Monday, January 13th - Sarah

This day was a national holiday. I believe it is to remember the day Tanzania acquired Zanzibar.  The HIV clinic here was supposed to be closed due to the holiday, but the patients were not aware and so they showed up anyway and the physicians staffed the clinic anyway.

Many patients have to travel very far to get their medications and so it was nice of the physicians to be open anyway. I don't think this would ever happen in the U.S. The HIV clinic is referred to here as the CTC clinic here in order to decrease the stigma. It stands for center for treatment and care. Many acronyms related to HIV are changed to decrease stigma. I was in the part of the clinic where the medications were given out. The patients would come in to our room one by one after seeing the physician and present their file and a medication card. The card had columns for the date, the date they were to return for another check-up and more medication, the medication they were to receive and the quantity. Most patients received one month's supply, but if they traveled from far away, they were often prescribed two months worth. The pharmacist would then sign the card, document the medication to be dispensed in a log book, and then dispense the log book.

We saw two patients in this setting who presented with serious skin conditions and we sent them back to the physicians to determine treatment. I'm not sure whether these patients had bypassed the physicians their first time through the clinic or if the physicians had made a clinical decision not to prescribe further treatment for these patients. Upon examination the Tanzanian physicians determined that one of the patients had leprosy and the other had a horrible case of shingles that left a deep wound that had gotten infected. The appropriate treatments were investigated, but I wonder if the patients will be able to obtain them. Drug cost and supply are difficult issues here.

In the afternoon, we visited the Ilula Orphan program where we were greeted by a group of singing girls. They sang "Karibu" meaning "welcome." We then signed the guest book and spoke with Berit, the Norwegian woman who started the program. After a concert by the girls which included everyone being pulled up to dance, we learned about all the additions that had been made to the program to improve the lives of people in the area. They grew crops and raised animals including pigs, goats, cattle, and chickens. There were areas for making shoes, sewing, welding, and carpentry. Recently a library was opened with lots of financial assistance from the people of Norway. The high school was very impressive with its comparatively well equipped chemistry lab and also appeared to be well respected. We saw a Lexus from Dar arrive to drop off a few children after the long holiday weekend.

Samantha - What a week it's been!

I'm a senior at Gustavus Adolphus College and will beginning medical school in the fall. I've been enjoying my time following the other members of our group and learning so much from them all. 

On Thursday we had a group of kids visit from Gustavus. They toured the hospital and and we had an interesting conversation about healthcare in Tanzania. 

Today I joined Emily and Laura K at the Ilula Orphan Program. We started out varnishing and sanding down the doors with the high school students and ended by playing games with the young girls. I delivered photos and letters written by fifth and sixth graders at the Church of St. Peter in Minnesota for the girls at IOP. They seemed very excited to learn about what life was like for other kids their age. The girls are working on a letter to reply to the children in Minnesota. 

When I returned to the hospital campus, we had dinner and sat around having discussions with the group while listening to Dr. Hurley and Dr. Moody sing along to Johnny Cash. I am looking forward to see what other adventures this trip has in store!

Samantha 

Theo Edwards - 1 week down:

Sitting here in Iringa at an internet cafe, finally getting a chance to write a few things for our blog. I think the best way to summarize this adventure so far is to reiterate our debrief today. We were asked what has been our biggest challenge, what has amazed us, and what we are looking forward too. So I will start with my thorn (biggest challenge). This has been just trying to make sense of the chaos that goes on in the hospital. Communication has obviously proved to be a major obstacle, and we do the best with what we have. Now I could go on about this, but I will just leave it at that. My rose (that which has amazed me), is a number of things, but I will only name a few. 1) I am amazed at what a significant impact Randy, Gary, Ken, and all the others have made through the years, and they are very humble about it. So Bravo!!!! 2) I feel incredibly lucky to be working along side such an amazing group of people. Everyone has their own unique talents (from nutrition, to pharmacy, to psychology), and I see this paying dividends in the lives of our patients each day. Lastly, I should mention what I am looking forward to in the coming days. Yes, spending 3 days on safari next week will be a magical experience, but moreso, I am excited to what surprises are in store each day. A quote I heard when we arrived has kinda stuck with me. "you come to africa trying to change africa, and you realizes that it is africa that changes you". Asante Sana!!

Theo

1/17/2015 - Astrid

Everywhere I turn, I see beauty.  I wake up every morning thinking about what the day will bring. The minute I step out of my dorm, this is what I see:

*can't seem to upload a picture here. Imagine a beautiful scene... a beautiful valley with great seemingly blue mountains in the background. Simply breathtaking*  Oh! Here it is!

I have been learning so much these past few days. On January 13th, I had the opportunity to spend some time with Emmanuel, Ilula Hospital's laboratory technician. He graciously offered to show us the hospital lab and took the time to teach us about the Malaria parasite, P. Falciparum, its life cycle, and the diagnostic tools available to him. It was fascinating! I looked into the microscope and there it was right before my eyes: A seemingly harmless and microscopic organism. This parasite kills hundreds of thousands of people each year. As fascinating as it was to learn about this parasite and its interesting history and evolution, I often stopped to think about the suffering that it causes to millions of people each year. The book, The Fever: How Malaria Has Ruled Humankind for 500,000 Years, has answered many of my questions but raised many more. I often wonder if we will ever come up with a vaccine.  In the meantime, we will continue to look at blood smears under the microscope to determine if someone is infected so that they may receive proper treatment.  Emmanuel also discussed the use of a malaria rapid test in the initial diagnostic process. 

In the following two days, we spent some time in the lab with Phil.  We learned about some hematologic disorders and had the opportunity to use the microscope again to observe different cytology samples that included cancers such as CML, CLL, and AML. We also observed samples showing schistocytes, sickle cells, and "cookie bite" red blood cells resulting from G6PD deficiency.  Randy showed us sample smears of Anaplasmosis and Babesiosis.  This experience could only be described as AMAZING.  I did not expect to learn from hematologists/oncologists.

In the past week, I have been lucky to get to know the local people and my colleagues better. I do need to take a Swahili class. I would love to hold conversations and learn more about the culture, the stories… everything. The pharmacy students and I have been discussing residency opportunities, interviews, HIV medications, infectious diseases, antibiotic therapy, among other topics. It changes all the time. I am learning so much from them. Seems like I was in school just yesterday (I did just graduate), and yet there is already so much more to learn about - new guidelines, new drugs, new everything. Keeps me on my toes. It has been very interesting to compare the different guidelines from Tanzania , WHO, and the US.

I have also spent time exploring the town of Ilula and Iringa with others. Today is actually our second time visiting Iringa. Such a wonderful place!  I have much more to tell you all about. But, it is time to go. Until next time. 

Siku Njema! (Have a nice day!)

1/9/2015 Steve Clappier

After two long 8 hour plane rides, the group was very excited to get out of a plane and see Tanzania. I wasn't super excited that we had to endure another 9 hour bus ride to Ilula but we got to enjoy some awesome sites along the way! My favorite part of the bus ride was getting to see the wild animals from the bus. We drove through a national park. We saw gazelle, buffalo, giraffe, and elephants. 

One thing that I didn't anticipate is how green Tanzania is. We are arriving at about the time of the rainy season. The bus ride was beautiful  and took us through the countryside of Tanzania. 

When we arrived as Ilula we had a host of people to welcome us. The hospital is in a beautiful location overlooking green fields with some rolling hills. We are all very excited to start clinical care and see how things are done differently here. 

We hope everyone is doing well at home and look forward to sharing more stories with you!

- Steve

Progress at Ilula!

As this is my fourth journey to Ilula I have to say that it is incredibly inspiring to see progress.  The first item to note is the road in Ilula is paved!  All the way from the highway to the hospital.  Randy and I did both note that a little bit of the ambience of Ilula was lost but of course it is best for patients and staff of the hospital as well as villagers.
The second bit of progress was the new Pharmacy Technician:  Gift is a Tumaini trained technician that assists Frank in the CTC with HIV medications and other functions. Frank truly has much documentation to care for as the medication management system is entirely manual; Gift is truly a gift!  They both hope to recieve training to electronically document anti-retrovirals- they have a computer and software and await the education.
The third piece of inspiring news is medications are listed on the back page of the chart (similar to our "blue books").  Although this is not a MAR per se, it is documentation that I have not seen before.  We still struggle on rounds to understand if the medication was administered or not but minimally a list is helpful!  Meds are documented in a separate notebook at the nursing station as nurses draw meds up at the station and document at the same time.  We have sadly seen many cryptococcal meningitis patients for which there is no medication available on campus.  At Ilula the drug of choice is fluconazole and the hospital is out of stock.  Patients families can buy the drug outside the hospital walls but it is $30 a day- this in a country where the average annual healthcare expenditure is $20/year- a significant problem with challenging solutions.
Finally, it is inspiring to have Astrid returning and teaching.  We sat down for 3 hours the other night and put together HIV medications 101- adults only- just information that you need to get started.  It was very helpful to both of us and we will give the lecture in the next day or two.  Emily, Sarah and Grace have all participated in a mobile clinic in the village.  Next couple of  days will bring Malaria Meds 101- DPQ is a second line agent here and we can all review.  I also hope to interview Frank Sanga the pharmacist along with our students- if I can get my technology to work I can show the video to pharmacy students.  Technology challenges are not trivial- at the present time, internet is not functional at Ilula and electricity is out on campus- we had a big storm last night.
Safari Njema to all of our second-half colleagues!  Jill

Mark 1/14/2015: HIV Clinic; Joy and Grief in the Maternity Ward

Another fascinating day at Ilula hospital today.  As the only psychologist in our group, I have been looking for ways to plug in. The mental health needs of these patients seem to be immense from my perspective as US trained MH clinician, yet everyone seems to get by despite great hardships.  Today, I helped out with the HIV clinic; we saw over 50 outpatients in about 5 hours.  I have not had much exposure to HIV, but after less than one week in this hospital, I have a much better understanding of the disease and treatment options, thanks to the pharmacy staff and MN students that have been so helpful in explaining the complexities of HIV drugs available in TZ.  The mental health status of these patients is across the board, from withdrawn and sad to upbeat and smiling and grateful to have the drugs. Attached is photo of Grace and Astrid with one of our happy patients. 

Grace, a new friend and Astrid

 The patient that stands out for me is a 45 y. o. male who presented with a stocking cap drawn over his right eye. He removed his cap and told his story that he lost his right eye about 4 months ago due to an abscess. There was disfigurement around his eye-socket and discoloration of his skin above around the eye-socket and right forehead, not a pretty sight.  He saw that I was wearing glasses and inquired if he could get some glasses to help his vision with his remaining eye.  Anita, the TZ medical officer prescribing the HIV meds, did not know what might be available to him.  My impulse was to give him my glasses, thinking this patient is struggling with vision and obvious body image issues. I don't need these glasses, and this was the least I could do to help him. But I knew that would not be best... a feeling of helplessness and frustration came upon me. Anita was kind and supportive to him, and he seemed appreciative when he left. I hope he can get those glasses somehow.

Here I come!

Right after seeing this patient I was pulled to OR to observe a C-section, my first ever.  C-section seem to be more common here than in US.  Ilula hospital is fortunate to have an updated OR and it is a busy place.  A healthy baby boy was crying within a minute of coming out.  Brought back to me fond memories when my first son was born 27 years ago.

Ten minutes old

Tomorrow,  I will do rounds on the maternity ward.  Dr. Saga has asked that I provide counseling to a 35 year old woman who is 28 weeks pregnant. She is identified as a "precious baby" patient. This is her 11th pregnancy.  All prior 10 pregnancies have not been successful. Today, an ultrasound revealed that there was no fetal heartbeat.  Jessica did great presentation during case discussion this afternoon as to reason for her failed pregnancies.  We have lots of questions as we don't know her medical history clearly - no EMR here.  We will share with her the news of the ultrasound and do what we can to help her work through these major grief and loss issues. Sure wish I could speak better Swahili.  

Mark