Home again

After Peponi I began the very long and tiring journey back to England. Getting back to Dar es Salaam involved a broken down daladala and an eleven hour bus journey. My flight had a stop-over in Doha, a glitzy and tacky shrine to extravagance and materialism; amongst dozens of exclusive luxury boutiques there were four supercars that were being raffled in the departure lounge, a vulgar contrast to humble Tanzania. In my sleep-deprived state I first got on the wrong train from Heathrow, and when I found the right one I had to buy a new ticket since my railcard was amongst my stolen possessions, but eventually I made it back home.

Here are a few of the great number of things I will miss about Africa:

1. I love it when young black men call me "brother". It makes me feel cool and accepted even though they are almost always trying to sell me something.

2. I love the culture of politeness. It is customary to say pole, roughly "my sympathies", in greeting a person who is ill or doing any kind of work, and to greet elders with shikamoo, roughly "I show my respect". I'm always startled when kids say it to me.

3. I love the optimism of Tanzanian people. It's considered bad manners to be negative, such that when asking how someone is (Habari...) you are basically expecting to be answered with "good" (mzuri) or similar. Even when a patient is terribly ill or dying they are unlikely to admit it and will usually report that they are "not too bad" when asked.

4. To an extent, I like the pace of life in Tanzania. There is literally never ever a hurry, and I am very surprised when things occur even vaguely on time. Even in truly horrendous traffic there is no stress or time-pressure, every driver seems in good spirits and reassuringly utters polepole (slowly slowly) to excuse any tardiness.

5. Whilst I'm not a huge fan of Tanzanian food I do like the drink. Stoney Tangawizi (unfortunately coca cola company) is a delicious ginger beer, kilimanjaro coffee is awesome and Zanzibar spiced tea is fantastically exotic. I've also developed a taste/dependency on some of the beers especially Serengeti and Tusker lagers, and I'm a fan of a generous glass of konyagi with ice and lemon, a fragrant mystery spirit.

6. I like the genuine enthusiasm some of the children show when meeting a mzungu (white person), some of the more outgoing younger children in more rural areas are likely to frantically wave, shout, sing and dance when we are spotted and it makes me feel extremely important.

7. I really like the friendliness of Tanzanians including the absurdly long greeting rallies undertaken when greeting even complete strangers, the openers and corresponding responses confusingly change depending on who is talking. It's a challenging but warm ritual.

It's nice to be home but I'll be back to Africa soon, I hope.

The North Coast

Tanga, Peponi, Pangani

I decided to take another bus to spend my last few days in Africa with Laura and Rhi at the coast. The bus took me from morogoro to Tanga where I hailed a Bajaj to take me the 30km down the coast to where the girls were staying. The road was like driving on cobblestones and the drive was impossibly slow and uncomfortable, after an hour we had managed to get just halfway. I was a little surprised when my driver abruptly stopped the vehicle and arranged for me to balance with my two rucksacks on the back of an adolescent’s motorbike to complete the journey. Whilst much quicker and more comfortable I spent the entire ride grimacing as I clung onto my bag and my driver, but managed to avoid falling off long enough to get to peponi (paradise) beach resort.

It certainly was a paradise, especially relative to some of the previous places I’d stayed. I’d become a little weary of staying in the worst hotels I could find and so was happy to pay a little more to share Laura and Rhi’s beach hut. It had a hammock looking out onto the Indian ocean and there was even reliable hot running water.

The following day we rented bikes, all rusting clunking single-speed machines and, initially at least, a joy to ride. We applied a generous layer of suncream and began to slowly make our way towards Pangani, 18km to the South along the coastal road. Amazingly I managed to transform both my T shirt and hat into a darker colour over the course of the trip using my powers of perspiration. Eventually the potholes took their toll on our comfort, my saddle broke as we reached our destination. We stopped for lunch at a deserted hotel where I sampled the mysterious “spaghetti with egg”, literally a spaghetti omelette about 2 inches thick, excellent carb-loading for the trip back.

We cycled around the town and visited some of the grisly decaying buildings used when Pangani was a slaving port. There are numerous horrific stories form this period, for example it is said that slaves were buried alive in order to strengthen the foundations of some of the buildings. Other buildings where slaves were imprisoned or executed have deliberately been left to ruin and are overgrown with trees whose majestic roots are hastening their downfall. I suppose that rather than preserve these buildings or commemorate the events with plaques the local people would prefer to let these memory be erased – stories from the slave era are still common as they have been passed down the generations.

The customs house, a site of previous slave imprisonment.
 It's now used to store coconuts and other products.

I tried to spend my last night at Peponi in the gently rocking hammock but even though I had carefully covered as much exposed skin as possible I was savaged by mosquitoes on my face, hands and the small area of briefly exposed skin on my lower back. I took refuge for a few hours in the hut but returned to the hammock early in the morning to watch the sunrise.

Witchcraft

The hike I did on Wednesday was as difficult as expected, but mercifully there were some clouds so it wasn’t as hot as the previous few days. I started from Morogoro at 7am with an enthusiastic trainee guide, Grayson, and his qualified supervisor, Evans (who inaccurately and pleasantly referred to me as Dr Jon, especially after I “cured” his aching feet with some ibuprofen), and we gradually ascended up uluguru mountain towards the rainforest. The higher we got the cooler it was and by the time we had reached the highest point at 1pm, Bondwe peak (2008m), my guides had got out their fleeces. It was especially steep in parts where landslides had obliterated the path and we were forced to take shortcuts directly upwards through the forest. The lower slopes of the mountains are densely populated with villages and farms of the Luguru tribe but there is an abrupt change at the treeline where pristine rainforest begins; I was lucky enough to spot an enchanting troop of black and white colobus monkeys, which I’m told are usually very shy and rarely seen. I ran out of water fairly early on but followed my guides in refilling my bottle from a beautiful but perhaps less than sterile stream, an infection risk that seemed necessary to combat dehydration as the afternoon sun came out fighting.

A black and white colobus (Colobus guereza)

Nearer the bottom of the mountain we were alerted to a woman’s blood curdling screams. My mind raced as I tried to think what could be the cause (in order: childbirth, trauma, grief, assault, epileptic seizure, psychiatric illness) and the guides quickly brought me to the source of the commotion. I had a very basic first aid kit with me and very basic medical student knowledge in my head but I concluded that if there was a medical problem there was a slim chance I could help. It turned out that I could not. We rushed to the scene, where a violently writhing woman was held down by four others, screaming a mix of incomprehensible gibberish, Kiswahili and her local language. There was no obvious physical injury and it didn’t look much like a typical seizure to me so I asked my guide to translate what was happening, I was surprised when he replied “evil spirits”.

The woman and her sister had been communicating with their ancestors and had inadvertently become possessed by malicious spirits (this is apparently very common and such communication with the ancestors is therefore discouraged). The priest had been called and he began to exorcise this woman’s sister who was being similarly restrained in a nearby house. The exorcism involved two men, at least one of which was a priest, shouting (I picked up some of the words from the daily church services at Machame e.g. “mungu” = God, “yesu” = Jesus) and frantically gesticulating over the distressed woman. This went on for some time and was watched by quite an audience of other villagers alongside me and the guides. Eventually the woman abruptly came round (no post-ictal state; further evidence against epilepsy) with apparently no memory of the previous commotion. The situation was completely new for me but I was just glad that I hadn’t had to do anything.

My guides explained that belief in witchcraft, evil spirits, warlocks and witch-doctors is very common here, alongside simultaneous belief in Christianity or, more commonly around Morogoro, Islam. Further, local people are much more likely to first attempt traditional medicine for most problems than consulting modern, western, medical help. I learnt that the beliefs permeate all aspects of life; a person is as likely to visit a witch doctor to bring them good fortune in work or love as they are for medical problems. I was surprised that my university-educated guide explained to me, in perfect English, how we keeps his money in a bible to prevent it being taken by evil spells, as that had happened to his less-cautious friend. He also warned me not to give money to warlocks lest they use my gift to magically extract the rest of my money from me.

There are many many traditional beliefs and superstitions that persist in Tanzania. People here are quick to confirm the existence of some of these practices – for example in parts of Tanzania and elsewhere in Africa twins are considered unlucky and are killed on birth, and albino people have been killed to create good luck spells and remedies – but quickly deny that they believe in these extreme examples themselves. As might be expected with the existence beliefs like this to continue, health awareness in the general population is mostly quite poor. For example my guide was amazed at my ability to remove pain with ibuprofen, he’d never heard of simple painkillers before. The dangers of smoking, alcohol or diet don’t seem to be widely known. “Blood pressure” is an extremely vague concept for most Tanzanians and many have bizarre ideas as to what causes and prevents it. Alarmingly given the prevalence of HIV, knowledge of condom use (still a taboo topic in Tanzania) is poor too; Laura and Rhi recounted how 20-40yr old taxi drivers in Moshi watched intently as a condom was demonstrated and explained to them using a coke bottle. Tanzania has a reasonable education and literacy rate for Africa (69%, ranked 19/52 countries, and improving), I suggest that increasing basic health education in parallel would be beneficial.

Mary leaves

Post Mary/ Weird things Mary does

Over the past six weeks I have had the privilege of getting to know my co-traveller, Mary. We are both from the same University and took the risky decision to go to Tanzania together despite not knowing each other at all previously. It has been a fantastic shared experience but nonetheless Mary has taken the decision to return home one week before schedule, allegedly to have more time with her family before the next academic year begins. It’s okay though because I am very familiar with women leaving me. 

Mary mentioned a while back that, shockingly, she had never read my blog. I expect that she never will – so it’s a safe place to record some of my observations of the nuances of her behaviour without fear of her finding out: 

- Mary is rightly very cautious about the dangers of unsafe drinking water – she has avoided tap water religiously for the entire trip. She instead has been drinking exclusively Serengeti brand lager, 8 bottles a day, plus extra for washing fruits and vegetables with. She’s a mean drunk.

- In addition she been vigilant in preventing disease from insect bites, having fashioned a burqa-esque garment out of mosquito netting that she insists on  wearing at all times.

- She has attempted to kidnap several African children from the hospital and orphanage, but thankfully gave up interest when she couldn’t fit them in her suitcase.

- Admirably Mary quickly became very proficient at Kiswahili, but communication is not completely problem-free as she refuses to pronounce any consonants.

Some of the above facts might not be completely true. However, what is definitely true is that I enjoyed our evolution from strangers to friends and will miss my companion as I continue alone, not least because I have eaten her leftover food at every meal for the past 42 days (yes, I am a glutton.) Further, for 42 days Mary has reminded me to take my anti-malarials, and also saved me by lending me money when I lost my debit card. 

I’ll quickly jot down my few days without my sidekick so far. I left from Zanzibar early on Sunday morning as Mary was preparing to spend her last African day dolphin watching. I took a comfortable ferry, a couple of taxis and a long uncomfortable bus to get to Morogoro by the evening time. I’m reassuringly quite sure that I am indeed staying at the cheapest hotel in town; the surly owner speaks no English and there is only very infrequently running water. On a few occasions I have been locked out of the place as the owner insists on taking my key if I go out, and then disappearing for long periods. 

I got chatting to an excellent local guy, Joseph, who has been invaluable showing me around. He fills his time working as an unofficial (uncertificated) tour guide and I opted to follow him up the mountain on Monday. Joseph, casually wearing jeans, genuinely couldn’t understand why I was so slow and sweaty on the way up, he often runs up the mountain to buy cheaper vegetables. The path was dubious in places but the views where spectacular. Joseph is unbelievably chatty and enthusiastic and talked pretty much non-stop. When we got back he introduced me to his family at his house and we had an truly excellent ginger-tea/coffee brew, (one could call it toffee. Or key). I joined him to watch Spain-Portugal in a local bar later.

Today I explored more of the town and I spent some of the afternoon reading in the poshest hotel in town. This has to be the main thing I’ve learnt from Tanzania – I’ve often spent the night in a terrible hotel for no money and then used all of the facilities at expensive hotels for free. I also made two trips daladala to the central bus station outside of town. The first attempt was unsuccessful, I was hassled by hustlers and I eventually found that the bus company  I was looking for no longer exists (I have annotated my guidebook for future reference), but Joseph came on the second and easily found me an alternative ticket, hopefully I’ll eventually get to Tanga and meet up with Laura and Rhi.

Tomorrow I’m doing more hiking in the Uluguru mountains, a different route further and higher than yesterday. I eventually decided not to continue with my planned overnight stay in the mountains as to my great surprise camping in the village worked out five times more expensive than my current crummy hotel. Elsewhere in Tanzania staying with villagers is a good way to save money, but there is quite an established programme here whereby extra funds go towards conservation and local development – worthy causes I would like to support more. Unfortunately since losing my wallet I’m wary about spending in case the money (Mary’s) hidden in my shoe runs out before I can get to the airport next week, so I’m doing the slightly cheaper option with the same programme but have to walk faster to get the hike done in one day instead.

The uluguru mountains from
http://www.panoramio.com/photo/18162682

A brief diversion

The blog has become stylistically stale. 

So here are some rubbish haiku about places in Tanzania.

Suffocating hill

women work the hot wild slopes

near Morogoro

- - -

Lost in stone alleys

grilled octopus at sunset

ships go sailing by

- - -

Tall ugly buildings

where busy rich people hide

dirt and crime are here

- - -

Doctors work nearby

clouds cover your snowy peak

and mosquitoes too

- - -

Quiet fishing village

the sea nuzzles close

and contentedly

- - -

Centre of nowhere

proud capital half-finished
many ways to leave

Uluguru Mountains, Stone town, Dar es Salaam, Machame, Gezaulole, Dodoma

To Zanzibar By Marine Craft

I spent 5 nights in Zanzibar. This became quite an overwhelming lot of blog so I’ve arbitrarily divided it into two more manageable chapters:

Chapter 1

(Temporal Zygomatic Buccal Mandibular Cervicalà branches of the facial nerve)

“Motorised craft” doesn’t have quite the same ring as “motor car” in the traditional mnemonic, but it is more accurate – we took a ferry from Dar to Zanzibar. Farcically, upon arrival we had to go through customs and immigration despite arriving from the same country. Another tense moment occurred when I was questioned about my (non-existent) yellow fever vaccination certificate– apparently a requirement for entrance to Zanzibar. I had opted not to get vaccinated for some good reasons I think: 1) Tanzania no longer requires vaccination for travellers from Britain, 2) Tanzania is low risk for yellow fever, but most persuasively, 3) The vaccine would have cost me about £60 and I’m cheap enough to really dislike having to pay to not get diseases I wasn’t planning on getting anyway (but I am aware that I may come to regret such hubris.) So overall I thought I should be allowed into Zanzibar without a vaccination, but instead I lied to the officer and mumbled that I’d lost my certificate, he frowned and let me through.

The ferry lands at Stone town or “Mji Mkongwe”, on the larger of Zanzibar’s two main islands, Unguja. 50km to the North lies Zanzibar’s forgotten other half, the more religious, conservative and less developed Pemba – where there is scarcely running water or electricity. Zanzibar was unified with mainland Tanzania in 1963, a few months after both parts gained independence from British rule.

It’s quite hot in Zanzibar and I think am at a risk of sunburn - particularly as one of the many common side effects of my anti-malarial tablets (cheap and cheerful doxycycline, £15) is increased sensitivity to the sun. So far I'm a bit burnt – I am an embarrassing and stereotypical Brit abroad, but I've no malaria or yellow fever yet. Doxy is also used to treat chlamydia, so there’s that. Most other travellers opt for the alternative tablet, Malarone, which is usually much better tolerated and gives the secondary benefit of recreational vivid dreams – but at over 10x the price.

Stone town itself is a labyrinthine mess of narrow twisting alleys linking grand Indian mansions and mosques, a cross between Disney’s Aladdin and Venice minus the canals. It’s impossible to not get lost to the point where to reach a destination it’s quicker and more enjoyable to turn corners at random until you chance upon where you want to be. From what I’ve seen, stone town appears significantly wealthier and more developed than most of mainland Tanzania and, given the stunning beaches, clear waters and lively reefs, is an extremely popular tourist destination – it has been strange to come across luxurious hotels and sea-view restaurants, most cafes even have wi-fi internet.

Consequently, for the first time so far this trip we have felt like proper tourists, holidaymakers rather than travellers, and have enjoyed the novelty of comfort. We have taken some dhow trips to nearby islands and snorkelled amongst menageries of colourful creatures. We’ve seen islands amok with crustaceans, including terrifying coconut crabs (tree climbing monsters as big as a cat) and gruesome public toilets home to several layers of pulsating hermit crabs. We’ve also clambered around a 1500yr old Baobab tree and done a fair bit of lazing on the beaches; I’m beginning to think the tourist hat really quite suits me.

I have also eaten more seafood than ever before in my life. I don’t even especially like seafood but it seems a shame not to sample Zanzibar’s famous octopus soup or barbecued lobster, all significantly tastier, fresher and cheaper than anything I could obtain in Birmingham. Today (Thursday 13th June) we visited Prison Island – once used to quarantine those with yellow fever.  The island is home to a managed colony of 200 giant tortoises, which were once common all over the islands. We made acquaintances with several of these beautiful and peaceful dinosaurs, including a devastatingly charming 189yr-old fellow.

Forodhani gardens evening seafood market is exellent

Chapter 2

I got tattooed yesterday. My first ink looks totally 100% badass: An awesome snake wrapped around a sword on my right deltoid. And it barely even hurt. It’s a shame that Zanzibar is such a Muslim country – I can’t sufficiently display my tattooed guns without being disrespectful. I hope the henna doesn’t fade by the time I get back to the UK.

Today (Friday 14 June) I took a trip 25km north of stone town to the fishing town of Mangapwani. Mary didn’t fancy another daladala trip so she stayed back to lounge by the sea. The daladalas in Zanzibar have open sides so they’re slightly cooler – but just as cramped; there was no room for me inside so I made to hang off the back with some of the other men. To my disappointment my comrades quickly concluded that I didn’t have the mettle to enjoy the breeze and so rearranged the passengers so there was room for me in the front passenger seat. This sort of special treatment is so common that I’m starting to believe that maybe I am VIP, it just hasn’t been recognised in Britain yet.

It was good to get away from the commotion and papasis of stone town, but doing so meant that I was kicked off the daladala in the middle of nowhere. I started walking down the road in an attempt to find the coast and the caves I’d been looking for only to later learn that I was headed in the completely wrong direction. After a fairly long and indirect walk I eventually made it to the coral cavern and was eager to go inside to take refuge from sun. The cavern contains about 200m of tunnels under the village and contains some mineral water pools, from which some of the locals collect water for drinking - in the company of lots of bats. A local boy with a flashlight became my guide and I duly followed as he scrambled and clambered deep inside, quickly regretting my flimsy sandals and cumbersome rucksack. It wasn’t nearly as cool as I’d hoped inside and, worryingly, the boy, Abdhul, would occasionally switch off the light to prove that it was indeed pitch black, before explaining that some of the tunnels had become impassable due to some cave-ins - 127 hours came to mind. Some time later, when my claustrophobia subsided, we managed to squeeze up a narrow chimney to the surface and I then made my way down a dirt track to a small quiet beach where I spent a few hours sitting pensively – and reading Stephen Kings Pet Semetary on my brother’s kindle (verdict so far: okay). When it started to rain I decided to keep exploring and came across the historical slave chambers, another dreadful pit used to hide slaves whilst smuggling after the slave trade was made illegal in 1873.

Attractive feet on my private bit of beach at Mangapwani (Arab's coast)

Now I am back at the hostel where I’m excitedly preparing for my last night in Zanzibar to be disrupted by the England – Italy match at 1am, I have begun to develop my 4-yearly interest in the sport and I really hope England footballs lots of goal-scores. Edit - It wasn’t worth it.

To Dodoma

Location: the rooftop balcony of DM hotel – second cheapest hostel in Dodoma
Time: The same time as the mosques call for evening prayers

We had originally planned to get Dar es Salaam via Dodoma: the bus to from Moshi to Dodoma, and then the train from Dodoma to Dar – but we heard rumours one or both of these journey legs were impossible due to road/track damage from rain so we omitted Dodoma and travelled straight to Dar es Salaam. A shame because train journeys are ace.

When we arrived in Dar we enquired at the train station and learnt that the train was back in operation and we booked first class tickets for the next available journey purely for the fun of the ride – to Dodoma, leaving in a few days. The line to Dodoma is one of two train service in Tanzania and runs twice a week between Dar es Salaam and Kigoma 1254km to the west.

We were told to report at 4pm on the Friday and that the train would leave at 5pm. We arrived to truly chaotic scenes at 3.30 – endless people shoving and rushing, shouting, sweating and carrying and passing luggage to one another. We joined what looked a bit like a queue to get onto the platform. We were befriended by a 12 year old boy who realised that we were completely lost and he explained that people were competing to get there luggage weighed on an ancient set of scales. His dad somehow allowed us to skip to the front of the queue (playing the confused foreigner card to our advantage again) where we pointlessly and inefficiently had our luggage weighed by some guards with klashnikov rifles. The boy, Khari, became our enthusiastic guide and saviour, taking us to the platform where we eventually found out we had to consult a tatty piece of paper on one of the walls to find out which carriage was ours. He also kindly translated for us and ensured I wasn’t ripped off when stocking up on bottled water. We exchanged facebook details, we’re best buds now.

Since we went first class, we had a sleeper room to ourselves which had a couple of bunks and a sink. There was a toilet cubicle in our carriage - a hole in the floor opening straight onto the tracks - and the next carriage down was the buffet car (serving only chicken and rice, of course).  We sat sweating as our cabin gradually became more and more suffocatingly stuffy until we pulled away from the station from at about 7.30, a mere two and a half hours late. I set my alarm clock for 7am as we expected to arrive early in the morning and I didn’t want to sleep through our stop. To prevent malignant hyperthermia we had to keep the window open throughout the night, though this meant we had to endure the mosquitoes – we both have several impressive new bites. 

The train went even slower than I imagined it could go, but we eventually got to Dodoma at about 2pm – having spluttered some 450km with frequent and seemingly random stops where local people would try and sell us food and drink (green/grey water in old mineral water bottles) from the trackside. I spent a large part of the Saturday morning enjoying the breeze with my head out of the window watching farmers working in the fields and waving at excited grinning children as we chugged past mountains and mile after mile of red and dry desert and occasional greener forests.

Dodoma is the geographical centre and political capital of Tanzania, a small town in the middle of nowhere. Its desert location brings to mind Las Vegas, but is arguably less exciting being about the size of Hereford but with infinitely worse transport links, and has the feel and layout of a mediocre car boot sale. After we checked into the hostel we walked around almost the whole town and promptly booked a bus back to Dar. I had a Tanzanian favourite “chipsi mayai” for dinner: chips omelette. It was ok.

Having not shaved for a week and a half I now sport the most impressive facial hair I’ve ever had – it looks like I’ve fallen asleep face down in some chocolate 100s and 1000s, and a very few of them have stuck to my chin. Tasks for tomorrow: 1. Shave, to try and look less like a paedophile. 2. Find some internet to upload these words. 3. Await bus back to Dar.

Travel Diary part 1: Dar es Salaam and Gezaulole

It has been a week since I left Machame hospital and I am now one third through my post-hospital travels through Tanzania. For the moment therefore this medicine blog will become even more of a travel diary merely recording the things I get up to with my tourist hat on*.

For example I am embarrassed to report that soon after putting on my tourist hat I was pick-pocketed in Dar es Salaam (“the peaceful harbour”). I have been in the country for 5 weeks without incident and had become complacent, confidently feeling streetwise to scams and tricks, but it only took a second to squash that feeling and now I am demoted to moronic foreigner once again. In a momentary lapse I hastily jammed my wallet loosely into my pocket as I left from a café, and within 5 minutes I realised it was gone – along with 20,000TSH (£7.14), but more annoyingly my debit card and driving license too. No great loss then, apart from the grievous injury to my pride, and the cost of an expensive phone call to cancel my card. Luckily Mary has lent me some money and I retain my other possessions, for the time being.

My spirit remains unbroken! I continue to have an excellent time despite that hiccup.

Upon arriving in Dar last Saturday we checked into the YWCA hostel for a few days, the cheapest in the city centre. It was nice enough; our room locked and we had some (holey) mosquito net, but the shared toilet had no seat or lock and there was no hot water. Most importantly we had a fan that made the unrelenting syrupy heat bearable, apart from a full day and night where there was a citywide power cut – a frequent occurrence I am told.

Dar es Salaam itself is hot, humid, big, scruffy, and really hot - even now in the middle of "winter". It’s the metropolitan powerhouse of the country (but not the capital, which is Dodoma) and nothing like the rural Tanzania we’d seen thus far around Machame. Instead of the small wood, mud or brick houses with tin roofs that are usual for Tanzania the city is heaving with towering and important-looking glass-faced buildings – many of which are unfinished. There are expensive hotels looking out onto pot-holed streets and smartly dressed business types stepping over beggars with polio, uncorrected clubfoot or any of a great number of other physical deformities. Here the richest people in Tanzania live alongside the poor, 70% of the 4 million people in the city have neither electricity nor running water.

Dar es Salaam

We spent a while looking around the city. Highlights include perusing the national museum for an overview of Tanzanian history, art, tribal anthropology and human evolution. We also made some brave explorations of the busy markets such as the amazing though pungent fish-market, and spent an afternoon on coco beach a little to the north of the centre, but we were soon fed up of perspiring in the exhausting and endless heat and bustle. We retreated for a few days 15km south of the city, requiring a ferry trip across the bay and a bajaji ride to Gezaulole village - a beautiful, small and spread out village much more typical for Tanzania and similar to what we were used to.

We stayed at the “kali mata ki jai” centre (I think it means long live black mother), the meeting place of the local women’s group, which had a basic guesthouse – the toilet was a hole, the shower a bucket, but it was lovely and only £1.70 pppn. The manager, Juliana, a delightful and scatterbrained matriarch, bent over backwards to ensure we were okay – cleaning our room from top to bottom and installing new nets since no one had stayed for over a year. We had excellent Tanzanian meals cooked by local women (the usual stuff = fish/chicken + rice + bananas + spinach), either in their homes or brought to us at the centre (via pikipikik a la domino’s pizza).

In addition to lazing around the place and visiting the beautiful uninhabited white-sanded beaches we rented some rusty old bicycles and went on a tour of the village. Our guide introduced us to everyone, including vegetable farmers, fishermen, quarry workers, the local doctor (in the middle of his clinic) and the local headteacher (we cycled straight into the school’s playground). We also learnt a little of the village’s history – when it was founded a witch doctor ordered a young girl be buried alive for good luck, and we saw her grave under a baobab tree. I also bought a shirt from a Rastafarian woman who has moved to Gezaulole from Portugal and has only had malaria 4 times.

Eventually we had to return to Dar where we cooled down in the café of a swanky air-conditioned hotel before making our way to the train station.

*don’t worry medicine will not be entirely absent: I predict several detailed posts about my personal health and whingeing about any minor and/or imaginary ailments. 

Last experiences from Machame hospital

Local Time:17:00 Sunday 1^st June 2014 – (Or 11:00 in Swahili notation)

Location: Traffic. Just outside of Dar es Salaam

We are seated on the Dar express, the luxury coach we have been on since 7am this morning, when we boarded it in Moshi. Compared to the other transport we’ve experienced so far this bus is certainly luxurious – Mary and I have seat each and don’t having to squeeze next to Tanzanians. Currently the vehicle is stationary in a colossal traffic jam, amidst fumes and chaos as zillions of people and vehicles compete for space to manoeuvre. Like most of Tanzania (but more so), the road is shared by buses, cars, pick-up trucks and daladalas,  all of which are heaving with passengers and cargo and around which buzz pikipiki (motorbike taxis), bajajis (rickshaws), hand carts, and people selling anything and everything. The majority of the highway code seems to have been lost in the translation but they do at least drive on the left, most of the time. Our vehicle has just been hit by a car, an event which ought to be far more common . It seems that our bus is unharmed but the car has lost its front bumper and its owner seems quite annoyed.

Some Bajajis in Tanzania

The bus journey has been quite an uneventful 10 hours, and it has been nice to watch the world go by out of the window in between snoozes. It was a mostly smooth  ride since the Arusha-Moshi-Dar highway is one of the few paved roads in Tanzania, but punctuated by frequent and unforgiving (but necessary) speed bumps and quite a lot of dirt track and temporary road surfaces, road work crews and road rage. En route I thoroughly enjoyed a complimentary ginger beer.

 So we’re on a completely smooth, motionless, section at the moment and I can record the last bit of medicine for a while – I’ve finished the 4 week elective placement but I’m staying to look around Tanzania and Zanzibar for another few weeks.

The Children’s ward

I haven’t ruled out paediatrics as a future speciality, perhaps because I haven’t studied it at all so far.  Misanthropic though I might be, I find it hard to dislike people who are too young to have done anything wrong. And from an efficiency point of view it seems like a good idea to try hard to cure ill children since arguably you get more bang for your buck than with (mostly elderly) adult patients. To be clear, “bang” is a QALY – quality adjusted life year. And bucks are pounds.

So I was excited to see some paediatric medicine at Machame, despite knowing that here more than ever I wouldn’t understand much of what was going on. Like in UK hospitals, the paediatric ward is a bit nicer than the rest of the hospital – It’s a bit more colourful and there’s a large tingatinga-style animal mural on the wall. The names of the rooms could be improved however: malaria room, pneumonia room, diarrhoea room and isolation room.

The first patient we saw was an extremely cute 2yr old Maasai girl. She was tiny – 8.4kg (18lbs) and very anaemic – her haemoglobin level was 5.7g/dL but she seemed paradoxically active and alert. She had had a cough, problems breathing and a fever so a diagnosis of pneumonia was made, and she improved with antibiotics. There were several other children with similar presentations, organised by room.

The doctor explained how for a lot of these children nutrition is a big factor in their health. Breastfeeding is usually recommended, except for HIV+ mothers due to the risk of vertical transmission. High energy formula milk and foods are available but come at a cost, and parents must provide food for their children whilst in hospital, so doctors try and recommend foods that the mothers are more likely to be able to access at home - for example many Maasai eat almost exclusively cow’s milk, cow's blood or raw flesh. It is clear to the doctors that many children will continue without adequate nutrition and so are more likely to succumb to further infections, so common in Africa - particularly when the drinking water is not the safest.

In the isolation room there was an unfortunate 9 year old girl with quite severe skin lesions. She had previously had a fever and was covered in fluid-filled  vesicles – particularly around the neck and armpits. Initially this was diagnosed as chickenpox but soon the condition progressed, the lesions enlarged and some became filled with pus, and eventually there was extensive ulceration around her mouth. It brought to mind some autoimmune skin conditions I know only from textbooks (bullous pemphigoid and pemphigus vulgaris) but both are much more likely found in adults. The doctors decided to treat it as a severe adverse drug reaction, though there was no history of any medications, on the severe end of the continuum of erythema nodosum– Stevens-Johnson syndrome and Toxic epidermal necrolysis. The name and cause of the condition less important than the outcome: the girls was started on steroids and greatly improved.

For another young patient I offered that the appearance of red spots on the chest might help diagnose typhoid fever. It wasn’t a great suggestion: the doctor pointed at me and snorted, “Perhaps visible on your skin!”

A case from outreach

One Thursday Rhi and Laura went on outreach to another difficult to access village and came back quite distressed about a case they had seen, and I think it’s worth briefly telling their story (not plagiarised - I got their permission).

Near the end of the afternoon the girls saw a particularly nervous-looking 15 year old boy who came with his parents. He was small and weak and complained of problems breathing, a problem that had been affecting him for several years, preventing him from playing football with his friends or functioning normally. It was clearly necessary to examine the boy’s chest but he was extremely reluctant to uncover his torso. After a lot of coaxing the cause of his anxiety became clear – he had a large chest deformity. The centre of the boys chest extruded alarmingly forwards creating a sharp bony prominent sternum – known as pectus carinatum, or pigeon’s chest.

One of the Dutch students auscultated the chest and reported that the lungs sounded normal but the heart sounded abnormal, possibly there was a murmur (myself included, when asked to listen to a heart students will always say “I’m not sure but there might be a murmur”). The clinical officer recommended that the boy should come to the hospital for an ECG and X-ray.

The girls were concerned that the boy might have a significant illness, possibly some congenital heart problem or a severe lung disease. Pectus carinatum can be asymptomatic and idiopathic but the history the boy gave made this case seem more worrying. Further, both of his parents were HIV+ but the boy didn’t know whether he had the virus himself.

The clinical officer then revealed that he thought it unlikely that the boy would come to the hospital, the family were very poor and the journey difficult. The tests at hospital, and any treatment would need to be paid for and it didn’t look like the family would be able to afford anything.  The girls offered to contribute to these expenses but remained concerned as to whether the boy would come to the hospital, or indeed whether this would result in any treatable diagnosis. They spent the night worried about the boy.

Miraculously, the boy did turn up at Machame very early the following morning. Rhi and Laura found him and his family (all wearing their finest clothes) in outpatients after church, and thanks to the girls’ funding it was arranged for him to be seen by Dr Sartori, the hospital director and most senior doctor. Happily, after some more tests the boy was diagnosed with simple asthma and given the necessary inhalers. Supremely common, usually benign, very treatable asthma – a good result indeed.

An example of pectus carinatum. (This patient is not Tanzanian.)

This story doesn’t have any fancy presentations or shocking diagnosis, and that’s why it’s worth telling – representative of so many people’s stories in Tanzania. Its a good example of how individuals, and most especially those who are poor, can be terribly affected by even very simple diagnoses. I don’t think it’s an exaggeration to claim that the concern Laura and Rhi showed, and the (by western standards) smallish amount of financial help they provided, vastly improved the lot of a young Tanzanian boy and his family, an appreciated gesture that won’t quickly be forgotten.