Karibu sana

To the reader: Sorry to be so slow in posting. There are many stories, its the writing that is the hard part. This true story is from 2014. Attempts to follow up on the patient in 2015 failed. Now that I am back for 2 months I'll continue the search.

After Sunday mass ( disclaimer: I go for the African mass music) I go visit a 28 yo man named Imani who was admitted during the night after a road traffic accident. He had a simple looking fractured tibia but now has a neurologic and vascular complication and cannot move or feel his leg or foot. His leg is massively swollen and I think he has Compartment Syndrome ( google that). I'm worried he will be crippled for life if I don’t do something or send him to Bugando Medical Center (BMC), 6 hours away on a bumpy road. I discuss with surgeon on call. She has a rapid Swahili conversation with him. He has no pesa ( money), does not want and can't afford to go to BMC and he also does not want surgery. And, just to complicate things I don’t think the surgeon wants surgery either. We will wait 18 hrs, I am afraid by then his leg will be too ischemic and he will be a one of those many dys-functional, handicapped people you see hobbling around here. This is the way it is. I am familiar with the culture here. But I am still a visitor, still a guest. I can’t force or lobby hard here like I might be able to at home. If for no other reason then this:with my poor Swahili prolonged in depth dialogue with the pt or the family is impossible. And I am mzungu (white man). We waited. I felt bad. Although I was not 100% sure Compartment Syndrome was the cause of his paralysis or that operating was guaranteed to make him better. I felt guilty for him loosing the function of his foot.

The next morning with no improvement he changed his mind and agreed to surgery. I took him immediately to the OR and with barely sterile conditions we did a 3 compartment fasciotomy of his left leg. By making 3 incisions down to and thru the fascia, the membranous sack that holds the muscle groups in your leg, it released the muscle which was swollen, engorged and dying because the pressure in the compartment was higher then the venous pressure. Since venous blood couldn’t get out, arterial blood couldn’t get in and the muscle was starving, dying. As soon as I cut thru the thin tight cellophane like fascia the muscle oozed out of its compartment like toothpaste out of tube. If you have ever traveled from sea level to Aspen you know what I mean. But in this case I had slit the tube wide open. That muscle was necrotic and looked gray. Not the nice beefy pink you would expect. I reached under the wound and with a long scissor slit the fascia open inside, up and down the leg. We made 2 more incisions I opened the 3 major muscle compartments of the lower leg. Over the next few mins. the muscle started to pink up and ooze bloody fluid. It was over in 15 mins. That muscle was definitely under too much pressure. We did the right thing, the question was : were we too late? We loosely packed the wounds and waited for the best. Besides sending him to Bugando Medical Center, there was nothing we could do but watch and wait.

This is very hard for me to accept as a westerner. Maybe as hard for the patient to accept having a mzungu stranger tell him he wants to slice open his leg to make him be able to walk and feel his foot again. This is the part of poor country medicine we from the west have a hard time grasping. Sometimes there is no doctor, sometimes there is no nurse, sometimes there is no medicine. But sometimes its more simple then that. Sometimes there just is no money. There is no money for the hospital to offer “free” care. And there is no money for the patient, the patients family or the patients neighbors to pay. The result, Imani will be another poor crippled man. Another male who can not contribute to society, cant afford a family, cant pay taxes, cant contribute to an economy that wants to take off but is over burdened with uneducated, undertrained and thousands of crippled men. Men who despite their stupid behavior from fighting, drinking, and DWI cant get fixed and then become the guys you see sitting around at mid day in every town and village, crippled men. There is no Africans with Disabitities Act here. The money spent on day 1 to take care of Imani would have been well spent compared to the lost productivity and social cost of another non productive male in this society.

The fasciotomies helped but Imani’s lateral compartment never recovered. His leg swelling improved and the pain decreased but the muscle was irreversible damaged and the attempt to repair it was too late. I took him back to the OR 2 days later and removed lots of dead muscle from his leg. His calf muscle recovered but he never was able to move his toes or ankle.

I found him a pair of aluminum crutches, a lucky break for him. There are no crutches here. People hobble around on a wide assortment of home made canes, single crutches made from branches or they have nothing. We don’t know this but this is how it was in the days before orthopedic and reconstructive surgery. Break a leg badly and you are a cripple for life. Break a hip and your bed bound for life or dead.

Imani went home on day 8 with less pain and less swelling with 3 open wounds on a flexed dysfunctional leg with his 2 aluminum crutches. He seemed happy to go home. Soon the realization will set in that he will not get better and he may still lose his leg. All because of unrecognized trauma from a” simple” fractured leg and no money to treat the resulting complications. The result: another broken life. That is the status of health care in this country today.

CROSSING TANZANIA CHAP 4

The Mocray Hotel was in Kahama. Knowing that really didn’t bring me much piece of mind. But nothing really mattered because I passed out 1 minute after I hit the pillow. I did have to get up once around 4. That’s when I saw the 3 ( or 4 or more) cockroaches that run the night shift in my (their) bathroom. But at this point they were of no concern. Crawling back into bed I had another one tangled up, but outside, my mosquito net. Outside is good. Insensitivity rising, I fell back to sleep till my alarm woke me at 5:00. I was outside and back at the truck before six. Dennis, who doesn’t seem to sleep much, was up, the truck was running and Elami suddenly appeared from the bush. We were on the road at 6. These guys are on a mission and so am I. I think everybody was up because this was going to be our last day on the road. My new friends are going home and I am nearing the conclusion of now 17 month project which had almost failed. Now, knowing we were close to a successful conclusion I was starting to feel pretty good too. From Chapter 1 you know that we were pretty foolish to do this project. I have been to Rulenge several times now over the years. It is the end of the line. Go any farther west and you’re in Burundi. Which is not a great place to find yourself.

The point is Rulenge is very needy and about as far a way as you can get and still be in Tanzania. So the idea was valid. Knowing the trouble we had on the 1^st container the transportation process was pretty stupid. What is the definition of insanity? Then our worst fears crystalized. The container got stuck in Dar es Salaam for 16 months. One of our agents ( facilitators?) at Caritas probably walked away with a few thousand dollars and then disappeared. Meanwhile I keep calling and emailing Caritas and Rulenge (opposite ends of Tanzania) and was getting stonewalled by passivity. It looked like that container would join the thousands of other containers you see around Africa, trashed and looted. But all that, including trying to disprove the definition of insanity made me all the more determined to get the stuff to where it belonged. Besides what else am I doing at this stage of my life? I had a strong need for adventure and I had a responsibility to Rulenge. There was also this feeling I had about making things better, you know the tag line for The Sandy Christman Foundation. As president or CEO or what ever I am, it started to dawn on me that if anyone was going to jump start this project it was me. We had already invested more then $12,000 USD so what’s a few more thousand dollars if it gets us to success…or had least completion. And besides I was coming to Tanzania anyway to work in the hospital on Biharamulo. Finally, what was I going to tell all the people that had contributed to the SCF if we just let the whole project fail? That wasn’t fair to them or the SCF. I mean I was responsible for all that donated money.

When people donate money to an NGO for a good cause they just assume everything will work. In America we bitch about administrative costs, big salaries and lifestyles for CEO’s of non – profits (think The American Red Cross). That’s not even a daydream at SCF. Our challenge is getting stuff we promised to its target. Not easy when your going to half way around the world to Rulenge, Tanzania. I will go public before I close the deal on the Lear Jet.

No, I felt I was definitely doing the right thing and now as we drove west into Kagera (the California of Tanzania…mountains, most west…but no ocean), seeing the end in sight I thought this just might work out.

It’s almost impossible to tell but as you leave the hot middle of Tanzania and get closer to Kagera you are climbing up a gentle flat slope. By the time you start to see the green hills and the thick vegetation you are above a 1000M of elevation and still climbing. There is some kind of continental divide up ahead where all the water heads east and north into Lake Victoria and the Nile and eventually the Mediterean (hard to believe). Everything else heads west and south to Lake Tanganyika. Kagera also reminds me of Vermont, verdant, cool and rich (soil that is) to a fault. Kagera is higher then Vermont and that is good thing because we are 2 degrees south of the equator and if we weren’t more then 1500M high we would be roasting like in Dar es Salaam. But I quess that’s where the similarity ends. There are no peaked mountains and no skiing and as far as I can tell a snowflake has never touched the ground here.

Oops, another roadblock. We slow down to a crawl, pull to the side right up to the big log across the road. Two police one man, one-woman come out of the bush. They are dressed in white uniforms white hat and the man has a long white trench coat. Isn’t he hot? They approach the truck. I am lost in translation but I can tell Dennis is not happy. He is arguing. The lady cop does the usual. Walks around back, comes to my window and wants to speak to me. The window is down; she wants me to come out. Dennis and Kami and arguing with the other cop about mwendo (speed). I get down out of the truck. Unenda wapi? (Where are you going?) Unatoka wapi? (Where are you from)? Wewe meerikani? (You are American?) Nice guess on her part but really, where else could I be from with my ridiculous New York - Swahili accent? She just looks at me, maybe a little scowl. I’m sensing, sans language, that she doesn’t like me. I think we are in a classic speed trap and now that she knows I’m Meerikani the speeding ticket price just tripled. We are marched across the road to a little wooden table behind a tree. On the table, a radar gun. The male cop is being dominant, posturing, almost threatening. Dennis is ready to shoot him. I’m thinking we could almost get away with that here but now other trucks are stopped because the log is across the road. The lady cop goes out to drag the log back and get traffic moving. Then another cop appears on bicycle. He has a radar gun and I think he must have gotten us on radar maybe a kilometer or so back. Ok, so we are guilty (not) but lets just pay up and roll on. Dennis is not giving up…maybe he's afraid he will gets points put on his Tanzanian license? Nah, they wouldn’t be able do that here. I’m not even sure these are cops. Bottom line, we pay 60,000TzS ($30) or we stay here and argue and I miss dinner in Rulenge. I pay. We get back in the truck Dennis is steaming (he has areal temper, I’m starting to think he is not Tanzanian). But I’m the one who paid the 60,000 TzS. Fine!

We roll on. By noon we are back in familiar territory. The road is deconstructing with each passing mile. The clouds are thickening as is the vegetation and the hills are getting rounder and steeper and greener. We stop at Muzani ( google map that!). This is the end of the pavement. Its raining and actually cool, maybe 65. Everyone here has a jacket or rain gear. Its rainy season and that means mud everywhere. Elami is under the truck doing something and then runs off into a bunch of low single story buildings, shacks really. He’s back in a flash and heads back under the truck, in the mud. Fearless. I figure out latter we had a fuel line leak that some how he fixed very quickly. I am feeling strung out and very near a headache. Despite sleeping in a bed last night I have been getting less then 6 hrs of sleep in a horizontal or sitting position for the last 2 nights and every time I don’t feel well I start to get paranoid. Malaria, typhoid, cholera, food poisoning, hook worm, schistosomiasis, the list is endless. But I’ve never had any of these maladies and I’m prob just exhausted. My first go to treatment is Coke a Cola. I know that sounds horrible in the US, so processed, so sugar loaded with empty, teeth destroying calories. But here..it works. The caffeine sugar rush does something in my brain and if nothing else, it’s safe. Call it what you want but Coke is safe to drink, especially if you’re paranoid. I must buy stock in that company.

Back on the road, now dirt mud, sometimes straight and smooth, sometimes serpentine and rutted. We pass villages of mud and straw huts and I wonder what it’s like inside those on a day like today.

Kagera

on the road to Rulenge

There is no” Welcome to Rulenge” signs as you enter the greater Rulenge metro area. The town has no catchy title like “cutest town in Kagera” No Rotary Club or Knights of Columbus. But you can tell there’s something different. There’s a lot more clearing, farming (especially this time of the year) and development. Rulenge has real brick ( locally made by hand) and stucco buildings dating back to the 1960’s and earlier. I don’t know what was here first but I do know some of the first white people to come here in the late 60’s. When I first came to Tanzania in 2008 my wife Barbara and I were greeted at the airport in Mwanza by Sr Margie Wolfe. It was July 4^th and as we walked off the plane Sr. Margie was there to greet us waving an American flag. It was a welcoming site. Especially since we didn’t expect anyone to meet us. We were sleep deprived and in deep culture shock. To see a white women (the only one) and an American flag (the only one) was well….reassuring. I didn’t know the word mzungu (white person) then but at that point there were 3 of us….and that was it. I was about to learn the word mzungu in just a few minutes as we attracted lots of attention in the airport and that’s how we were addressed by local drivers and porters who tried to grab and carry our bags to a cab or truck despite Sr. Margie’s firm use of Swahili negatives.

Only later did I learn Sr Margie was maybe the 2^nd white nun to come into Kagera and Rulenge and take up permanent residence. She built schools, taught kids, noviate nuns and seminary students. Just about every local African priest I meet here was taught English by Sr Margie. So, as we enter Rulenge in our fancy (OK no A/C but still…) big truck on relatively OK dirt roads I think of her and what it was like driving (?) into Rulenge in 1970….my hero. I love her! My idea of a local Mother Theresa. I’ve tried to get her to write a book. She will have nothing to do with bringing attention to herself.

downtown Rulenge

bus stop in R town....a little like the Alamo

preparing dinner, you may have to zoom in

We wind thru the village and head into the hospital grounds. The “campus” also serves as a rectory for local priests, nuns and others. The hospital is a rectangle of one story buildings connected by a concrete covered walkway. The hospital is dirt poor and has capacity for maybe 40 patients. The buildings are all 1960-70 vintage maybe earlier. There are 2 new things built here since maybe 1975. A new water tower and solar panels. Both projects directed by Fr. and Dr. Florence, the medical director. He is a real breath of fresh air, actually a tornado. High energy, determination and battling all impossible obstacles so characteristic of Africa. Father, Doctor Florence (love that) was with us in Dar to help with the loading. He has taken a bus from Dar ( non stop) and has beaten us by a day.

We have arrived! The weather is drizzly and cool but we are psyched to finally get here and be greeted by just about the whole hospital staff, maybe 15 people. After a few introductions, the matron, Sr Monica, has several workers ready to unload. We have 25 beds, 2 generators, x-ray view box, a million pair of crutches, walkers, centrifuges, lab equipment, bicycles, clothing, medical supplies, surgical instruments and boxes of stuff that I never identified but Fr Florence did.

one of the dreaded bikes in background

fast yes, delicate..no

the hospital grounds with solar panels

About the bicycles…… let me just say never promise anyone something that creates a rift or animosity or feelings of inequality amongst equals in Tanzania. Elami has had his eyes on one of the bikes since we packed it away in the truck in Dar. He has reminded me several times in the trip that he would like the bike. It’s a Rock Hopper mountain bike, 19990 vintage, no shocks but pretty cool for this part of the world, which is loaded with Chinese, knock offs of the classic the English upright bikes. Now the workers have brought the six or seven bikes out and Elami is all over me. I am feeling very good about things now ( see Coke works!) and I say “ sure its yours”. Sr. Monica is giving me the evil eye but hell, he deserves it…..besides I feel at this point it’s mine to give. Later, as time goes by, I am noticing bad vibes from Dennis. I mean he can’t even look at me. He is off to the side, looks pissed and he’s kinda scary when he looks pissed. Later as the workers finish the unloading and I’m eating strange crackers and tea with Sr. Monica she tells me “you can’t reward Elami and not Dennis”. So that’s it! I wasn’t rewarding anybody! He asked for it (a million times). Dennis never asked, for all I know he has a bike. Hmm…. Maybe not, maybe I’m up against some sort of culture thing here. But he’s acting like a baby! He’s a fucking badass truck driver! (Ok, I didn’t say that to her). Why doesn’t he come over and tell me?

Ugggh! Tanzania!! I keep forgetting I’m the mzungu Meerikani. I try so hard to fit in. I keep thinking I’m black. But I’m not ….never will be. Most of the time I’m half paranoid. Especially when we are at a scary truck stop. But you (and I) know, that is just my inbreed, inculturated, latent, insidious American Racism peeking through my veneer of politically correct behavior. I really can’t deny it. I think I’m enlightened, liberal but let’s face it: all white (Americans) are racist…..to different degrees, but its there. We had slaves! We learn about it in 4^th grade. It is depicted as bad but there’s something that marks your cortex when you learn that whites had black slaves. You are imprinted with some sort of latent superiority. It is bad. And when I’m paranoid I’m practicing profiling. And it’s even more basic than that. It’s in our DNA. Not racism but differentiation. Unlike magnets and electrochemistry where like repels and opposite charges attract. In the animal world like attracts. And opposites or “different” is....well….just be careful out there, stay with the herd and be wary of different. That is primal fear. That is survival. You don’t see wilder beasts and lions hanging together here. I know this sounds like Donald Trump but, unlike The Donald, I am weary of irrational fear and its dangerous reflex: fight and flight. I believe there is hope. I believe dialogue overcomes DNA. Understanding leads to enlightenment and bilateral acceptance. Want more on DNA? Read E.O. Wilson. Want more on fear? Read history or follow The Donald....not to get political

Back to Dennis and bicycles and feelings. I have to remind myself in this case I’m in charge of this little adventure; I’m paying for it. I’m not just mzungu, I’m Meerikani mzungu! I’m also Bwana, now. I’m not just the truck driver. So Dennis is taking it personally. I have to talk ( sentence fragments) to him. We figure it out. I was going to give him a tip anyway. He busted his ass and I’m still not sure if he sleeps. But tips here are rare, maybe unknown. So I will make it right. But I need to do some research first and I know just where to go to get some answers.

The truck is emptied in record time. Fr. Dr. Florence wants me to go to Ngara, the next big town, to deliver the truck with Dennis and Elami. I can sleep in the rectory there and he promises me a big dinner. Sleeping in a rectory and free meal sounds a good and I’m glad to hang with Dennis (who seems happier now) and Elami. We need to come to closure and celebrate over a beer. I will be back in Rulenge in the morning and besides priest quarters (rectory) are always pretty nice…and clean. I put on Michael Jackson, we head down the hill to Ngara, empty truck, job done and looking for beer.