I Heart Elephants

The chances of me doing justice to my last ten days in Tanzania grow increasingly slim as the days zoom along. This is especially true given that I'm heading out to Peru tomorrow morning, accompanying a group of fellow medical students as we visit urban hospitals and rural clinics in the Peruvian health system. After Tanzania, I have to admit that Peru seems like a much easier hill to climb: I can speak the language (decently, anyway), I'll be in the same time zone, I'll be traveling with friends the whole time - and I've even been there before. Not nearly as nervewracking as my departure for Dar in mid-June.

But a quick sum up of the Denny Family Adventures, before I fill my brain with aventuras nuevas. Successfully navigating the airline ticket craziness (see two posts down), Dad and Lexi arrived early in the morning on Friday, looking both sharp and exhausted in the way that only well-dressed international travelers can. The three of us spent a few days in Dar, alternating between city strolling and jet lag reeling; we didn't manage to get to the Annual Dar es Salaam Charity Goat Races, but we did manage to hit the city fish market on a pretty good day. (Enormous manta ray, anyone? I always wonder if their "horns" are delicacies.)

Then off on safari! We flew to Kilimanjaro airport and headed to Arusha, where we met our guide Juma. Over the next few days we visited four parks: Tarangire (rolling plains spotted with baobab trees, sprinting warthogs, 30+ flocks of giant ostriches and scores of elephants), Manyara (my personal favorite, a soda lake surrounded by forest, where a sudden turn in the road can put you face-to-face with 80 baboons or a family of elephants. Plus an delightful hippo pool and an excellent array of giraffes), the Serengeti (camping in the confines of the park was exciting to the edge of terrifying - hyenas stole our trash, baboons our breakfast), and Ngorongoro crater (a 20 km wide volcano crater with a condensed population of wildlife: hundreds-strong herds of herbivores with an accompanying smattering of cheetahs and lions). Each park area felt very different. The Serengeti, especially, is a truly amazing-looking place, even aside from the animals; vast, flat, grassy plains run out for miles in all directions, right up to the horizon. The name comes from Serenget, the Maasai word for "endless space". True story, Maasai, true story.

The Maasai, it should be noted, have been kicked out of the confines of the Serengeti National Park (or rather, were strongly pressured to "voluntarily leave" in the 1960s), but they still have free reign in Ngorongoro crater. This leads to amazing scenes where you have hippos, zebras, hyenas, and wildebeest all in your view - and then you notice a Maasai man and his cattle strolling by about a half kilometer behind them all. Neat.

After 5 nights of tent camping (although it's hard to say we were "roughing it" by any standard - I think it's safe to say I ate better food on safari than I did for the rest of my Tazanian stay), we headed to Zanzibar. We arrived, in fact, on the first full day of Ramadan, which I think added some extra interest to our stay on the island. Zanzibaris are about 95% muslim, which means that finding food or water during the daytime became quite a bit of a challenge for us; we were reduced to sneakily taking sips from our bottles in dark alleyways. It's like contraband. But at night fall, the whole island jazzes up noticeably. A huge siren announces the official sunset, and then locals and tourists alike go seeking food. One of my favorite aspects of Stonetown, the capital, was Forodhani Gardens, where a couple dozen local chefs nightly serve up tables heaping with seafood or fresh-pressed sugarcane juice or "Zanzibar pizza" (an egg/veggie combo fried in a very thin crepe). The seafood itself is often labeled in particularly egregious (and delightful) English; I myself opted for a skewer of "tuner fish", but there was also "black sneeper" and "paracuder" for sale. Other highlights included a spice farm tour, where we knowledgably sniffed our way through several dozen different varieties of spicy barks and leaves. The scent of cloves, especially, seems so very exotic.

After a particularly rough ferry ride back to the mainland (ie, sick bags were distributed), we spent a final dinner at the Badminton Institute with the housemates before our very early morning departure. That in itself was a bit of an adventure - the taxi didn't show at 4 am, thanks to the insanity that is Swahili Time, so I spent my last few hours in Dar jogging through the darkness in search of a ride to the airport. Sort of put a nice cap on my whole experience, really. Cairo was the typical craziness, London was pleasant (and cool!), and Chicago has been very welcoming. It's a little sad to me how quickly I fall back into my old lifestyle patterns; I'm trying to be more conscious about the way I live, particularly about how I spend my free time and how I interact with other people.

There will be photos posted soon (some already made it to Facebook, the destroyer of worlds), but in the meantime, an interesting article about women, birth control, and East Africa.

Nyumbani

Four time zones, three flights, two Tube rides and one terrifyingly late taxi later...I am home. Back to my toddlin' town.

I will write a bit more tomorrow, when I can remember what day it is and where I woke up more clearly. The absent weeks were spent adventuring with Dad and Alex in the Serengeti region (heck yes we saw elephants!) and Zanzibar (during Ramadan, no less - daytime water is for the weak). The trips were excellent - really amazing parts of the country, truly. Good photos to share.

But now I have to try to begin adjusting to my new apartment, where my room is full of moving boxes and the sound of TV seems terribly jarring. I'm a bit discombobulated; it took me a good two minutes to figure out where I was and what was going on after my nap this evening. Hopefully all will seem more reasonable in the morning.

Karibu, Baba na Kaka

You know that feeling you get when you think you've reached the botton of the staircase, but there's actually one more step? And you experience a half-second terrifying shot of adrenaline before hitting the ground?

That deeply unnerving feeling of having the ground briefly disappear out from under you - that's sort of like what my Dad and brother went through 48 hours ago. (Although theirs was much more expensive.) Approximately 20 hours before they were planning to depart for Tanzania, my brother Alex realized that instead of buying plane tickets for the first leg of their journey for Wednesday, he'd actually gotten the same flight for Thursday. Which meant they'd be 24 hours late to London. Which meant they'd miss all subsequent legs of the trip to Dar es Salaam, including the flight to begin our safari on Sunday morning.

Instant terror adrenaline surging on all fronts. They tried to just move the flight up a day; Continental said no. (Or rather, no unless you give us $6000.) They tried to buy a one-way flight to London in order to be on time for their second flight; Continental said their policy is to cancel the return tickets for anyone who doesn't check in to their outgoing flight. It is now 8 AM on the day they must depart.

Long story short, they had to buy brand-new, day-of tickets to get to London in time, stopping in Canada on the way. Oy. But they made it! Picked 'em up at the airport this morning and then let them go straight to bed. (Although I did wake them up to have them eat lunch at the office with us. Everyone said we looked alike. "You all have merry faces," announced Christine. "You smile from your hearts.")

Another day of jet lag adjusting tomorrow (and of course the Dar es Salaam annual charity Goat Races in the afternoon), then off on safari on Sunday. Send me an email if you want me to bring you back a baby hippo.

You gotta fight for your right to...go to clinic

Good God. I promise to never complain about my commute again, even when it's -17 degrees and I'm trying to bike over the ice to school.

For I have seen the Posta-Masaki daladala on a weekday morning.

It is completely and totally out of control. I've had fairly good luck getting out to CCBRT before via the Posta-Masaki route, but I think before yesterday I've been riding a little after the peak of rush hour. The number of buses on this route is completely insufficient given rider demand, so big groups of people are already running alongside the bus as it pulls up to the Posta station, masses of hands clutching at door frame. People inside the bus trying to disembark have to literally fight their way out - I saw one woman actually get trapped inside the bus by the entering mob, unable to get out the door. As soon as (most) people inside have exited, the door hangers (mostly young men) go absolutely nuts, shoving each other and throwing themselves up towards the door in an attempt to get on board, giving no quarter to kids or the elderly or small women also trying to get in. Particular tenacious teenage boys jump up through the open back windows. A huge chunk of the waiting crowd is always left behind (usually those unwilling or unable to shove), hoping to wedge onto the next one. It took me three tries to board a daladala yesterday (I think the trick is to come at the door at an oblique angle). It'd be funny if you didn't have somewhere to be, but if I had to do that everyday on the way to work I'd go crazy. Or I guess maybe I'd start shoving.

But I finally made it to CCBRT hospital again in the morning, probably for my last visit. (Though maybe not - I feel rather welcome and wanted at this point, so much that I'm considering visiting on the day before I fly home. The nurse gave me a hardboiled egg yesterday! Nothing says appreciation like a hardboiled egg. We'll see.) I arrived mid-ward rounds again. Dr. Robert greeted me by announcing that several women were leaking urine that morning - he termed it a "disaster" but didn't strike me as that concerned. Later patient file review seems to indicate that leaking is not that uncommon for fistula patients that later experience full recoveries. Ward rounds are kind of funny: Dr. Robert kind of acts like a sardonic uncle figure to all the patients. At each patient's bed he cracks jokes, mostly making fun of her, and she and all the other women giggle. It's like The Today Show for the fistula ward.

After ward rounds, Tuesday clinic commenced. Last Tuesday I was surprised that only one true fistula patient showed up; this time, there weren't any true fistulas at all. Or at least no clearly obvious ones. But I do think that the kind of women who end up at the clinic give a sort of representative snapshot of life as a woman in Tanzania. At one end of the spectrum was an 80-year old woman who arrived with her two daughters, incontinent and a bit senile but clearly well-cared for. The nurse noted quietly to me, "Look how much those two ladies love their mother." Seemed to be true: their mom was confused, stubborn, and clearly feeling the pangs of a hard-lived life (her permanent hunch made her about 3'5" tall), but the good-natured daughters kept her clean and rather sharply dressed. At the other end of the spectrum was a 10 year-old girl with painful urination; it was unclear to all involved why she'd been sent to the fistula surgeon. Off to urine analysis she went.

Then, in between these two extremes, we saw two women of childbearing age whose main problems had actually been inflicted by the Tanzanian medical system. One woman, complaining of incontinence, had obviously had some massive surgery in the past. She wasn't sure what the doctors had done, but the scar on her abdomen was enormous and Dr. Robert pointed out the marks of at least three drains on her belly. "In these cases, we have a song," said Dr. Robert. "You know 'Return to Sender'?" So back she was sent to her original Kilimanjaro hospital. The second woman was suffering uncontrolled urination after her delivery in a Dar es Salaam hospital three weeks ago. The C-section scar was clearly fresh - so fresh, in fact, that the nurse discovered a bit of suture still in the skin that the doctors had simply forgotten to remove. That's hygenic, I'm sure. Oy. Dr. Robert suspected that her problem might actually be due to the C-section itself: every so often doctors will detach the ureters during a C-section surgery and reattach them in the wrong place, leaving them to drip urine into the abdominal cavity and causing incontinence. The problem is technically considered a type of fistula and can be repaired at CCBRT, at least, but she'll need more tests.

And finally, the dye tests. Dye tests are the moment of truth for fistula patients: after two weeks of post-operation rest, their bladders are filled with bright blue dye to see if there's anything leaking out. Two ward patients were up yesterday. One was a success: no blue leaking, even with pressure, so when she fully heals she'll be on her way home. The second, sadly, was a no go - bright blue dye came seeping through her stitches almost immediately. She'll have another two weeks of waiting around with a catheter in hopes that things will spontaneously heal. It seemed very unfair, particularly for this woman: she's 30 years old, but it's clearly been a hard 30 years. She looks to be in her early 50s. And she's all alone - the one child died during childbirth, and her husband left. She deserves some good luck at CCBRT at least. Fingers crossed.

Ladylike

Perhaps fittingly, my last weekend in Tanzania before the arrival of my dad and brother was a supergirly weekend. Yet supergirly in a distinctly Tanzanian way, I think.

For one, I went to a tailor. A tailor! The anti-Target. I've never had anything tailormade; it always struck me as simultaneously glamorous, old-fashioned, and entirely out of my price range. But the majority of women here have at least a few tailormade outfits, usually a fitted top with short sleeves and bum-hugging long skirt to match. Almost all are made from kitenges, these durable and super colorful fabrics you can buy in 6-meter swaths (minimum length) from jampacked little stalls just east of Mnazi Mmoja park. The purchasing process alone is a lot of fun - lots of sifting through bright patterns and feeling up material and hemming and hawing over whether this one is just the right one for you. (All the salesladies have opinions.)

Back in Kongwa, Mama Elizabeth (the Reproductive Health coordinator) had lent me a shawl with a really pretty cowrie shell design all over it. The same fabric popped up again a month later, for sale in a narrow little store on Uhuru Street, so I decided it would be mine. Hoping to get a simple dress made, I took the fabric on Saturday to an equally narrow tailor's shop deep within the complex of stalls near the Morocco gas station. The tailor didn't speak any English but seemed rather enthusiastic about the project. We'll see how things turn out on Thursday. Adventure!

If girliness includes clothes, it must also include hair. But luckily, not my hair. Nina and Magdalina had decided a week or so ago that they wanted to try out a specific style of tiny braids sported by lots of women in the city, including our housemate Happy. This specific style is actually a traditional Maasai style - in fact, it's the traditional Maasai men's hairstyle. (Maasai women go bald while the men sport long, waist-length braids. Interesting gender reversal.) But it's non-Maasai Tanzanian women who want their hair done, not with the traditional beads and stuff but with the hundreds of tiny braids. Thus, quite a number of young Maasai men in Dar make their living by going to private homes and spending a few hours braiding ladies' hair.

So that's what I came home to on Friday and Saturday: one German girl cross-legged on the porch positioned between two twenty-year old Maasai guys, her hair being heartily yanked back and forth as they steadily twisted and spun and pulled it, all the while smoking cigarettes and drinking Konyagi. (That stuff is seriously foul.) It took them - I kid you not - 7 1/2 hours to do all of Nina's hair. Oy. Magdalina got away with only 6 hours, lucky girl.

But after the men headed off back into the city, the girly part took over: all of the women of the house, which I think included at least five countries, helped out by braiding the braids and dipping them in hot water to seal them in place. All of the boarders, plus the house matrons, plus a few of the house matron's visiting sisters - everyone pitched in. It was good times on Kibasila street.

And despite residual two-day headaches, Magdalina and Nina look pretty nifty. When they first made their plan, we three talked how Europeans and Americans tend to view braided hair on white women with disdain, as a sign of wannabe-Africanness. It made them a little reluctant to go forth. But now that it's done, it seems that all the African women here think it looks fabulous on them. Walking around with Magdalina yesterday was really fun, with random strangers on the street continuously shouting "Unapendeza!" ("You look nice!") at her. There's no way I'd ever do it (7 hours? I can't even sleep for 7 hours without getting a little bored), but I'm happy to be associated with them.

Last week of work. Dad and Alex arrive on Friday morning (and have already been invited to lunch at the office). Looking forward to adventuring with them.

This post is worth 1000 words

Put some new photos up on Picasa, including the marvelous zebu cattle and the Pugu Forest Reserve that wasn't:

http://picasaweb.google.com/colleen.denny/

There are some various and sundry recent photos also up there, from Bagamoyo and such. Fancy cameras I have none, but some of them turned out fairly well, I think.

The first data fix is free...

Quick afterthought post for all you data junkies out there:

I'm researching this week about child marriage and its relationship with maternal morbidity and mortality. Turns out that 14 year old mothers aren't a great idea, healthwise (and probably many otherwises.) Go figure. But check out the UN Data on legal age of marriage throughout the world:

http://data.un.org/DocumentData.aspx?id=126

I think that a couple countries are tied for the oldest minimum age, with the groom needing to be at least 22. Please note the "exceptions" column for Trinidad and Tobago, where the minimum age for the bride (with parental consent) depends on whether you're Muslim (12 years) or Hindu (14 years). Also, apparently there are US states where you can marry off your daughter at 13 with parental permission. I am disturbed.

Meat and Greet

There is a place of legend in northeastern Dar es Salaam, a place whose very mention seems to cause uncontrolled salivating in a large percentage of both the local and expat population. That place is known simply as...Morocco Burgers.

The actual set-up for Morocco Burgers is quite humble. There is, for example, no official sign; "Morocco Burgers" just becomes the default name due to its location near the Morocco daladala stop and its single menu item. Nor is there any indication that food of any sort is available within. You just have to know. Burgers are served from inside what looks to be an old train car, painted bright red and permanently parked in the back lot of Morocco petrol station. There is no place to sit or eat (save the concrete curb), no posted prices, and no speaking of English, but the place smells unbelievably good and I've never been there when there wasn't a waiting line. (Or rather, a waiting cluster. Tanzanians don't really do lines, per se.)

I was rather shocked by that delicious aroma when I first passed by Morocco burgers (sadly, on my way to dinner elsewhere). I've been a vegetarian for about three or four years now, and I don't really miss meat - I never ate it that much to begin with, and the smell of meat cooking is usually something I can take or leave. But goodness. That scent eminating from that little red box reminded me of those Saturday morning cartoons, when a good smell becomes a pair of long fingers that tickle the character's nostrils and float him through the air towards their source.

Despite the vegetarianism, I decided before coming here that I would be content with eating Tanzanian meat. For one, I (correctly) figured it'd be a significant part of the culture that I'd be missing out on. For two, I reasoned that the animals that become food in Tanzania tend to live happier, more animal-like lives. There aren't any factory farms here, or feeding of antiobiotics to livestock, or any of that stuff that freaks you out in "The Omnivore's Dilemma." Your typical American cow would never see anything as wide open as the Pugu Hills cattle market, but it seems that most cattle here take such big expanses for granted. In fact, my daily living space in Dar intersects with that of livestock fairly often - there was a rogue chicken in our courtyard last night, for example. Goats are kept in front yards. Daladalas swerve to avoid cows on the roads. The urban arena probably isn't the most salubrious environment for them, but it reassures me that animals raised for food in Tanzania at least have room to move. And that simply makes me feel better about eating them.

And then for three, I suspected that it might be considered rude not to partake in meat - or if not rude, exactly, at least one of those things that would be a weird, white person thing to do. This turns out to have been mostly correct as well. The typical Tanzanian meal is: green veggie, non-green veggie (bananas count), and meat with sauce, all dumped over rice. Fruit is always served for dessert. If I try to order this combo at a Tanzanian restaurant without the meat centerpiece, I am met with consternation. Am I sure I don't want meat? How about chicken? Or fish?

This same combo has been my lunch at the Women's Dignity office every day that I've been here, and although the exact identity of the players changes, the basic line-up is always the same. And the sassy mama lisha who serves our food, Mama Salma, already intimidates me. There's no way I'd dare to tell her to hold the meat. Not a chance. Telling her to hold the china (a spinach-peanut thing to which I am allergic) was already scary enough. Man, did I get the Eye.

So I have been making my way through a fine variety of meats at work lunches. And I haven't been sick at all, though I do get a little grossed out every so often. Chicken and fish are pretty easy, although eating them always involves handpicking the edible bits out from the bones and skin. The chunks of beef and goat are a little harder to stomach - they're no longer on the actual animal carcass, but big bits of gristle and often bone are still attached. Luckily, I haven't yet found myself presented with octopus at work. Octopus is fairly common here - it's on sale from street vendors all over Dar, with little orange tentacles dangling over the edge of their trays. But putting aside the wisdom of eating raw octopus from a street vendor, I think my love of cephalopods may be just a little too great to eat one of their numbers. We'll see if the situation presents itself on Zanzibar.

No, the only meat of Mama Salma's that really throws me off is liver. Liver is my food nemesis, I've decided. The smell is disgusting. The texture is way too homogenous (I thought I was eating a mushroom on my first bite). And the taste is somehow both bland and sour, vaguely menacing, just a little too similar to the taste of blood in your mouth when you bite your tongue. Ick. Yes, liver is gross. I've taken to hiding it under napkins or papaya rinds when it comes through the rotation, so as not to incur Mama Salma's ridicule.

Aside from the vile liver, I think my summer meat adventure is going fairly well. But I still expect that when I get back home, I'll switch fairly easily into my old veggie ways. The things that pushed me into vegetarianism in the first place still hold, to the point where I notice that the things that particularly ick me out about meat are the things that remind me that it's meat - gristle, bone, skin, the things that tend to be absent in American meat. I figure that if I don't like eating the parts of an animal that remind me it's an animal, that's probably indicative of some sort of internal denial.

So last night Johann, a dutch fellow housemate who works out near Morocco, kindly brought us all back burger dinners. I haven't had a burger for two or three years, I think, and I have to concede that my meal was pretty darn delicious. And if that's the last burger I have for another two or years, by golly at least I went out on a good note.

I think I shall make my future clinic staff call me "Dr. Colleen"

Just after I posted the last entry, my office rat reappeared! He scuttled out of the closet and miraculously wedged his chubby little body under the door to the hallway. I'm not sure what his presence means for the hygiene of our nearby kitchen, but at least I feel reassured about opening the closet again.

Spent the morning at CCBRT's fistula clinic, trying to counterbalance my surgical time with a little straight-up medical experience. Dr. Robert (the surgeon who struck me as a bit of a curmudgeon last week) is the presiding physician at the Tuesday clinic, assisted by a very kind nurse whose nametag is always, always backwards. I will have to learn her name by sneakier means.

I arrived just as the two of them were making their way through daily checkups for the 25 or so women currently in the ward as inpatients. Some women were waiting for surgery, but most were recovering post-operation; turns out Dr. Masemga made it through an impressive 16 repair surgeries during his visit last week. The checkups were pretty quick - as Dr. Robert quipped, "We have really only two words in this clinic: 'Well' and 'Dry'." True story. The nurse wrote that phrase down for every single post-surgical patient.

The ward is a pretty peaceful place, save for the blaring television in one corner. (Everytime I've been there, it's showing some sort of American music video channel. Beyonce has fans everywhere.) The recovering women sleep and rest and occasionally shuffle around, carting their catheter bags with them in plastic tureens. I did note a rather sweet scene near the ward door, where a patient was sleeping with her little infant curled up alongside her. Every so often, it seems, babies who get stuck in labor do make it through OK, even if mom's a bit worse for wear.

With all inpatients seen to, the clinic for new arrivals began. A group of women had assembled outside Dr. Robert's office wall, waiting patiently on the outdoor bench until he yelled their names through the window shutters. (HIPAA would be aghast.) The clinic was rather surprising for me in terms of clientele: Although women are referred to CCBRT from all over the country for reason of suspected fistula, only one woman of the seven or eight we saw actually had a fistula. A few had natural incontinence due to various causes. One seemed to have had a botched earlier surgery that had become problematic (the woman herself wasn't sure if she'd had a surgery and had to ask her husband - gives you an idea of how much physicians in this country actually explain things to their patients). Another woman was actually a nun, who'd had to undergo surgery for an iatrogenic fistula after doctors accidently poked a hole in her vaginal tissue while trying to remove a bladder stone. Extraordinarily bad luck, really. You'd think a nun, of all people, could avoid worrying about fistulas.

So lots of significant and quality-of-life-impinging health problems, but not particularly problems that the CCBRT fistula ward is designed to solve. And of course CCBRT itself is not designed to be a general care hospital. If you don't have one of a rather short list of conditions, there's no one there able to take care of you. Unfortunately, referrals are pretty thin on the ground in Tanzania; the woman with the botched surgery, for example, was simply told to go back to wherever it was that she'd been orginally treated. (I hope her husband remembers, at least.)

Dr. Robert seemed to warm up to me a bit as I asked questions, so I've been invited to next week's clinic as well. (Hoping to learn a good Swahili phrase for "It's ok/Don't worry/Try to relax" in the interim; Dr. Robert's style of pelvic exam, where he mostly ignores the woman and certainly doesn't warn her about what he'll be doing, seems to cause a bit of understandable anxiety in the clinic patients.) The recovery period for fistula surgery is usually about 14 days, so I'm looking forward to seeing the patients I saw in surgery getting to go home.

Hoofin' it

Wow, a rather large rat just launched himself across my office floor and into my closet. This is problematic for two reasons: first, there's no way I'll dare to take anything out of that closet for the next week. Second, my uncensored reaction to seeing this rat was to gasp "Oh my goodness!" and put my hand over my heart. "Oh my goodness"? Who am I, Mrs. Doubtfire?

So it turns out that the Pugu Hills have a lot fewer day visitors from Dar es Salaam not because they're a hidden gem, but because...well, they're pretty lame. Suffice it to say there were NO elephant shrews, despite the very prominent photograph of one on the Pugu Hills website. Blatant false advertising.

It probably didn't help that our little band of travelers (me, Nina, Magdalina, and Zalha, a Tanzanian med student) got lost repeatedly throughout the course of the day, always in a situation that meant extra time being rather too hot. And we started our routine of getting lost early, right off the bat. Despite the daladala driver huffily insisting that he knew exactly the intersection where we were supposed to disembark, we completely blew by our stop without a peep from him. Zalha and the other passengers gave him a thorough tongue lashing (there's really a certain moral superiority you get when fellow riders of public transportation take your side), but we still had to ride all the way to end of the line just to double back. And pay again.

And then we got all turned around on the throughly signless walk to the Pugu Hills conservatory, missing turns and wandering through chicken-filled yards and ending up at one point at what seemed to be a gravel quarry. (Several surprised-looking ladies there kindly inquired if we needed any gravel. Not today, we replied. They nodded wisely. Sometimes one just wishes to inspect gravel, not buy.) Lots of uphill trudging in the unfiltered sun before we finally arrived, only to discover that 1) they'd given our reserved guide away and 2) the actual forest was, in fact, closed to hiking. But would we like a Coke? Well, yes. We would. Love that real sugar soda.

With no forest, we chose the next best option, an hour-long walk to a huge regional cattle market. Even in the early stages of heatstroke I tend to be delighted by the prospect of livestock, so I was happy to go. The sun was still being all sunny and stuff, but hey, at least this time we were walking/sliding downhill. But we clearly hadn't picked up on the "Getting Lost" theme of the day - our assigned "guide" had actually never walked this route before. So we spent quite a bit of time walking down suspicious-seeming paths, then stopping, then waiting as our guide had a hushed cell phone conversation with someone, then turning around to double back the way we'd come. The one upside of this was that his detours often took us through people's small backyard orchards. I can now identify cashew trees, baby coconut saplings, and cassava bushes, thanks to Zalha's instruction (and frequent quizzes).

We finally did make it to the cattle market, which I have to say was pretty exciting. These were not your typical boring Jerseys or Holsteins - these were zebu cattle! With huge horns! And these delightful fat-filled humps that kind of jiggle whenever the animal starts trotting! Man, I wanted to poke those humps. But it's rather intimidating to be stared at by a 250 kg animal with two-foot horns, even when that animal is of the bovine persuasion. The market is just a huge courtyard, with humans and cattle milling about unchecked, so most of my time was spent trying to keep an eye on all cattle in my vicinity without getting too close to any one. Plus it wasn't as if I could casually blend in - there were virtually no women at the market, and certainly no other mzungu women, so my poking would not have gone unnoticed. (Zalha was constantly fielding offers from various cattle salesmen - they'd seen our group come in and tried to figure out why we were there. Were we interested in buying this bull here? Very good price? Perhaps the Germans were looking to acquire a small herd?)

We stopped briefly on the edge of market to hide from the sun and to enjoy a small snack of Coke and Nice brand cookies (in keeping with the day's healthy diet), then boarded a long daladala ride back to Dar. We arrived at the legendary burger stand outside the Moroco gas station, the tastiest burgers in town - only to discover it was closed on Sundays. Ah, it kills ya. We stood staring uncomprehendingly at the closed serving window for awhile, stuck in that state of mind when you're too tired and hungry to make another plan of action, until we finally mustered up the energy to head downtown for some traditional Tanzanian grub. Oh, savory banana stew. We will always be friends.

So my official recommendation, if you must go west from Dar, is to skip the Pugu Hills entirely and head straight for the cattle market. If you play your cards right, I can get you a good deal on a nice steer. Though he may not fit in your carry-on.

Lay Down Your Heart

Denny's Theory of Blogging posits that for a blog to be readable, there must be a relatively even balance between sobering, depressing entries and happy-go-lucky ones. I think the scale has been tipped a little too far towards the sobering lately, so perhaps now is the time to backtrack to my activities last Saturday. I give you: Adventures in Bagamoyo!

Bagamoyo is about 70 kms (that's right, I'm all metric now) north of Dar es Salaam, right up along the ocean. Once, long ago, it was actually the capital of German East Africa. Almost all European missionaries began and ended their journeys there (sometimes for good - the body of Dr. David Livingstone, of "I presume" fame, rested in Bagamoyo before his final trip back to Westminster Abbey). It was also a huge center of the East African slave trade, where newly captured slaves were held before their transport to Zanzibar and further places. The whole city reached its peak around the 1890s - whereupon the Germans made the crucial decision to relocate their capital to a little harbor called Dar es Salaam. It was all downhill from there for Bagamoyo, I'm afraid. Nowadays, it's an example of my favorite type of city: once grand and important, now delapidated and mostly abandoned, with grand buildings in thorough states of disrepair and little hints everywhere of its former glory.

Fellow travelers Nina and Magdalina and I took a series of daladalas up the coast from Dar, navigating like pros. The one minor snag was that the final daladala terminal turned out to be quite a bit inland of historic Bagamoyo - we didn't quite know which way to walk, and the taxi drivers descended like jackals. Luckily Nina and Magdalina deal with these guys in the same way I do: walk confidently in one direction, even if you have no idea where you're going, until the touts/drivers finally give up and you can consult your guidebook in peace.

Having finally determined which way was east ("I see ocean over there!"), we popped out onto a long, neatly bricked pathway running right along the coast and through the center of town. Immediately to our right were the old German BOMA, a fancy-pants administrative building left roofless since El Nino, and the simply-named Fort. Both had that solid, this-building-will-be-here-for-generations look common among old European structures in this country. If there was any residual hope among the Bagamoyans that these Westerners might just go home after a few years, I think the Fort may have persuaded them otherwise.

We ambled north along the pathway, politely refusing a constant stream of offers ("Baisikeli [Bicycles]! Ice creami! Wood carvings!", etc.). The main buildings in town, near the ocean-side fish market, all have this great rundown appeal - very shabby chic, if you will. The outer walls are chipped and crumbling and clearly haven't been patched up in years, but the doors - oh, I took a lot of pictures of the doors. They're done in the Zanzibar, Omani-influenced style: really thick hardwood, with beautiful carvings bisecting the door and running around the edges. Apparently each tiny carving design has its own symbolism: a chain for protection, a lotus flower for prosperity, a wave to indicate a fisherman's home. Of course, no one has done any conservation for the doors any more than the rest of the town, but luckily they're so solidly made that they're survived fairly well.

After appreciating the hilariously low tide characteristic of midday Bagamoyo, we set out on unexpectedly long hunt for lunch, finally ending up with plates of rice, beans and veggies in a oceanfront field of picnicking locals. We all agreed that food tasted much better when you'd had to wander around seeking it for a few hours. Sour grapes, perhaps, but those beans were totally awesome.

A quick ice cream cone apiece, then off to St. Joseph's mission, a large chunk of land just off the coast. The Holy Ghost Fathers, among the first Christian missionaries to plant themselves in East Africa, established what became a rather sprawling complex over the years: church, bell tower, farms, living quarters, school, and a tiny but surprisingly good museum, with more information about Bagamoyo than seems even to be available on the internet. (I know, hard to believe.) We spent a good hour in the three-room museum, checking out items from the whole history of the town: pre-European tribal masks, Omani ash trays, slave chains, deeds of freedom for slaves ransomed by the priests, WWI-era German newspapers, 1920s handrawn British maps. Ran the whole gamut, really. We emerged, pleased and vaguely self-satisfied with our new knowledge. (Once a med student, always a med student.)

With the light waning, we strolled back towards the bus station, stopping to visit the huge fish market on the way out. Somehow during our walk back, our stabs at asking for directions in Swahili acquired us a series of friendly escorts: an older man walked us to the fish market, a younger man took us to a place to buy water, a middle-aged woman walked with us to the daladalas. Capped the day off nicely, really, and sort of gels with what I've generally found in Tanzania - a genunine attempt at Swahili, even a bad one, earns you a lot of good will. It's encouraging.

A bumpy trip home in the gathering darkness, notable only towards the end when our daladala went zooming right through a police checkpoint. Good times. So the first day trip was a success, I think; planning a second one this weekend to the Pugu Hills, where I shall seek the elusive giant elephant shrew.

EDIT: Almost forgot: "Bagamoyo" means "Lay down your heart" in Swahili, although it's not quite settled how it got that name. Some sources say that it was because Bagamoyo was the big city, fun times, lay down your cares and worries and all that. Other, more plentiful sources say that it was named during the slave trade: if they captured you and you found yourself taken to Bagamoyo, give up hope. Sort of fits nicely with with my aforementioned theory of blogging, I thought.

Return to CCBRT

A worthwhile day, yesterday. I felt content with the day's business when I crashed into bed last night, and marinating on it for another 24 hours has only made me more pleased that I went back to the CCBRT hospital. It wasn't particularly a happy day (though I suppose the women on the operating table will be pretty happy in two weeks, if everything heals properly). But I saw a lot, learned a lot, built up some relationships. And that's the point of this summer, right?

It occurred to me during a chat with David "The Yellow Dart" Foster that maybe I should explain what obstetric fistulas actually are, though again hopefully in blog-appropriate terms. You don't really hear about them in the US and Europe because...well, they don't really happen there. An obstetric fistula is basically a really bad complication of childbirth. As Dr. Masemga told me, every patient story he hears is essentially the same: The mother is stuck in labor at home for 3, 4 days, pushing hard, before someone finally takes her to the hospital. There, via C-section, the doctors deliver the baby - usually stillborn. But the pressure of the baby's head pushing for so long actually destroys the tissue between the birth canal and the bladder, rendering the woman incontinent. So then your child has died, you can't control your urination, and your husband/partner often leaves because you smell bad all the time. (The CCBRT fistula intake form actually has the question "Did husband leave because of fistula: YES/NO". Most of the ones I've seen circled yes.) Women do go on, of course, and show amazing resilience, but it's essentially life-shattering.

So that condition, then, is what the VVF operating theater sets out to remedy. CCBRT actually has a special theater set aside for fistula repair surgeries, with a special table that can be rearranged as different stages of the surgery require. Part of what made my second day in surgery more rewarding, I think, was that I had an idea of what was supposed to be going on and how I could help - adjusting the overhead lights for the surgeon, hoisting patients onto stretchers, fetching suture material, etc. Small things, but made me feel useful and more involved.

The other improvement for me was my chance to actually talk with the visiting surgeon, Dr. Masemga. He's actually based near Kilimanjaro, but as one of the premier fistula surgeons in the country, he agreed to do a week with CCBRT while their usual fistula surgeon was on leave. We started the day in the same silence as Monday, but towards the end of the first procedure a friendly Indian surgeon dropped in and made a point of asking a few fistula-related questions in English, assuredly for my benefit. Dr. Masemga was happy to respond, and then happy to recieve a few follow up questions from me as well. Ice = broken. It later turned out that out of Dr. Masemga's three trips to the US, one was to Duke University (where I went to college) and another was to the National Institutes of Health (where I worked for three years). The fates wanted us to bond. I wondered later if my perception of the surgeons' indifference wasn't mostly due to Dr. Robert, the vaguely grumpy assisting surgeon playing second fiddle to this hotshot visiting young guy. (Dr. Masemga's maybe in his mid-30s.) Who's to know.

So the team made its way through four repair surgeries yesterday. All were pretty fascinating to me, but two of the cases really stood out. One was an older woman whose fistula had actually come from radation treatment for her cervical cancer. Rates of cervical cancer are much higher here in the developing world, and the few women who actually do get treatment and manage to survive sometimes have tissue destruction that's functionally the same as childbirth-based fistulas. Luckily hers was a very small tear, easily shut.

The other case was the last woman of the day. So many things about her just made my chest tighten. For one, she was 17. For two, she was so delicate, really willowy and beautiful and not at all built for childbearing. Her fistula had developed from her first child (stillborn), and her husband had left soon after the fistula became apparent. Then, during the course of the surgery, the doctors actually determined that she had not one but two fistulas, the expected one connecting her bladder and vagina, but also a second one tearing from her vagina into her rectum. So the surgery ended up being twice as long and complex. But the final sadness was that she'd been circumcised some years ago. (FGM, many call it.) The resultant tightening and scarring made the surgery very difficult, just as it had made her first childbirth experience very difficult.

I was grateful that she was the last case of the day, I think. The more I thought about all the things conspiring aginst her, all the cultural and institutional forces that control her life and limit her choices in fundamental ways, the more overwhelmed I felt. But as I write this today, I'm sort of heartened by the key fact that she wasn't passive in the face of all this - she did get to a surgeon, and a very good one at that. The odds are good that she'll heal well, and that she'll march out of CCBRT in two weeks with her congratulatory kanga and go on with her life, with a chance for a partner and children (via C-section) and normal social life again. Those things shouldn't be underestimated, even if the greater problems that brought her to CCBRT in the first place still remain.

In which medical terms are used

I opt to go a bit out of order today, skipping over my exotic weekend day trip in favor of writing about my day yesterday while it's still fresh in my mind. (Random tangent: "Fresh" is a very hip slang word here. Someone asks you how you are and you reply not with "mzuri" (good) or even "poa" (cool), but "fresh", in English --> instant street cred.)

Although last week's attempt to observe a fistula repair surgery was thwarted by an untimely onset of patient malaria, I had learned at that time that a noted fistula surgeon would be visiting the CCBRT Hospital this week, with approximately five surgeries scheduled every day. So yesterday morning I hightailed it north on the Posta-Masaki daladala and made my way down the newly paved road to the hospital. (True, the paving actually only goes as far as the bar that shares the street with the CCBRT. But then, halfway's better than none, right?)

The CCBRT specializes in disability repair - they fix orthopedic problems like club feet and polio, eye problems, fistulas, and a few other specialized treatments. I threaded my way through the very crowded waiting room and returned to the fistula ward, a shabby but clean room with lots of light and beds for perhaps 25 women. Dr. Robert, who I'd met before, has his little office off to the side of the ward, assisted by an quiet but efficiently friendly nurse. Waiting for the cheif surgeon to arrive, the nurse decided that I was a worthy visitor (I think sometimes the sheer asking of questions earns one brownie points) and began showing me patient files and surgery logs, all of which helped me immensely to figure out what was going to be happening that day. She also introduced me to a fistula patient being successfully discharged that day - the patient had received a congratulatory kanga from the hospital and was happily trying to see how the color suited her.

So by the time we were called to the operating theater, I felt a bit more confident. I'd felt rather unprepared going in that morning, honestly. Fistula surgeries are simply never done in the States, or taught in med school, because they don't happen to US patients. I didn't know the theory of the surgery, or how long one repair took, or what made a surgery more or less difficult, or any of that stuff. Maybe it's because I'm a slacker and any good surgeon wannabe would have somehow figured it out, but some of it must also be due to the absence of the surgery in the West. Why learn or teach what you'll never use?

This post now becomes a little tricky, because I want to talk about the surgery but I also don't want some of my more squeamish readers to get queasy. (I see you, Matt Rocklin.) Even in sterile medical terms, it seems a little indelicate to describe in great detail on blogspot. Plus it's a tough surgery in terms of dignity - these women are already dealing with strange men (because all the doctors were men) in delicate areas. They don't need me further chipping at their privacy via the interwebs.

So I'll try to describe things a bit more experientially. The surgeon, in the traditional Tanzanian style, was very late - 3 hours late, to be exact, meaning that we didn't get to half of the scheduled women. Such is the country. I spent the extra time looking on during club foot repair surgeries (8 month old with two full-leg casts = sad panda) and drinking tea with the nurses. As a peace corps volunteer here told me, Africa is all about waiting, waiting and chaos.

Once the surgeon did arrive, he made his way quickly into the theater, where his first patient had been waiting for him ever since her scheduled surgery time 3 hours before, reclining peacefully. I introduced myself and he nodded courteously, but that was essentially the end of our conversation for the day - neither surgeon made another effort to talk to me for the rest of the surgeries. I really haven't done much surgery shadowing in the US, but I gather that it's not atypical for surgeons in any country just to leave onlookers to their own devices, so I was fine to just observe over their shoulders as they worked. It's not a particularly tricky surgery, though it certainly requires a lot of attention to detail, and luckily it's not a tiny orthoscopic thing or anything like that. So one can learn a lot via silent shoulder-spying.

Academically, it's actually a rather clever surgery, I think. It essentially involves making a new wall for the vagina out of tissue that's already there. At the end, the surgeons even check their work, filling the woman's bladder with blue dye to check for even the smallest of leaks. Very thorough.

But I felt a little bad for the woman - she's awake the whole time, with just an epidural for waist-down anesthesia, and the surgeons/nurses never tell her what they're doing or try to reassure her. They didn't even introduce themselves to her at any point. And there are little things the surgeons do for their own convenience that seemed undignified to me, like temporarily sewing the woman's body in certain ways so as to be able to see better. I know she can't feel or see it, but...I'm not sure. It's hard to know what I should be offended by here, whether it's different than surgery back home. Not that surgery back home is always inoffensive either, of course. It's confusing.

But despite mixed feelings, I'm planning to go back tomorrow. I'll never get a chance to see these surgeries for the rest of my medical training, most likely, and I actually like the environment at CCBRT a lot. It's a hopeful place. Also hoping to continue my record of not passing out (yesssssss).

Parasite Unseen

One of my favorite classes in the Spring quarter was an elective course that my friend Katie G. convinced me to join. (Thanks Katie G!) I forget the actual name of the course, but it should've been called "Wow, Problems in Global Health are Really Super Hard". Or something along those lines. I loved that class, and not only because we managed to turn it into a weekly potluck. The prof did a great job of steering us away from the typical introductory global health discussions; instead of a class about how sad it was that all these developing nations suffered curable epidemics, for example, we'd talk about how epidemics actually happened - what made them grow, what made them self-limiting, and what that meant for the proper timing for any sort of intervention.

One of our best class discussions was about malaria - again, not the usual "Malaria is Bad" lecture, but a long conversation about whether certain malaria interventions were all that useful, or whether a hypothetical vaccine would ever even be able to wipe out malaria, given what we know about the disease. Really interesting stuff.

And I think about that discussion fairly often here. A significant part of my life in Tanzania is dedicated to the noble goal of Not Getting Malaria. 1) I spray myself in a vaguely bubble-gum-scented mosquito repellent around 7 PM each night, just as the little suckers start to appear. 2) I sleep under the bed net, every night, and am getting better at not thrashing around while I sleep and undoing my careful tucking of net under mattress. 3) And, of course, I take a big, electric-blue antibiotic pill every day in the hopes of protecting my liver from parasites. Because despite the first two measures, I definitely still get bitten - little pink spots all over, especially my ankles.

Taking prophylactic antibiotics every day does make me a little uneasy, but then, the prospect of malaria seems a lot worse. My American friend Teddy, who's been here for about a year, told me that he spent his first few months in Tanzania being sure he had malaria every time he felt the least bit queasy. "And every time, it turned out I didn't have it at all. So when I finally did get malaria, I initially thought to myself, 'Ok, well, I know it's not malaria. Made that mistake before.' And then they took me to the doctor. And then there are two days of my life that I can't remember at all."

So that's the aim, avoid having my own story like that. But the interesting thing is that native Tanzanian adults are pretty blase about it. When I recently visited my housemate Happy and asked whether she always folded her room's bed net so neatly, she confessed that she'd actually never used it since she moved into the room. "Eh." She's had malaria before. Yes, she gets it every few years or so. It's not that bad. And then I learned today that not one but two women at the office today currently have malaria, including our executive director. But, you know, they have things to do, they're not taking the day off for a little thing like that.

It sort of makes me feel like a wimp, really, all my drugs and nets and nervousness and they're shrugging it off like it's a headcold. Even if I know it'd be a lot worse for me, since I never had it as a child, I still feel like I ought to toughen up a bit. You can't even see this parasite, you know? How bad could it be? Suck it up, mzungu.

It's a savannah out there

I have a rather deep and abiding love for transportation systems, particularly trains (this earned me serious points on the Autism Quotient test!). While it's a bit of a stretch to call transportation in Dar a "system", I've realized slowly that there is a sort of fundamental code governing the daily chaos amidst which I walk home.

Also, in preparation for my father and brother's visit to Tanzania in mid-August, I have been reading a LOT of safari manuals, learning about the shyness of elephant shrews and antelope migration patterns and watering hole congregating during the dry season. There's a characteristic pattern to those books that I thought might fit my transportation post nicely. Thus, I give you:

A Field Guide to Transport in Dar es Salaam:

The Pedestrian (Impala) : So clearly the lowest rung in the hierarchy. Traveling around on foot in Dar is a constant excercise in not getting smeared by the next passing vehicle; it doesn't help in my case that I'm constantly confused about which way the traffic is coming (stupid British driving system). There are crosswalks, in the sense that sometimes white lines are painted across small sections of road, but these are actually death traps for unsuspecting wazungu who foolishly assume cars will slow for them. Pedestrians even move like impala - we congregate nervously in the medians of the big roads, hovering on the curb as traffic whizzes by, then leap gracefully en masse onto the asphalt when traffic slows, darting between vehicles. (There actually are traffic lights in Dar, which change color and everything, but relying upon them to actually stop traffic will only lead to sorrow. And smushed toes.)

The Bicycle (Honey Badger): Slow, strong, and tenacious. I love the way bikes fit into the culture here. There's no road or mountain bikes, of course - everyone's got a low-riding one-speed with big curved handlebars and a once-cushy seat. And, of course, the essential bike rack. My friends, it turns out that what we can carry on a bike rack is only limited by the scope of our imaginations. A bike is not a one person vehicle. No no, dear reader. A bike can carry at least three. It seems like every other cyclist here has a friend or family member casually riding along on the back, sometimes side-saddle but usually astride. Sometimes it's an older female relative, often it's a pair of 10-year old male friends, and I even saw a dad riding along yesterday with his little girl who could not have been more than a year old. She was completely cool. The diaper cushioned her ride.

And even if you lack a bike buddy, you can carry SO MUCH STUFF back there. Jugs of petrol. A five-foot pile of laundry. Two enormous baskets full of live chickens. A bundle of sticks that must weigh at least 60 pounds. And despite the crazy car drivers, the bikers seem so serene. They ride along steadily, in no hurry, wearing their typical collared shirts, trousers, and flip flops. (Most riders are men, though I did see a skirt flapping around a bike seat today.)

I've only seen this Biker Serenity break down once, which also happened to be the only traffic crash I've seen since my arrival. Many men use their bikes as mobile fruit stands, usually with two enormous baskets full of produce counterbalanced on either side. One of the other bike variations is the hand-powered bike, where riders with disabled legs/feet are able to sit in a low chair while pushing a chest-level set of pedals in a circle - very clever design, really. In any case, I witnessed a very slow crash between a fruit stand bike and a hand-powered bike. No one was hurt, but oranges were rolling all over the road and everyone was seriously grumpy.

The Bajaji (Hyena): This is by far my favorite way to travel in the city. You know that game Mario Kart? Bajajis are Mario Karts come to life and zooming around the streets of Dar. There's a 3-person bench in the back, a little canvas over your head, a total of three wheels approximately 18 inches tall, and no doors. I find it absolutely impossible not to make "vrrrrroooom" noises under my breath the whole time I'm riding in one, and I often end up giggling uncontrollably as we bump up and down over potholes. It's just hilarious.

The bajajis ("tuk tuks" in Kenya) generally like to lurk in packs near big intersections, hoping to pick up some fares from folks that would otherwise go to taxis (bajaji fares tend to be cheaper). They're scavengers, really. And their owners tend to deck them out in bright solid colors and soccer team emblems. Very festive.

The Car (Wildebeest): Big, ubiquitous, but kind of boring, in my opinion, though occasionally necessary when trying to get somewhere far away after dark. Cars get right of way over bikes and pedestrians easily, but often end up thwarted by daladalas. Lots of folks drive SUVs in this city, which I've decided is actually more of a necessity than a luxury; trying to navigate unpaved potholed streets in a sedan makes you just cringe for the undercarriage.

One funny thing: there are certain corners in town that have been designated official kituo cha taxi (taxi centers), and every time you walk by all the drivers will call to you, hoping you need a ride. What I didn't understand, however, was why some drivers offered me a "taks" when gesturing to their vehicles, rather than a "taxi". Linda the Kenyan finally explained it. In Swahili, every word ends in a vowel, and English words are often made Swahili by adding an "i" at the end - doctor becomes daktari, for example. So Swahili speakers often assume the English version of a word is just the Swahili version minus the "i" - hence, "taks". Apparently some people will also try to sell a soft drink called a "Peps."

The Daladala (Lion): Ah, king of the road! The daladala knows no natural enemy. I've written a bit about them before, but the basic idea is that daladalas form a semi-regulated, semi-private bus system for the citizens of Dar. Most are these beat up, 15-seat Toyota Hiace vans. They have both their terminal destinations painted clearly on the front, with the sides and back painted with whatever strikes the driver's fancy(I've seen everything from "Praise Allah" to a very detailed drawing of Spiderman). And then, shuttling back and forth between those destinations, they haphazardly pick up and drop off passengers along the way. It's a two-man operation: one man drives while the other man collects fares and leans out the open door of the moving vehicle, eyes peeled for potential riders. Two open-palm slams on the side of the van signals the driver to stop; another two slams and they take off again.

They also tend to be ludicrously crowded. It is often flat out impossible to scratch your nose in a daladala because your arms are truly pinned to your sides. It's really shocking just how many people can fit inside (or if not inside, at least on board - sometimes the door has to stay open to accomodate). Luckily these close quarters make it less likely that you'll fall down when the bus screeches to a halt. Usually you can't actually see where you are in the route, so you have to wait until the fare collector announces an upcoming stop and yell "Shusha!" if you want to alight there.

But hey, for 20 cents a ride, can't be beat. And there's nothing for that "among the people" feeling like a daladala, particularly in rush hour.

The Coach Bus (Elephant): The real buses (ie, not daladalas) tend to do their own thing. Rarely do you see them among the inner city traffic, but they're everywhere outside, migrating in long lines all over the country. Trains in this country are hilarious slow (if they were in this guide they'd probably be porcupines), so buses are really the only way for the non-flying traveler to go long distances. Most, though not all, entertain their passengers with a constant stream of loud rap music for the duration of the trip. Perhaps the thinking is that this distracts them from the lack of toilet.

And that is how I've been getting around. I do miss the El, but in the meantime this is pretty fun.

Guacamole. American as apple pie.

One month in and one full bottle of malaria pills consumed, I think I'm getting a better grip on my preferred lifestyle as an expat. On one hand, I know I'm too old to ever really identify as a native Tanzanian, let alone over the course of 10 weeks. There are certain things I'll always do a little awkwardly, certain absent foods I'll always crave (god I miss you cheese). On the other hand, I'm very wary of becoming one of those expats here who constantly swims against the tide to live a completely American/European lifestyle, complete with overweight pet dog, a high pointy fence surrounding the yard, and a total refusal to eat unfamiliar fruits. (How the last item is even possible is unclear. Guavas are like 20 cents a pop here.)

So this weekend was a bit about balancing these two aspects, the when-in-Rome instinct versus the born-in-the-USA! one. Saturday morning I putzed around the Indian quarter of town, window-shopping past the confectionaries on my way to the National Museum of Tanzania down by the docks. The museum is a rather odd little complex of buildings with a rather odd collection of items, ranging from bits of Tanzanian history (German tax collectors' strong boxes), a special exhibition on Tanzanian soccer (lots of shiny headshot photos), a biology hall (stuffed dugong in the corner - ugliest "mermaid" EVER), and a big collection of items from Tanzania's 100+ tribes. Last one was probably the best. Still, for the equivalent of $2, I'm glad I went.

And then Saturday night was probably my most Western night since I've come here: the Harry Potter movie and pizza afterwards with two of my German housemates, Nina and Magdalina. They're two of my favorite people at the house, really friendly and kind, who shame me with their perfect English and seem to be striking a similar expat balance to my own.

On Sunday I spent the earlier hours gathering food from street vendors (parachichi, nyanya, pasheni na mkate - avocados, tomato, passionfruit and bread). Something vaguely satisfying about buying your comestibles directly from a blanket spread over the sidewalk. After an afternoon beach trip with a few other housemates and their friends, the Germans and I attempted some dinner with my earlier purchases. No stove in the house, but we made some pretty good guacamole and then toasted bread to smear it on. Passionfruits for dessert. Not bad. I thought it was a nice, edible combination of the familiar and the new. Went to bed feeling all warm and fuzzy, my chi aligned with Dar es Salaam, and wasn't even that annoyed when the crazy rooster next door started his usual crowing at 4:30 AM.

Though there are, of course, some balancing aspects over which I have absolutely no control. For instance, the complete absence of running water in my neighborhood for the last 48 hours. Buckets are all well and good, but unlike my Kongwa hotel, our house is not equipped to function without taps. Really hoping that starts working again. Or, another example, my first attempt to see a fistula repair surgery this morning. Made it all the way out to CCBRT hospital only to discover that the surgery had been postponed due to the patient's contraction of malaria. Which had happened while she was in the hospital. Oof. We'll try again in a few days.

No way! Women doctors?!?!

So this is interesting. A whole blog entry on my feet and I completely forgot to mention the event that rates highest on the MAI (Mom Alarm Index). Not sure if my brain's blocked it out or gone into denial or what. But back in Kongwa, I spent several hours one afternoon walking on tilted, uneven concrete along the side of the highway, wearing a pair of very cheap flats that I pulled out to try to look presentable for government officials. Half an hour in I was experiencing these weird, twinging pains in the inner balls of my feet, but I just sort of adjusted my stride and powered through. That night, however, I realized that my both my big toes, down to the main inner joint, were completely numb. Aaaaaaand....that hasn't exactly resolved, three weeks later. The left is a little better - I think - but the skin over both big toes still feels like it belongs to someone else. I ran it by Dorothee, who's (almost) a German doctor, and she told me not to worry. So I shan't! I have become comfortably numb, as they say. Don't worry, Mom. They're just toes. I have LOTS of toes.

After a pretty slow week at work, I opted to spend Thursday at the Medical Women's International Association conference, hosted this year in Dar es Salaam by MEWATA, the Medical Women's Association of Tanzania. I'm glad I went, and not only for its hilarious motto ("It's Women Doctors!"). There were some really interesting presentations, for one: a lot of discussion about cervical cancer, which is significantly more of a serious problem here than in the States. Quite a bit as well about how to fight brain drain. And then a bunch of smaller studies that I probably wouldn't see at home - "At What Age Do Mothers Plan to Reveal Their Children's HIV+ Status to Them?", for example. (Answer: age 15-18. From the standpoint of preventing the spread of disease, probably too late. Interestingly, moms are also much less likely to ever even tell their female children.) Also managed to meet a very interesting woman working on microbicides; hoping to meet with her again. Good, interesting stuff, right up my alley.

And of course the other intriguing part is getting to see how a big, academic conference goes down in Tanzania. I feel like I've been to more than enough American conferences (my collection of monogrammed canvas bags is nonpareil) so I was comparison hunting. At first glance, you might see the individual water bottles at each seat, the dishes of mints spread along tables, and think the Westernization was complete.

But that would be mistaken. The rather casual approach to scheduling was a key divergence - by the end of the day we were running approximately 2.5 hours behind schedule (a significant improvement over the day before, apparently). There were also quite a few scheduled presenters who simply never showed up, leaving me to wonder sadly about whether flash heating breast milk really DID improve child health outcomes. A "comedic" presentation near the end of the day was definitely the weirdest powerpoint I've ever seen, and reminded me forcefully that I do not understand Tanzanian humor at all. I'll post it if they make it available, but suffice it to say that it featured photographs of a child licking a pig, Robert Downey Jr. flexing, Obama punching someone in the face, and topless women (not in a medical or anthropologic sense). And then, of course, I've found that most American conferences are tragically lacking in group singing and ululating. Tanzanian women have resolved this.

One interesting discussion I had with other medical students there involved the conference's seemingly heavy focus on breast cancer. On one hand, I don't like the idea of dismissing the toll of disease that kills a lot of women, or insisting that we shouldn't discuss one health problem until another one that I or someone else deems more important has been solved. One of my weirder social moments over this past month occurred during a conversation with a friend of a friend. About five minutes after our introduction, he asked what I'd been working on that day and I mentioned some of the statistics I'd been organizing for the Maternal Mortality and Morbidity conference. He actually cut me off, saying "Oh man, that's nothing. Do you know how many women are raped in South Africa each year?" and rattling off numbers. I was sort of trying to get my bearings, which I guess he took as awe, so he announced "I work in HIV/AIDS, you see." It was such an unsettling interaction. The sort of single-minded focus on one particular disease or condition, and the competition among different global health fields to establish their particular issue as THE important issue, can't really be good for any of us.

At the same time, four presentations about breast cancer just struck me as a little...premature, I guess. The average female life expectancy for Nigeria, one of the countries heavily represented at the conference, is only 47, and the rest of East Africa isn't much higher. About half Nigerian women won't ever get the chance to die of breast cancer, honestly. But I suppose US donations to build mammography and other screening infrastructure can't hurt, really. And maybe it'll just lead to everyone's ship rising. Not sure.

Agony of De Feet

If my feet survive their time in Tanzania unscathed it will be miraculous. Just thought I'd let everyone know. I am looking at them now, and though they don't complain much, I can tell they are pining for their former days of luxury treatment like socks. Tanzanian feet live rough-and-tumble little lives down there.

Naturally, of course, there's no reason to wear anything but sandals here - even at work, all the ladies just switch into fancy sandals. So the feet see it all, tripping over enormous rocks in the uneven street, getting stomped in daladalas, and generally ending each day in a not-so-thin layer of grime. It's the dry season here, so those roads that are unpaved (read: 90% of roads) are essentially just packed down dust. A couple times I've looked down and thought, "Geez, my sandal tan is getting out of control", only to discover that a significant part of that "tan" could be scrubbed off. Ew. (In Kongwa, where all the dirt/dust is a pretty red-orange color, I was sure every evening that my feet had gotten terribly sunburned.) Probably doesn't help that I'm traveling around in rather shoddy sandals, either. I already ripped the between-the-toes piece out of the left shoe once on Sunday and had to shuffle around for a few hours, a rubber band holding it all together, before I found a fundi ya viatu (shoe repairman) open on the Sabbath. (But it's ok, because the shoes are purty.) Maybe my callouses will eventually let me wander around barefoot. Something to shoot for.

The frisbee excursion was a bust - turns out there IS a Tuesday frisbee league, but only when school is in session. Bummer. I'll bide my time until August 10th.

I do my best thinking when completely deprived of personal space

Last night, in a rather masochistic decision given Dar's rush hour traffic patterns, I accepted an inviation to "Mexican food" at Sarah's home out in Mwenge. (I have to say, she did a pretty decent job. If you overlooked the fact that the chips were made of cassava rather than tortilla, you'd judge the meal almost perfectly TexMex.) The ride out took more time than I'd care to say. But at least as I stood crammed against the door of the outward-bound daladala, dripping sweat and watching us creep forward about a half mile every 20 minutes, I had lots of time to think.

First, I grumped to myself about Dar's terrible, awful roads. Putting aside the question of enormous potholes and paving and such, there's simply not enough road space for the traffic in this city. I'm sure the streets were laid out perfectly well when the town was thousands of cars (and millions of people) smaller. But the city quickly built itself right up to (and over) the curbs, and denizens nowadays are faced with a crazy situation where the main highway - the only route out of town, really - is a two-lane road. Traffic between 4 PM and 8 PM is both completely jammed and completely unavoidable; there's no other way to get home. There's a certain novelty to the ride for me - I'm still dazzled by the candle-lit road stalls selling bits of fruit and ugali and octopus - but if I had to make the commute every day I'd go nuts.

And it's hard to imagine how they'll fix it, really. I'm not an engineer, but I can't see how you'd turn the Morogoro Highway into the modern thoroughfare Dar needs without enormous upheaval. There are sprawling markets for miles right along the side of the street, with permanent stores and homes (when daladalas go off-roading, as is their wont, they often have to honk their way through throngs of shoppers buying that evening's dinner). I have a tough time imagining the Tanzanian government mustering the willpower to shut down and raze thousands of small businesses. And can you really ever close down your only highway, even for badly needed renovations? How will people get into/out of the city?

And then I thought about Tanzania's transportation problems in relation to its health sector problems. In the former case, there's clearly massively insufficient infrastructure. Not only do adequate roads not exist, but it's hard to see a clear plan for ever creating them. With the health sector, however, I realized I'm a lot more optimistic.

Perhaps naively, no doubt. I've actually been reading rather gutwrenching health statistics all day in preparation for WD's upcoming Maternal Mortality and Morbidity conference. Tanzania's one of the top ten countries in the world in maternal deaths - 1 in 24 Tanzanian women will die from complications of pregnancy or childbirth. (Compare this with the US's 1 in 4,800 or Ireland's 1 in 48,000.) More than half of women never make it to any sort of health facility when giving birth. And the birth-giving starts early and goes long: more than 50% of 19 year olds are either pregnant or mothers already, and the average number of children in some regions of the country is 7.4 per woman. (Fifth page.) And this doesn't even consider all the women who are injured or permanently disabled during childbearing. Oof.

BUT. While the health system is clearly not serving its women (or anyone, really) all that well, it doesn't seem to be at the same sort of complete cluster...fudge....as the transportation system. For one, the physical health facility infrastructure is actually pretty decent. The government is doing a fairly good job of peppering the country with basic health facilities, and in fact more than 80% of Tanzanians live within 5 km of such a site. The problem is not the facilities - the problem is the lack of resources, particularly human. The sorts of things I saw out in Kongwa and Chamwino - a lack of staff, or consistent electricity, or antibiotics - those struck me obviously dire but not insurmountable. I/Tanzanians/the global health community can think of lots of different ways to try to fix those resource gaps, even if we all know its easier said than done. Furthermore, unlike the roads, you can keep the health system going while you attempt to fix it, training staff on new procedures or buying new supplies or increasing starting salaries for nurses. Seems like a key feature.

So I guess my final conclusion, as I rolled off the daladala into a sea of bodies and food stalls and sidewalks bedecked with cheap plastic goods, was that the Tanzanian healthcare system seemed....not a lost cause. I realize that's not the strongest of praise. But the current system is a bit like those little divot-covered platforms they have at the Lego stores - not much to look at now, but with clear building potential. (My analogies are AWESOME.)

Might, just might, have discovered a Dar-based Tuesday frisbee league. Checking it out this evening. Fingers crossed.

I've got a fever, and the only prescription is MORE ULULATING

My fellow housemate Linda informs me that when you reach the latitude of the equator in Kenya, everyone likes to show visitors this neat trick where you put a leaf in a bucket on the northern side, watch it drain in one direction, then move 10 feet south over the equator and do the same thing, watching it spin the other way. Science! It works!

But I've decided that perhaps this hemisphere reversal accounts for my exceedingly poor sense of direction here. I spent significant chunks of Friday evening and Saturday day totally lost, wandering for hours on what should've been a leisurely stroll to my destination. Friday was particularly bad: I was minding my own business, out to do a nice loop past the Muslim cemetery and along Bibi Titi Mohammed Road before heading home, when suddenly I was magically trasported blocks away to the corner of Mnazi Nmoja park. Or that's how I account for it, anyway. Still no idea how it happened. I kept walking, trying to look like I was just where I meant to be, thinking I was heading home but probably going completely in the wrong direction. Eventually it got dark enough to make me nervous, so I executed the equivalent of a reboot, hopping onto a daladala terminating in Posta, the station just down the street from our house (though not at all on my original route). When faced with a new problem, reduce it to a problem you've already solved, right?

I tried to brush Friday's unintentional adventure off, but the fact that I found myself lost again on Saturday seems to indicate a more systemic problem. I've decided to attribute it to a combination of a bad sense of direction, the complete lack of street signs in most parts of Dar (not so important when there's no home mail delivery in the country), and a rather liberal sense of scale in my guidebook maps. And, of course, magic.

Sundays are strange days in Dar, when the throngs of working folks that stuff the downtown "sidewalks" (the dirt between the pavement and wide gutter) simply disappear back to their families around the outskirts of the city. It's like a 24-hour ghost town. So I decided to follow everybody else's lead and head out of the city. One of my hostelmates, Happy, invited me and two of the lovely German girls here along on her typical Sunday routine: Catholic mass in Swahili at the simple cathedral by the harbor, then out to her sister's for lunch. I honestly think I got a lot more out of the Swahili mass than the usual American English version; true, the sermon didn't sink in much (I got "baba yetu" - "our father"), but the music is just wonderful. We sat in the pews right behind the choir and got to fully appreciate the clapping and fish-shaped tambourines and swaying and non-Western harmonies and the truly unearthly sound of women ululating. (I desperately want to figure out how to ululate, but it seems rather rude to practice in a house with 12 other people trying to sleep. Maybe in Chicago. Won't my new neighbors be surprised.) It felt so much more like a celebration than American mass and I got a little dizzy and tingly after some of the songs, possibly because I stopped breathing.

Then into a daladala, truly the most crowded and most awesome way to travel in Tanzania. We drove 30 minutes out of town, all the way past the big crazy bus station, then leapt out of the van on sort of lonely stretch of highway. Happy's sister Grace and her two daughters live up an uneven rocky path from the road, left past the hairbraiding stall, under the power lines and over two small hills. We were greeted by Irene the 5-year old (running super fast!) and then Grace herself, beaming and carrying 6-month old Agnes. (Agnes is adorable, with these enormous eyes that sucker mammals everywhere into having offspring.) Lots of asantes and shikamoos and introductions, then into Grace's home, a pair of small but neatly kept rooms rented at very high city prices. She had already purchased enough Cokes and Fantas for everyone to have exactly two, and had cooked us all lunch on the little bit of sheltered concrete just outside her front door. We feasted on rice with meat and potatoes, topped with slices of huge, shockingly yellow bananas and avocados as big as grapefruits. Food was repeatedly foisted on us (Grace pulling sad faces and insisting "I cooked all of this for you!") so we ate like champions, settling happily afterwards onto the big red couch on one side of the room or Grace's bed on the other. We talked about Grace's work as an assistant nurse, pondered the differences between Iringa and Dar, teased Happy about her inferior cooking skills, all the while everyone in the room trying to be as polite and gracious and thankful as possible - the wazungu ladies trying to avoid any faux pas, the Tanzanian women trying not to make the wazungu ladies feel bad about their many, many faux pas.

As I sat, I thought a lot about what sort of gift or offer we could make in return; we'd brought cookies for the two daughters, but this seemed so insufficient for a woman who had made a bevy of complete strangers a huge, wonderful, homecooked meal and was working 80 hour weeks to pay her $50/month rent. It sometimes seems like such an overly fine line between expressing gratitude and unwittingly giving offense, between giving gifts and giving charity. There are so many lines I haven't yet learned to walk here, and this is one of the harder ones.

Happy belated birthday to my brother David! Hurray for palindromic years!