Spaces in Between

And wham. Just like a time warp, a black hole, space travel to the other side, I'm back in New York. Instead of morning Muslim prayers, car alarms wake me. Not only the people, but the ads, the characters on TV, and indeed, the whole power structure is resurrected for muzungos, like myself. On the whole, everything seems really shiny to me, very clean, and very fabricated.

Still, it's great to be home. The graduation between rich and poor is reassuring. My last night in Dar I went out with a new friend Leka, who helps run the Ifakara medical training center. We painted the town, going from club to club, where live bands played local and pop music and the crowd was getting down. The spots were amazing--completely beautiful, and filled with beautiful people, and mostly located in places like Oyster Bay, which hold a mix of the ex-pat community and government employees. But in the taxi rides in between, flickers of fire would make you turn your head, and you realize that there were literally hundreds of people huddled on the side of the road. Or walking. Or just barely existing, in whatever way they could.

Mark has a song called "The Spaces in Between." In Dar, which is experiencing a boom compared to other regions in East Africa, these people filled the spaces in between. And coming back to the US, the third world fills our spaces in between. In Tanzania, the upper class knows this. But as I drove past the crowd of hipsters on my way home last night, it occured to me that people in the US don't realize it.

There's much to write about. I can't wait. So stay tuned.

Morning Reville

It's a different type of morning reville at Temeke Hospital. More than a 100 patients line up on the wooden benches outside the TB clinic. One by one, they walk to the front, place their green patient card under a stone in the order in which they arrived, and walk back to their seats to wait until their name is called.

Temeke Hospital is a district hospital located 10 km from the national hospital of Muhinbili in Dar Es Salaam. But it's truly another world. Instead of gleaning white floors and doctors coming to and from, the building is old, covered with dirt, and no doctors are apparent. The TB ward in Temeke serves about 4,000 patients. Dr. Kapalata, the regional supervisor for TB, says that the number of cases in the 1990s was about 1,500, but HIV has caused many patients to develop TB faster, and indeed, caused TB in carriers who otherwise would have not developed the disease. It's a struggle to care for these patients, with such a limited staff and a small space. After all, he TB unit is merely an office, a supply closet, and a greeting room with a curtain that sections off an area where the nurse injects patients with streptamyacin, the drug added to the TB drug combination for patients who have become resistant to the standard DOT combination.

For those patients, they must come to take the injection each day the clinic is open--6 days a week. This particular patient also takes 11 tablets (because he is 55 kilos) every day. The nurse says even though the pill burden is high, the patients do not complain much. At most, you will hear the patients who have developed resistence talk about the struggle to pay for the syringe each day (about 50 cents). However, the DOT tablets are free, distributed under the government through a grant from WHO--at least for the next few years.

While the nurse administers the shot, the other nurse on duty, Sarah Wilson Ochogo, prepares the cups of medication. I sat with her this morning. As she calls each name, the patient steps forward with a bottle or packet of water in hand, and takes the medication while she watches. She says it speeds up the process to administer the drugs to three patients at a time, and in unison the three patients--one child, one young woman, one old man--swallow the pill, and then start out to their day's activities, while the nurse records the administration

The next patient is a baby, who an't be more than 2, and the nurse hands a pill to the mother. The mother splits it in half against her palm, capturing all the shards that fall, and mixes it with water so the baby can drink it. When I ask about the problems with this system, Nurse Ochogo says to me that it's not perfect, but it works...and this is Africa, after all.

$7.1 Billion Dollars??!!??!?

OK, JUST because there was nothing on except the latest Bollywood flick, I watched Bush's speech on avian flu. I am so boiling, I don't even know what to do with myself.

7.1 BILLION DOLLARS! FOR PREVENTION OF A POSSIBLE PANDEMIC OF AVIAN FLU? How about some real money toward the actual pandemics that are now ranging throughout the world? Compare this money to the $15 billion Bush put toward AIDS for five years for something like 17 countries, and it makes me realize that it's not that the US can't help diseases like TB that are wiping out 2 million people a year, it's that we choose not to. It's not that I want avian flu landing on my doorstep--and indeed, some of the measures will be good for the industry and help spur development of other drugs. It's just that I can't see putting that kind of money toward something that has affected global health so little, something that is not causing the genocide that AIDS, malaria, and TB are.

Ah, don't mind me. I was just surrounded my a crowd of children this morning asking for food and money. I gave them some candy, and it almost made me cry to see how happy it made them. I looked back and a little girl was blowing kisses at me--the image is so haunting, the children were so dirty, that I just can't erase it from my mind. It's hard to switch from viewing poverty that way to thinking about avian flu.

From AIDS grants to TB grants

Just came back from Muhimbili Hospital, where I visited the newly created outpatient clinic and refurbished lab, compliments of the Abbott Fund. Very much needed, as before there was no clinic (five or ten doctors just gathered in a room and shepherded patients in like cattle) and the lab can now get test results back in 4 days, rather than 3 months.

Now, when Abbott decided it wanted to be involved in Tanzania, it really just wanted to focus on HIV/AIDS. But the minister of health (MoH) was able to convince them to invest instead in expanding general hospital services. Some docs I spoke with threw kudos to Abbott for being flexible, and not stalling for years upon years when the MoH insisted on a different plan.

Recently, the MoH made another request of Abbott: they wanted the company to invest in TB services, primarily at Kibongoto, the only TB hospital in Tanzania. Now, Abbott's focus is not TB--they don't make TB drugs or tests, for example--but they decided to give money anyway, in the name of being a good partner. They gave a one-off grant of $40,000 (peanuts, but most comparisons), but I think it will have far-reaching consequences.

First, it shows the willingness of the company to serve the government's need, rather than their own PR interests. It makes them pony up to their focus on "health infrastructure" rather than drugs. Second, it shows the mechanism through which pharma will be brought in more strongly against the fight against TB--personal relationships at partnerships. Kenneth Lema from Axios even says this is the tip of the iceberg--it is inevitable that MoHs in other countries will also ask their pharma partners who mostly have AIDS programs to enter into TB. And lastly, the MoH was able to show the government that the TB hospital had secured support from a pharma company, which convinced them it was an important cause, and they granted 5 million Tshillings toward it next year (will get back to you on what they allocated for it in last year's budget).

Not sure if pharma will kick and scream as they enter into TB, an area that hasn't secured the kind of visibility as AIDS. But it seems that there's a chance to lead governments into doing it the right way--before another PEPFAR happens.

A Simple Night of Sleep Would Do

Rolled back into Dar today, into a deeply Muslim neighborhood. I think the end of Ramadan is drawing near, and so many women are covered from head to toe. Some just wrap themselves with kangas, while others wear black and cover their face. In Zanzibar, where they had the elections today (which will hopefully quell the fighting there), the population of Muslims is so large that it's illegal during Ramadan to eat or drink in public during the day.

Maybe once they start eating that will slow the fighting? I know how I am when I'm hungry.

It's so interesting to be in the middle of this culture, but with only one drawback: The Muslims pray five times a day. Now, this is fine in itself, but when you consider that they blast the prayers over huge PA systems (and the first prayer time is 5 am), it starts to be a bit intrusive.

Giant TB-Smelling Rats

The diagnostics to test for TB are so ancient, it seems that giant African TB-smelling rats can do a better job than the tools available today.

Research from Tanzanian's Apopo Centre, a research program at the Sokoine University of Agriculture in Morogoro, shows that a certain kind of rat taken from the bush can be trained to detect TB in patients' sputum. Perhaps more importantly, these rats can test 2,000 samples a day--compared to a lab technician, which tests somewhere between 20-40 samples. (And their efficacy hovers around 70 percent, some 20 percent better than the traditional diagnostic.)

The rats were originally trained to detect land mines...and makes me reconsider how I've thought about those critters all along.

They've been testing these rats for some time, but it seems like the idea is gaining steam as a sort of third-world solution to lack of personnel and microscopes, and other lab equipment. I think it's pretty cool. And the research presented at the meeting moved some donors, so hopefully the group will get more funding to continue thier research.

Absorbing Aid Before It Hits the Ground

There's a metric out there somewhere that 40 percent of Tanzania's economy stems from foreign aid.

That's great that the world is just rushing to their help. But more and more, I see that the stipulations attached to those contracts are preventing them from doing the most good.

Case in point. The Chinese government gave lots of money to build a railroad. But Tanzania had to hire a Chinese company, and buy all the raw materials from China. The same could be said about the US: Bush is funneling PEPFAR money to this country, but it must be administered by selected NGOs, many with bases in the states, and it will all be . And don't forget about all those ex-pats living here, with their swimming pools, 4 wheel drives, and gated communities.

How about letting Africans help Africans? Any thoughts out there?

Womens Rights (NOT!)

There's nothing like a jaunt around Tanzania to remind me how far we've come in the US in women's rights. I mean, I complain all the time that Pharm Exec doesn't feature as many females as it should, but compare that against "hunting" a bride and locking her into the house for two days while you summon your cows for her family, and it really puts it into perspective. Oh, the Chagga tribe--those crazy Africans.

But even in the city. Last night I was the dinner guest in a businessman's home (Gasper...he helped Ronnie and I with the car after it broke down). The meal was wonderful, the company was great--even though they talked mostly in Swahili--and I even prompted a dance-off among the guests in this small home! But Gasper's wife just sat on a stool, beneath us, holding the baby, cooking, cleaning, and generally just being invisible. Meanwhile, earlier in the week, I saw him with his "other" wife.

On the bus to Moshi today, a man asked me what I thought was the difference between women in Tanzania and New York. I told him for some women, there were big differences, for others....well, maybe not so much.

The Maasi Tribe and Cow Blood

Let me tell you a little bit about the the Maasi tribe.

They live in the Northern and Eastern part of Tanzania, as well as some parts of Kenya. Although they are transient, most stayed in the wild open plains where their goats and cattle had plenty to graze upon.

Back in 1996, the government uprooted them from the Serengeti, and displaced them further east. Since then, some have drifted further toward the cities, and on any given day in Arusha, you can spot them out.

They dress and act quite different. They are warriors, and once the men are circumcized at age 18, they dress in certain robes, with pretty intricate jewlery. Most have part of their earlobes cut out to about the size of a quarter, from which it is quite handy to stick a pack of snuff in.

The women are also circumcized, at about age 16. And there could be about 20 wives to each man, depending on how much cattle he has. Feminists, they are not.

Part of their culture is to drink the blood from the cattle. They spear it in the neck, mix it with milk, and then smear some cow dung over the hole to let it heal.

They sleep on cow skins, in mud huts, and are quite experienced in local medicines. After the men are circumcized, they are exhiled for 6 months (maybe to heal?), and work with the elder warriors to learn this knowledge. That's the only schooling they receive.

Bus Ride Strategies

Some advice for my fellow African tourists. Please take the following advice into consideration when taking the bus.

1.) Choose your seat wisely.
Now, this may not really be a choice, since you are assigned a seat when you purchase a ticket. If you are lucky, you will get the window seat (as I did). This way, you can regulate the window and choose between how much smell you can stand, and how much hot air you want blowing on you at 80 miles an hour.

2.) Stay thirsty.
Although this is Tanzania, and one would try to remember the importance of hydration, in the bus situation, there are no rest rooms. You must choose between being thirsty and having to pee. Now, I know there's no rest rooms on, for example, MTA. But our dear bus only stopped once in 11 hours for a bathroom break.

3.) Be skinny.
Make like an African, and be skinny. The buses fit about three seats to every two American seats.

4.) Bring a range of clothing.
Before a bus takes off, it will sit in the baking sun for maybe an hour or so until it fills up. At this point, the closeness of your neighbor will combine and before you know it, your back will be dripping with sweat. This sweat pattern will continue, even as you take off and wind starts blowing, because it is so hot. However, once the sun goes down, your sweat will freeze, and it will turn quite cold.

5.) Pack a lunch.
The bus will slow down around corners, where people will run alongside the bus and try to sell you food. That will be better food than the kind offered a rest stops, which consists of french fries and greasy types of meat. I personally wish I went for the packaged cookies than the french fries, washed down with another 6 hours of bumpy bus ride.

6.) Lastly, remember to enjoy.
Remember, it's important to interact with the people, not be separate from them. It also brings the greates rewards. Just look at the window as you go through hours of desert, without a single light. YOu can see more stars than you thought were there. A Masai tribal man will get on the bus--with his robes, jewlery, and walking stick and smile at what an odd sight you are--and you learn just a little bit more about Africa.