Last Impressions

(from Georgia Hoyler)

The entire experience of being in tanzania was, as one must expect, a thrilling an rewarding one. I remain in contact with the medical students who were our translators, and I find myself at times missing their company as much as any Duke friend I have here in the states--working together on this project really made me appreciate the added benefits of doing international research. Those connections that I have made as a result of this project are to me as important if not more than the results of our studies themselves, because I learned so much about the tanzanian culture and positive outlook on life by being infected with it through these wonderful guys. I don't have any pictures of them for posting on the blog, but i know the other girls do.

I want to thank the Global Health Institute for funding this research, as I do believe that it has made members of Duke's university better world citizens, with a broader world view and a deeper understanding of the meaning and purpose of international work, which is not solely to collect data about a foreign population. I find myself drawing similarities between our mental health system here and there, and I have learned about ways to improve ours from studying theirs.

Making a Difference, Building Lasting Bonds, and Saying Goodbye

(from Leslie Modlin)

When I told my family and friends that I was spending the summer in Tanzania, the reactions were variations of the same theme – a biting cocktail of utter disbelief with a perceptible notion that I’d lost it, stirred in and ready to drink.

I’ve returned to the US and I keep finding myself wishing my time in Tanzania had been longer. Our friends had an impromptu send-off party the day I left, and as one male friend started crying, I, not surprisingly, found myself crying as well. As the taxi drove off I couldn’t withdraw my gaze from Kili – I miss seeing its majestic features on a daily basis. The mountain was draped in clouds of haze at its base, its top standing proudly in the milky pink sky as the sun crept down. I’m selecting amongst the (well over!) 1,000 photos I took while there to enlarge and decorate my room to remind me of our incredible journey. While I had been struggling in the last few weeks to determine whether I’d be back in the future, I had moments of unmistakable clarity informing me that yes, certainly I will be back. I’m not sure of the exact time, but I feel comforted knowing that I’ll return to this country soon.

One of the realities I struggled with most while there was the blatant dichotomy between how much I want to help and my current abilities to do so. In many ways, any small effort led to tangible change (the Albino program is an excellent example), but there were so many causes to which I was drawn that I myself cannot yet affect – the fact that there is one neurosurgeon in a country of over 40 million, one or two cardiothoracic surgeons, and 11 psychiatrists. Needless to say, I cannot wait to return once I have the skills to heal and touch many lives in an immediate, lasting manner – at some points of the year, then, there will be more than one neurosurgeon, or another oncologist (I’ve not yet decided! Which is fine.). I’ve worked with cancer patients since my freshman year, and in Tanzania, you’re essentially out of luck if you have cancer. I grew especially close with a man who had liver cancer that had metastasized to the brain – I was amazed he was still alive, given the country’s limited repertoire of chemotherapeutic agents and their general consensus that adequate cancer treatment is beyond reach. As my medical student friend explained, ‘If you have cancer, you just die.’ Yikes. If you are struck by a car, which seems to be a common occurrence given the speeds at which drivers go (it’s probably good my math is a little fuzzy when it comes to converting kilometers ph to mph!), it’s almost immediate amputation – the tools are just not there to properly reattach a limb (I’m glad I didn’t know this before going!), or even to monitor a set bone. My friends told me story after story of setting a bone, X-raying the patient, and realizing that it hadn’t been properly placed, only to break the bone again and re-attempt correct alignment.

I was asked by every single doctor I met to return to their country – every single one. “When are you returning?” “How many years?” “Bring your friends,” they said – no one I met was too proud to ask for help, they cared about their patients, their fellow Tanzanians too much to waste that kind of energy. You can’t not go back after this experience! You just can’t.

Beyond the hospital walls, I made lasting friendships with our medical student friends. We’re all trying to get them to America – they watch more movies from the US than I knew ever existed! – and are eagerly seeking any possible opportunity that would bring them to our country. I have two Tanzanian brothers – Philip and Andrew – and I was adopted into not one, but TWO families! I thought they were kidding, being polite and friendly yet insincere as we often are in our culture, but they were 100% serious. My first family is Father Muazo’s; his mother and father adopted me (after adopting Tina, so I think technically I’m their granddaughter and Tina’s daughter!) so now I have many pictures with my fam. My second family is Reverend Lyimo’s, who adopted Whit-Whit, then Cait, then me. I get to be the youngest (a treat, as I’m the oldest and I notice that I miss out on all the liberties and subtle mischievous doings that the youngest inevitably and most unfairly gets away with! Now I get to give my ‘parents’ a hard time!). Officially, that puts Rev at 19 children – he told his wife and she’s delighted. Needless to say, I have no shortages of available places to stay when I return! (Our group has also been offered a place at Reverend Biligue’s home – more accurately, a mansion by our and Tanzanian standards – he studied in Chicago for 6 years so it was enjoyable talking to someone from my neck of the woods.) I couldn’t have asked for more hospitality and generosity from everyone with whom I interacted (aside from those random instances in town which I wrote about earlier – I still haven’t figured out a reason as to why, but I’m sure all I need is more information to understand where they’re coming from, so I’m no longer bothered by it.).

Our project has already produced tangible results. We gave a presentation of our findings to the doctors, chaplains, and imams with whom we worked that was deemed ‘excellent’ by all who attended. We were quite happy, but the most important point is the fact that, as I type, our findings are being translated into an educational intervention program for patients and their family members, taught by chaplains who are being trained by Tina and Dave of our group. I’m thankful to have been involved in such a deep project that is able to give something back immediately – to help work at shattering the image of foreign researchers (Duke is very much included in this) sitting in their coveted office space on KCMC’s campus, taking, taking, taking from the community and not readily giving back. To some extent, the nature of research is such that it takes time to give back, to have the results of your labor materialize into something substantial, significant, and impactful in individuals’ daily lives, but there is always a way to do it sooner. I’m glad we’ve found one such way. I think that is a central, crucial component of researching abroad – being clear about your intentions and being open to give, sooner rather than later, as much as you’ve received. In such a generous culture, it may not always be possible to return as much as we’ve so heartlessly been given, but we can try.

This experience has shaped me in staggering, imperceptible ways. I’m more confident than ever in my decision to take a year or two off before medical school and I’m hopeful that I can continue to work abroad. Indeed, I’m more confident than ever in my decision to attend Duke – I am proud to be at a University that so strongly and obviously encourages its students to become diligent, active, and passionate world citizens.

I cannot thank the Global Health Institute enough for this opportunity – I know this has changed my life in an incredible way, and I cannot wait to see what lies ahead!

Wrapping Things Up

So after completing our interviews the girls and I have been organizing data and looking over our information. The weather has gotten slightly colder, as it is winter here, and I often forget that I am in Africa. But the women carrying ndizi (bananas) on their heads, and the rickety dala-dalas quickly remind me that I am indeed, in one of the most beautiful countries in Africa. I have learned a great deal of Swahili, which makes it so much better to relate to the people here. I can say just about every food that I've eaten here, as well as ask for food, drinks, and directions. The medical students (our translators) are so pleased when I say a line or two in Kiswahili. Its such a fun language to learn!

On Saturday evening Philip (one of the translators) took me to a Wedding Send-Off party. In tanzania the bride's family must officially give permission to her and the groom, so that she can be "sent off" to wed. This event consists of a big celebration (almost equivalent to the size of the wedding or reception) held by the bride's family, and the whole focus of the party is the bride. The groom is merely another guest at the party. There is usually a goat served at this occasion, and always: a large display or food and drinks. This party was themed with beautiful pink bows and white fabric lacing the venue hall. As are most things in Tanzania, this banquet hall was outdoors, with open sides, and just a roof. There was an entire procedure for the send-off party, with many speakers, songs, dancing, and processions. I had the chance to sit with other medical students and chat about school, life, Tanzania and of course many other things. I finally had the chance to talk with a female medical student, which was great. I learned a great deal of things about her pathway in medicine and the many things shes needed to overcome. She wants to be a neurosurgeon, however everyone keeps telling her that its too difficult, and will be too hard for her. I told her thats pumbaa (nonsense) and that she needs to listen to her family and friends, but ultimately listen to her heart for life decisions such as these.

It has been a great 6 weeks in Tanzania. Our project went very well, and we are looking forward to publishing a paper. We've also made a photo essay and taken thousands of amazing pictures. Unfortunately the emotions, conversations and love we've also encountered in Tanzania can never be captured in an essay or a photo, and so we have all stored these memories in ourselves, hopefully changing us for the better.

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.