Do I walk funny?

So, it poured here last week. I mean, POURED!!! And since I mostly walk on dirt roads, it quickly became a quagmire of mud all around me -- and I didn't escape unscathed. Even though I thought I was being so smart wearing capris, my legs and pants were covered in mud. It seems like that should be par for the course, but much to my chagrin, everyone else looked like they had just walked in from a perfect 80 degree sunny day, even down their shining leather shoes. So clearly the only conclusion to draw is that I must walk funny -- I mean whose legs run into each other with such frequency!?! But anyway, on the bright side, at least I got a mud leg mask, right? :) And Kili came out in the morning, for the first time since I've been here!

Other happenings of the past week --

So there's a KCMC Wednesday morning clinical conference, essentially a hospital grand rounds. I've only been to a few so far because you have to introduce yourself in front of everyone so that one of the hospital directors knows who the newcomers are, and I kept postponing that dreadful day!! But I did it, and survived, although I spoke so fast I'm pretty sure no one understood me!! Well, except for the random Stanford undergrad who also happens to be at KCMC for a few weeks!!

Anyway, the quality of these conferences really varies, as you'll soon see from my story. This week was general surgery presenting conference on various syndromes of polyps in the colon. After their case presentations, they start reviewing the medicine behind the various syndromes, and start with FAP -- familial adenomatous polyposis, a syndrome of polyps that we ALL learn about in med school ad nauseam. Of course, their powerpoint lists it as the hereditary proctotypical polyposis syndrome !!!!!!!!!


I died laughing so hard and grabbed a picture on my conveniently located iPhone (yeah, I was definitely responding to emails during conference). If you squint you can totally see what I'm talking about. And no, that's not a typo -- procto means rectum. Talk about Freudian slip!!

Then, halfway through this review of polyposis syndromes, some lady comes in and writes on the blackboard, "Casuality doctors, emergence," underlines it, and walks out.


Now, there are about several comments to make about this --

(1) No one gets up!

(2) Everyone spells casualty (which is the emergency department) as casuality -- almost like they're talking about their attitude towards it -- casually

(3) There is no one covering casualty during conference!?!

On a more serious note, it's pretty sad. Casualty here has 4 beds and is run by AMOs -- assistant medical officers, who are mid-level providers, more than nurses but less than MDs. No one wants to go into ED medicine here, so the acute emergency care is sadly so inadequate.

But every week, these conferences do provide a more-than-anticipated level of amusement. This week I plan on sitting closer to the middle so my pictures are better :) I do wish I could offer my spellcheck/grammar services to all the presenters, but sometimes I think it's just a lack of attention to detail that results in poor formatting and editing -- this theme often pervades work in many different spheres.

I also hit one of my high and low points on the same day! Starting with the high...

We're resurrecting the practices of holding journal club, where one person presents an article, its methodology and strengths/weaknesses, and everyone discusses. Actually they are quite fun because you learn to critically read the literature. But in order to do that, the residents and interns need a basic epi/research design refresher course, and I had to present the first one -- an overview of clinical research designs and epidemiology/biostatistics metrics. It ended up going really well -- the consultants were very excited, said it was one of the first time all those messy definitions of case-control, cohort, cross-sectional studies made sense -- and they especially liked my crude chalkboard grabs and silly examples of fake research studies that would fulfill the different types of research.

I even got an intern to ask a question!! Amazing in a society that quietly sits through presentations without ever saying a word. Honestly, how can people not have questions!?!?

But the best part was an intern coming up to me and really wanting to get involved in our research group, participate in our journal club, and even present!! And, she also offered to take me shopping for better shoes for the muddy season :) Yup, it all comes full circle...

To the low -- actually, it started off as a great day, because after the presentation, I found out that my mom's package had finally arrived, 23 days later. So I recruited Shangwe, a guy who works with the Duke-KCMC project, to come with me to the post office. Of course, getting there requires riding the dala dala. What's a dala? These pictures say it all....

So basically it's an oversize van that should fit about 10 people but of course fits anywhere from 20-30 people. You're seriously packed in like a can of sardines, and though I'm sure it gets old, it's kind of fun! Locals have such a blaze attitudes about them -- look at this guy playing with his phone...

Of course, 20 second later, he lost his SIM card to the dala forever.... hakuna matata! But they range in class, from zebra print covered roofs, inside lights, and stereo, to a roof so low that even I am too tall for the dala (obviously couldn't take a picture in that one!). And the guy hanging out the window -- classic. He collects your 250 shillings (about 15 cents) and also adjusts the sliding door that always teetering on its rails and about to fall off.

Anyway, so we get to the post office, at 1pm; of course, customs went to lunch at 1259pm, so we had to wait until 2pm for them to return, at which point after my prolonged altercation with the lady because I didn't have my passport, I returned home dejected, parcel-less, and frustrated for the first time in Moshi. Lucky for me, Shangwe came with me to town the next day, and this time, many shikamoo's later and no bribe needed, I got my parcel, hamna shida!!! and, in time for my birthday :)

More to come on my birthday -- as usual, my personal motto for Tanzania says it all -- it's always an adventure...

So, what am I actually doing out here??

Yeah, so I know you're wondering, "Why exactly is the U.S. government funding you to be in Tanzania for a year?!?!" This is probably the only entry that I can legitimately claim lateness in posting due to actually being busy with work!! But at least I should explain what I'll be doing next year... and then hold myself accountable for actually accomplishing something, 10 months into the future.

(For all those of you living life in Moshi vicariously but not so interested in research, this is where you can happily tune out :))

This is KCMC

So it turns out that I'll be doing a multitude of random projects, which seems like it could be totally discombobulating, but actually, it fits my multi-tasking, quasi-schizophrenic thought process and need to be busy... and believe it or not, my research goals. I'll spare you some of the details, but the gist is to understand the intricacies of clinical research, especially in a developing world, and to participate in various projects at various stages of the research - for example, idea generation vs. data collection and analysis vs. paper-writing. And of course, to be involved in projects on many different topics in women's health, so that I find my passion within this huge field.

Some background first -- it's hard to get one single project done in 10 months, from inception to completion, because of the inherent pace of the research everywhere as well as the roadblocks in Tanzania, intended and not. Being a foreigner proposing novel research here is incredibly difficult, time-consuming, and just plain bureaucratic. Then, there's always the unanticipated delays like no internet, getting data, being caught up in some other clinical activities, etc. So, that narrows down feasible research options to pre-existing, nationally-approved projects, retrospective data analysis, or quality improvement projects. With that said, here's a brief description of some of the projects I'll be working on (and some pics of my office) ... I know, the list is long and ambitious...

(and by the way, since there are no good pictures for this post, i'm adding mostly random ones).

My office

(1) Why do women with a history of domestic violence come to an HIV testing center? Are their reasons for seeking this service different than women who've never experienced domestic violence? For this project, the data has already been collected and I'm just the Stata monkey, analyzing the data and hopefully finding a unique relationship. Believe it or not, I actually like programming, so this will be a quick refresher course in stats and writing code... made even more fun since I can work on this remotely, ie from a coffee shop or under a tree in the middle of a field somewhere :)

(2) One of the huge studies here, being led by Duke, is a 4-year prospective study with over 1,000 people looking at the relationship between trauma, life stressors, other negative life experiences, sexual risk behaviors, and HIV status and medication adherence, to understand the barriers to taking HIV medication appropriately. We thought this would be a great opportunity to ask many people in the surrounding region about women's health issues -- contraception use, female autonomy about fertility preferences, health outcomes during pregnancy like miscarriages, stillbirths, child mortality, access to quality health care, and even the attitudes of men towards contraception and knowledge about HIV. I'm really interested in the contraception issues -- what women choose to use, what they'd like to use, whether they have a choice in using contraception or not, and how the psychosocial variables affect these questions. So we're adding a ton of questions to the survey and will get data back almost at the time I'm leaving in May/June, so it will be a mad dash to the finish line!

Lawn-mowing here, machete-style

(3) As you've probably seen from previous postings, women die here needlessly. It's awful. But one of those reasons is no blood! So with my new and young enthusiasm for a blood drive and Jeff's similar longstanding desire, we're going to start a blood drive primarily for the mzungus among Moshi residents (there are a lot!!)... and an O-negative registry as well, because since they are the 'universal donors' of blood, it's always hard to find. Did you know that O type blood is most common in the world, around 38%!?!? It doesn't make sense because it is a recessive trait. Characterizing the blood types here would be such an interesting project!! (and, I guess, if you stretch it far enough you could say it's a women's health project, but there's no time to do everything.) Anyway, so that's my goal this year -- to create a model for mzungu blood drives that are self-sustaining. My idea is to do it at the Watering Hole, the mzungu bar, and give everyone free movie/beer passes, but not on the day of donation!!! Sadly, I can't donate, my blood count is too low for their cut-off, but getting a lot of people to donate is a far better service. So even though this isn't research, this is probably the project I'll be most happy about achieving!!

(4) As a companion project, I think we're going to try to assess the accuracy of the clinical assessment of anemia compared to a lab measurement. You're probably thinking, why don't you just rely on the lab?? Well, here, the lab is totally unreliable!! You never know when you'll get the data back and even if you do, you have no idea how accurate it is. I don't think people can survive on a hemoglobin of 2. But apparently our pregnant patient was. Obviously she was low and needed a transfusion, but there are some patients for whom they are on the borderline of needing a transfusion -- so if you couple the lack of blood and the concern to 'save' it for a possible post-partum hemorrhage later that day with the lack of certainty about a laboratory value, you can see why being good at a focused physical exam for anemia is a great skill.

(5) I know, you're thinking, more projects?!?! Don't worry, this one is also data crunching, but happily, it's totally different -- infectious diseases -- and really interesting!! (for all those of you gunning for me to go into Medicine). So there's also a large Duke-HIV collaboration out here, and they recently did a study of patients presenting with febrile illnesses and looked to see the pathogens causing the fevers. Surprisingly they found that non-typhi salmonella (the kind of salmonella that doesn't cause typhoid fever) is really common, but they also found much higher than expected prevalence of leptospirosis and q fever (both bacteria). And just recently a paper from a very prominent ID guy and advocate for research on neglected tropical diseases, Peter Hotez (who spoke to us at Fogarty training!!) said that there is no known prevalence/epidemiology data on pathogens like this in sub-Saharan Africa. So one of the smaller projects in this huge study is to look at the clinical and lab characteristics of patients with these diseases -- and that's where I come in :) My PI on this project is definitely ambitious -- he wants it complete and accepted for a presentation at a meeting in 9 months!

(6) The last one is a bit iff-y -- depends on whether I need national IRB approval, at which point it will be a no-go. But basically, we'll be looking at a 6-year registry of cervical cancer screening clinic patients and seeing what the data shows. This is actually one of the most interesting projects because cervical cancer is huge -- out of the burden of disease cervical cancer poses worldwide, Tanzania is the most affected country. Can you believe it? And with proper screening and early treatment, it's curable. Yeah, exactly! So hopefully we get this project approved, but since I'm a foreigner starting a new project, there could some serious roadblocks.

Random flowers bloom on my way through the field to work

Sooooo, that's the round-up of my anticipated research life for the next 9 months. It should be awesome!!!! And I think mostly doable, barring some unforeseen roadblocks. I'm really, really excited!! And hey, I'd love some feedback on these research ideas -- like the "I wonder if..." thoughts that ran through your mind as you read this (if you made it to the bottom).

One day I'll learn to write succinctly....

Wow, I've been here for 4 weeks exactly -- part deux!

Please tell me you've all seen Hot Shots -- if I've seen it, it's pretty pitiful if you've not.

So, the epic entry continues...

Well, last week had some interesting adventures -- probably the best is my ongoing internet saga. Every week my newfound buddy at Vodacom kept telling me my wireless modem was coming 'next week.' Last week, we'd had enough of the runaround and Jeff and I went down to Voda to get the story. "100%," they said, "100% it will be here Monday." Of course, they thought I brought male reinforcement so the entire time we were discussing my modem woes, Jeff and the Voda guy were talking. Somehow, Jeff's gets DHL'ed to him within 2 days.... but Monday rolls around for me, and miracle of miracles, the modems arrive. 100% (our new joke, because nothing here is ever 100%!!!!) Five new modems, which they promptly sell to 5 other customers even though they were to save one for me. Of course, they texted me the news and offered to just save one for me next time, but I convinced them to drive one over from Arusha -- only 90 minutes away, but still! And, get this, they even gave me a 30,000 shilling discount!! (that's $20 off the original $80!) Buuuuut, it was too good to be true, and though I sit at this very moment longingly looking at my modem, it doesn't work. 100%, yeah right! So my adventure will continue with another visit to Vodacom this week. If I skype you, you'll know it's working :)

The only other event worth talking about was definitely not an adventure for any party involved. I watched a 20 year old girl suffer and die. She was pregnant, near term, and sick -- a chest x-ray showed what was likely to be TB, but because of varying opinions, she wasn't started on those medications right away. As she became sicker -- she stopped eating, was occasionally have seizures, had bloodwork showing worsening liver function -- her baby died, but she only continued to worsen. The morning I saw her, she was completely out of it, breathing very raspily and vomiting up her stomach contents. Her reflexes suggested her brain was severely malfunctioning. Probably the most disturbing sight was that her sclera (the whites of the eyes), which had turned yellow and were extruded out of her closed eyelids. None of the senior physicians, both American and Tanzanian, had ever heard or seen anything like that. So many things about this shocked and saddened me -- that the suction machine to prevent her from aspirating is a foot-cranked machine that exerts about a half of the vacuum pressure you exert when drinking from a straw, that an immediate ('stat') transfer to the ICU here takes about 30 minutes (at least), that there is only 1 ventilator for the entire ICU, so the patient who needs it most and has the greatest change to survive gets it, that the culture of medicine here isn't always to tell the family what is happening. In essence, we transferred her knowing she would die soon but hoping she would get better care. With so severe an illness despite being in a young patient, it's really hard to say whether it was fortunate or unfortunate she passed away.

Some milestones in the first month....

--I confidently use squatting toilets!! Even though I too did not think it possible, you don't fall in! And, if it's just a little more gross than I'd like, I've even developed the skill, and muscle, to be in my tippy-toes while squatting. Too much information, I know, but seriously, it's always an adventure!! Oh, and I think I'll buy stock in purell when I return :)

--I've watched more TV shows, movies, and Michael Jackson music videos here than I ever do in the U.S. -- Scrubs, How I Met Your Mother, Harry Potter, The Hangover, Notting Hill... How I Met Your Mother is hilarious -- I fell asleep this past weekend watching my computer, only to wake up at 3am with my face totally on my computer and a nice geometric square pattern on my cheek :)

--I save every last piece of plastic, paper, food possible. It seems so insignificant, and definitely I was not wasteful in the U.S.--but after having been here for even just one month, I know that I'll never use plastic silverware just once and toss it, that I'll re-use every single ziplock bag til it falls apart, and that I'll question how much I really 'neeeeeed' such-and-such. I told my dad today, a lifetime of lectures on need vs. want do nothing to impress a mind in comparison to living here, or surely any developing country. I do think there is a difference between living and visiting, though -- to live here, you have to want to learn how things work, be flexible, and try to get things done the Tanzania way. I want to integrate into the system and obviously I'm flexible, but still, it's frustrating when things don't happen the way you want them to.

--Thanks to Brandi, I can make pizzas, pasta sauce, eggplant parmesan, chili, even tortillas, not to mention dessert!! Life is good :)

Wow, I've been here for 4 weeks exactly!

Can you believe it?!?! I can't! Only 9 more months to go... not sure if that's a good thing or a bad thing... thoughts?

So even though I'm exhausted and should be either (1) sleeping, (2) working on my presentation, or (3) working on another post about my research, I thought I'd write the more reflective (part 1) and entertaining (part 2) entries first -- you choose which you want to read :)

It's fitting that today is the day I should have received an email asking me all the important probing questions about my experience here -- what do I like most, what do I like least, what do I miss and not miss from the US, how this experience is changing me...

I guess I owe all of you some answers. What do I miss most? people. friends. my family. the news, but actually it's very easy to not know, and not need to know, about the world outside of Moshi. And I'll admit, a good shower with water pressure. (yes, it's high time I make a Seinfeld reference, but the elephant showerhead would be amazing right now).

I don't really miss the food, the daily life, medical school -- although I think that's because I can be in the OR as often as I want and I attend ob/gyn morning report daily, where there's always some crazy story -- like today's 18-year old new mom with purposeful organophosphate (ie, pesticide) poisoning, or the ovotestes, which I sadly missed. Yeah, lots to always "Why don't you look that up and tell us tomorrow?," except I end up just making a list for myself because no one else cares :)

What do I not miss? It's hard to express -- I don't miss the superficiality. People here are so genuine - you'd think they'd get karibu'ed (karibu=welcome) out because they say it so much, but no, they mean it every time!! When I was at Duke for training, I shared an apartment for literally 36 hrs with 2 labor ward nurses from KCMC. We only saw each other twice because they were up at 5am (gotta love OB!!). Yesterday when they saw me, both of them yelled "Malavika!" down the hallway and gave me a hug and welcomed me to their country -- even though they were the ones who had just returned from a long journey!! Maybe that would happen in the US, but I don't know... at least it wouldn't be common.

What do I like most? That I have time to think about my life, my work, my world, how I hope this experience shapes me. That I'm happy here. That despite the occasional frustration of the (daily) power outages exactly when you want to watch a movie, or make dinner, it reminds you what life is about -- that even when there is absolutely nothing else in the world to do, there is always someone to talk to, to get to know better. That I like my self-sufficient lifestyle -- chickens making my eggs, trees making my avocados and bananas, veggies making my carrots and beans and lettuce and onions... I'm radically changing my previously held views of never having a garden!! That, believe it or not, I don't actually need the Internet (even though I do kind of miss the instant gratification of looking stuff up -- like all those Michael Jackson questions we have!! :) ). That I get to see and participate in the clinical side of things and constantly devise and revise ideas for projects to actually address important problems and useful questions that will make a difference in patients' lives.

(here's a picture of the hospital courtyard -- note all the colorful kangas!)

What do I like least? That's easy. The sadness I encounter daily. That patients die here from causes that could treated so readily in the US. Simple things, like only 1 ventilator in the ICU, or no blood in the blood bank, or not enough staff to take care of patients, or no access to the curative medication, or that the ER is only 4 beds so everyone else waits on a stretcher outside. Oh, what's a stretcher made of, by the way? 2 wooden poles with some tarp in between, laid on some rolling contraption about waist height.


ok, I took a picture after all -- the little door is the way into casualty, which has the 4 ER beds. it's a daily occurrence that overflow patients, even really sick ones, just wait in the lobby

I've only been here for a month and already it makes you want to cry and scream at the same time. I don't know how the Tanzanian and the American doctors deal with it -- how much can you wall off your emotional response to these pitiful situations? That look of tragedy in so many women's eyes is heart-wrenching. I'll spare you the details, except to say that nothing is worse than a mother laboring to deliver a dead baby. Something about that just elicits a visceral reaction in me every time.

the OB ward. 5 beds fit in this room. more pictures of the other rooms soon...

On a personal life level, I hate that I don't speak Swahili yet, really. I can obviously say a few things, but I can't wait for my 3 week intensive course. Otherwise, the food is not my favorite so far -- at least in Moshi, though mostly I've been eating non-Tanzanian food (well, they also realllly like meat) -- but some good rice and beans can't be beat :)

So, those are my deep thoughts. I'm sure I'll be glad to see familiar faces and things when I leave, but I also can tell I'll be very sad to say goodbye to Moshi. It's a great place -- come visit!

(the back of the hospital, where I come in from every day...)

The Theatre

Before you get too excited, that's the "OR" here. Where do I begin? The patient, the infrastructure, the surgery, the sterile technique....

How can I describe our patient? A 13-year old girl with supposedly a 6-year history of bilateral labial masses, each weighing maybe 2 kilos? Most likely due to lymphatic filariasis, also known as elephantiasis.

For all the non-medical people reading, a brief description: filariasis is a parasite infection that people in endemic areas (most commonly sub-Saharan Africa, next is SE Asia) get from mosquitoes; the larvae mature into worms and live in the lymphatic system. Over time, they cause a lot of inflammation that scars the lymph system, usually in the lower leg or groin, and prevents it from doing its job of draining fluid. Have you ever seen pictures of men with 'elephant legs?' That's filariasis, called elephantiasis when it's so bad.

So that's what happened to our patient, except in her labia. Imagine a bag of 3-4 tennis balls, then put 2 of those bags between your legs and try to walk. It was so sad, it broke my heart. I'll never see that in the U.S., and hopefully I don't see it again -- although my PI, Jeff, has seen it twice in the year he's been here. We took pictures, but I can't post them. (sidebar -- the whole asking-the-patient-for-consent-to-take-a-picture isn't deemed necessary by the local physicians, so we only need permission if we publish it. It definitely felt strange to be taking pictures without asking, even if she was asleep!)

I looked it up (of course -- that will never change, even w/o an iPhone -- just a list of all my 'look it up' questions on real paper!), and 40 million people worldwide have severe disability due to filariasis. And once yearly treatment for 5 years of communities in endemic areas can reduce the prevalence of the disease by.... 70%, at least!

We took out the masses and took the specimen with us -- hopefully to send it to Duke with the next unsuspecting victim returning to Durham. Our hospital recently lost its lone pathologist which, as you can imagine, is just a huge disaster!

Anyway, so the rest of the experience -- you really see 'resource-limited setting' in action. I've never seen an attending ever throw so many interrupted stitches from one suture! The theatre isn't so bad -- it's large enough, I think there's a generator, and they have the basic stuff. I've never seen anesthesia, mostly run by nurse anesthetists here, tape a stethoscope onto a pt's chest and listen all surgery long -- but they don't have the monitoring capacity for all the vitals. As with many things in surgery, you see the differences tangibly and realize that so much of what we can provide is training, teaching, and supplies, but one definitely wonders -- how is this sustainable? I am so glad our group focuses so much on clinical skills and quality improvement initiatives -- yay Jeff! :)

I don't mean to be critical -- it's different but it's the reality of the situation here, and for me, there's so much to learn. New problems, new surgeries, new techniques. I can't wait to go back to the theatre again! (and hopefully at some point this year, maybe even scrub in!)

Random updates: penguins, singed sleeves, scrubs/house of god combo

I'm learning so much! Like how to bake, how beans grow (in pods!), how to sms on cell phones -- the ones that have three letters per numerical key -- and how to save penguins :) I can start there -- thanks to Brandi I learned the best analogy!! Our brains are ever shrinking icebergs and there are only so many penguins, so some of them end up jumping at some point, unbeknownst to us until it's too late, but we should figure out which penguins are worth losing and which are worth keeping. Of course, this all came up because I asked one too many, "But why??" questions :) (Brandi, if I messed it up feel free to comment.)

Because it was Jeff's birthday, Brandi was baking -- a 4-layer lemon curd cake (i helped!), chocolate hostess cupcakes, and coffee cake. They were yummy and definitely made up about 50% of my caloric intake for a day. Definitely the hostess with the mostest, I cannot wait for my birthday!! :) I've requested a carrot cake, mmmm. From scratch. Even including the frosting. I am sooooo lucky :)

Otherwise, a pretty quiet weekend -- I finished Three Cups of Tea, which is definitely worth reading if you (a) like education, (b) like an 'against-all-odds story,' or (c) like to learn about different cultures; and started the House of God and Scrubs simultaneously. It's funny how the book and the show basically say the same thing even though they're 30 years apart. And omg, turfing and bouncing pts are from that book!! It's definitely a fabulously entertaining read and I only wish I'd also read it as a pre-clin student, when I would have been so disbelieving of the cynicism that pervades medicine. I also bought 2 bollywood DVDs -- caved in to the pilfered market that is DVDs in Moshi, only to find that both of them are damaged!! :( there goes 5 bucks, haha.

I promise I'll write about my research next (well, after the one following right now). Just processing my meeting and presentation from Monday, which could have gone a little better, especially since the day began getting ready by candlelight and singing my sleeve in the process! No shower, no tea, no cell phone charge -- great start, hunh? :)

Attack of the Animals

What started as an innocent blog on the animal life here has quickly turned into my harrowing escape from the fire ant attack!! Ok, a little dramatic -- but my somewhat brazen attitudes towards these insects totally came back to bite me -- literally! All of a sudden I felt this sharp sting on my knee and yanked the ant out of my leg, then another one from my foot. And then I just started freaking out with every slight twinge on my body. I thought they had crawled
halfway up my thigh so i stuck my hand down my pants and broke my pant button in the process! But I'm ok and with a newfound respect for ants. Yet another reason to walk with a flashlight here -- I'll have to take a picture of these ants streaming across our paths all the time.

Anyway, I was initially going to post about how we really live in harmony (almost) with the animals here. And I'm not even talking cool, safari animals, but the roosters and chickens, the owls, the dogs, the cats (including the black cat that stalks our house -- at least i'm not superstitious!), the bush babies, the amazing birds, the rustling in the bramble we suspect are snakes. I will admit, I was definitely a little weirded out at first, but now the sounds are soothing and just seem to make sense -- it seems only natural we share the world with animals. Today I saw these geckos defying gravity and I just don't get it -- how do they climb up a wall?? And this amazing blue bird perched on my office window and just peered in for a bit. I definitely have to
get a much better camera for safari. I mean, how many times am I going to see lions, rhinos, ostriches, flamingoes, timon, and pumba? :)

Tonight was total mzungu (foreigner) night at the watering hole, this bar owned by an american who goes to medical school here (yeah, kind of confusing, but it's not like the granada thing). it was my first time and bev's last night there, as she leaves for the US tomorrow -- so the only time the 4 girls would be there together :(

the watering hole has great drinks, yummy quesadillas, a movie every thursday night, and pretty much all the foreigners hang out there on thursdays. i still prefer tusker beer to the other beers here but i'm trying them one by one (no dogfish head though) :) and animal-themed south african wine. somehow i'm definitely going to have to figure out what all these people are doing out here?!?! but we were by far the most 'touristy,' to the horror of brandi, bev, and ruchi, as I sat there taking a million pictures. but how can you not, when the night started off with our
getting there in an army jeep? :)

PS -- had to add the picture of me with my tanzanian bag -- so cute :) and i have a matching wallet (of course), to the great relief of Brandi, who thought my bright orange wallet was asking for trouble. now it's getting dusty in my drawer :)

What's that smell?

So I'm no super-smeller, but there is definitely this smell in Tanzania that is indescribable. It's not food, it's not pollution, it's not that sticky-smell in humid countries (moshi is far from humid!), it's not even BO (though I definitely smell that often)... I could keep naming what it's not, but unclear what it is. At least it's not offensive, only very noticeable. I'm afraid it's seeping into my pores and I'll never smell the same again!!! Any thoughts what this could be?? Needless to say, oil of olay is going to make lots of money off of me as I guzzle body wash!! Even though my shower pressure is like a trickling stream. We had to jury-rig the shower head to put it about head level to create some pressure, but really I think we're just trying to make ourselves feel better. It takes about 5 minutes for all the conditioner to wash out, and I just cut 3 inches of my hair off before I came here!

But at least my house is all back in order after our party! I'm sure Mama Rosie had a heart attack to see all those dishes piled up in the sink and my white shirt that got splattered with pasta sauce and needed some serious rescuing -- but she saved the day :)

Best news -- I found all my favorite indian biscuits in the store this week!! I'm stocked with the parle-g and mcvitie's digestive equivalents -- now to find the bourbon street equivalent and I'll pretty much be living off the most unhealthy diet ever. My lunch is a peanut butter/honey/baby banana sandwich!! I really should make a sandwich with vegetables, but that would take too much effort at 630 in the morning. Lunch options at the hospital are wali maharagwe, wali maharagwe, oh, and some wali maharagwe. ie, rice and beans. It totally depends where you get the rice and beans, but it's hit or miss depending on where we go, and they serve me way more rice than beans, so I end up not eating much and probably offending the Tanzanians. So I figure if I bring my own lunch, I'll never be unhappy (even if I do get a bit bored of the same sandwich!). Last week I even had to suffer eating the avocado salad where they just removed the chicken from the top and served it to me. I know it sounds crazy, but it was really hard for me -- I haven't eaten meat in years and the thought is just so unappetizing (to put it politely). But I survived :) Anyway, we'll see how the year goes -- at least the indian-influenced food makes me happy -- what more do I need besides chai and chapati? :)

P.S. I just saw the Milky Way!!!! Tonight felt like a planetarium -- except in real life. Totally makes the power outages and the occasionally discomfiting rustling sounds of bush babies (I think) worthwhile. But there was no way to take a picture of this -- how can I capture a 360-degree view in one still picture? Guess you'll have to come visit, and we can sleep outside under the stars :)

Trying to find a routine...

Well, I write this as I am watching a bad bootleg copy of Harry Potter and the Half Blood Prince -- someone definitely filmed this in a Chinese movie theater. It's been so long I don't even remember what happens in the movie. But I'm not complaining, this is going to be the only way to watch movies for the next year... and we alllll know how often I watch movies :)

I'll try to update in chronological order, though I am still slightly disturbed by having just been asked for my phone number by an 11 year old boy (who says he's in primary school!)! Anyway, lazy Sundays here are fabulous -- definitely got on an organizational kick last weekend, cleaned out the kitchen and rearranged the bookshelf (and found some gems in the process -- no need to have packed so many novels!). I'll have to take a picture before someone messes it up!! ... yes, I know, I am OCPD, but it was very satisfying. Today was just more catching up, trying to prepare for meetings this week, and reading crazy articles Chez Bev/Brandi's internet cafe (they have wifi!!!) Have you guys read the story on Radovan Karadic as the new age guru during his time hiding out? Spermosans, people, I mean who comes up with that?? http://www.nytimes.com/2009/07/26/magazine/26karadzic-t.html

I've been consumed this week with The Red Tent -- seriously a good book, and not only because after a year of doing women's health here I might be convinced into going into Ob/Gyn!! Sidebar, as this is a whole post in and of itself -- haven't even had much clinical time except for morning rounds, but patients' problems here are both really sad and really interesting. I feel like it's going to be a constant struggle to rationalize my scientific interest in their problems with feeling really sad, about everything. But I guess that's why we're here -- to see problems and find solutions for the patients.

So now I've moved on to reading Three Cups of Tea -- a Moshi-must. Greg Mortensen, who's the main character, was born here -- and his parents founded KCMC, where I'm working!! All this reading has been awesome, but I've definitely neglected my daily Swahili studying -- really counting on Bariki (my Tanzanian twin scholar) to bolster my language skills!!

Workwise, the week was great! So many cool projects going on, so many to choose from, and definitely many opportunities to learn how to do clinical research and hopefully leave a mark. The only awkward part is rounding daily but no one has introduced me to the residents!! And as friendly as Tanzanians are, they aren't friendly until they've been introduced. But Friday I met one of the Tanzanian Indian (and punjabi) residents, and I think we'll be friends pretty quickly :) It's amazing how Indians ask you the same questions no matter where you've grown up: Where is your family from, what language do you speak, how often do you go back to India, etc....

We also were in the throes of preparing for our first inaugural meeting this past week to create a women's health network in East Africa -- which went fabulously well! And of course, I'm the fastest typer because I'm the youngest, so I naturally was the day's scribe -- which provided endless amusement to our guests. So definitely lots more research potential across other sites. Anyway, my big meeting to actually define my specific research goals will occur this week, so I'll keep you posted on what I decide to focus on. I'm a little nervous about finding good/interesting results, but I guess all I can hope for is to ask a good question and go from there.

Outside of work -- I started running again!! So far, just inside the compound -- not the most interesting loop, but there are so many rocks that you're just paying attention to the ground. Good thing Kili has been under cloud cover all week -- though today was another glorious view! It's also funny to see how Tanzanians react to my running -- they all call out, "pole sana," which means 'you poor thing!' If only I could make them understand how happy it makes me to run. Anyway, about to expand to a 3.5 mile loop outside the compound with the Peds ID doc from Baylor. I definitely thrive with a running buddy! And, I found out the international school across the street has stables. I'm set!! Time for some new barn friends...

My weekly trip to town and to the market (I know, you're thinking, which little piggy are you??) was very fruitful -- found a super cute scarf and, of course, earrings!!! And, thanks to Brandi's repeated encouragement to rid myself of my ginormous, bright orange wallet in favor of a simple wallet, I found this cute pink cloth wallet and matching purse -- with a bow that ties shut :) Yup, nothing's changed, even in Moshi. And I'm taste-testing the various coffee shops for their coffee and spiced chai -- so that when you visit, my recommendations are Red Guide worthy! Probably the best was bargaining down one of the market shops for the mangoes I bought. So it's well-known that they upcharge us mzungus (foreigners) -- you should have seen the lady's face when I asked for a 300 shilling discount!! That's like $0.25.... although when I convert shillings to dollars, even I feel guilty about ever bargaining here.

Some highlights from shopping...


We also met Jimmy Carter in town, again. Yup, there is this guy dressed like a Rasta who comes up to all foreigners and says he's Jimmy Carter. Ruchi said she was Sarah Palin and Bev was Hillary Clinton -- but he didn't get it! Once this year I'll have to take a picture of him.

Probably my most significant achievement was cooking dinner for 12 people Saturday night. I know, can you believe it!?! (although this whole week I've barely had to make any food, since someone's always cooking and inviting everyone over -- so it was definitely our turn.) We had so much pasta in our house that it was time for a pasta party -- so I made pasta sauce!! Not that difficult in the abstract but trust me, I was stressed!! Good thing Bev came to the rescue and made a second lot of sauce :) And we had yummy lettuce/avocado salad from our garden, plus some great coconut macaroons for dessert. No one died of food poisoning, which I'm taking as a sign of success :) It was great hanging out with everyone, especially the two girls, who I feel I'll be spending a lot of time this year... hopefully as the cool aunty and as partners-in-crime at the stables (even if their parents regret the day they introduced us!) :)

But I was definitely exhausted by the time the night was over, and cuddled in bed with my book, my mosquito netting, and read as some people down the street had a Shania Twain party.... yeah, it's weird. Good thing Mama Rosie will be helping to clean up on Monday! Anyway, my next project: find a bare wall in our house to project a movie for post-dinner entertainment. Almost bought a best of hrithik roshan dancing dvd this weekend...

So my second week was great -- very busy and somewhat schizophrenic -- so I still have not found a good routine, but that's ok. Goals for this week -- shorter blogs, longer runs, and riding. Oh, and I guess some research, too :) My IRB (research approval from Stanford) is due far too soon :/

Well I'm done posting, even though there's so much more I could say, and completely lost in the movie -- time to wikipedia the plot :)