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.

Greetings from Gulu - Reflections on Soc Med Course from Aarti Bhatt (MP3)

Posted on behalf of Aarti Bhatt, MedPeds 3rd year resident

Greetings from Gulu, Uganda!

What is Social Medicine and how do I implement it into my practice and day to day life? How do I truly work for social justice and health equity? These are the questions that led me to Gulu.

I have the privilege and the opportunity to spend 4 weeks learning and teaching about the social determinants of health with medical and nursing students, physicians, anthropologists, sociologists, economists, allied health professionals, village health workers, and patients. The course is called Soc. Med, and is crafted by Amy Finnegan (Sociologist) & Mike Westerhaus (Physician/Anthropologist). This is the 5^th year of the course which is held here in Northern Uganda. The 27 medical and nursing students taking the course bring their perspectives from various regions of Uganda, as well as from Rwanda, Zimbabwe, Argentina, USA and Lebanon. 

The Soc. Med experience challenges my understanding of why injustice exists in our society and subsequently leads to health inequity. We dissect topics ranging from colonialism to neoliberalism to intellectual property and the WTO. It is emotional, exciting, confusing, eye opening, awe inspiring, and an exercise in humility. It is also really fun. 

  

I’m still processing a lot (which is part of the reason it has taken so long to write this post), but will briefly offer some reflection. Additionally, I invite the broader community of health professionals to engage in critical, reflective and constructive dialogue about health equity that goes beyond the biologic basis of disease.  

Students come together to “look upstream” at the structural and societal factors that influence biologic illness

The “3Ps”, and unofficial mantra of Soc Med.

Getting Personal

The Danger of a Single Story. (this is a link to an awesome TED talk)

Part of my role as a facilitator for this course is to help incorporate concepts of narrative medicine into the Soc. Med curriculum. Narrative medicine shakes up the traditional structure of the doctor-patient interaction by challenging (as well as complementing) the biomedical model. In an era where health professionals are busy, focused on diagnostics, and patients don’t feel listened to, this method of of history taking deserves some attention. It involves bearing witness to the patient’s story (referred to as an “illness narrative”) while at the same time pushing the provider to examine his/her own biases and assumptions which are inevitably carried into the encounter. Students are encouraged to make statements like “Tell me about your health” or “What worries you?” instead of the more traditional questions which focus on symptoms and reason for admission. In debriefing, many of the students bear witness to stories of suffering, poverty, living through war, and injustice in the health system. Equally as important, students learn who their patient’s are, what is most important to them, and what brings them joy. Narrative Medicine is intensely personal, and getting personal is part of social change.

Social Medicine students visit Paimol and take a walk through the community with local village leaders. They learn about the  economy, daily life, the effects of the war on the area, and some cultural health beliefs. We discuss the ways in which community members negotiate their health  by engaging with local healers as well as government health services.

You may or may not know that the place where I am right now sitting, as well as the place the students above are walking, was in the midst of a bloody civil war from 1989-2011. The war was between the Ugandan government and a rebel group called the Lord’s Resistance Army (LRA). Many women and children were displaced from their homes to IDP camps. Young boys were coerced into becoming child soldiers. Human rights atrocities were committed from both sides. I feel mildly ashamed that my only prior exposure to the conflict was a youtube video created by an organization called Invisible Children. But I think it is safe to say that the narrative about the war created by Invisible Children was the dominant narrative (and sometimes the only narrative) most Americans were exposed to. Now, I have seen the movies Uganda Rising and War Dance (highly recommended), and I have engaged in dialogue with historians. I have listened to the stories of student colleagues and friends in this class who lived through, navigated, and are personally affected by the conflict. I am beginning to really understand the danger of a single story.

I will end here for now, though expect more to come. 

Love from Gulu! 

Aarti

Hope Pogemiller, Global Health Chief Arrives in Arusha, Tanzania

Content posted with permission from Hope Pogemiller, current Medicine Global Health Chief and graduate of UMN MedPeds Residency Program

Greetings from Arusha! 

As the children energetically yet patiently teach us each day, Jambo, Mambo, and Good Morning Teacha are just a few of the many acceptable salutations offered to everyone encountered.  This reflection of intense community spirit is a welcoming reminder of the incredible value of universal salutations and the respect they engender.  It's wonderful to be back in the land of long walks, random chats with new people, and compulsory salutations.  It is remarkable how respectful these children are with playful greetings and light conversation in Swahili (which I can pretend to understand by judging the nature of their smiles).  Some roll tires or bike wheels alongside us, greeting us in Swahili, trying a little English, or just smiling and staring up at us a little-- without chanting and only rare demands for money.  They seem to be accustomed to living with Mzungus, and they enjoy interacting with us as real people.  The 6 km walk to work is hilly, but it has been a delightful form of exercise with the accompaniment of schoolchildren.

My flight through Amsterdam found me a new batman wristwatch, and my voyage was only slightly delayed with de-icing in Amsterdam prior to departure and a little intense visa discussion at the airport. My taxi driver waited for me for a few hours, and he looked purely relieved to see me...the last person from my flight out of the airport.  I tried to explain the need for de-icing the planes in Amsterdam, but it was a complication that seemed rather peculiar to him.  As we walked to his taxi, his buddies at the airport all shouted out to him that they were glad he found me.  There was so much support and no irritation for my delay-- a lovely introduction to this culture.  We had a lovely chat en route to Arusha on a beautifully paved road.  

My "host-mother" Linda (the wife of the doctor who moved here after residency at the U to start 2 hospitals) met me at my house around midnight and gave me some keys and a phone along with some basic orientation.  Linda is an effervescent woman with a heart of gold and a creative, quick wit that is a pleasure to experience.  She drove Ryan Fabrizius (4th yr MedPeds resident staying in Arusha through Feb) and me to the " Pic n Pay" Middle-Eastern Grocery Store for one of the most lively grocery visits I've ever experienced.  She gave us a tour of the 5 aisles and greeted every third person whole-heartedly (they were close friends) as she shopped and advised us on our shopping.  It was a great introduction to the community, and it was followed by a visit to the Dutch fruit/vegy vendor.  We pulled up to the gate and noted that it was closed, but she was not deterred.  She found a way to slide open the gate and walked in to ask what their hours were.  It was 5:58, and she thought it had closed 2 minutes early.  She came running back to the car in a minute to tell us we could enter to buy food.  The market had closed at 5, but the vendor was more than happy to welcome us to buy some of the most delicious mangoes, avocados, greens, oranges, and tomatoes.  Arusha is a very large city, but Linda has delightfully created a tight-knit community that suddenly gives it the feel of a warm, small town.  Today we heard that she took out a few of the medical students from New Zealand cheese shopping, which caused a instant pang of jealousy and regret.  The Linda fan club is vast but devoted, and I can't wait to meet with her again!

We met with Dr. Mark Jacobson and Dr. Steve Swanson, toured the 2 hospitals of Arusha Lutheran Medical Centre and Selian, and have now had an opportunity to follow interns, registrars, and AMO students on rounds at Selian.  There has been talk of the creation of didactic sessions such as morning report and case presentations. However, presence during daily rounds and coaching with the ultrasound machine seem to be of particular importance for the hospital staff at Selian.  After a few more days learning the system, I plan to ask some of the staff what their needs are and try to match them with my skills to pave a position for the global health chiefs in the future. 

Medical Students and Ryan Fabrizius, MP4, walking

Purple flowers marking the outside of the house

In the meantime, I'm thoroughly enjoying refreshing rains, long walks to the hospitals on bumpy dirt paths surrounded by bright green foliage, banana trees, palms, and corn fields with cows herding by, the same African dog calmly watching, and an endless stream of energetic children walking to and from school and fetching water.

Hibiscus flowers

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.