Visit to Ocean Road Cancer Center, Dar es Salaam, Tanzania

The group consisted of Randy Hurley, Kitsada, Tara, Emily and me. Randy is a hematologist-oncologist with Health Partners; Kitsada is a resident in Internal Medicine at the U of M who will be starting a fellowship at the University of Iowa in a few months in Oncology; Tara is a labor and delivery room nurse at St. John’s NE in Maplewood and Emily is an OR nurse at the VA Medical Center.

Randy had previously made an appointment for our visit with the cancer center’s director. The director was not in, so the assistant director gave us a tour. He showed us the nuclear medicine department where they are able to do bone scans. From there he took us to the radiology department which is equipped to do simple x-rays, but ct scans must be done across town at a larger medical center. He then took us to the radiation therapy department where they have two cobalt machines and another unit which is very old. The physician in the radiation therapy department told us that sixty percent of their patients are cervical cancer patients and estimated that they treat about 1500 cervical patients a year. This number does not account for the women who are diagnosed in outlying hospitals who live in remote villages and never make it into town to receive treatment.

We were then shown the outpatient chemotherapy clinic. The clinic was equipped with hoods for mixing and nurses were dressed in gowns, masks and gloves to mix and administer the chemotherapy. Three physicians were seated behind a table writing orders. Patients were not taken to an exam area to undergo a physical exam, the physicians simply wrote, “Patient seen,“ in the chart and orders were written.

Next we saw the inpatient wards which included a very crowded pediatric ward. I believe that they had over 20 beds, many of which had two patients in each bed! A pediatric oncologist, from Ireland, Trish Scanlan, answered our questions. She has been at the cancer center for about 2 ½ years. They see a lot of Burkett’s lymphoma, some neuroblastoma, Wilm’s tumors and a small number of leukemics. Dr. Scanlan was very enthused about the chemotherapy nurse whom they have on staff. She rechecks doses, mixes and administers all of the chemo and serves as a great role model for the other nurses on the pediatric unit. Trish told us that the whole country has a total of 8-10 pathologists and that it can take up to 2 months to get a confirmation back on a tissue sample. We then visited the men’s ward and women’s ward. I believe that the most common diagnoses on the men’s ward are Karposi’s and lymphoma. The ward was filled with very emaciated men, obviously suffering from HIV.

The women’s ward had curtains up for privacy. A list of the 10 most common diagnoses seen in women with cancer was posted:

1. Cervical cancer
2. Breast cancer
3. Karposi’s sarcoma (seen exclusively in patients with HIV)
4. Esophageal
5. Endometrial
6. Ovarian
7. Leukemia
8. Squamous cell carcinoma of the tongue
9. Choriocarcinoma
10. Anorectal cancer

Another list was posted with the major nursing duties. I wish I had taken a picture of this. They were listed in order of priority and cleaning was listed above assessing the patient! From there we divided up in groups. Tara, Emily and I went to the cervical screening clinic and Randy and Kitsada went to the chemotherapy clinic. The screening clinic consisted of three nurses one of whom had to abruptly leave for her niece’s funeral. Visual inspections ONLY were done. The one nurse, Beatrice, did the exams and another nurse did the intake. Beatrice has a four year degree from the Aga Khan Nursing School in Dar and an additional 2 year degree/certificate in public health nursing. Beatrice would have the patient step up onto the exam table after she had wiped it off with alcohol and proceed to dip the speculum in a tiny cup of water (for lubrication) and shove the speculum into the patient’s vagina. Each of the women was in a significant amount of discomfort during the exam. She rarely said anything to the woman during the exam regarding what she observed. We were allowed to observe the exam including looking at the tissue through the colposcope. First she would coat the cervix with .3% acetic acid, wait a few minutes, visualize the cervix, then coat it with Lugol’s solution, then revisualize the cervix. Neither pap smears nor biopsies were ever done, no matter if there were aceto-white changes present or not. (I guess the rationale is why do them if you only have 8-10 pathologists in the country. Nobody ever mentioned whether or not they have cytotechnologists.) The women were then instructed to wait for instructions from the intake nurse – for follow-up instructions or prescriptions in the event of signs of bacterial or yeast infections. At one point during the exams, the intake nurse came back to where we were standing, took a close look at the earrings I was wearing and said to me, “I have holes in my ears also. You give your earrings to me!” Later she did the same to Emily. Then the two women proceeded to grill us on our personal lives – whether we were married, if we had children, asking Tara and Emily why they weren’t married yet or have children. I told her that I was not leaving Tanzania that evening as the other two were set to; that I plan to stay a total of six months. She responded, “You come to Tanzania for 6 months, with no plan what to do!?” I responded that I was there to volunteer, that I am there to work without pay. Did she have something she would like me to assist with? She misunderstood me and responded, “Oh you want job; you want to make money.” When I corrected her, her response was, “Oh you must be married to a very wealthy man!” Soon she said that she was done seeing patients.

The three of us then went outside to get a bottle of cold soda. While we stood there, a woman approached Tara with what appeared to be a script/receipt for chemotherapy. She was speaking another language (Swahili?) the receipt stated Adriamycin---83,000 Tanzanian schillings (TSH) (about $78.00 and another drug, the dose being 8mg, iv stat for 300 TSH (less than $3). (Dr. Hurley later told us that the second drug was zofran. She obviously wanted us to give her the money for her medications. My initial thought was, “okay, so we give her the money; what is there to stop a mass stampede on us to pay for everybody’s meds.” My next thought was, “so I give her the money, what happens when she needs the next course of chemo?” Later, Dr Hurley told us that they presently have a shortage of Adriamycin and the staff was sending patients out to purchase their own chemotherapy and bring it back to them for administration. I now wish that I had given her what limited amount of schillings I had, because hopefully by the time her next course was due, the clinic would provide what she needed.

Dr. Hurley and Kit met up with us about 45 minutes later and shared what they had observed.
Among others, they had seen a patient with ovarian cancer who was receiving Cisplatin and Taxol and another with cervical cancer who was receiving cisplatin in addition to radiation therapy, (not too unlike what our patients would receive in the states.) They do not have some of the newer drugs and if they do, the government requires that patients pay for the newer meds because they are so much more expensive.

Trip to Dar

We spent the last few days back in Dar so Sue could visit the cancer center and I realized it has been a week since I updated the blog. After our time with the Vinton's we relaxed over the weekend and attended a village near the main road to Ilula for church services with our friend, Israel Kaponda, translating for Lamont, who is a visiting pastor teaching at Tumaini. Israel Kaponda, or babu (grandfather) as we call him, is a retired pastor who is a lot of fun and who was our translator on our first trip to Tanzania and again last June. His son also came with us and Imanuel is studying biology at Ruaha College in Iringa and hopes to continue to become a doctor. Babu is not much over 5 feet tall and is full of witty sayings. He grew up when Tanzania was a British colony and is well educated. Whenever he gets the chance to talk to students he grills them about working hard and says "No Pain, No Gain. No Sweat, no Sweet. No Money, No Honey". He also cracked us up in june when he slept in a little bit and came out saying "I was practicing my death". He is deligtful and has lots of stories about earlier times in Tanzania.

I had some meetings last week with Reuben, who works with the well program, and Itiweni, who works with microfinance. This week I will be working with both to start visiting some of the villages with microfinance programs and do an inventory of well drilling supplies with Reuben. It is hard to get reports from the microfinance groups, or SACCO's Savings and Credit Cooperative Organizations which are government regulated. They are supposed to file monthly reports with a government officer but have not been so we are going to have to visit each and check their accounting and learn how things are going. These are rural village SACCOS so the loans are three month (beans) or six month (maize) for seed and fertilizer. There is concern because some of these villages are in drought affected areas and crop failures have probably created problems with repayment. Bega Kwa Bega is working with the diocese to bring maize to these villages to help them last until the next harvest comes in May or June.

The bad thing about a trip to Dar is the 8 hour bus ride each way. The good thing is part of that ride goes through Mikumi national park where we saw lots of elephants, giraffes, impala, zebra, cape buffalo, and water buck. We also stopped in Morogorro for lunch and saw one of the few golf courses in Tanzania. It was open, flat, and featureless, just the way I like them. The greens were black sand and the course had a beautiful mountain behind it for a backdrop. We went to Dar with a medical group and while they were visiting the cancer center (see Sue's blog) I and a couple others went to the National Museum which is small but interesting. I had been there before but they are expanding the Tanzania history section in a new building and I enjoyed it. I also learned why there is a WWII memorial plaque in the park in Iringa for the 40 or so Iringa people who lost their lives in the war. Tanzanian troops were brought all over the war fronts by the British. Tanzania was German East Africa until the end of WWI when it was given to the British to administer and called Tanganika. It was a British colony until independence in 1964 when it was combined with Zanzibar to form Tanzania. Tanzania started as a socialist government and its economy was slow to develop compared to neighboring Kenya. However, Julius Nyere, the first leader, did a good job of unifying the different tribes into a national identity which has made it a relatively peaceful place in Africa. They have a democratic constitution now and the current president, Kikwete, is considered one of the best leaders in Africa.

We took Scandinavia bus back to Iringa and I was sitting in the same seat that I was in when I was in a bus crash in Feb 2008 which made me think of that. We had to wait more than 2 hours at the bus station and did not leave Dar until 12:30 which means we would be arriving in Iringa well after dark. The driver was careful about passing which was reassuring but was on the cell phone half the time and would use the hand on the wheel to shift instead of the hand on the phone. These big busses apparently do not need a lot of steering. The ride was uneventful but we had to climb the escarpment in the dark and passed a truck and a bus that were on their side, apparently losing brakes coming down and driving into the hill side to turn over and stop. The highway between Dar and Iringa is narrow two lane and we were lucky neither accident blocked the road or we would not have gotten back to Iringa that night. Because of road construction, we didn't get to Iringa until 9:30 but it felt good to be back. We did the traditional end of trip things with the medical group and when we dropped them off at the airport I was glad we were not going with them. We have been here three weeks now and I like it. I am looking forward to working with students when the term starts but have quite a bit to do in the mean time.

Vintons at Madisi

We stayed with Steve and Susan at their home in Madisi with their two sons. Village Schools Tanzania is run by a Tanzanian and Godfrey and Steve travel all over southwest Tanznania visiting schools, meeting with government officials, and recruiting teachers much of the time. The school at Madisi is one of their first and is where the Vinton’s and Sarah Bickel live. Sarah coordinates all the volunteers that come to the schools to help teach English and other subjects and trains them for going to their villages. The school buildings and teacher homes are all made by the people in the village and are now all wired for lights from a generator. Students come to school at night to study because it gets dark about 6:30 here near the equator and most would not have good lighting options at home.
Susan teaches English at Madisi and they stress learning English well early because it is the language of instruction in secondary school. The VST schools all ranked very well in recent national exams for Form II (second year) students, clustered in the top 100 schools out of 570 in the Southern Highlands zone. This is remarkable for a school that accepts all students in a small village that competes against top schools that select top students from all over Tanzania. It is an example of the students in the villages working harder because they appreciate the opportunity to go to school so much more. The results were posted on a class room door and we would see students coming up at night to check the results. They are very proud of their school and accomplishments.

Posted school exam rankings (note highlighted VST schools at top) and reminder to speak English that is on every class room door.


The students at VST schools work as well as study.


Susan Vinton, Sue, and Sarah Bickel with Natural Forest behind them. The school is on the other side of the forest at the top of a hill. This was one of the better stretches of road in Madisi.


Sue helped organize the medications that Susan keeps to help the village.


The Vintons live as Tanzanians which means cooking mostly over charcoal, pasteurizing your own milk, home made yougart, roasting your own coffee beans, and using your village resources efficiently. Some villagers whould help out at the home during the day when Susan was teaching.


This fellow slept under my pillow every day and was there three nights in a row when I lifted my pillow to go to bed.


Me with Hobbs getting a cat fix.

Madisi Home Visits

As Dan informed you, we arrived in Madisi about 3 in the afternoon on Wednesday. We were in time to briefly meet Dr. Leena Pasanen. She is from Finland and has served Ilembula Lutheran Hospital in Ilembula for many years. It has a nursing program attached to it, so I hope to visit the site in the future. Dr. Leena left her adopted son in our care because she wants him to realize how good he has it in life. He was an orphan in Tanzania and I am not certain how he ended up as an orphan. Susan (Steve Vinton’s wife) took us to see her “friends” shortly after we arrived so she could make food, clothing, and blanket deliveries. Her “friends” are people who are HIV positive and have recently started ARVs and are not yet strong enough to have resumed farming again or have so recently, but do not have anything to harvest. At the first home was a woman who is blind, whose husband had died. She lives alone in a brick structure that has many gaps for the wind to go through and her foot had an ulcer on it with three of her smaller toes involved. We left her a blanket and some used clothing items with a promise to revisit her the following day to more thoroughly evaluate her foot.
The next family consisted of a woman with HIV who lives with her mother and her daughter. Her toddler daughter also has HIV and Susan left nutritional supplementation for her. She also left blankets and used clothing with them. Her mother would not let us leave until we each had had at least one banana. At the next house, an elderly man was taking care of his 5 grandchildren at least one of whom was positive for HIV. The children’s parents were already deceased and the man’s wife was also deceased. Susan left formula and blankets and this man gave her a chicken as we left. (The chicken was not happy in the car and she would squawk every time we rode over a bump – which was often.) These people have nothing and they are so giving!
The following day after tea and breakfast (homemade yogurt with granola) Susan, Dr. Leena, two of Susan’s students and I went on home visits. We visited Mr. FP who is married and has tested negative at least a couple of times and he has had a chronic leg ulcer for at least 3 years. One of the students put on gloves and we cleaned the wound with hydrogen peroxide then dressed it with a mixture of honey and sugar. We needed to return the following day to recheck it, cleanse it and this time applied papaya to it to enzymatically debride it of necrotic tissue. Then we applied a new dressing. He spoke Hehe and in a very frustrated tone told us that he had been a successful farmer and now because he cannot work, he is very poor. He lives on the hillside in a house made branches and one of his grandchildren is HIV positive and had previously been very malnourished. He was so grateful for our care and has a very positive outlook that his wound will heal and he will be able to return to farming. Dr. Leena put him on a couple of broad spectrum antibiotics. The second day we closed our visit with him with a prayer.
The next woman (“B”) we visited is HIV positive. She is a widow and in her 30s. She had started school and was doing very well in her studies. She had been selected to attend secondary school because of her academic success. Unfortunately she could not complete her dream of completing secondary school because she broke her leg. She kept spontaneously breaking bones and has osteogenesis imperfecta. She has two young children and lives with her mother. Her skull has begun to bulge unusually b/c of this disease and consequently she has an unusual appearance and is tiny in stature. The past season one of the students at the Vintons’ school noticed that her field had not been planted. The students organized a group to go over and hoe and plant her fields. Understandably, Susan was so proud of her students. Now they are going to fix her roof. “B” is such a sweet positive lady and is a victim of such horrible circumstances. She had developed shingles and was quite uncomfortable from this.
J, 19 year old girl, was the saddest case of all. She is HIV with metastatic Karposi’s sarcoma. She lives with her mother who cares for her. She acquired this “wonderful” disease when she was raped at age 13. We cleansed and wrapped her foot wound. She is clearly in a significant amount of pain. Susan left peanuts, sugar and another food item as well as a pretty soft quilt. We closed this visit with a prayer also. At one point in the visit I literally had to pray for the Lord to give me the strength to get an emotional grip on myself. I simply felt like sobbing!

That evening Susan showed us a fresh water pond that forms a reservoir. A ram pump collects water which hydrolically pumps water up to the house complex and the school. After she showed us this we went to visit Godrey’s wife, Grace and daughter (Godfrey is one of Steve’s assistant.) Susan explained what my role is in the states. Some time ago Grace had seen a screening clinic ad on TV and went in to Iringa to get a pap smear. There is a team based out of the Cancer Hospital in Dar which travels around Tanzania and does pap smears screening for cervical cancer and dysplasia. Grace is well educated and when Susan explained that I am very interested in this topic and how it relates to Tanzania, she said, “It is a good thing for the women of Tanzania”

Steve got home that night after nine o’clock with his two assistants. He had been visiting schools. Steve and Susan have very long days and continue to work with the students and HIV patients in the Madisi community. In one area, Susan said that she estimates that 80% of the households have at least one person with HIV. They live on a shoestring budget with each of them “earning” 150 thousand shillings a month. This is the same amount he pays each of his assistants. If you are interested in their work, check out their website: www.villageschools.org and if you want a good cause with almost no administrative overhead, this is it! They are incredibly giving, loving and dedicated people.

Bus to Madisi

Our trip to Madisi started in a 25 passenger coaster with 32 passengers and a chicken. Fortunately, I am quite a bit bigger than most Tanzanians and there was plenty of room. This bus took us to a smaller town called Mafinga where we went to a small restaurant for lunch and waited for our next bus to leave in the afternoon. Sue and I together had 4 meat samosas, 2 roasted bananas, 2 mondazi (deep fried Tanzanian doughnut), coke and water for 2900 Tsh which amounts to a little more than $2. I tried to leave a 500 tsh tip and the manager gave it back to me. Tipping is not common here and he couldn’t figure out why I was overpaying.
The next bus was a public bus called Likikima and someone at the bus station was looking out for us (knew we would be coming through) and got us situated in the front of the bus next to the driver. We waited on the bus watching the shirts in the crowd. One said “I haven’t lost my mind, I sold it on Ebay”. Many of those shirts we discard end up in Africa and are worn by someone who doesn’t have a clue what they mean. We once saw two girls holding hands with one wearing a shirt that said “I like girls who like girls” and in the villages they would only understand a simple, innocent meaning for this because they have no concept of anything else. (If they did they would never wear the shirt) The first stop for the Likikima as the conductor was collecting fares was the diesel pump. Cash flow in Africa is often tenuous and we were paying for the gas directly from our fares. The bus ride was a 3 hour trek on pretty bad roads (read slow) until we saw another bus and a man came to our window and asked us to change to that bus.
It was the huruma bus from VST that then took us through these beautiful tea plantations on the hillsides. Tea is a thick low bush with bright green leaves that grow so close together that the slope looks like a carpet. Pickers with large baskets strapped to their backs were in the fields picking leaves from the plants. We arrived in Madisi around 6 PM just in time to visit some friends of Susan Vinton’s who are getting back on their feet from AIDS with the help of ARV treatments. Ordinarily, AIDS might not be too severe in a remote area like Madisi but because of migrant workers and trucks that come for the tea, this area is not socially isolated. ARV drugs have been made available in Africa if people suffering from AIDS can get to a clinic for them. This is the purpose of the Huruma bus and Susan knows the people in the village and helps them while they get healthy enough to take care of themselves. Sue spent a couple days visiting patients with Susan and a Finnish doctor and I’ll let her tell about her experiences.

Off to the Vinton's

Sue and I are heading on a bus to Mafinga today where we will meet a bus that Village Schools runs to transport AIDs patients to clinics for treatment. It runs every day and will take us to Madisi where the Vinton's live and built the first school. Sue will be spending time there with a Finnish doctor who has worked in Tz for 29 years and make rounds of AIDs patients. I will follow up on the science project we did last June with their son Joshua and some teachers from Madisi. We will return Saturday and hope to go to Kising'a on Sunday for the first time. We had planned to take a beach vacation the following week but have decided to stay here so I can focus on the microfinance program and Water program. Here are some photos from around town and the bus terminal where we will leave from today.

Just received a text from Steve, their bus to Madisi is not running today. Trying to come up with Plan B. Par for the course here.
UPDATE: Have a plan B, will take a different public bus the two and a half hours to Madisi and get there before dark. Should be interesting.

Streets of Iringa with beans drying:


Wingreds, the largest grocery in town. They have a freezer with good meats and cheese, yougart, and milk in the refrigerator in back. The packaged items are typically more expensive than US so this market is not used by most Tanzanians.


Local daladala bus terminal:


Main Bus terminal, large buses go to Morrogorro, Dar, and Mbeya. Smaller coasters go to nearby towns like Mafinga an hour away:

Two days at the Ilula Hospital

I just got back from two days in Ilula with the Medical team. Spent one long morning in the Maternal Child Health clinic. It was a well baby clinic during which the baby/toddler is weighed and updated on his/her immunizations. Three women were HIV + and were counseled about “safe sex” and feeding the baby only breast milk for the first 6 months so mom’s antiviral meds are passed to the baby at the full extent. Then we had a woman who needed a tetanus shot b/c at that time I understood that she had been bitten by her spouse. Two women were from Isele and I tried to identify our church’s partnership with Isele and Kisinga, but I don’t think that they understood. I was impressed with the fact that they had come such a distance to the Ilula hospital for their care. The babies did not like having a Mzungu (white person) involved in checking their weights so many times they would cry when they would see me helping their mothers with this task. One woman came in the tiniest triplets!
The Vice President was supposed to come to Ilula for a dedication of the medical center as a district hospital so his secret service was occupying the onsite rooming house so the medical team was staying with Dr. Saga. His home was full to the brim, so I stayed with the nurses in their compound. They have very simple living quarters and I was made to feel like royalty. The nursing director, Grace, made sure I had a warm bucket of water with a smaller plastic pail for my bath/shower in the morning – no running water in the shower. All of her belongings are in her one room and each day she gave me a cup of hot cocoa to drink in her room. I have not used a cell phone to its full capacity ever in my life and tend to be quite technologically challenged as my husband and coworkers back home know. I kept hearing this beep that kept moving around in my room and then in her room. I asked Grace, “What is that noise?” She said, “ It is your cell; it means your battery is low.”
I went on Medical Rounds with Randy Hurley, and Kitsada (a U of M medical student who is from Thailand and is so very gentle with the patients) as well as the Tanzanian doctor, the nursing students, and Dede, an infection nurse from Regions Hospital in St. Paul. Dede is trying to make some suggestions, some of which are listened to and one of which got shot down yesterday. Lots of patients admitted with malaria, TB and HIV. The health care providers are in a position of high authority and they do show authority when necessary. One very emaciated man refused to be tested for HIV and the following day the doctor told him that if he did not agree to be tested, they could not deliver proper care to him and, if so, he may as well be on his way. Cancer is simply considered a disease of death. Saw a woman who had advanced cancer of the cervix and she had been diagnosed two years before. She could not afford to travel to Dar for treatment so never received the radiation therapy that had been recommended. I had asked a few doctor earlier how they screen. They simply don’t. So I would like to check into this further, see whether it is done elsewhere and what kind of interest there is in making any changes. A child had been admitted for what appeared to be either HIV or late stages of malaria. She was very listless and Randy guessed that she would not last long.