Cubicle on the female ward

The Human Immunodeficiency Virus, or short HIV, is a topic you cannot circumvent, when working in the medical field, especially in most parts of Africa.
In 2018, the World Health Organisation reported 37.9 million people worldwide are living with HIV/AIDS with 770.000 deaths from HIV related illnesses. Around 25% of these people however do not know that they have the virus.

In Tanzania an estimated 1.5 million people are living with HIV in 2017. HIV testing is more commonly available and antiretroviral treatment (ARV) is available for free. Roughly 68% of the adults and only 46% of the children living wth HIV do receive the lifesaving treatment.

The woman, called Veronica, got admitted due to diarrhoeal infection and severe malnutrition. Veronica is suffering from opportunistic infections, common in patients who’s immune system is severely weakened. Her case is typical for treatment failure. However the underlying problem, why she did not adhere to her treatment regime remains unclear.

Many immune compromised patients are like Veronica suffering from similar opportunistic infections. Most common in the hospital in Shirati are Tuberculosis and Cryptococcus neoformans.

Tuberculosis (TB) is a bacterial disease and usually attacks the lungs. However also other body parts including kidneys, spine and brain can be attacked. There are two forms of TB, the latent form, where the person does not get sick and the TB disease form, with a possible fatal outcome if not treated properly.

The 40 year old man is lying in bed with stomach and muscles pains, fever, cough and headaches. Symptoms which can be attributed to various diseases. We ask the man a few questions about his lifestyle and medical history. What then catches our immediate attention is the man’s profession. He is a local fisherman and is fishing nearly daily in the lake Victoria, the biggest lake in Africa. To the doctor at the hospital the diagnosis is clear even before the stool sample would confirm it hours later: Schistosomiasis. 

Schistosomiasis, or also known as bilharzia, is a disease caused by parasitic worms and it’s one of the most important poverty-related neglected tropical diseases. More than 230 million people are infected worldwide, whereby the 30 million people living at the shores of lake Victoria are at special risk. 

People can get infected when their skin gets in contact with contaminated freshwater in which certain types of snails which carry the parasites are living. The parasites penetrate the skin of the people, for example fishermen, children playing in the water or women washing clothes. 

Symptoms of schistosomiasis are not caused by the worms themselves, but rather by the body’s reaction to the eggs. Undiagnosed and untreated, people develop a chronic form of Schistosomiasis, which can seriously and permanently damage the internal organs, including the digestive, urinary and nervous system as well as the heart and lungs. In children it can lead to reduced growth and problems with the cognitive development. 
Once diagnosed, the treatment is relatively easy with Praziquantel, a medication taken for 1-2 days. However the rate of reinfection is high, due to the importance of the lake for many people in this region. 

The male ward in the Shirati KMT hospital is divided into three cubicles with six to seven beds in each one. Patients from age twelve onwards with different diseases and conditions are lying here next to each other and are supervised by Dr. Chirangi, his Team of doctors and the ward nurses.

The next patient, who was involved in a motorcycle accident, broke his spine and is unable to move his extremities. Lacking a CT scan or MRI, the hospital in Shirati is unable to proceed with a more specific diagnosis nor can it evaluate on any treatment options. The only chance is the transferral to a hospital in Mwanza, five hours away by car. 

Road traffic accidents are widely common in Tanzania and the unpaved, bumpy roads around Shirati, night driving without lights and drunk driving are the prime factors of many accidents and the main reason for admission to the hospital.
Many villages and houses are only accessible by motorcycles, also called pikipiki, which make them the main means of travel in this area and carry passengers around as taxi service. Few drivers are wearing a helmet and some never acquired an official driving license. 

But also bike accidents do occur. One young man fell of his bike, as the breaks suddenly blocked. Besides multiple and large abrasions on his head and body, he additionally broke his elbow joint. The X-ray shows the difficult fracture and the doctors suggest a transferral to Bugando Hospital in Mwanza. However the patient decides to go with his injury to a traditional healer in his village, also called a bone-setter. The term alone, about someone without medical training resetting bones, honestly gives me the creeps.

Traditional healers are still widely common in rural Tanzania and their methods very controversial. In terms of fractures most people are often left with a lifelong disability or inability to move the treated side adequately. However deeply rooted cultural beliefs and lack of money to afford an operation consistently draws many patients to traditional practices.

These are just two examples of diseases and conditions often being present on the male ward. However there are so many more. Some rather harmless, others life-threatening. Every day there are newly admitted patients coming onto the ward. Many of them will be discharged a few days later with just a drug prescription in their hands and a smile on their face, all while someone in the other bed might be still fighting for his life.

The woman is clearly restless. She paces around the delivery room and has absolutely no intention of laying back down on the old and battered delivery chair. When another contraction is approaching, the woman spreads out her Kanga, a big thin cloth, on the ground in front of the chair and lays down, panting and whimpering. Laying on her back on the ground, she quiets down for awhile. But only seconds later she gives out a short, hardly audible moan. The nurse in charge approaches her in determined but relatively relaxed steps and kneels down to her. As I look over her shoulder, I can already make out the head of the baby and just moments later, the nurse holds up the newborn in her hands. 

The maternity ward at KMT Hospital in Shirati receives more than 250 expectant mothers each months to deliver their babies. The majority of those women are able to deliver naturally in the delivery room of the ward. However obstructed labour, fetal stress or other risk factors can make a C-section necessary and inevitable. 
HIV infection in expectant mothers is a common risk factor in this area, where HIV prevalence can reach up to 13-15%. A C-Section accompanied by an antiretroviral therapy (ART) for the pregnant women to decrease the viral load are the main factors to decrease the risk of mother-to-child transmission during birth. 

The next mother in the delivery room is a young local woman, being in her third pregnancy, after a miscarriage two years ago. The prolonged labour and the resulting fetal stress, makes her a candidate for a C-section in the operation theater (OT) and with no further delay she is wheeled off. The baby and the mother make it through the operation without any further problems and are discharged a few day later. 

Miscarriages and stillborns are quite common, due to malnutrition, infections and other factors. One woman came to the hospital being in her late third trimester of pregnancy. The doctors and nurses however couldn’t make out a heartbeat or fetal movements. The fetus had already died in the uterus, which is also called late intrauterine fetal death. Shortly after this devastating diagnosis, the birth is initiated by medication and the woman gives birth to her dead baby in the same delivery room, as the other expectant women. The corpse of the baby is then kept in a seperate room, next to the delivery room, until family members pick it up to take home for the funeral. A refrigerated morgue does not exist in the hospital.

Also premature births and children with a low birthweight are seen in the maternity ward on a regular basis. However the hospital is not equipped to provide intensive care for neonates, lacking especially incubators, reliant oxygen therapy and monitoring. Premature neonates therefore face a harsh destiny here in rural Tanzania and are rarely able to survive. 

Not every pregnant woman delivers their child in the hospital, which is due to various reasons. A woman might not be able to reach the hospital in time and delivers at home, with or without help, or on the way to the hospital. Furthermore traditional birth attendants (TBA) are still common in rural villages in Tanzania and help pregnant women through labour. However complications during births and the lack of adequate emergency care for the baby or mother can often put them both in danger.

The Maternity ward can be a lawless place sometimes. Always on the brink of chaos. For sure it is a very raw place. A place where unbearable pain and sheer joy and happiness can be felt so intensively, where feelings and emotions cannot be hold back and where life and death are sometimes just an armlength apart.

Welcome back to East Africa. More precisely Tanzania.

Nearly six years have passed since my last visit to Eastern Africa. However a familiar feeling overcame me, when arriving in Nairobi, the bustling capital of Kenya and my official starting point of my three month long Africa trip.

After a short stay in Nairobi, which I mostly spent by feeding baby elephants in the David Sheldrick Elephant Orphanage and giraffes in the Giraffe Conversation and Breeding Center, near the Nairobi National Park, I also managed to organise a bus ticket to Isebania, the border town to Tanzania.

The distance of roughly 330 km took around nine hours on roads which changed from decently paved to absolute nightmarrish dirt roads. The breath-taking views into the Rift Valley in Southern Kenya were accompanied by my sheer terror of the steep slopes leading down into the valley and which came unspeakably close. However the musical entertainment on the TV screen in the front of the bus helped to distract me not only from my fears but also from any normal thought in general. On full volume I received a nine hour long program starring many, if not all, gospel choires of Kenya.

In the border town, Fred, my Tanzanian host, was picking me up with the car, which took us around an hour to my new home in Shirati. Here I am currently doing a clinical internship in the regional KMT Hospital, to gain more experience in the medical field in Africa. Shirati lays a rough 45 minute walk from lake Victoria, of course depending on how often you are being stopped by children and other people happily greeting you.

How do I live?

My new home for the next two month is a big house with five bedrooms which are mostly shared. Fred, who is the owner of the house, is renting out the rooms to volunteers and interns either working in the hospital or doing research for their studies in this area.
At the moment I am sharing the house with him, his cousin Grace and two other students from Maastricht, Christof from Belgium and Diann from Rwanda.
We have three bathrooms with, wait for it, running and even hot (!) water, proper toilet seats (no squatting) and best of all, electricity. From my Kenyan experience in 2013, this is absolute luxury and I love to hang around in the house. Especially when it is to hot to go outside, which is quite often. There´s a big kitchen and living room and Mama Jenna (called after her firstborn), a local women, is cooking for us twice a day. What a treat!
The house is surrounded by nature with some neighbouring houses, where other family members of Fred and Grace live. It is pretty rural, with cows, goats and chicken running around. The rooster often crowing before my alarm clock goes off. Pure idyl I have to admit.

What kind of hospital am I working in?

The Shirati KMT Hospital is a 150 bed regional hospital, a short 5-10 minute walk from my house.

There´s an Out patient department, an operation theatre, a laboratory, an intensive care unit, a female and male ward, a maternity and pediatric ward as well as a leprosy center and a nursing school right next door.
There are nearly only local medical staff working in the hospital, but thanks to the continuous efforts of the medical director, Dr. Shirangi, there is an ongoing exchange of medical and research staff from abroad in and around the hospital.

What do I do in my free time?

Well if I am not in the hospital, which is mostly in the evening or at the weekends, I like to do some walks around town, to the food market or the monday market with local clothes (second hand) and household items (20 minutes), to Oboke mountain (1 hour) or to the lake (min. 45 minutes).

There are some local bars, where you can play pool, darts or even play your own music (yes, for real).

The next bigger cities are Musoma (1.5 hours) and Mwanza (4-5 hours) by car. As I was mostly staying in Shirati and partly at the hospital during the weekends, I have not yet made a roadtrip to those places. Otherwise it is also nice to hang around in the house, watch a movie with the others or play cards. Pretty chill lifestyle, don´t you think?

A team of young locals and me collected donations to purchase food and hygiene items for the flood victims in the greater area of Colombo in May 2016.

Music by Chris Zabriskie

Sunset at Delta Beach

​1. When you start wobbling your head from left to right when talking to someone without realizing
​At first the wobbling head looks like the shaking of your head, indicating a “No”.
​However, after a while and many questionable “No´s” from the locals later, we realized the small difference between shaking and wobbling your head.

And suddenly life made much more sense.

“Is this bus going to Udupi?” A head wobble response, which has always been interpreted as a “No” and leaving us standing waiting for the “right” bus for quite a while, was now an invitation to hop on.
And after more than three months in this lovable head-wobbling country, I often find myself wobbling my head in agreement anywhere I go.

2. When you complain that your food is not spicy enough
First: “Indian Food is not that spicy as I expected”.
Then: “Maybe I can handle spicy food better than I always thought”.
But then: The ugly truth.

Many restaurants in India serve mild and sometimes even plain dishes to Western people, as they think they cannot handle the spiciness of the real Indian food.
Go for the real Indian food, even though you sometimes have to be persistent when ordering and even though this decision might leave you breathless or with tears in your eyes. When asked, if you enjoyed it, just smile the tears away and wobble with your head.

3. When you wear long pants, a shoulder covering shirt and a scarf at 37 degrees without even batting an eye
The eye lids become heavier every minute, the voice of the teacher has turned into a snoozing noise in the far distance and the overall heat surrounds you like an unescapable cocoon. The seat in the classroom is always wisely chosen underneath a rotating fan.

Long pants, shirts and a scarf when all you want to wear is the shortest of all shorts and the thinnest tank top you own.

But starring men and women nearly everywhere you go and not being able to enter certain public or religious buildings, make you rather obedient to the common culture and customs, even though this will include a thin layer of sweat on your skin, nearly all the times.

4. When the luggage rack in the train, is a decent alternative to the crowded train compartment
First class, second class or local ticket?
When deciding for the latter, prepare yourself for a rough fight for a seat in the crowded compartment in the back of the train. As soon as the train arrives at the train station, people grab their belongings in a hurry and start sprinting alongside the still moving train, managing to jump on it before everyone else, just to get hold of one of the favored seats. Often not capable to imitate the Olympic sprint abilities of the locals, the luggage racks on top of the seats form the only decent alternative for us, when not willing to stand or squat on the ground for hours during the journey.

5. If you have at least one story to tell about having an upset stomach
Details only in private conversations ;).
However one thing is for sure: You never leave India without a good s*** story.

6. When you are asked to be on photos with absolute strangers more or less every day
From children of all ages, to mothers, whole families, single men and large groups of men.
Sometimes it seems to be that everyone wants to have a picture with you.
Most of them are harmless requests and just the pure enjoyment of people having a photo taken with a western looking person to show and brag about in front of their family and friends.
However be careful not to give out your personal details to anyone. Love and marriage proposals, daily text messages with photos or unwanted tagging in pictures with being called the new best friend or love of their life are more than common.

7. When sitting in the front row of the bus doesn´t cause you a nervous breakdown
My personal advice for anyone who is already anxious about the traffic in Europe:

Do not sit in the front row of an Indian bus.
And not in the back.
Maybe you should not be on a bus at all.

However when travelling through India, there is no way around being involved in the Indian traffic.
The roads are shared by anything you can imagine, including trucks, busses, cars, rickshaws, motorcycles, bicycle carts, scooters, bikes, pedestrians, cows, camels, chicken, dogs, pigs and all kinds of rubbish.
The bus driver navigates the rattling remains of the bus violently through this madness, ignoring and breaking more international traffic rules one is able to count and honking on average every two seconds at anything that moves.
Luckily all other motorized road users including the rickshaw drivers try to stay away from the bus driver and his suicidal driving skills, however this does not prevent them from honking fiercely at the bus and cutting him off every now and then to overtake him.

And lastly … when despite all the chaotic, messy and unorganized conditions, India still manages to put a smile on your face and surprises you each and every single day …

View from our balcony in Manipal

​​It has been already 2 months since I have first set foot on Indian grounds and even though I was not planning or looking for it, it somehow has arrived, the daily routine.

Within the last few weeks six of my colleagues from Maastricht and myself managed to rent out two private apartments in Manipal with a breath-taking view from our balcony on the flourishing green valley of the city. The first few weeks of our stay were spent in the university hostels on the campus, which were on the one hand separated for girls and boys and on the other hand very strict with visitor rules and midnight curfew.

The weeks have passed quickly with all the experiences, impressions and daily adventures we came across. The two main subjects at my elective track of social work included “Psychiatric social work” and “Medical social work”, with both of these subjects providing plenty and diverse information about the health care system and the provision of medical services in Karnataka and India in general. On Tuesdays and Wednesdays we went into the field and gained insight into the practical work on the ground of various local organizations including a community health care center, a shelter for destitute and mentally challenged people, a palliative care center for the terminal ill and a human and child´s right organization. All these examples showed us the daily opportunities and challenges faced by various groups of people in India, the health care professionals and social workers. The Indian government spends only 4% of its annual GDP on health, compared to 11.3% in Germany. Many private organizations and NGO´s are therefore struggling with financing themselves and are highly reliant on external donations and funding.

Since a few weeks I have been visiting the Ave Maria Palliative Care Center in Mangalore more intensively, to get a deeper understanding on the hospice developments in India. Laveena, the director of the hospice, has been working and living in the USA, until she decided to come back to India. She sold all her possessions and returned to India with a suitcase of money and one dream. That dream has now solid walls and space for 14 terminal ill patients, who have been given up by their doctors and who cannot be supported from their families at home. Especially people suffering from late stage lung and breast cancer are being cared for by Laveena and the nursing team.

​The hospice is not receiving funding from the government, but relies solely on donors and well-wishers from India or abroad. One well-wisher donated money to buy a rickshaw, which is now mainly used for home visits of terminal ill patients who are cared for by their families at their homes, but who need regular check-ups or wound dressing from the nurses or psycho-social support from the social worker. I accompanied the nurses on their daily shift, which lasts 12 hours and includes tasks like washing and helping the patients to get dressed, feeding them, administering medicine for example oral morphine tablets and furthermore talking and helping them with worries and concerns. Many of the patients lack support from their family due to separation, divorce or former arguments. The team of the Ave Maria center helps the patients to find closure by inviting family members to talk to each other and settle their disputes. The stay and care at the hospice is free of charge and is open to everyone, independent from their religion, ethnicity or caste. However if possible the patient or the family are asked to contribute to the medical bill, for example paying for the medicines or wound dressing materials.

The rest of the time is mostly spent with our other courses from Maastricht University including an online tutorial, in which we work in small groups with students from Maastricht and Canada together in planning and developing a health intervention proposal for a fictive fund of 3.5 Million Euros. Furthermore we are slowly preparing our thesis proposals as from May until the end of August we are going to work and research in our thesis placements all over the world. Currently I am planning to go to Sri Lanka to work with stakeholders on the prevalence and stigmatization of HIV and AIDS in the country.

The weekends are either spent here in Manipal with exploring the city and going to the nearby beaches or travelling to various places in South India, including city trips to Mumbai and Mysore, a backwater tour in Kerala, some beach fun in Goa or hiking in the hills of Madikeri. Travelling is inexpensive with night busses and night trains covering most destinations, however it can be quite exhausting as a single trip can take up to 12 hours or more, due to bad road conditions, distances and traffic even at night.

Living in India has been incredible so far. Every day is an adventure and we cannot stop smiling about the craziness, beauty and happiness of this country.

The journey started on the 2nd day of January, when I boarded my flight from Düsseldorf via Abu Dhabi to Mangalore in the state of Karnataka in South India. Of course you might say it must have started far earlier when I made the decision to come here. However those weeks before, filled with the application for my study abroad, the final decision and acceptance of my application and the applications of the other 19 students from Maastricht University, the visa approval and booking of the flights were racing by without realizing what was laying ahead of me.

After quitting my job at the Chidren´s hospital in Cologne, sub-renting my room and many, many (tearful) good-byes from my family and friends, I grabbed my one-way ticket to India and 15 hours later touched down in a different world.

I am currently studying a Master in Global Health at the University in Maastricht. A one-year program filled with subjects in policy analysis, biosciences, statistical analysis, health innovations and governance and most important, the possibility to go abroad and study at one of our partner universities.

That is, what brought me here to Manipal, where I now study social work and mental health at the Public Health Department. Next to lectures, with an average temperature of 27°C in the classrooms, we take part in weekly field trips, in which we visit local community organization and NGO´s and get direct information from the field related to local health care provision and services. As these visits often have touched us deeply, I would like to share my experience with you, about meeting incredible and inspiring personalities, who are constantly trying to improve the lives of their fellows.

Shanti, a middle-aged Indian women and her husband have been infected with HIV for years themselves and Shanti knows how tough life can be within the community, as discrimination and stigmatization of HIV positive people still prevails all over India. However when Shanti had to visit the doctor, to get an official statement of the HIV status of her children for their school, she had an encounter which changed her life. In the doctor´s office, she was sitting next to a mother with her son, who had to get the same statement about the HIV status of her child, however her son was positive. Shantis children on the contrary were HIV negative. This was the moment Shanti realized, that a mother and her child shouldn´t go through this and be forced by schools or anyone at all to disclose their status, especially if this would have negative consequences for their daily lives.

In the office of Deepajyathi Organization in Udupi

Today, Shanti is part of the board of the Deepajyathi Network for Positive People in the region of Udupi. She and her coworkers offer individual and group counselling for infected and affected people with HIV. In small support groups they provide knowledge and information on HIV, its transmission, treatment possibilities, but they also educate the people on issues like nutrition, hygiene and do offer support for the families of their memebers. More than 2700 people and 150 children have already been registered with the organization, however Shanti estimates over 5000 unregistered cases in the region. Through awareness raising in youth and women groups the organization tries to promote safe sexual practices, prevention and empowerment of women in general. As there is no sexual education in schools or within the local families, Shanti and her coworkers are doing valuable and meaningful work, trying to combat HIV stigmatization and discrimination in their region.
​
The program is currently funded by the Global Fund for AIDS, Tuberculosis and Malaria, however this funding is going to run out this year and Shanti and her organization are not knowing if the project will be prolonged. Most organizations like Shanti´s only survive through external funding like donations as the annual national health care budget does not exceed 4.2% of the GDP. Thus no help of the government can be expected and alternatives for funding still have to be fund…

We are sitting in front of the telephone. Waiting. Impatiently.

Suddenly it starts ringing. It´s him. Dr. Mugalo from Eldoret Hospital.

We can hardly concentrate on what he says. We hear words like operation, 5 hours,  attempt, very difficult, rebuilding urethra, Emmanuel awake, the rest  in God´s hands.

We hang up and look at each other. Let´s hope the best, we think.And the best is what happened.

Emmanuel got his operation. As Dr. Mugalo described via the phone, it was a difficult task as the urethra was to fragmented and the gaps to wide to reconnect it. He therefore circumcised Emmanuel and used the skin to build a bridge and connect the several urethra parts.

Emmanuel woke up from his narcosis with two urine catheters, one supra-pubic, like he had before his operation and one stabilizing his urethra. After some weeks of waiting and letting the wounds heal, Dr. Mugalo removed the urethra catheter and blocked the other catheter.

And the urine was flowing.

I cannot describe our relief and happiness (actually we were jumping up and down in our house).

Though Emmanuel still has a long way to go and for example first has to learn again how to use his bladder musculature in order to hold his urine, he has changed enormously already.

When we first met him, he was a very shy and silent boy, with a serious facial expression which made him look very grown-up. After his operation we got to know a new Emmanuel. The first smile on his face, we will probably never forget.

With the money from all the donations we were not only able to pay for the whole 5 hour long operation and Emmanuel´s one week hospital stay, but we also bought him a new football to play with, as well as 3 goats (one male and two female) and we gave away our chicken White cap and five of her small children (yes, White cap is now a proud mother of 10 small chicks) for the family to have a more balanced diet and the possibility of generating more income to feed and educate their children.

Don´t go into her house.

Don´t shake her hand.

Don´t use the her fork.

Everlyne (38 years) carrying her harvest

Maybe it is time to meet someone…

Someone like Everlyne, 38 years old and HIV positive.

Everlyne got tested for HIV when she became constantly sick during her pregnancy. After she got to know, she cried for days and stopped eating entirely. HIV and death were so intertwined in her mind that living seemed no option anymore. Friends and neighbors started ignoring her and stopped visiting her in her home, afraid of getting infected themselves. Her in-laws believed that a witch doctor brought the disease to her. She was not allowed to eat with them in the same room, she had her own plate, cup, fork and knife. They did not touch her clothes, not even after being washed. People she knew said to her face that she is going to die soon and that the disease has already spread to her brain.

Everlyne lost more and more weight, she hid in her bedroom, afraid of leaving the house and facing other people who would point at her and talk behind her back. Her husband left her for another women after she told him that she is HIV positive. Her husband has never told her that he is HIV positive himself. He took his medication for HIV secretly or when Everlyne saw him taking his medication telling her he is taking pain tablets. Now she is left alone at home with her six children and five orphans from the community, whose parents died of HIV, to take care off.

Agnes (36 years) in her hut

Or meet…

Agnes, 35 years old and also HIV positive.

Agnes also got tested after being sick during her 5th pregnancy. After she found out she was positive, she did not disclose her status to her husband as she was afraid to tell him.

What she did not know by then was, that her husband was already tested HIV positive without telling her.

When her family in-law found out that Agnes is positive, they started to ignore her. They walked out of the room, when she came in. They rejected the food she was cooking for them. They blamed her of bringing the disease into the family.

In church no one wanted to give her anymore tasks as everyone expected her to die soon and they never got tired reminding her. Her friends from the choir even washed and prepared their choir uniforms as they thought they were going to sing at Agnes funeral any time soon.