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On medicine in the country-side and hard-hitting police work in Moshi…..
In a place with such enormous medical challenge, and so many people dying of preventable causes, palliative care is understandably not a priority. Why invest resources in helping people die more comfortably when you might be able to keep them from dying at all? And yet, why shouldn’t it be? In any setting, you could always devote more resources to preventing death than to managing it. If there is a moral case for doing that in the first world, why not the third? If you can’t keep people from dying, they should be made as comfortable as possible.
These photos come from our visit yesterday with Dr. Yesiah Meru on a USAID-funded palliative care project in a very poor, very rural area between Moshi and the town of Machame, where they are based. I was journalistically curious and it fit in nicely with Maria’s interest in finding ways to help front-line health workers offer rudimentary mental health services. If ever there were a good target population for depression, this would be it.
We visited about a half-dozen homes over the course of the morning, spread across a few villages that were poor even by the standards we have gotten accustomed to. Despite all the recent rains, it was clear this area has not received nearly as much of it as the foothills visible just a few miles away; the earth is slightly muddy but still cracked and hard.
In fact, not all of our visits were really palliative; clearly that is one focus of this project, but it also visits people in a range of circumstances. Our first stop (first photo) was actually a bereavement visit, to pay respects to the families of people they have worked with who have passed away. The hosts were the parents of a 42-year-old woman who passed away just three weeks ago. As our jeep pulled up, the father, mother, a brother and a few scattered children — the family structure wasn’t entirely clear but at least one belonged to the recently deceased woman — gathered a few plastic stools and pushed them against the outside wall of their home in a line to capture the sliver of shade under the hot sun for their guests. A bell clanged away from the neck of a scrawny cow, while a few chickens and tiny goats wandered around the courtyard and in and out of the house, a crackly radio playing folk and gospel songs in the background.
This couple was very dignified but had looks of truly deep sadness etched into their faces. The little boy looked totally lost. The father had a white patch of hair and wore a pair of old, crooked glasses, jean shorts and plastic sandals. He and his wife reported they had seven children; four have now died. The latest story was somewhat murky to me in the translation. The general cause was HIV but the immediate one less clear. She had been receiving some anti-retroviral treatment, but did not receive her diagnosis until the case was quite advanced. Whether or not she was properly taking the daily drug regimen is unclear. Virtually all of the 1200 patients in the project have HIV, though a few older patients have other conditions like terminal cancer (which is rarely identified here. One reason is people don’t live long enough to develop cancer, or if they do it simply is never diagnosed).
In any case, death certificates are rare and autopsies non-existent, so it often isn’t clear exactly, though HIV is typically a contributing factor. Reports that AIDS has somehow been cured in Africa are sadly mistaken; people still die from it all the time.
Dr. Meru and two social workers, Deograsisu Mrosso and and Elly Meena, respectfully asked how they were faring and checked on some of the other children in the home who had been left with a package of school uniforms and rudimentary supplies. The brother led everyone in a long prayer. Then we walked through a muddy patch of vegetables and into a clearing where the daughter is buried in a shallow mound of dirt with a white cross, with some fresh bows and ribbons dropped on top. Dr. Meru asked several times if I had any questions for them, but it felt very intrusive. I only asked their daughter’s name: Janet Samuel.
We next visited several patients: a bed-ridden elderly woman in her home who claimed, almost (but perhaps not totally) impossibly, to have been born in 1896 and remember World War I as a young adult here (basically, very few people in Tanzania older than about 40 know precisely when they were born, and exaggeration is very common. Still, who knows?). She is cared for her in her home by her son. We spoke a bit about how rare it is in the United States for family members to take care of elderly relatives in their own homes. This seemed to confirm everyone’s worst opinions about life in the United States. Another woman we visited, tired-looking but smiling, is HIV-positive, but hopefully not a palliative case as she is receiving anti-retrovirals. The treatment distribution, and the drugs themselves, are substantially more effective than just a few years ago, Dr. Meru told me. Still, there are enormous challenges; people simply don’t have the few cents to take the bus into treatment centers. More and more clinics are sending vans into the villages to distribute drugs directly.
Our final stop was an elderly woman with a leg injury. She lives with her extended family but sits all day on the ground under the shade of a small propped-up thatch-roof structure that doubles as their kitchen, with a small fire pit next to her. She has no cane, wheelchair, or access to rehabilitation. A depression diagnosis could be made visually, from 20 feet away. The program has access to handful of pain medications (no opiates) and other drugs (an anti-worm medicine) it is able to distribute; getting a basic (and available here) anti-depressant like amitriptyline added to the list would seem like a worthwhile project.
On the public bus home, we became real visitors to Africa; somebody snatched Maria’s wallet. One looks back on these things and always things “if only we’d……“ Gotten off the bus one stop early instead of heading into town for lunch. Not taken the seat. Taken a purse with a zipper. Maria is beating herself up over letting it happen and what she might have done differently in the chaotic moment when she realized it was gone, when everyone was disembarking the bus and several people around her knew what had happened but refused to point out which person had done it or do anything about it (I was at the front and didn’t realize what had happened until it was too late). Personally, I wish she’d just started shouting really loudly and causing a commotion, but I think it was actually a lesson learned at a pretty modest price. We got away pretty easy - she had about $35 in the wallet, and one credit card to cancel, and is so angry hopefully she will be super careful in the future (if we ever taken another public bus… a big “if,” considering our limited experience). Since you can’t use credit cards anywhere here, we didn’t worry much about that. But I think I understand why she is so upset about it; it isn’t losing the money but your faith in people around you who don’t speak up to stop something. You come to a place and try to help do some good and now this. The experience seemed to take on the burden of all her frustrations over all the obstacles here that have made her work difficult and frustrating.
We decided somewhat irrationally to go to the police station, which is right next to the bus depot. We stood for around 10 minutes while functionaries ignored us. Then, a friendly, English-speaking man took us to a desk where he and another officer began filling out forms. And more forms. They wrote down the missing contents. All sorts of irrelevant information, on various pieces of paper. Her religion? Really? We tried to explain that we just thought they should know what had happened might want to talk to the bus driver and door attendant, who were probably still at the bus station (and, in my opinion, were in on the theft, since they refused to stop the bus and contributed to the commotion). They know their regular passengers, and while the wallet was certainly gone it wouldn’t hurt for them to see the police showing some interest in petty crime on buses.
Ha! So naïve. Then filled in the boxes. One section that was not be filled in had to be x-ed out, but with perfect lines, so they got out a ruler to make sure the lines they drew through one section of the form were perfectly straight. This from a country so obsessed with procedure and paperwork that across the street from the police station sit a stand of three or four stalls where people literally sell rubber stamps.
Then they took us to an upstairs office By now I had concluded our efforts to be good citizens and report the crime were completely misguided. More forms. Finally a woman starts filling out a receipt. Maria notices first and ask what the receipt is for. She informs it’s 500 Tanzanian shillings (about 37 cents) for the privilege of receiving a form confirming our items have been stolen. And here, a streak of what I frankly consider pretty heroic patience during three-plus months in Tanzania comes to a crashing halt. I commence a volcanic eruption that threatens European air travel. An f-bomb drops quietly beneath my breath. More loudly: “Let me get this straight. You want US to pay YOU to report a theft?”
The man seems genuinely surprised at my surprise. It is for the form, he says. Why do we need a form, I ask. What good does it do us? So you can be reimbursed. By whom? The government of Tanzania? He suggests this form will be necessary to collect reimbursement from our insurance company. I struggle not to laugh at the thought of an alternate universe where this would be covered, but only if accompanied by a 5-page report with stamps on it. I explain once again the reason we came: to report the theft in case you wish to try to actually do something about it. Slightly calmer now, I tell him we have absolutely no intention of paying and he can keep the report; sorry for the misunderstanding and to take up his time. Maria makes the obvious point: I just had my wallet stolen. What am I supposed to pay you with?
Our refusal flummoxes him, and he insists we go downstairs. He relays the story to his corpulent supervisor, who asks where we are from and he says he just spent six months in America at an FBI training college. “So at this FBI training college,” I am tempted to ask, “do they advise you to handle theft investigations by filling out endless forms, or actually going to the scene of the crime and talking to people, at the very least to fly the departmental flag?” Probably wisely, I restrain myself. With a dramatic flare, he removes 500 TS from his own pocket and pays the fee. I regret not insisting he take the money back, but eventually we just thank him and take our report, and head home. Now you are a real visitor to Africa, I tell Maria.
Final update: the Almond family arrived in Africa late last night, on a cloud of homespun West Virginia wisdom courtesy of KLM. They came five days later than planned due to the volcano (insert in-law volcano joke here), bearing 130 pounds of medical supplies, cookies and other sundries. Chacha, our driver, was I think a little overwhelmed by two delirious West Virginians talking constantly about their home state during the ride home from the airport. They are still asleep as I write (11 a.m.) and tomorrow we depart on a two-day safari. Wednesday night I depart for Paris. At that time the blog may fade away as I don’t think people care as much about some guy touring through Europe. If it persists, the new emphasis will probably tend toward cuisine, as that will be the unrelenting focus of my trip. So be forewarned: good-bye development issues, public health, education, and African political analysis. Hello European food porn.
