The highway is better than the dirt roads. Sometimes.

Mt. Meru is in our backyard.  Almost 15,000 ft tall.

Driving down the main road (paved) through town is pretty good in the daytime.  Rush HOUR is from 6 to 7 PM.  Now it is just one lane each way, but it is just as much bumper to bumper as LA. Just on a smaller scale.  Right after rush hour, it gets dark and scary.  There are no street lights.  None.  So it is very dark. The center line and side lines are pretty much worn off so it is hard to see your lane well especially since many of the oncoming drivers want to see well so they drive with their high beams on. There are push carts sans lights or reflectors rolling along mostly on the shoulder.  They mix in with the pedestrians who are usually on the shoulder.  Every once in a while you see the lights of  an oncoming car blink which means that a dark-skinned, dark-clothed pedestrian has run across the road in front of that car and is now in your lane somewhere in the darkness. Maybe, hopefully, they are across or maybe they had to stop on the center line to wait for a clearing of the vehicles in your lane. Standing in the darkness in the road.

None of this is as big of a  problem as the pikipiki (motorcycles) that are passing you going both directions down the center line and going both directions on the shoulder. In the dark.They jam into any space that isn't physically occupied by a car.  They usually have headlights, but functioning tail lights are not a priority.  When they pass you at night, they disappear into the darkness.  You know they are out there somewhere.  You just can't see them. They also uniformly run red traffic lights and make turns from the wrong lane.

Pikipiki is an example of a Swahili word based on a sound.  Onomatopoeia for you English majors.  I know who you are out there.The motorcycle sounds like this - pikipikipikipikipikipiki. I was just in a town on the island of Zanzibar named Bububu.  There was a train station in the town so it was named after the sound a train makes going down the tracks.  Bububu, Bububu, Bububu. 

I don't care if they have a fun name.  I still don't like pikipiki. Quite a few of them are motorcycle-taxis.  Most of the drivers wear a helmet.  For the passengers, it is BYOH (Bring Your Own Helmet) so they don't wear helmets.

The Attack of the Mianzini

We were driving down to the highway. There were two roads we could use. One was a horrible, bumpy, narrow road. The other, Mianzini, was horrible, but less so. You need to understand that both are 1 to 2 lane roads full of ruts, potholes, speed bumps (Poor Debi gets motion sick even when I am driving 10 km/hr - that's about 7 mph for you metric impaired ones.)

It started out as the usual terrible road, then we got to where a bulldozer had deposited some boulders in the middle of the churned up road. No problem. Just drive around them as we are driving a four wheel drive Land Rover.  Then there were narrow strips of navigable loose dirt in  a morass of  tree stumps, boulders, deep trenches, and piles of dirt.  We were past the point-of-no-return so we followed where cars tracks lead us. At one point, we were in a deep, steep hole with the way out being a 45 degree left turn.  I was stuck and just killed the engine when I tried to lurch out of the hole. The vehicular spectacle drew a crowd so there where helpful people who pulled three large rocks out from in front of my tires, shooed the following car back from my rear bumper so I could get a minuscule run at it and corrected my tire angle.

We bounced out of the hole and across to the other side of the road where another driver was awaiting his turn to run the gauntlet. I swerved to the right just in time to avoid crunching into his door. Instead of smoothly going past, I planted the right front bumper against a stump.  The other driver pulled around behind me but couldn't get totally past me until I moved forward. I couldn't go forward or back.  The spectators jumped into action, got the other car out of my way, and coached me around the stump.  We scraped through other tight spots, finally getting to the highway. I vowed it would be a cold day in......  well, a cold day in Africa before I drove on Mianzini again. Mianzini means "in the bamboo trees," but should mean "in your worst nightmare."

Equatorial Africa is COLD

I was not expecting Arusha to be this cold.  We are 3.3 degrees south of the equator for crying out loud.  I did not expect it to be cold.  I have been here before and don't recall Arusha as being cold.  I recalled Ngorongoro Crater rim as being cold, but that is 7,500 ft and, of course, Kilimanjaro was cold at 19,343 ft.

Arusha is up at 4,500 ft on the foothills of Mt. Meru and it is "winter" here so daytime highs are just over 70 and it gets down to 50 at night.  I have to wear a fleece sweater to work where I switch to a white coat. I am just on the cold side all morning since we start hospital rounds with the hospital interior temperature being as low as 60.  Furnaces are pretty much non-existent here. The windows are these louvered arrangements that don't really close and are usually open anyhow for infection control purposes.  Gotta keep the wind blowing through the hospital to blow out the TB bugs.

We have traveled a bit at the lower elevations where it is warmer and dryer.  Somehow that feels more like Africa

Dirt Roads

The attached photo shows my commute to work. Yes, that is a one lane dirt road.  So far that hasn't been a problem since there is so little car traffic.  There are some motorcycles (pikipiki in Swahili) and lots of pedestrians. This road, to my surprise, is on Google Maps and is their recommended route from my house to Selian Hospital. The road is much rougher in most spots than what you see here.  It is the shorter way to the hospital and much more scenic than the highway.  Corn fields, banana groves and native forest.  Occasional glimpses of Mt. Meru.

The two dirt roads to the paved highway used to be just as rough, but the city recently graded both of them and widened one of them.  Both of them can be one lane roads due to narrow spots or cars parked on the road.  They are, for the most part, 1 to 2 lanes wide with the wider spots being filled in by parked vehicles and road side vendors. There are pedestrians on both sides and crossing the road and motorcycles going wherever they please at a high speed.  The result can be chaos.  People, push carts, and livestock block your path in addition to having to take turns going through the one lane parts.  Even the wider sections usually involve driving frighteningly close to the oncoming traffic on your right side (Yup, we drive on the left side of the road here.) and pedestrians, etc on the other. One swerves back and forth over the entire road whenever possible in order to drive over only the smaller rocks and potholes.  It is initially disconcerting to have the oncoming traffic swerve directly in front of you until you realize that they are just avoiding a pothole and will swerve back just in the nick of time to just barely miss you.  You need to know that this vehicular ballet tempo is adagio, not presto. Top speed is around 15 mph and usually the speed is under 10 or even 5 mph.

God Save the Queen.

Although her actual birthday is April 21, for some reason, the international birthday celebration for Her Royal Highness, Queen Elizabeth was this weekend.  As we Tanzanians are part of the Commonwealth, we had a celebration here in Arusha although judging from this photo, we weren't wearing odd enough hats.. First was appetizers and drinks that were called Pimms. Very British, old chap. Then a wonderful picnic dinner.  There was live entertainment by local musicians who were all excellent. You haven't lived until you have heard the Beatles's I Want to Hold Your Hands sung with an African accent.  It was also a fund raiser to expand internet access for schools.  We bought two weekend getaways in the auction so I figure we put internet into several schools. We got weekends at what my sons would call kick-ass resorts. I would call them very nice resorts at a very nice price..  Google Four Seasons Safari Lodge.  We don't stay in places this nice. I think I could get used to this.

Children

I went on a bike ride with my brother, Erik. Now that was challenging mountain biking. At one point I lost sight of him on a footpath through a banana plantation and had to ask a pedestrian in my broken Swahili which way the guy on the bicycle took at the fork in the trail. Definitely not like the limited mountain biking I have done in the US. A great part of mountain biking through the countryside is all the kids. Riding a bike makes for a whole different connection to the community compared to driving a car.  The older school children are more reserved, but the little ones want to show off their English. It is always the same thing. "Good morning. How are you? Do you think Bernie Sanders will get very many super delegate votes at the convention?" OK, I made up that last sentence, but they are still very cute. Greeting us in English, waving, and a great big grin on their face.

The medical team

The diseases I am seeing now are quite different from what I saw in the US. Some are due to poor sanitation. I have never treated neurocysticercosis until I got here. It does exist in the US, but it is very rare. Some diseases are related to being in the tropics. I treat as many patients for malaria in a week here as I did in over three decades of practice in the US. (I saw one case of malaria in my medical residency and then never again.) Arusha is located at 4,000 ft on the foothills of Mount Meru so it is a bit too cool for the malaria mosquito.  We don't see as much here as in other areas.  Some medical problems are related to poverty. Typically people wait until they are very sick before they present to the hospital. A common scenario is a patient coming to the hospital with a 3 month history of diarrhea and two weeks of vomiting.  By the time they get to the hospital, they are emaciated. I have never used children's blood pressure cuffs on adults before. I do this on a daily basis here because of so many extremely skinny arms.

In the US, AIDS is treated by AIDS specialty teams for inpatients and outpatients. While there is an outpatient AIDS clinic here, when the patients are admitted to the hospital here with a complication of AIDS, I treat them.  In addition to triple drug therapy for the AIDS virus itself,  there are medications used to prevent infections depending on the CD4 count. There are also additional treatments for actual infection complications. A normal CD4 count  is often above 1000 and definitely above 500. Getting down under 200 is a high-risk situation. Just this week, I saw a patient with a CD4 count of 4. There are a variety of misunderstandings and logistic reasons that people end up not taking their AIDS pills.  

There are few functioning sinks on the medical words. So much for hand washing. I go through a pocket-sized bottle of hand sanitizer a daily basis. There are only multiple patient wards. There are no isolation rooms. TB patients are put next to the window in hopes that the bugs go out the window instead of onto the other patients. I am definitely going to get checked for AIDS and TB when I get back to the US.

The photo shows the medical team including an American resident here for one month and the Tanzanian Assistant Medical Officer.  An AMO is like a physician assistant in the US.  She has her hands full filling all the gaps in my medical knowledge.