On economics and education

I think we are all feeling the need for a break and I am glad to say that tomorrow we are driving to the coast to Fish Eagle Point, which I hope is a beautiful beach lodge, for Aaron's birthday and some much needed R&R!

We have been ill again with weird Tanzanian bugs and i had horrible pus on my tonsils so am on antibiotics.  I am also feeling a bit jaded at work so am including my latest BMJ posting for you to read.

I promise I will post some cheerier fare whilst we are away...

  

On education and economics

There are many differences between health care and medical education in Tanzania and in the UK, but the concept I find hardest to understand is “attendance or sitting allowance”.  This allowance is paid to all staff that attends courses for their health care education and it seems that staff will not attend educational events unless they are paid their attendance allowance.   The allowance can be a significant sum and the educational facility providing the training event is expected to cover the cost.

Apparently this practice originated many years ago when the WHO began running educational events and courses about HIV/AIDS and now seems to be ingrained.   I am used to a society where we seek and pay for medical education and now with the reduction of study budgets it is common practice to self-fund attendance at courses and meetings.

Now I understand that western salaries are much greater than salaries paid in Tanzania but mixing economics with education seems to be detrimental to the will to learn.  Perhaps a different form of attendance bonus allowance based on an 80% attendance in the workplace per year would be more successful, although I am not sure how it would be policed or funded.

The Tanzanian government is struggling to meet the doctors and nurses strike agreed 100% pay increases and this is due in part to the fact that within a population of 45 million there are only an estimated 800,000 tax payers.  There was another mini-strike of 2 days recently and we are awaiting a re-shuffling of the cabinet.  I don’t think there will be many willing volunteers stepping forward for the job of Health Minister!

Currently we have 4 Spanish surgeons who come each year to the RDTC, at their expense, for a 10 day period, to operate on our patients and train the dermatology residents in surgery and dermatopathology.  Last Monday was amazing as there were over 100 Albino and Xeroderma Pigmentosa patients in the department being screened for surgery.  All the patient expenses are paid for by a Spanish organization, as well as attendance allowance for the local staff, and some patients had traveled for 2 days across Tanzania thinking they had skin cancer to be told they had tinea capitis (a fungal infection of the scalp)! 

Xeroderma pigmentosa is a dreadful autosomal recessive disease where there is a defect in the gene responsible for repairing DNA following photodamage. Photo-damage begins in early childhood and is characterised by cutaneous and ocular changes such as freckles, photophobia, corneal keratitis and ulceration.  In Africa if strict photo-protection is not adhered to then malignant tumours such as squamous cell carcinomas, basal cell carcinomas, keratoacanthomas and malignant melanomas develop in children as young as 3 and 4; death from metastatic disease occurs from the teenage years.  

Peter and Mafalda trying to sort out paying out the expenses to the patients

queing up for the expenses with Peter trying to keep order!

It is very difficult to arrange for children to be operated on under general anaesthetic due to no dedicated paediatric theatre space.  It is the first place I have worked where adults are prioritized over children but perhaps this is due to economics as well.  As in many places there seems to be a two tiered system with those who can pay being fast-tracked to theatre and those who can’t waiting weeks and sometimes months.  We have watched a 4 year old girl’s scalp tumours multiply five fold whilst she has been an inpatient for 6 weeks.  I have found this the hardest part of my job watching but not being able to get her to theatre as inevitably there is an adult emergency and she is bumped off the list.  This week however she has been operated on thank goodness.  Dermatology are currently building their own wards and theatres so if dedicated anaesthetic time can be arranged, and this is a big if, we will be at last be able to operate on our patients.

On the facts of life and running the Kilimanjaro Marathon (25-26 Feb 2012)

Tobias not gloating at all as he beats Aaron across the finishing line!!!!

It has been another action packed weekend - at this rate we will all need to go home for a rest!  However saying that it is great to have the time to do so much outdoor activites and to feel properly fit again.  Well I do but unfortunately Aaron has come down with man flu - or a viral infection he picked up by hugging Martina (and yes she is blonde and attractive even with flu!) who was poorly when she flew back from Sweden.

So Thursday saw me get back into tennis as I haven't played since before my knee operation.  I played against Terri Emmanuel (who runs the stables at the ISM school where we ride) as she was playing in a tennis tournament that weekend.  I was very rusty but had a tennis lesson booked for Friday afternoon after the boys had a lesson with Ron who is an ex-professional coach from the USA.  In the morning I went out for a wonderful ride with Terri across the coffee fields and on the tracks behind the school and it was brilliant to be cantering along the tracks in the sunshine.  I was in clinic by 10.45 am and am pleased to report that the intensive 2 week period of exams for our ADDV students is finally over.  There does seem to be a huge emphasis on exams in Tanzania and it has a huge impact on clinic time.  I do think that there should be more emphasis on teaching and learning and less on exams.  After the exam meeting reading the complicated computer analysis of the grades I was glad to get onto the tennis court.  Ron is a superb teacher and a few pointers on hand position and wrist flick have made a huge difference to my ability to hit the ball hard and in the right direction!  The boys enjoyed it too although Josh kept wanting to show Ron his "best throw" - wrong game Josh!

Another fabulous Friday night dinner but i had to leave Aaron languishing in bed feeling poorly and then I had to get 2 grumpy boys up early as I was off to Arusha National Park with Vicky and Catherine a Duke (medical school in the USA) research student working on projects in Tanzania.  We took a packed lunch and left at 8am and did not get home until 6pm. I have to say that much as I love my children it was exhausting, not due to the driving or the heat or the bumpy roads but because I had 10 hours of relentless questions from both Zac and Josh!

The road between Moshi and Arusha is pretty hairy due to the fact that buses/ dala dalas (mini buses extremely overcrowded), cars etc... tend to overtake at moments where visibility is nil usually up a hill or round a bend causing much knuckle biting. You can imagine that Zac and Josh fighting in the back of the landrover, sometimes with sticks was not conducive to concentrating on the road!

Arusha national park is a small but very pretty park about 90 minutes from Moshi.  The park was very very dry and dusty but the views were beautiful, particularly from the top of the caldura (volcanic crater) and over the string of alkaline lakes.  

Me and the Biblical Boys, Catherine and Vicky

We saw giraffes and zebras and warthogs and lots and lots of baboons and monkeys much to Zac and Josh's delight.  The forest in the park is well known for its colobus monkeys which are furry black and white ones with bushy tails and mime artist faces.  I wandered into the forest watching them hurl themselves elegantly, almost flying with arms outstretched high up in the canopy of trees.  









Meanwhile Zac and Josh went into the little museum filled with very old stuffed birds.  Zac came out and loudly asked me "why does that man have one blue eye and one brown eye?" and then Josh went into full whine mode saying "can we buy a stuffed bird?" and when I said no he said " but we only need a small one"...  In true Josh fashion he went on and on and on and on and on and didn't seem to think that my not wanting to cart a dead bird around Africa and then back to England was reasonable.  I tried to distract him by getting him to look at the flying colobus monkeys but as only Josh could he told me he wouldn't because I wouldn't buy him a dead bird! Clearly I am a most unreasonable and unkind mother!!!

Ooh there is a yummy louse..

We saw amazing icing sugar pink flamingos who all had their heads buried in the water until Zac and Josh came charging along shouting.  They then kindly popped their heads up to see what the racket was much to the pleasure of a photographer with an enormous zoom lens.  The boys then proceeded to get their croc shoes covered in a mixture of mud and flamingo poo which they delighted in sinking into on the lake shore.  

What was that terrible noise ? say the flamingoes

I asked them to wipe their shoes off on the grass but no Josh knew better so went down to the lake shore to rinse off his shoes.   So Zac followed and let go of one shoe which began to float off.  I then shouted "NO - Zac get your shoe" bringing the flamingo heads up to rapid attention - and fortunately for him he managed to lean out and hook his shoe with a stick!!  Never a dull moment with my boys...  

Just before Zac let go of his shoe!

I am sure there is a lion out there somewhere......

Luckily they fell asleep for a while which gave us all a respite and then Zac woke up to do great game spotting.  We saw a big bird which i think was an eagle, a dik-dick (antelope with very short legs) and more baboons.  Vicky had been to the park a couple of times before and was an excellent driver and guide.  She has 3 grown-up boys herself so is used to noisy boys but I think Zac and Josh have worked their natural contraception magic on Catherine.  So you are probably wondering about the facts of life conversation...

Catherine and I by the water.  Where are the children? Catherine is thinking "thank goodness the children are not right here!"

On the way out of the park we went to a deserted looking safari lodge for a drink.  We are not sure how they survive as there seemed many staff, no guests and only 2 drinks on offer: the ubiquitous coca cola or Safari beer.  We were so dusty and dirty that it was great to have a wash and a cold drink.  I think I was telling Vicky and Catherine how we came to be in Tanzania; the choice I gave Aaron of either having another baby or coming to Africa when Josh suddenly said "How do you get pregnant?" None of us could cope with that particular conversation so somehow I deflected it and then Zac said "You don't want to know it's disgusting"!!

Back to the ISM school for a quick pre-marathon pasta meal by the swimming pool where there was an outdoor showing of Chariots of Fire.  Aaron rose from his sick bed to eat large volumes of pasta and then the boys had another melt down as they were supposed to be showing a childrens’ flim: Puss in Boots but it wasn’t happening and by 8pm we thought the boys should be in bed as there was an early start planned for the morning.  Aaron had decided to run the half not full Kilimanjaro marathon due to his damaged knee and flu and the boys and I were to run the 5km fun run around Moshi. 

The full marathon was due to start at 6am, the half at 6.30am and the fun run at 7.15am so we all got up very early at 5.30am!  Actually we had to practically drag the boys out of bed as after 2 late nights they were pretty tired.  To add to the mix there had been torrential rain in the night and it was still raining in the morning so Aaron took the car to the school to catch the ISM bus to the start point.  We were going to go in the car with Mafalda but she decided she wanted to stay in bed at the last minute but luckily drove us there in her pyjamas.  So there we were all in the muddy stadium by 6.15am but this is Africa so first the inflatable start line fell down and then lord knows what happened but everything started very late.  Aaron set off about 7am and then we had to walk 1km to our start line and set off at 8am – so we were glad we got up so early!!!

Before the start and we are all very muddy already!

The fun run was great though and Zac and Josh even ran quite a bit with Noga and Amy until Zac ran along a kerb by the roundabout and fell over and hit his knee…  There was an incredible atmosphere as it was the 10th Kilimanjaro marathon and everywhere you looked there was a sea of orange T-shirts worn by the ISM brigade.   The Kenyans sprinted through Moshi like gazelles, lapping the half marathon participants!  I don’t know how they keep the speed up.  The weather cleared up and it was a blessing that it was overcast and cool.  Aaron came in at 2 hours 7 minutes I think and was just beaten by Tobias who has been gloating a lot….

At the end with lollipops and coca cola

Aaron and Mebrato at the finishing line.  Mebs ran in 1hr 45mins and Aaron in 2 hrs 7 mins but he was ill and had a dodgy knee...

Team ISM - can't lose this lot in all this bright orange!

Taking off over the bumps in true para olympic style

A very pleased Tobias !

We then had a great brunch at Camilla and Jeremy’s house followed by tea and swimming at Katie Burton’s house before collapsing into bed after another quiet weekend!

On challenging patients and weekend exploits

As we enter our 4^th month in Tanzania I seem to be becoming busier and busier.  So I think I am going to go for the little and often approach as otherwise these blogs are going to become few and far between.

These blogs will be less about my medical experiences as I am now writing a blog for the BMJ and the first one can be found at http://blogs.bmj.com/bmj/2012/02/21/susannah-baron-will-there-be-lego-in-africa/

ITU in the corridor whilst cleaning went on

Since the strike and Kelvin taking over the ward we have had a huge number of challenging adult and paediatric patients.  We had a man admitted with toxic epidermal necrolysis, which is when all your skin peels off due to a drug reaction, and this is a dermatological emergency (yes we do have emergencies in dermatology!)  We do not have up to date treatments here so treated him with IV hydrocortisone and he was nursed on ITU.  Fortunately the inflammatory process switched off and he has made a good recovery as mortality is usually up to 50%.  We have had up to 18 inpatients and many of these have had other difficult blistering conditions and I think Kelvin, the ward resident is jinxed as the ward is the busiest it has ever been!  The ADDV students are in the midst of exams so Kelvin and the medical students have been very active.  I was in charge of the ward whilst other senior consultant staff were at an albino outreach clinic in Tanga.  Surprisingly I actually really enjoyed the diagnostic and clinical challenges of managing all these complex, sick patients.  We forget how fortunate we are in the west where investigations such as biopsies and blood tests are available and are free as many patients cannot afford the limited investigations and medication available here in Tanzania.  You can read more about the ward on my next BMJ blog.

So what have we been up to?  We spent a fantastic weekend back at Marungu Hotel camping with a group of friends.  Sadly it was Sebastian and Julianne’s last weekend and also joining us was Tobias, a Danish physio and his 2 children Alex and Edvin and Camilla and Jeremy, both homeopaths, and their children Ike, Amy and Noga.  The weather was glorious and we splashed about in the hotel pool on the Saturday and then did the beautiful waterfall walk on the Sunday.  

Nguduru falls at Marangu

This time however the sun was shining and the Ndura falls were spectacular and we all dived in and swam (well not Aaron as he is such a wuss in cold water!) and Zac and I swam right under the waterfall.

Amy and Noga wrapping up at dinner whilst camping

Juliane and Sebastian

The boys have started a weekly horse-riding lesson which they love and on Friday they will start tennis lessons as last week it was rained off.  Yes we are getting some rain now, which is a blessed relief as it has been SO hot.

 

Last weekend we drove out to the hot springs which are literally an oasis in the middle of nowhere reminding me of passages from the bible!  You drive and drive and turn off the road and down dusty, forking tracks which wind through villages where we had to keep stopping to ask directions.  Eventually a 4WD truck beeped us and we followed him in a cloud of dust until we arrived at a tree fringed beautiful pool full of green, glassy water. 

where are we going????

Vicky Yates, my work colleague and Aaron getting his feet nibbled!

going, going...

gone....

In the water are tiny fish that nibble the hard skin off your feet, a sensation the boys and Aaron loved but I hated!  There was a rope swing which we swung on to jump into the water and I managed to stop the boys from climbing an enormous tree to jump in even higher!

We returned dirty, tired and happy and slept very well.  

On Sunday was the hash and this time it was held in the hilly region of Machame.  The walk was stunning and we tramped up and down into gorges and over rivers and through banana and avocado fields.  I think we are all getting fitter and the boys seem to be used to 2-3 hour walks now.  I hope this will continue when we get back home!

This weekend we are off to Arusha national park on Saturday and Sunday is the Kilimanjaro marathon.  Aaron is running the half-marathon due to his knee and the boys and I will be running, or more likely walking, the 5km fun run along with the whole of Moshi I think!

Simon Matui the current record holder for running up and down Kilimanjaro unassisted in 8 hours!!!! 

making chocolate brownies for Friday night dinner!

And now some other animals that i couldn't upload to the last blog.  And yes I do like elephants!

 

On safaris, amazing animals and lego in Africa

We have exciting news we now have lego in Africa! The boys were sent lego star wars storm troopers and rebel men in star ships by their grandmother Chris, much to their delight!  They say a big thank you for this fantastic present.

Fantatstic: the Star Fleet made it to Tanzania!

So very much after the event the boys want to tell you about their amazing safari adventure on 4-7 January 2011

Zac

On the safari we saw amazing animals.  On the first day we went to Tarangire national park and we saw hundreds and hundreds of BIG BIG elephants.  

Tarangire national park

They were grey with very thick skin and their tails were like the end of broomsticks.  We also saw tiny, very cute baby elephants, which were bigger than a man.  

Natural sunscreen - grass

The exciting thing was when we were right in front of an elephant he began to flap his ears and paw his foot.  Our guide Tuma told us that it meant that the elephant was very cross and about to charge and so we were scared and drove off.

do you fancy a dust bath?

The next day we went to Serengeti and saw spotted leopards in a big, tall baobab tree.  Very early the next morning we saw two amazing yellow and spotted brown cheetahs stalking out an imapala. 

cheetah

After that we saw some gigantic snoring lions who was sleeping in a trench underneath the car.

The next day we went to Ngorogoro crater and we drove down very early in the morning.  However it was worth it as we saw a gigantic black rhino, more lions and thousands and thousands of wildebeest.

My favourite part of the safari trip was seeing the enormous lioness sitting on top of the rock in the Serengeti.

Zac's lioness looking out for breakfast..

Our trusty safari jeep

Adventure on safari by Josh HT

On the way to Ngorogoro crater we saw baboons.  When we were having lunch we saw lots of monkeys who tried to steal our food. 

Josh loved these monkeys

In Nogorogoro crater we saw all the BIG 5.  The Big 5 are cheetahs, leopards, lions, rhino, elephants and buffalos.  At the lake we saw hippos and an ostrich. On the path there was a baby giraffe running after his Mummy.  The wildebeest and the zebras grazed together so that the zebras could look out for any predators that might eat them.  The wildebeest showed the zebras where the food was.  Mummy says that this is a symbiotic relationship but I don’t really understand what that means!

We had a very good time camping and in the car on the way back the chef fell asleep and he was dreaming about making food with our guide Tuma.  I liked camping and sleeping in the tent with Mummy and Daddy.  On the way back I got a necklace that was an elephant’s head and Zac got a necklace that looked like a tooth.

Popping out the pop up roof

It's all too much this early in the morning!

Zanz

We were picked up at 5.30am on the Wednesday morning so you can imagine how difficult it was to get Josh out of bed!  He immediately assumed his back seat sleeping position which he perfected over the next few days.  We had a fabulous guide called Tuma and he had a great black book which had information and pictures of all the animals and birds in Africa.  Zac loved spotting and looking up all the animals that we saw and then telling us about them.

Leaving Moshi at sunrise.  I was the only one awake in the jeep!

A poor monitor lizard run over by a bus thundering by

Safari was exhausting but great fun – we spent hours bumping over the dusty dirt tracks in an ancient landrover with over 300,000km on the clock and this was just the number that the speedometer stopped at!  We kept passing pristine, gleaming landcruisers that had broken down by the side of the road, whilst our trusty ancient beast kept on going.

My favourite park was Tarangire.   I am not sure if this is because it was the first park we visited or because I so loved being extremely close to elephants, such prehistoric creatures.  They are amazing animals with thick, lined hides, tiny eyes and that dexterous, sensitive trunk.  The first night we spent in a lodge with a swimming pool, which the boys loved, and then we drove through the Nngorogoro conservation area where we saw the incredible migration.  As far as the eye could see were thousands and thousands of wildebeest, rhino and antelopes grazing quietly in the lush grass.

bachelor impala

It was such a difference entering the Serengeti where the land went on and on and on and when you reached the horizon it went further and further and further.  

a huge baobab tree with a hole rubbed by the elephants as they chew the bark

No wonder as the Serengeti covers an area 15000km² – the name is derived from the Masaii word serengit meaning “endless plain”.  The Masaii migrated into the area in the 17^th century but now it is a national park they live in Masaii villages outside.

 The Serengeti was green and had quite high grass due to the recent rain which made animal spotting quite hard.  We camped that night and unfortunately the campsite was packed and a far cry from my last safari 20 odd years ago with Lizzy and Jo when we camped out in the middle of parks on our own with no-one else to be found for miles!  How times have changed…  Still social Zac made friends with a large group who were sitting around a big campfire.  In true Zac fashion he sat down, made himself at home and then started questioning 2 girls who had just climbed Mount Kili. 

I was so impressed by the 3 course meals that our amazing cook produced every night.  He didn’t seem to understand that the kids ate approx half an adult portion and was constantly making mountains of food.  The next morning we set out on a game drive at 6am and yes Josh went straight to sleep on the back seat waking up periodically to munch biscuits.  It was amazing seeing the sunrise over the Serengeti and we and one other truck traveled together on our own leaving the masses behind.  The early start was so worth it as the safari driver in front spotted a cheetah in the grass.  We were so close to him and then as we were watching another head popped up a few metres away.  They are such stunningly beautiful creatures and as Tuma our guide says they walk like models on the catwalk swinging their hips elegantly.  I had never noticed before how giraffes walk – they are very unusual as they move the 2 legs on the left together and then the 2 on the right when they walk which is very unusual in an animal.  When you look closer you can see that they have to walk like this due to their necks and how their front half is much higher than their bottoms.

Masaii warrior

On the way to Simba campsite we visited a Masaii village which was fascinating. 

playing ring a ring a roses..

 The Masaii children spend their days walking long distances with their flocks of goats and cattle.  They live in round huts enclosed with walls but have no electricity and no running water but wash in nearby lakes and rivers.  They are a nomadic people and often walk miles with all their animals to another grazing land.  

I am a Masai warrior too

Their diet is based on the cow and they drink milk, eat meat and drink the cows' blood but eat little else.  I think they also eat roots as otherwise they would have little vitamins and minerals in their diet.  The Masaii use the money they obtain from visits to their village to improve facilities and they have built a kindergarden where we saw all the children which was fantastic. 





 Our visit ended with a huge football match outside which was hilarious.

who's going to get that ball?

Camping on the rim of the Nngorogoro crater was amazing and waking up to see sunrise over the crater was incredible.  Another early start and we were one of the first vehicles into the crater which was brilliant as by late morning it was packed! The crater is the worlds largest intact volcanic caldera – the floor of the crater is 260km²  and the floor is 600m below the rim.  The crater supports a huge concentration of animals in it’s lush enviromens.  We were very lucky to watch a cheetah stalking an impala and it was fascinating watching how patiently he waited and watched.  Unfortunately he wasn't hungry enough to go for the chase and so went back to sleep much to our disappointment.  We saw all the animals in the crater - black rhino, wildebeest, buffalo, beautiful zebra, flamingos along the lake and lots and lots more lions.

very early at the Nogorogoro crater

Back to a hot lunch at the campsite and then off on the long drive back home via the Arusha National Heritage centre where Zac was very happy to show us all his favourite exhibits.  This is a very strange place which seems to be a glorified shop pretending to be a museum.  There is even a handy DHL centre in the grounds where you can arrange to ship all your large objects home!


By the time we got home we were filthy and very, very tired but very happy as we had had the most wonderful safari.  We have stayed in touch with Tuma our brilliant guide and met up for lunch with him and his 6 year old daughter Grace a few weekends ago.  The boys, especially Zac had a wonderful time and they both drew fantastic pictures in their diary books of all the animals they had seen.  Zac actually tried to draw the animals as we were driving and became very cross if we drove off in the middle of his picture!


And for the old folks here are some east african birds:

Red billed horn bill

superb starling

crown crested crane - Ugandas national bird

And more exciting animals.....

blue balled monkey!

mud too makes an excellent sunscreen