationships alive and flourishing. If anyone sees me drinking tea but not eating they often insist on buying me a samosa or cooked banana from the tea lady....just to make sure I don't fade away!

 

Yet another way people are brought together is trade! Most hospital staff have some other business interest or other. The physiotherapist makes mosquito nets, one of the junior doctor sells chickens, another nurse sells soap, another fabric. If you want avocados pharmacy is the place to go and so on.

 

So many ways our lives can touch. I am still a total outsider in many ways, but there are moments I am brought in and each of these is special.

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#6 The Colour of Life

Working in Mbalizi Hospital, the days vary. Many are uplifting. On those days there are patients with enormous courage who tolerate severe pain calmly, critically ill ones who do well, or a mother and baby who survive a ruptured uterus. Aside from the good clinical outcomes, I love many other aspects of working here, including the colour all around me. There are wonderful fabric prints encircling babies just born and adults alike. Sunbirds flit in and out of hibiscus bushes outside my ward and there is the ever present blue of Mbeya Peak towering above the hospital. Relatives carry food in bright plastic buckets and of course I carry my favourite red stethoscope with blue swirls and glitter. I love the practice of long greetings and of stopping to say hello to those you know. I love that patients say thank you.

 

I also find many things deeply frustrating. The fact is that I don’t fit in to the system here. I only have a basic command of the language. I do things differently. I think differently, not all the time or in every case, but more often than I expected I would. The evidence based medicine that I love does not have a position of value or importance. Problem based approaches and careful tailored histories, working through the differential diagnoses, are things I am reluctant to part with, in fact I cannot. I don’t mean nothing here is based on evidence but that there is little questioning of existing practice and that for most people prescribing behaviour and management decisions are based on what they were taught years ago or on anecdote or even on the word of a pharmaceutical company.

 

Another oddity I don’t sit easy with is the additional trust often (so my Tazanian colleagues tell me) bestowed by patients on ‘Wazungu’ (Caucasian) doctors. This was evidenced by  a brief but memorable encounter the other day as I was walking along a corridor on my way home. A relative called me into a four bed room. There a woman called out in-between gasps ‘Naomba nisaidia  Mzungu’ (please help me white person). As she was minutes from death from end stage HIV related cardiomyopathy  with severe bouts of pulmonary oedema I was not able to do very much about any of it except offer words and my hands to hold.  But the plea to my skin colour is a common one.

 

 

I continue very much to be aware of the differences in me and around me at the same time as taking great pleasure in serving some truly wonderful patients and working with lovely people. Life has many hues.


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#4 All things Chronic

I properly started my 3 days a week at Mbalizi hospital in August. Now I can sit back and reflect on my first month and a half working in Tanzania.

 

GPs are at times fond of exploring a patients ideas, concerns and expectations. What of mine? I had a few ideas about what I hoped to achieve. I wanted to help with chronic disease management and look at primary care and the role it might have in the future of a small DGH hospital serving both the local community and those further away through outreach clinics and the like.

 

 

Concerns. I was concerned about communicating with both staff and patients adequately and had little faith in my own language abilities. I was unsure what demands would be made of me and how I would meet them.

 

Expectations. I expected sick patients, HIV, and a lot of acute infections, particularly respiratory and gastrointestinal. I had read the national statistics and I knew therefore that in the top ten causes of mortality were the non communicable disease groups: stroke, hypertension and diabetes.

 

In some ways I was pretty close to the mark, but in others way off. I was right about the language.  With acutely ill patients I can get all the history I need most of the time. With those where history is the most important part of all, such as possible  epilepsy, loss of consciousness, or depression, of course it is much harder. However, the real communication barrier is the enormous difference between the way the medical world I come from works and the one in which I now find myself. It is like another new language. It takes more than 30 minutes, explaining to a fellow doctor, what my speciality is and roughly how it works. Here if you use the term 'primary care' is is understood as what patients do for themselves at home, self treatment of minor ailments and the like.

 

This space between my old world of work and my new also creates frustration for me in little ways. If I am honest I miss many things I previously took for granted. I miss prescribing guidelines, outcome  frameworks and audit; I miss renal function tests and the tradition of writing the time in the notes. There are countless other things - trappings of an affluent society with a national health service - that I miss and I have reflected long and hard on many of them. If I had to pick one thing I miss the most, what would it be? I am not sure, but I think it would be accountability. Accountability for ones actions.

 

Ghana's minister for health, Hanny-Sherry Ayitey, has recently been quoted as saying that the biggest challenges facing Africa are ignorance, injustice and lack of accountability. 

 

I had not realised before working here the profound and all encompassing effect this has on medical practice in a given place or service provision. Here, errors in diagnosis, timeliness of intervention, appropriateness of investigation or in prescribing of medication are, on a day to day basis, unlikely to bring repercussions of any serious nature to health care workers.

 

Food for thought.

 

You may find :http://www.worldlifeexpectancy.com/country-health-profile/tanzania interesting.

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