Stark Cultural Differences: Native Resentment, Family Ties, Patient Response, and Medicine

(from Leslie Modlin)

One of the greatest obstacles I’ve been having is understanding the local Tanzanians in our interactions in town. In the villages, everyone I meet is smiling and could not be friendlier. Yet in town, we’re constantly pointed at, yelled at, touched, and even followed and surrounded (we were surrounded and followed by 8 men the other day – it was frightening…). It’s a very unique (and not a positive) feeling to have an entire road of people stare at you as you are minding your own business running errands. The children are friendly, but the majority of the adults glare at us, which is uncomfortable and upsetting, especially since we haven’t ever met them before but they have some sort of preconceived notions of us. At the same time, there are a handful of people in the town that are so welcoming, so it’s difficult to understand these stark contrasts. I’m still trying to figure it out – we all dress very conservatively, know conversational Swahili and are attempting to learn more, know the do’s and don’ts in terms of cultural mores…it’s a challenge.

Fortunately, everyone at the hospital is both friendly and (more importantly) respectful. I’ve had lunch with one of the social workers and he invited me to dinner with his wife and son for this coming week. We spoke about our project, compared the US HIV/AIDS situation to the epidemic in Tanzania, discussed poverty and politics, and he was very intrigued by specific aspects of our culture, like gay marriage. (Clearly I am way more liberal than what Tanzania is used to on this issue, so it was an interesting conversation, to say the least!)

Another obstacle is having time to really learn Swahili – for the first few weeks when we were doing 5+ hour long interviews each day (and I had two, one for the patient and one for the family member…), it was very difficult to have time to do anything, even going on a run or just doing yoga. Thus it was essentially impossible to dedicate enough time to learning the language, but now that things have calmed down considerably, I’m able to pick up and understand much more. Swahili is similar to Spanish in the pronunciation, which is a help.

The portion of the project that I have been most involved in – patient interviews – is complete, three weeks ahead of the schedule. I loved the experiences of listening to each patient’s story, comparing it to their family member’s perceptions. The family is an extremely powerful concept here – patients are always accompanied by a family member to the hospital for most every disease, even if they are healthy enough to travel by themselves. Last week, there was a terrible accident – the large trucks we use in the States to transport livestock are used here to carry farmworkers into the mountains. The truck overturned somehow and many people died including children. Many, if not all, victims were transported to KCMC and the entire hospital transformed itself into an emergency room of organized chaos – psychiatric nurses were administering IVs and dressing wounds, for example; it didn’t matter what department you were trained in, you just helped. There was blood everywhere. Perhaps the most striking incident was seeing roughly 100 family members gathered outside of the gate, waiting calmly but with strained looks on their faces. I asked our translator friends why the families were outside, and they explained that there are visiting hours three times per day and they were waiting their turn. I told them how, in the US, few would have enough patience and composure to not demand to see their family member immediately after such a terrifying and horrific accident. Here the families were, in sweltering heat, locked out of the gate that leads to the hospital. It was heartbreaking to know what was going on inside and how many people died while their family had to wait to see them.

This past week, we had the privilege of traveling to Marangu to visit Father Muazo’s family. (Father Muazo is a Chaplain working with us on the project. I’ve made hospital rounds with him at night to visit patients in other wards, which has been an incredible experience.) We drove up in a rickety white diocese pickup truck – the bumps along the way propelled us out of our seats and were reminiscent of a theme park ride. Especially since we were driving on a narrow road up the side of a steep mountain! It was best not to look out the window for too long, I concluded early on. I met Father Muazo’s entire family – his mother, father, siblings, and many cousins and neighbors. They were all so excited to show us their home. They actually had two separate buildings for their house – one where they ate and slept, the other where they prepared the food AND held two cows, 4 goats, and a few lambs. Needless to say, it was quite surprising to open the door in the kitchen and be greeted by a massive, snotty cow’s face. We spent a lot of time talking to the family. I had visited Father’s father in the hospital at KCMC when he was a patient. He’s unlike many of the patients I’ve worked with at Duke in a good way – I feel that some patients want to appear happy and positive for fear of being labeled a ‘bad’ patient, so they don’t actually express how they are feeling. That was certainly not the case here! He was very open about how badly he felt and complained often, which I think is good because I was able to listen to him vent. He has a voice like Yoda (from Star Wars) and speaks emphatically, like ‘Whyyyy arrrree YOUUU makinggg meee exerciseee?’ when his son, Tina, or I would help him with his stretches.

This week, I’m analyzing our patient and family data to explore the themes for the paper(s). I know this will be a daunting task – 42 transcripts to go over, each of which is an average of 9 single-spaced pages. However, I have a good idea of what the themes we’ve heard. Today, we’ll be working on a draft of our manuscript to figure out what messages we want to send. We want to give Dr. Ringo, the nurses, and the Chaplains a draft of our paper before we leave when we present our results in a few weeks. This week as well, we are all working on a grant for the Bill and Melinda Gates Foundation for establishing a national mental health clinic. This is very exciting, and I’m sure Tina will update you more on this specific aspect! I am also working with the dermatology department to establish a program to help the albino population in Tanzania. I’m not sure if you read the article in the NYTimes about the situation, but people with albinism are being hunted in Tanzania – witch doctors are still prominent, and they’ve created a demand for albino body parts. It’s extremely disturbing to me that these individuals are being slaughtered because of their skin color. Nineteen have been murdered this year alone. If they’re not murdered, they die from skin cancer because sunscreen is so expensive and we’re quite close to the equator. As a result, I’ve been meeting with members from the dermatology to determine what types of help this population needs and how best to accomplish these goals. I’m confident that I’ll be able to secure donations from US companies that produce sunscreen, and that we’ll be able to come up with other solutions once I have a clearer understanding of the problems.

A Unique Response to Disaster, A Maasai Viillage, and A Citry/Country Divide

(from Whitney Woodhull)

So my time here has truly been more incredible than I imagined. The people, the things, the colors, the sights, the smells we have seen and experienced, are extraordinary, and could never be expressed in words or pictures. To begin, I'll recap on this last week. So we finished up our interviews are beginning our analysis of our data, writing an outline of our paper, which is almost finished, and working on the photo-essay/film. Meanwhile, when we are out getting groceries, or visiting the hospital, we never cease to meet more people and hear their stories.

One day last week there was a terrible bus accident, where many people died, and tens were crippled and brought to the hospital. All day the gate outside the hospital was scattered with family members and loved ones waiting to get in. We asked our translators(now, our very good friends) why the people were hanging outside the hospital gate. And The boys responded, "Its not visiting hours yet." Apparently visiting hours are from 7-8am, 12-1pm, and 6-7pm. It was then 9am, since the accident happened shortly after 8am. These people would be waiting for another 3 hours before being let inside to see their loved one, if they were even still alive. Among our barrage of questions were: It is so hot outside, who brings them water? Where are their chairs for sitting? Surely they can't stand for that long! What about food? How do they even know that their family member is in there and not at another hospital or dead? The answers were sad, but blunt- No one brings them water, food, or places to sit. They have their faith and each other to comfort them in this heat, and it won't be until noon that their hopes will be confirmed.

This past weekend we traveled to Arusha to visit a Maasai village. The Maasai are semi-nomadic African tribe that live in very remote areas of Tanzania. We also went to a museum that spoke about their culture. During the tour, our guide was dressed in the typical maasai outfit. We of course asked him after the tour, if he really does live in a Maasai village, etc. And he said "Yes! I do." So we asked if we could visit him sometime and meet his family. We got his mobile number and so the following day we hired a taxi driver to take us to his home. We drove for about an hour across savannas and around mountains, to reach his hut, which was supposedly "not far at all, since I ride it every day on my bicycle". Well, it was very remote, and we arrived eventually, only to learn that we were the very first mzungus(Swahili word for "miracle", but that is what white people are called here) to visit his community. It was incredible. We sat inside a dung hut (yes, a hut made of cow dung and mud) and sipped chai, as the flies swarmed all over us. We met the people, who surprisingly knew a little English, but our Swahili really helped us out.

As far as obstacles, one theme has been eerily following us. The women, and sometimes men, give us an unfriendly stare. We live out in the country, and most people out here are incredibly nice and always return our smiles and greetings. But in town, people either ask us for money, want us to buy something, or just give us a rude look. We've tried overcoming this by giving them a friendly "Jambo!" or smile, but sometimes even that doesn't work. We are getting better with our Swahili, and many times a simple sentence asking them how their day was, can help to lift the curious barrier. One day in particular the other girls were feeling uncomfortable in town, as we were grocery shopping, when a couple of young male vendors followed us for a half an hour. I knew that they were simply wasting their day on us, rather than pursuing other customers, and that they would eventually leave us alone. So I just kept shopping, not worrying about them. But I could understand how it can be unsettling. Eventually they left us alone and we headed back to our house on a rather unusually hostile dala-dala (Swahili bus). We got pushed around a little, and again the rude looks for no reason. It was just a very interesting and disconcerting day, that left a bitter taste in my mouth about the people of this country. As we got back to the house, we decided we needed to just spend the night together, rather than inviting friends over as we had been planning on doing all week. As we returned to our house, it felt great to be back in the comfort of our home, and even the roosters that never stop crowing outside our window, had a comforting shriek. I kept an open-mind and tried to remember all of the other incredible people we've met so far, and didn't let this experience taint our perceptions. The following morning I woke up, and felt much better about everything.

Dinner with the Tour Guide, Hostility in the Dala Dala

(from Caitlin Thomas)

This week was amazing! We finished our interviews and our data collection. We also traveled to Arusha for the weekend to visit the Maasai museum. The museum is run by actual Maasai villagers who live nearby. With the exception of cell phones, the tribe is largely untouched by the ways of "civilization". That is, they make/kill all of their food and build their houses by hand using sticks, sand, and manure. After touring the museum, our tour guide invited us to visit his home. The next day, we picked him up after work and he guided us on an hour journey to his house. The only road was a dirt path that was worn down by cows, so the ride itself was very bumpy. We arrived at his village to learn that a white person had never visited the village before. It was strange to see that many of the children were afraid of us. After about fifteen minutes, they overcame their fear and started smiling and talking to us. We saw the huts that the women make and got to taste some boiled milk. We saw the children herding huge masses of cows and goats (cows signify wealth in this culture and are actually used by the males to buy more wives) and men with huge holes in their ears. Overall, it was an awesome experience.

The only stressful obstacle we encountered this week was a social encounter. Leslie, Whitney and I rode a dala dala (a bus with tons of people in it) into town to pick up some dresses that we had made. The ride there was uneventful, as was the trip to the fundi (seamstress). However, on our way home, we had to squeeze on another dala dala. The dala dalas are really just large vans that probably sit about 15 people. There are seats that fold down into the aisles, so everyone is cramped together. On top of that, the drivers usually cram even more people in, so there can be up to 30 people in a 15 person bus. The bus we took on the way home had about 26 people in it, counting us. We had to stand on top of each other's shoes next to the door. The moment we entered the bus, the riders started to glare at us. They proceeded to glare at us the whole trip home, even though we tried to smile and be friendly. At one stop, Leslie and I were rudely pushed off of the bus by people who were exiting at that stop. We later asked our translators about the experience, because almost everyone we have met has been helpful and kind. They told us that we must have been on a bus with a bunch of people from the city. They said that the people who work in the city have very different (sometimes hostile) attitudes toward foreigners than those who live in the suburbs.

Growing Reception & Accomplishments

David is doing an Excellent job with the chaplains - we have a program which is growing rapidly and organically AND is culturally sensitive and specific. We now have 4 chaplains and 1 Muslim imam, 3 social workers and 2 psych nurses on board!

I have asked for and received a US donation for 6 laptops for this project which hopefully will arrive by June 20.

Dr Ringo along with the current chair of the Tanzania Labor Party have both asked me to join them with creating a revised national policy and structure for a prototypical mental health clinic - A meeting with Dr Shao (exec director and Dr Ringo and myself is being arranged as I type and David and I may meet with the Health Ministry for a meeting on this afterwards. - more on that later.

In addition, Dr Ringo has asked me to present a lecture on the biology of personality to the medical students sometime next week.

Finally, after years of international travel (I have presented workshops and have done therapy in several third world and developing countries) I have learned how to connect and communicate well without mastery of a second language. I did not realize that a preparatory how-to" lab has not been offered in which students are trained in the basics of travel, group dynamics, and cultural communication. I have an idea for creating a course designed to prepare our students in a very pragmatic way (i.e. One class is to bring a back pack that they themselves have packed for travel to any third world country for one month; another is to divide into working group and have established group meta communication etc).

All of the above was accomplished in 5 days, which I think says a lot about the readiness of the people we are working with and the need for the above programs.

whew! - The work is extraordinarily well and even beyond our most optimistic dreams.

Slow Churning Success

This week has been very successful! We had two focus groups with Muslim leaders, ventured further into town, and established some lasting connections with people in the community. Although I've only been here a short time, I feel very comfortable and adjusted. I have even stopped waking up to the random rooster crows throughout the night. I went further into town this week, and was very enchanted by the town market. The vendors lay their food and other wares on blankets on the street, and the flies are usually constantly swarming overhead. In comparison to the strictly sterilized supermarkets in the United States, this is quite a culture shock. However, it is also an authentic taste of Tanzanian culture. Although there are some tourists in Moshi (mostly those wishing to climb Kilimanjaro), it is not a "tourist town", which allows for a true experience of the culture. The language barrier has also become less of an issue as I have been quickly learning some words and phrases. Many of the people here are very excited to show off their English language skills, so I help them with English and they help me with Swahili.

Luckily, the IT guy finally stopped by the house, so we all have working, (if really slow), internet. Our biggest struggle this week has been downloading the qualitative software. We planned to download it before we left the U.S., but unforeseen technical difficulties prevented us from doing this. Because the internet connection here is so slow, we may not be able to download the software here. We considered ordering a disc version, but it may arrive after we leave because of shipping time. We have been brainstorming creative ideas for acquiring the software, but so far have been unsuccessful. We are considering doing more in-depth interviews in our remaining time and may focus on coding after we begin returning to the U.S. We have already made plans to divide the coding in order to streamline the process.

As I mentioned before, we held two focus groups with the Muslim leaders on Saturday. They had some very interesting ideas about the causes of mental disorders. In the focus group that I oversaw, the leaders all agreed that there are 2 main causes of mental illness: 1) biological causes (inherited genes) and 2) man-made causes (either drugs cause the symptoms or the person commits bad deeds and is punished by God). All of the leaders took our email addresses and are eager to keep in contact. One even volunteered to be the spokesperson for the group and to work directly with us. Other than that, we have been interviewing all week long and are ahead of schedule in terms of number of interviews.

This coming week will be very eventful. We plan to finish our interviews at KCMC by the end of the week. We will also be visiting the regional hospital to finish interviewing different health care workers. We are also working on planning a trip to a secluded village in the country. The chaplains have suggested that we go to a village in order to get a different perspective on mental disorders. These people are less "touched" by society, so they will probably have some
really interesting perspectives. We plan to bring video equipment as we have been told that taking pictures would not be offensive. I hope it will work out because I'm really excited about it!!

Learning as we go...

So after being here for about 3 and a half weeks, things are really starting to come together. We are ahead of schedule on our interviews, but each day we are running into new challenges. Electricity seems to go out for a few hours each day. Which, of course knocks out our internet, lights, and sometimes water. But its kind of funny how we've begun reacting to things. We don't really notice the big hiccups, we just go about our day with cold showers, no lights, and cold dinner. It doesn't even phase us, except when we go to get on the internet- and then we realize we have no connection. :(
A few other challenges we've been running into, is our difficulty with Swahili. Most people can understand what we're saying in English, but every once in a while, things are hard to get across. Our translators are great, and I find myself asking people to teach me new words and phrases. Yesterday I was waiting(whats new?) somewhere for 45 minutes, and I had a great im-promptu Swahili lesson from an elderly reverend, and then another encounter with a taxi driver who taught me some things as well. People are so friendly, and willing to listen to your broken Swahili attempts. Not without a little chuckle however :)
We are looking forward to finishing our biggest hurdle: the patient and family member interviews today, and then we will be almost done with our religious leaders and health care workers by the end of next week. We are hopefully doing a documentary film, but this is a huge undertaking, and will be very time-consuming. We have all experienced an incredible educational experience here, and the work we are doing will definitely impact the lives of those here. Making a documentary can even further insure that our work will not be forgotten, and can hopefully educate others in this area. We are grateful for all of those helping us out here, and looking forward to the weeks to come.
Asante. (thank you)

Cultural Differences in Bananas and Chance Encounters in the Street

Our whole group is finally here. We've been very busy at work conducting interviews and we are ahead of schedule in terms of the number of overall interviews that we hope to accomplish. We are all intrigued by the cultural differences here. For instance, there are 4 kinds of bananas in Moshi. The groups' favorite are the big yellow bananas (which look just like American bananas, but they need to be cooked before you eat them). It is common to see Mamas carrying huge platters of bananas on their heads through the streets of Moshi. The genuine friendliness of all the people is also very surprising. Everyone says hello and most people are more than willing to help us with directions or with the language. The girls and I often talk about how open the people here are in comparison to the people in the United States. We've decided that the people in the U.S. aren't unfriendly, but that that culture is more individual-based. In contrast, the culture of Moshi is much more community-based, which could account for their sunny attitudes toward strangers.

The main struggle this week has been lack of internet access. The internet in our house has been working on and off (mostly off), so we have had to adjust in terms of sharing transcripts with one another and communicating with our families. In order to overcome this, we have taken trips to the internet café and contacted numerous people in hopes of fixing our internet. Another struggle

was one that Whitney and I encountered. We had ventured into town to buy supplies when we were approached by two young men who were trying to sell us scarves. This is a typical occurrence in Moshi, so we politely declined and kept walking. However, the two men proceeded to follow us throughout town for the next two hours. They pestered us to buy their wares and would not take no for an answer. They even waited outside our café while we ate. Luckily they eventually lost interest and left us alone. From this experience, we learned the importance of traveling in groups and were reminded that we should always be aware of our surroundings.

Jumping Back Into Tanzanian Culture

Well, for me (Georgia), it's been a wonderful experience to jump back into the Tanzanian culture and style of life. Generally, this lifestyle includes a very laid-back pace for work, and after we are done with our interviews, we get to experience that here…but I have actually been surprised with how fast and efficient we have been able to work during the past week and a half since the first team members' arrival (Georgia and research coordinator Jen Nolan, followed 3 days later by Leslie, and finally this past Wednesday, by Whitney). Our on-the-ground study coordinators have been wonderful, in fact, the first day we went in to greet Dr. Ringo, he already had 2 patients lined up for qualitative interviews! We had to be the ones to push back the meetings long enough for us to get our bearings.

All interviews started officially this past Tuesday, and we have been running full speed ever since. In fact, Tuesday was our longest day—we had 2 patient interviews, and two family member interviews, and we were interviewing from 8:30 in the morning until nearly 5:30 in the evening, with only a 20 minute break for peanut butter and jelly sandwiches. Since then, we have split up into two interviewing groups, with one of our wonderful medical student translators in each group, and have tackled the same number of people within a day but in half the time (thank god!). It has also been a blessing to work with these translators because they are such fountains of knowledge when it comes to cultural norms, the correct way to ask delicate questions, etc. On top of all of that, they are just wonderful people—Andrew and Phillip have been more than willing to lead us around town, even when it means sitting down inside of a small cloth shop for upwards of a half hour after interviews are over just so that they can help us girls bargain down the price of the fabrics and tell us what various Swahili sayings written on the fabric mean. Wonderful stuff!