Sunday, November 17, 2019

The Seventh Kingdom, Two Valleys Away.



11/17/10.      TWO VALLEYS AWAY
The clinic grounds

Preface: Futurist Kevin Kelly has talked ( see TED talk) about the Seven Kingdoms of life on our planet. You may recall from school Biology that all life on this planet can be categorized in 5 or 6 Kingdoms (depending on when you went to school). Kelly and others postulate how Technology is, or will be, a life form of its own thus Seven Kingdoms. We are not talking about religious or political kingdoms, this is biological kingdoms. Its stuff you either loved or hated in school. This story is about the boundary of the Seventh Kingdom.

   I went to visit a good witch doctor the other day.  His name is Pascal. My friend Ali took me. He came highly recommended (that’s always reassuring). Ali has used him in the past and many local people speak highly of him. He is way off the grid. We walked an hour and a half from the end of a dirt road into the jungle, maybe 6 kilometers. It was beautiful; a steep climb over 2 ridges and then we drooped into a lush green valley. No cell phone towers, no telephone or power lines. Water and sewer? For real? Here you’re on your own.
    When we got there things looked pretty normal. Pascal is a local healer aka a witch doctor. He is OK with either title.  As we approached his clinic he was sitting on a broken plastic chair in his yard. The seat was busted out but if you were careful you could still put your weight on it. He had 4 other plastic chairs in the same shape and a plastic table and some benches. They were scattered about the yard, tipped over at weird angles as if a big wind had blown thru last night (it hadn’t). The yard was hard pack reddish clay, nothing grew in the yard.  Pascal was busy with a big pile of local plants. There was a fire burning in the hot equatorial sun.  He was busy peeling a thin bark off them, saving the green stalks and boiling the bark.  As we arrived he continued to peel and then, after he finished the plant he was working on he got up slowly and greeted us. He was a gentle, smooth talking big man with a soft voice. He didn't say much and was not an overpowering presence. His eyes were ruddy and his teeth seemed in good repair. He was dressed in "fatigued" jeans and shirt and rubber sandals.  He was not alone.  In his yard were several chickens and ducks and several children. There was a single cow in a stick and log corral and 4 buildings formed the perimeter of his yard.
  There were 5 of us, my friend Ali, 2 medical students, nurse practioner and myself.  Pascal gestured for us to sit and make a circle as we balanced ourselves on the chairs, some with 3 legs all with missing pieces. Ali explained we were "doctors" and had come to visit him and see his practice.  He was OK with that. There were periods of silence where we all just sat and waited for a sentence to appear in the conversation. Pascal seemed to be translating Ali's Swahili, waiting 10 -20 seconds then responding with a soft thoughtful but short answer. Maybe his primary language was some 'local tongue”. There are over 60 dialects or local tongues in Tanzania. As we sat there I became aware of the sounds and smells Pascals home. There were sheep nearby, there was yelling and laughter of children. There was the smell of cows and cow poop very nearby, duck and chicken poop, and a cool green breeze as we sat in the shade of a big avocado tree. There were lots of flies and I wondered about mosquito's and night time here as I looked at the glassless and screen less buildings in front of me. His kids were nearby, dressed in hand me downs, shoeless, adorable and curious. They laughed and giggled as we shared digital portraits. Pascal’s wife appeared, she had a long red dress probably made from a Kanga. She was busy with kids, animals, planting and preparing food. Ali explained Pascal and his wife are both local healers and work together. I was introduced to his wife but her name was unpronounceable to me. I looked at Ali?  He pronounced a sound a couldn’t picture in my mind. If I tried to spell it would look like Ajebishewa, Maybe more like & (*$#@? |. I never did get her name right.
     Pascal's wife was more of a mystic; she did futures and clarified problems and troubles in your life and family. The medical students all had their futures read by her. I declined, deciding I liked uncertainty and besides I wanted to somehow ask Pascal about his herbs and " talk medicine" with him. With Ali's help we went into a dark un-lite hut and Pascal showed us his "pharmacy" There were at least 25 jars of stored herbs and plant extracts, most were in old Coke and Fanta bottles. Many of the herbs looked like ground up bark. I reflected that maybe Pascal is not so far off base here, Aspirin is derived from Willow trees and quinine, the original treatment for Malaria (rampant here), is from Chinchona tree bark.
  With Ali's translating Pascal explained he treats fever, sore bones and joints and headaches which by the way al all the classic symptoms of Malaria.  He knows about Malaria and diabetes and treats them with an herbal tea. There was a patient there who had broken his arm. Pascal had made a cast of bamboo sticks that surrounded his upper arm immobilizing the fracture and placed the arm in a sling. It was a beautiful piece of handi work and the patient was happy with the result. I asked how long will he keep that bamboo cast on and while the answer wasn't clear it sounded like days after the pain is gone. Thinking about it I'm guessing Pascal and his patient don't think of time in terms of days or weeks. This is not a calendar-based society. I asked what does Pascal do when someone is really sick and looks like they are dying. He didn't hesitate on this one, he is glad to send very sick patients to the hospital. I thought about that walk we just taken through two valleys and steep hills to get here, being sick, maybe delirious, maybe in the dark......
Broken arm set with a bamboo cast and sling

   Later as we sat under the avocado tree I showed Pascal a present I had brought him. I gave him my stethoscope. He knew what it was but wasn't so sure how to use it. After a quick 10-minute tutorial of how to place it correctly oriented in your ears, where to listen on the body and some quick pathology he seemed pretty happy to have it. I told him he had to practice every day. Wearing it around his neck he suddenly seemed to stand straighter, maybe a little more credible but still uncertain of its value to his practice.
  You might think it is waste to give an uneducated witch doctor who lives in the bush a $150.00 stethoscope. But try this. Pascal is the primary provider of health in this valley and probably several valleys around. He is educated, having learned what he knows from his grandfather, handed down in the oral tradition He knows his purpose here is to serve his people, to make them better and he is quick to say that. And he has “good reputation”, not on the Internet but here on the ground. Pascal brings medicine to the people, not people to the medicine. A stethoscope out here is also bringing medicine to the people.  While not technology it is a tool and a brick on the road to the Seventh Kingdom. Next year I'll bring a blood pressure cuff and see if Pascal has  a breakthrough medicine for that.
   It was a long hot walk back to the civilization of Biharamulo. I thought about how important it is to know our world and what is in it and about how close and yet so far we were from 21 century technology.  For Pascal and is family, the Seventh Kingdom has not arrived here but it’s only 2 valleys away.
Pascal and the stethoscope

Wednesday, November 13, 2019

Looks Like a 55 kWhr Day!

On clear sunny days like this the solar panels at Biharamulo Hospital can cover close to half of the energy requirements to run the whole hospital. And its CLEAN!

Saturday, November 2, 2019

When success gets you power, as in electric power.

   It took 2 years, patience, a trusting friendship, faith and the contributions of our donors but the solar panels at Biharamulo Hospital finally kicked into production last May. There were weeks last year when I thought the customs inspectors in Tanzania were out to personally torture me. It’s been a real education about how hard it is to do international business across many time zones. All of that is made worse by long distances and developing countries with evolving economies and policies.  
     I have waited to actually be here in Biharamulo to see it in person before filing this report on the Sandy Christman web site. Thanks to Power Providers and Clive Jones a solar engineering firm from Arusha the panels produce 30-40 KwHrs a day almost half of the hospital energy needs…at no financial cost and with no carbon footprint.  Solar power is such an obvious, intuitive choice for electricity when you are two degrees south of the equator. Even on rainy days it is a safe investment. We all need to remember the cost we pay for electricity is, although seemingly painful at times, a bargain since we don’t pay the social costs of CO2 production and carbon emission from our power plants. The WHO estimates that worldwide, there are more than 4 million deaths a year from air pollution. More people die from air pollution in a year then from automobile accidents. And then there is the threat of climate change. 
   This project has brought a steady source of reliable electrical power to the hospital, saving money and reducing CO2 emissions to help keep this beautiful country clean.


Thursday, October 31, 2019



     1)MORNING ROUNDS: The first day we made rounds on the men's ward with the nurse, a nun who was a doctor, two medical students and a clinical officer. We walked down the dark hallway, in need of lighting and entered the first room. This was called Ward I because it contained 9 beds, four on each wall and one in the center. Each bed contained one very sick patient, fully dressed in their own clothes, and two or three members of the patient's family. We had to squeeze between the beds to get at the individual patients, displacing the family members briefly. The family members are very important, for they provide the food and actually do the feeding and personal care for the patients. The hospital and nuns provide food only for the neediest and homeless patients.  When we stopped to see a patient with pneumonia, we wrote out a prescription for an antibiotic and gave it to the family, who then went to a pharmacy outside the hospital gates, bought the medicine and brought it back for the nurse to give to the patient.
   The first patient we saw was fairly young and was sitting up in bed, gasping for breath and virtually drowning in his secretions. He had end-stage pneumonia, which had not responded to an antibiotic and needed an endotracheal tube, suctioning and a ventilator and be transferred to an intensive care unit, none of which were available here. The only oxygen we could get for him was an oxygen concentrator machine which was eventually set up without much benefit. Unfortunately, he died shortly after noon. A bad start and a rather abrupt introduction into a very different level of care than the one I am accustomed to. The next patient was an old man with fever, cough and shortness of breath.  His chest X-ray showed complete white out of the upper half of his right lung, probably representing advanced TB, or possibly lung cancer. The third patient was a teen-aged boy who was immunocompromised from AIDS and had gastroenteritis.  His AIDS was being treated thanks to PEPFAR, the program started by George Bush, and he went home the next day. Next was a 10-year-old with severe malaria (fever, headache, anemia, confusion, dehydration).  We started him on IV quinine and transferred him to the pediatric ward. In the bed next to him, about 12 inches away, was a middle-aged man with cough, fever, dyspnea and delirium, who had obvious tuberculous pneumonia on his X-ray.  We moved him to the TB ward for isolation. Next in line was a 15-year old, who looked 10, with juvenile diabetes which was out of control, and severe malnutrition with dehydration and mental obtundation.  His family was too poor to pay for insulin.  This was exactly what happened to children with this disease prior to the discovery of insulin in 1922. The next patient we saw had a fractured femur from a motorcycle accident. He had been treated with a plaster splint on his lower leg, fused with a cylinder cast enclosing about three quarters of his thigh.  Since his hip and pelvis were not immobilized, the proximal portion of his femur was free to move relative to the distal half.  He needed a period of traction to reduce the overlapping bone ends, then a giant spica cast, made like a pair of pants, with the top at the level of the stomach, one leg extending all the way down the affected leg and including the foot, and the other leg down to just above the knee.  Obviously, if this could even be done here, which it cannot, it would never work in rural Africa.  The only reasonable solution was to ship him off to a much bigger hospital in Mwanza where an orthopedic surgeon could operate on him and put a steel rod in the femur so he could walk on it with crutches within a few days. Fortunately, he worked for the government so he had access to this care.  Then we moved on to the next room.

2)SURGICAL CHALLENGE:  There are a lot of instruments that are not available in the operating room here, but one instrument that is always present and often used is the Fly Swatter.  One or more flies nearly always show up at the beginning of the operation, often before the surgeon, immediately after the sterile instruments are uncovered, and the circulating nurse takes off frantically with the Swatter to clear the area before the procedure begins.  Yesterday was an eventful day.  We were watching an old man who was chronically ill with a 20 kilos weight loss and recent severe abdominal pain.  We were conflicted about whether or not to operate on him and look inside his abdomen, because he didn't have all the typical signs indicating that there was something we could fix, and we were reluctant to subject this frail guy to the big surgery unnecessarily.  We put him on a trial of antibiotics overnight.  That night I lay awake for hours thinking about that patient.  I realized that deep down I had been thinking all along that we should operate on that patient, but that my fear of getting into a difficult situation in this limited and unfamiliar environment dissuaded me from acting on my best judgment and I acquiesced to watching overnight.  I felt particularly guilty because I thought that Larry was, in a way, relying on my seasoned judgement to help him make tough surgical decisions just like this one, and I had essentially chickened out.  When we arrived in the morning, we found that he had died during the night, and this came as no surprise to me and confirmed my fears from the night before.  The nurses and MO mentioned it and expressed no real surprise, but Larry felt very badly and I felt even worse.  We consoled ourselves by reasoning that the patient probably had an advanced malignancy and it is unlikely we would have been able to help him, but we didn't know that.
      A short time later, we saw a young man with severe increasing abdominal pain after being hit in the stomach by someone's knee during a football (soccer) game the evening before.  After examining him, I was pretty convinced that he had a hole in the small intestine, caused by a loop of bowel getting squished up against the back bone; a rare injury but one I had seen before a long time ago and actually written a paper about when I was a resident.  We opened him up and were happy to find that this this was indeed what he had and we got him fixed up.  So that cheered us up and I felt at least partially redeemed.  I helped Larry do the case, and it was a great way to wrap up my time with him here at the Biharamulo Hospital.  That may turn out to be my last really productive medical day, as today Friday is a holiday, then the weekend, then we head off to Mwanza to see the Serengeti, then home.