Learning the nuances of the Tanzanian Greeting Hamna Sheda

Posted on behalf of MedPeds 4th Yr Resident, Ryan Fabrizius

Hamna Sheda Jambo from Arusha!

This week, I did my last week of pediatric wards with the all-star team led by Joseph (the registrar - a role like our senior residents) and Dr. Steve Swanson (a pediatrician from Hennepin County Medical Center, now serving at ALMC and Selian full time) and comprising Kahema (the intern), Sasita and Baraka (the two Assitant Medical Officer students- a role like physician assistant students). It has been a great experience working with this team, and I have been so impressed by their eagerness to learn, compassion for patients, and their cheerful attitudes.

Joesph, as I have mentioned earlier, is one of the best assets at Selian Hospital. The registrar is a position given to an MD upon finishing the one year rotating internship and can be an indefinite position, or often one taken while seeking out a residency spot in a specialty. Their role is to attend on the wards and to supervise the interns, though there are many duties they fulfill behind the scenes such as teaching the AMO students, participating in hospital administration, and seeing patients in OPD (outpatient clinic). There are 4 registrars currently at Selian, all of whom are excellent, but Joseph stands above the rest in his medical knowledge, enthusiasm, ambition, and compassion for the community he serves. He actively pursues solutions to "upstream" problems that lead to the sad conditions that we often see: malnutrition, difficulty with accessing care early in the disease course, and recurrent respiratory infections. He often purchases essential supplies with his own money and stays late awaiting tests that return hours and hours after they were requested. He hopes to gain a residency spot in pediatrics this next fall, though this is a difficult task in Tanzania, since there is not a steady source of funding for these positions. Either a trainee has to pay their own way, which is thousands of dollars per year, or they must obtain a sponsorship from the government, church, or pursue an international training program. It would be a loss for Selian when Joseph leaves, but we truly hope for his success as a pediatrician, a field that is greatly under-resourced in a country with greater than 50% of the population younger than 15 years old and two pediatric residency programs.

Though learning Swahili has been quite slow for me, certain phrases seem to be preferred by different people. I have already discussed "Karibu" and the greeting ritual, but we noticed fairly quickly the phrase most preferred by Joseph. "Hamna sheda" (no problem) is mentioned in almost every interaction with Joseph. For Lion King fans, this phrase is a close cousin to "Hakuna matata", though for some reason wasn't chosen for musical glory; perhaps because matata is more fun to say. Examples of it's uses include responses to: 

• "Joseph we don't have any oral rehydration solution and we don't think we'll be getting it anytime soon",
• "the family cannot afford the antibiotics you recommended", or 
• "all of the thermometers have disappeared". 

He uses this phrase so much that Hope and I have taken to calling him Daktari Hamna Sheda. To an observer, I think this phrase could be generalized to represent the people of Tanzania as laid back, care free, no worries. The slower pace of life, simplicity of material possessions, and emphasis on relationships here fit this mantra well, but one might easily interpret this as laziness compared to the frantic lifestyle we pursue in the Western world. I have seen, though, that there is a different usage for people like Joseph. I really do not see him and others like him, resigned to be worry free in the midst of a community suffering under the weight of poverty and it's ghastly burden. "Hamna sheda" is not permission to avoid reality, but I think it is one way to accept reality but not to let it frustrate or corrupt. Though I am clearly frustrated with the lack of resources that I take for granted in the practice of medicine in the US, Joseph is able to see what is lacking but to not give in to despair. For him, it seems, "hamna sheda" is a recognition of factors beyond control and a challenge to strive for the best for his patients with the resources available.

I truly hope that places like Tanzania will someday have the infrastructure and resources that all people deserve, but I am encouraged by people like Joseph who are able to overcome these circumstances and to make Tanzania better.

Ryan Fabrizius (MP4) relfects on community in Arusha

Posted on behalf of Ryan Fabrizius, 4th Year Medicine Pediatrics Resident currently in Arusha, Tanzania

 

Mambo Jambo from Arusha, Tanzania. I hope this update finds you all well, I appreciate all of your responses, thoughts, and prayers. This week has flown by and I have been blessed that it has been filled with great experiences, coworkers, and friends. I am becoming more accustomed to work at Selian Hospital, and continue to learn new things everyday.

 

This week I have been reflecting on community. As many of you have experienced, there is nothing quite like finding yourself in another culture to make you aware of your own. Though my experience of culture here in Tanzania is doubtlessly affected by my obvious "foreignness", I have been finding the community here particularly enchanting. It has been explained to me that Tanzania is made up of over 120 different tribes, each with their own history, beliefs, and sometimes language. This is thought to be a real positive for Tanzania, since there is no one tribe that can dominate the others, as has been the unfortunate reality of many other African nations. It seems, from my naive perspective, that several tribes have maintained their way of life in a way that is so obviously different from the typical city dwelling Tanzanian. An example of this is the well known Maasai tribe, prominently donning their red and blue patterned scarves, beaded ear adornments, and patterned scarification on their cheeks. As a pastoral people, they are often seen tending to large herds of cows and goats, even in relatively urban areas around Selian hospital. It is a regular occurrence for us to run into a traffic jam of livestock being tended by a young Maasai herdsman. This contrasts to some of the other urbanized Arusha residents, many from other tribes like Chaga, who have taken to city life, working as shop keepers, taxi drivers, and other urban jobs.

 

One particularly fascinating aspect of life here that I have seen in my limited exposure, is how these different groups interact with each other and with outsiders, like myself. A prominent display of these daily interactions occur in the greeting of one another. Each day, myself and Hope, take our scenic walk to Selian hospital and are pleasantly barraged with endless greetings. The most common greeting is "mambo", which is a sort of slang term, much like "what's up?". To this greeting, we have been learning new responses in unlimited combinations. So far, we have learned "poa" (cool), "safi" (clean), "mzuri" (good), "mcima" (well), "fresh" (fresh?), and my favorite "poa kuchezi cama ndezi indana ya fridji" (cool like a banana in the refrigerator). There is also "habari" (what's the news?) and shikamoo (I respect you), which are more formal. Then there are the many school children eager to use their English phrases, like "good morning teacher" and "how are you?". Though I can barely scratch the surface to communicate in Swahili, I can sense the rich feeling of community in people greeting each other. When I watch others great one another, it is almost never a short interaction. Honestly, I have no idea what is being communicated, but I can sense the sharing of their intertwined lives. They stop to share a cup of chai, to rest in the shade, to carry their produce from the field together. 

 

In the hospital, I have seen how families rally to collect money for medicines and to search the countless "dawas" (small pharmacies) for the right medicines. I have seen how patients in neighboring beds support each other, like when a Maasai family cannot speak Swahili well and the neighbor will help fill in the details of whether they have received their medicines as ordered or have been taking the recommended refeeding formula. I have seen how the local doctors here will often buy necessary supplies with their own money, such as Oral Rehydration Solution, extra food, and even clothing for their patients. There is a sense of cooperation and support for one another that extends beyond family, tribe, and language. The people here have been gracious to greet us everyday, but I see that below this surface greeting there is such a richness of community here that amazes me. It challenges me to consider how I relate to others and how we as Americans (or whichever subgroup we find ourselves in) can look beyond ourselves to build stronger community with one another.

Tanzania awes Ryan Fabrizius (MP4) as he begins his 2 block elective

Posted on behalf of Ryan Fabrizius (MP4)

 

Karibu Jambo from Arusha, Tanzania! 

 

I am so grateful and blessed to be here in this beautiful country with a genuinely lovely people and culture. Prior to starting work at Selian Hospital, I had the wonderful opportunity to see some of Tanzania's true treasures including Zanzibar and the Serengeti National Park. With this introduction to the country, I was still in a sense of awe, a feeling of other-worldly experience at these sights I had seen in pictures but never expected to see first hand. I arrived at Selian Hospital and Arusha Lutheran Medical Center on Monday looking forward to starting the work I came here to do. 

 

Karibu, in Swahili, as many of you know, means welcome. I have already heard it used in a number of contexts, ranging as widely as (paraphrased in English to my understanding)

• "welcome to our country", 
• "you're welcome to drink chai now", 
• "please come into my store and have a look around", 
• "I'll give you a ride on my motorcycle taxi", 
• and as a response to "thank you". 

Though our English word "you're welcome" seems to cover many similar meanings, I have been struck by how frequently this word is used. It could be that I am so obviously a foreigner (not too many 6'8'' bearded Caucasian men in this country) that I am consistently offered a welcome. But I like to think that this offer is an invitation to enter into the community here, to experience what life is like for the people who call Tanzania home, to learn the triumphs and struggles that Tanzanian's experience on a daily basis, to share in the efforts to bring high quality medical care to the community. 

 

I am familiar with the false belief that the complex social and economic problems of the developing world can be solved by benevolent humanitarians from rich countries. I sense the temptation to feel that certain people might "welcome" us foreigners to solve their problems. But I have seen a convincing glimpse of the resilience and commitment of Tanzanians working to build a country with opportunity, fairness, and help for the poor. Their Karibu is not "please rescue us"; it is, to me, "please join us in learning together" and "let us share a commitment to each other". I have seen this particularly in a few of the medical workers in the hospital here, including Joseph, the pediatric registrar at Selian Hospital. 

 

Joseph has completely shattered all my expectations of what local doctors at the government hospital are like. He has a tremendous fund of knowledge about pediatrics, an inspiring compassion towards the children that he treats, and an encouraging drive to learn more in his profession. I will have more to write on him and other local doctors and trainees later.

 

I would like to end with a short story.  During pediatric rounds, we came to a 1 year old who had been admitted with Severe Acute Malnutrition, a terribly common reason for admission at Selian. The child had been transitioned from the initial F-75 refeeding formula to F-100, showing good tolerance of the formula and some increase in weight. Though the child was still in need of at least a few more days of refeeding in a hospital setting, to assure that he had no complications (such as return of edema, refeeding syndrome, or infection), the mother was requesting to leave the hospital. Fortunately, care of children under the age of five years old is covered by the government (not including certain medications that must be bought at outside pharmacies), so it did not make any sense to me why the mother was requesting to leave. 

 

When I asked Joseph about why they wanted to leave so prematurely, he responded that "if the child stays, the mother cannot eat". There is no food service for patients (other than refeeding formulas for those with malnutrition) or families at the hospital, so they must provide their own, which is extremely difficult for families coming from far distances. When I expressed my awe at the terrible situation, he responded "welcome to Tanzania". 

 

It would be easy to take this as a fatalistic declaration of the state of health care and social determinants in this country, however, that is not how I took it. I watched as he and the medical team came up with a plan together to assure the ongoing treatment of the child without leaving the mother to have to choose between her health and her child's. In this situation, I began to catch a glimpse of the awful reality of poverty, but a ray of hope in the commitment of people like Joseph in coming up with solutions. 

 

This "welcome to Tanzania" said to me: this is the current state of things, but we are already fighting to make it better.