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The Path to Healing & Helping in Guatemala

The following entry was written by Victoria Valikova, medical doctor and founder of Health & Help. It is a follow-up piece to Victoria’s first post. Health & Help recently opened their clinic in Chuinajtajuyub, Guatemala with the help of MedShare.

When you realize that you have the power to change something, you have two paths you can take from that moment on: go home and forget about what you just saw, or go and change something.

Health & Help’s people are dreamers. We dreamed about what we could do here in Guatemala, in a remote village called Chuinajtajuyub. So we built a clinic, a clinic that would spend every day, 7/24, attending to people in need.

We started from the very basic: we opened a health facility in a local school. Now we have a clinic with three consultation rooms, a laboratory, a pharmacy, and three beds for our in-patient room. Volunteers live on-site and provide permanent support in emergency situations. We assist deliveries, suture machete cut wounds, and help severely sick patients every day. Quickly, we became the number one health center in our area. People are sure when they come to us they will get help and support.

Health & Help Clinic works with severely malnourished kids and elderly people. We provide education and treatment for people with Type 1 and Type 2 diabetes. We promote family planning and we take care of pregnant women in every trimester of pregnancy.

We have a nice team of professionals and we’re always searching for more volunteers to work with us. If you are interested to work in Guatemalan mountain village – please contact us at viktoriya.valikova@gmail.com.

Last, but not least: we have a great friend, their name is MedShare. They make our work so much easier because with them we don’t have to worry about running out of medical supplies. We always have materials to take care of our patients. We are always sure that we will be able to help, because of them.

From Guatemala with love,

Victoria

Medshare Aids Women’s Healthcare in Micronesia

The following entry was written by Juliane Poirier, a team member with Canvasback Missions,  a Medical Mission Team supplied by MedShare.

Canvasback Missions, of Benicia, California, was recently aided by Medshare in sending a well-supplied team of U.S. health professionals to Micronesia, Feb. 3 – 17, 2017. Canvasback’s 20 volunteers operated a free women’s health clinic on Majuro, capital of the RMI (Republic of the Marshall Islands).

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The clinic waiting room was packed with patients. During the two-week clinic, medical volunteers provided more than 450 medical consultations while simultaneously teaching Marshallese nurse-practitioner students, who translated for patients and staff. The needs were great, both among the nursing students and the patients eager to be seen by a doctor.

A clinic worker on her first trip to the islands described being touched not only by the beauty of the islands, but by the kindness and generosity of the Marshallese. It was reported, for example, that not one person complained at the clinic, even though they were obliged to wait their turn for much longer than would be tolerated in the U.S. A number of Marshallese women waited patiently for up to 10 hours—including those well past middle-age— to been examined for the first time in their lives by a gynecologist.

Some had suffered for years with afflictions requiring medical procedures not routinely available to them on their remote home islands. A 25-pound cyst was removed from one woman’s ovaries and, unrelated to gynecology, a 55-year old male was relieved of pain from a severe liver abscess when our radiologist drained 40 cc. from the man’s liver. The Canvasback physicians also worked cooperatively with Marshallese doctors at the Majuro Hospital on a number of patient diagnoses which were aided by the ultrasound, cytology and radiation results provided by medical volunteers.

 

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Overall, there were 34 operations performed, 711 clinical procedures completed, and 61 medications dispensed in the course of the clinic, as our team diagnosed many cases of cervical cancer which, in the U.S. is considered a preventable disease.

“Most women can avoid cervical cancer by routine screenings,” explained Canvasback volunteer Kathy Nelson, a gynecologist from Montana.

One 40-year-old woman who came to the clinic was diagnosed with cervical cancer so advanced that she had only months to live. Marshallese women diagnosed with cervical cancer must have more than a 50 percent survival expectation in order to be sent, at RMI government expense, to an off-island location for treatment; otherwise, they are provided with palliative care.

In this isolated region of the Pacific, diabetes is epidemic among both old and young. But positive changes are taking place to extend the health and vitality of Marshall Islanders. Canvasback runs a Wellness Center on Majuro, providing diabetes prevention education, affordable and healthy meals, exercise classes in an air-conditioned gym, and educational materials for improved lifestyle habits, including vegetable gardening.

Canvasback Missions has been sending medical specialty teams and supplies to Micronesia for over 35 years. Medshare has been helping tremendously with supply donations to help Canvasback teams provide critically needed healthcare for people of these remote Pacific islands.

 

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Racing in the Rain

The following post was written by Jalal Clemens, MedShare Western Regional Council Member and Young Professionals Committee Chair

We had quite the adventure this past Saturday morning at the Mt. Tam Wild Boar 10K. Despite the cold light rain all of the MedShareFundraising Run Team members showed up early and ready to go. After the race director Dave gave all the runners an overview of the course one of our team members was pulled out of the crowd to help Dave, the race director, lead the whole field of runners in “America the Beautiful,” a tradition for these special trail runs.

The course itself was simply stunning as we ran along a muddy single-track trail cut into the side of the newly green mountain slope near the Bolinas ridgeline topping out with Mt. Tamalpais. As we came around the first curve we were treated with a view of the ocean crashing on the beach and cliffs, nearly 1,000 feet below us, enhanced by the occasional patch of beautifully formed fog mini clouds. The amazing view caused me to forget the near freezing temperatures and cold light rain that had encouraged us to start at such a brisk pace just to warm up.

We weaved into the pockets of the mountain where wonderfully fragrant evergreen trees grew and, at the inner crease, beautiful waterfalls begged for us to ford them. As we continued along the trail I realized I could not think of a more perfect way to experience movement through nature. With the repeated stunning views of ocean and waterfalls along a graceful ribbon of earth, the first five miles blew by in what seemed like only a minute.

As I arrived at the 5 mile aid station in a near trancelike state of joy, despite the increasing intensity of the cold windblown rain, I sadly realized I only had a little over a mile left. Noticing the tight vertical switchbacks staring at me past the cheerful volunteers snapped me back into the reality that the last mile was not going to be like the first 5 transcendent downhill loops.

Powering up the switchbacks, I gradually slowed to a shuffle and then a walk as the course began to more closely resemble stairs than a trail. Finally, I saw I was nearing the crest of the hill. Summoning my reserves I burst out of the trees into driving hail, yes, small balls of speeding bouncing ice, that chased me the last .2 miles soaked and now thoroughly exfoliated.

As members of our MedShare fundraising Running Team team crossed the finish line, only a few minutes apart, the team exploded in cheers as we all hopped and huddled trying to stay warm under the few little tents protecting the post-race snacks and water. For some, it was their first race ever and I was so happy to see they enjoyed the truly unique climate experience this unusual race provided. After one last team photo we all darted for our cars, still proudly wearing our soaking MedShare team hats and shirts – headed home for a hot bath we would appreciate as likely never before, already warmed inside by knowing our fundraising efforts would help repurpose and send unused and unexpired much needed medical supplies to underserved people globally and locally.

Renewed Hope in Marsabit, Kenya

The following post was written by Henry Kahara for The Reject Newspaper, a monthly publication of the Media Diversity Centre, a project of African Woman and Child Feature Service. See original article here.

A few years ago, residents of Marsabit County couldn’t find a reason to visit their district hospital even for basic medical care.

The hospital, meant to serve a huge number of the county’s population was in ruins. The staff were overworked, departments under-equipped and, understaffed.

Although the hospital staff strived to provide the best care for the patients under the circumstances, with lack of equipment and supplies necessary to do the jobs they had been trained to do, their efforts were a drop in the ocean.

However, thanks to collaboration between Marsabit County Government, Partners for Care, Medshare and Coca Cola Africa Foundation, the residents now have a reason to smile.

According to Connie Cheren, founder Partners for Care who spearheaded a project that saw the hospital acquire a new phase, it took a collaborative efforts that saw stakeholders do an overhaul on every department to give the hospital a total face-lift.

Cheren who is a nurse in the USA, mobilized different stakeholders after learning of the hospital’s sorry state. She explains: “Once during a visit to the hospital, I realised the locals hardly made hospital visits. My quest to find out why women particularly were shying away from delivering at the hospital, led to a shocking discovery.”

Says Cheren: “There were old broken and rusty beds at the hospital and almost half of the patients’ beds didn’t have mattresses.”

Cheren notes: “In addition, most of the machines at the hospital were dysfunctional and it was difficult to offer even the basic care needed for a woman to deliver. My heart bled and I felt inclined to do something to change the situation.”

Cheren’s efforts led her to get the support of Medshare, a humanitarian organization dedicated to improving quality of life for people by sourcing and directly delivering surplus medical supplies and equipment to communities in need around the world.

Coca Cola Africa Foundation joined on board to form a strong partnership. Medshare donated beds and equipment to the hospital whereas Coca Cola African Foundation funded the shipping and transport to Marsabit.

Former Chief Executive Officer of Marsabit Hospital, Dr Dima Galogalo recalls how health providers at the time would refuse to be stationed at the hospital.

“Things were so bad that at times patients would die from curable diseases. Many organisations had come before promising help that eventually would not be forth coming,” explains Galogalo. He recalls: “So when Cheren and partners pledged to assist the hospital, we were at first naturally sceptical.”

However, Galogalo decided to talk to his team and as that they give the partnership a chance “as any help was better than none”.

Help at last!

In August 2013, the first container with equipment arrived to the disbelief of the hospital team. This changed everything about the hospital including the number of patients coming for treatments.

Galogalo, who is currently Marsabit County Health Director, says the hospital services have greatly improved, so much so that now the hospital serves patients from as far as Moyale among other areas.

“Now, we can afford to offer high quality medical services thanks to Medshare, Coca Cola Africa Foundation and Partners for Car,” he notes.

With the demand for medical services having gone a notch higher, the Marsabit County Government has further chipped in and equipped the hospital with 10 ambulances, a great improvement from the one broken down ambulance they had originally.

Maria Elema, nurse-in- charge at Marsabit County Hospital says before the improvement at the hospital, the maternity wing especially experienced great difficulties.

“Women had to come with their own gloves among other basic supplies needed for delivery,” says Elema. She explains: “The risk of infection coupled by a low bed capacity posed a major health risk to both mothers and babies.”

Elema notes: “This discouraged many women from seeking delivery services at the hospital, but today the narrative has changed.”

The hospital is currently managing more than 120 deliveries every month, which translates to four deliveries daily compared to before when on a good month the numbers were at 50

In addition, the hospital has baby warmers and this face-lift has gone a long way in reducing not only maternal mortality but also neonatal death.

The partnership also equipped the hospital with furniture and computers to collect accurate data. Previously, the hospital had shut down their therapy department but with the donated equipment, the services have since resumed.

Abshiro Hapicha, Chief Executive Officer at the hospital says they now have state-of-the-art equipment. Some of these include all new electric beds, mechanical lifts, walkers, canes, wheelchairs, braces, hundreds of boxes of much needed supplies such as bandages, gloves and protective clothing for staff among other basic items.

According to Hapicha, Marsabit County Hospital has struggled for years to serve the overwhelming needs of the 200,000 people in its district. Even health practitioners would shy away from working in such a locality. However, the odds have since changed and in 2016, the Marsabit County Government established a fund to entice local students to pursue medical courses to deal with the severe shortage of health workers.

Now the residents of Marsabit County have renewed hope with quality medical services in place.

Surgical Supplies in Tanzania

The following entry was written by Dr. Doug Grey, former MedShare Board member and current Western Council Member, about his work at Muhimbili University Hospital in Dar es Salaam, Tanzania.

Things have gone well the first three weeks at Muhimbili National Hospital in the Upanga District of Dar es Salaam. We have participated in, assisted on, and performed many operations. We’ve experienced highs and lows, depending on the circumstances and the outcome, sometimes both in the same day.

The retired Chief of Surgery of San Francisco General Hospital, Bill Schecter, began this program with the premise of having a cadre of surgeons spend a month at a time helping with operations, making rounds, giving advice, and providing examples of how surgery is practiced in the US. The adage, “You can’t solve a problem that someone doesn’t know he has” comes into play. Bill visited many facilities in Africa and Muhimbili had interesting cases, some interested staff, and a pre-existing relationship with University of California, San Francisco. The Dean at UCSF had spent time in Dar and had actually helped sponsor a donated building to the medical center. So here we are. We have provided about 20 months of surgical assistance over the last four years for MNH.

The Scrubs and Gowns…

The surgical scrubs at Muhimbili are an experience. There is a sewing room where all the scrubs are hand sewn. Ordinarily, surgical scrubs come in a few sizes, are made of cotton, and have pockets for storage. They are extremely easy to put on. At Muhimbili, the sewing room has received some very durable new material that is more like tent canvas. It is hot. The gowns made from this materiasl are so undersized that removing them almost involves the Jaws of Life. They have a loop of cordon that is difficult to tie. They may fall down if the cordon knot loosens while walking. The pockets sometimes have holes in them and things fall out. But the older versions are thinner, cooler and do the trick. Many of us ended up using shirts that we brought and washing them at home every day.

Surgical gowns are typically fitted to put on easily, they have tapered sleeves and gathered wrists for ease of gloving, and are impervious to blood. The MNH surgical gowns are a different experience. They are of varying age, some new, some old, and are porous cotton fabric. Surgeons wear a plastic “butcher’s apron” underneath to prevent blood getting through. They are taped in the back to keep them closed. The sleeves are straight and have no wrist gathering. Donning gloves with these are a challenge, as nurses and surgeons glove themselves. Maintaining sterile technique is tricky, but thankfully absolute sterility here has not been a necessity, as was the case during the Ebola epidemic. The infection rate is extremely low, so what is done seems to work.

Disposables in the OR…

One curious aspect of the conduct of operations is the near total absence of expensive disposables during surgery. Things such as drains, catheters, sterile covers for cautery, etc. are all absent. These are replaced with lower budget common items. The disposable glove, in addition to being a glove, can be used as a drain, a surgical cover, a collection container, a specimen bag, and a bag for generating airway pressure. There are probably many more uses. The amount of anesthesia supplies in a typical hospital closet can be massive. But here, it is a few drawers of IVs, a few buckets of IV solution, and some intubation equipment and medications. They have learned to do without.

It has been a privilege to work this month at Muhimbili National Hospital.

 

 

Stories from Tanzania

The following are a series of entries written by Dr. Doug Grey, former MedShare Board member and current Western Council Member, about his work at Muhimbili University Hospital in Dar es Salaam, Tanzania

Week number two began in a different way. There is a religious complex at Muhimbili consisting of a mosque on one side of the cross campus walkway, and two back-to-back chapels on the other (one Catholic, the other Baptist). I decided to visit the 6 am service at the Baptist chapel. The chapel is open air and there are permanent square cutouts in the cinder walls that allow the signing or amplified preaching to be heard well away from the church. There were about 30 attendees, a preacher, and a man on the keyboard. The roughly 40 minute service was punctuated by preaching (in Swahili, and I would not want to be on the receiving end of whatever he was preaching against), singing, and praying. The singing was to me, most remarkable: it was strong, in unassigned three to four part harmony, and absolutely uninhibited. It was what I had heard the week before. There were a few “low alto” women who were inspired. They could not have been more welcoming.

 

The Patient’s Family at Muhimbili

One of the striking features in all the rounds of patients we have seen in this profoundly resource-constrained country is the obvious lack of many basic elements that we associate (read as “take for granted”) with good patient care. Many of these are startlingly absent at Muhimbili. Missing items can be as simple as provisions of food, bedclothes, liquids, and some basic elements of hygiene. Service varies here; some wards are provisioned well but the public wards are absolute bare bones. I mention this as an observation, not a criticism. Much, if not all, of the shortfalls in provision of these basic human needs are provided by families. From kangas (colorful fabric coverings that provide coverage and privacy for the patients) to drinks, food, dressings, and transportation needs are all provided uniformly, unquestioning, and cheerfully by family members. I saw this time and again in the outpatient clinic. An elderly family member would require a wheelchair and assistance with the most basic needs, and there would be one or perhaps two attentive sons taking on this burden without hesitation. And this is in an environment where aids for disabled people are not required by law as they are in the US – something which we take for granted.

During the seasonal cleaning of the wards all patients are evacuated into the streets, parking areas, and parks for several hours while the wards are scrubbed. It is disarming to see the entire ward out under tents being tended to by some nurses. This couldn’t occur without the family’s help.

 

Muhimbili Recycling in the OR

Recycling is popular worldwide, but Tanzania takes this to a level unimaginable anywhere else. OR chairs have a variety of different looks, based on varying states of disrepair, causing one to question “What is a chair?” Is it one without a back? How about a seat and back with no legs? How about just the seat resting on a stool? All of these are in use throughout the Operating Theatre. How about gowns? How much of the gown has to be lost before it is not usable? One tie? Two ties? All the ties? These can be replaced with gauze strips (not designed for re-use) or plastic strips that have to be torn to be removed, then retied with the next use. Where does this stop? If you have to cut a hole in the gown, how many holes are too many?

 

Hope and Change

One obvious issue that I have not addressed in prior blogs is how the suggestions for change are received by the surgeons and whether progress is inevitable. We have experienced this directly with the two groups with whom we interact. Firm 1 is the group associated with MUHAS (Muhimbili University Hospital and Allied Sciences) populated by motivated surgeons who are open to suggestions. They have added multiple operations to their repertoire in the last few years and have adopted many of the patient care habits that Bill Schecter has been modeling through his five years of service. Firm 2 is comprised of the Muhimbili National Hospital surgeons. There are many excellent surgeons, but a few of the older surgeons are somewhat rigid in their practice as well as uninterested in any suggestion of surgical alternatives for care. The issue of tiers of quality in surgical care is not new and peer pressure is probably the strongest motivator for change. In a truncated volunteer experience where time and cases are limited, it tends to be discouraging.

 

Patient Privacy

Patient privacy is paramount and sacred in the United States. There is a semblance of some privacy in Muhimbili, but the very public nature of “ward medicine” make this difficult. Exams are considered private for all ages and both sexes. This is not an easy task in public wards that are overcrowded. But small mobile privacy screens that roll up and down between beds can afford this for patients, at least to the degree that they will accept exams that are essential. The outpatient clinic is different. It has exam rooms shared by two senior doctors, each with a desk separated by only a few feet. So simultaneously, there are two patients, each with family, each giving an oral history. There is a shared exam table with a small privacy screen and a small sink, and this has to be enough to get the necessary exams done. When the exam is concluded, the patient leaving is asked to call out the next patient’s name to the throng outside. The waiting room is an inside courtyard with dozens of benches along the walls lining the courtyard. The next patient moves into the room and the process continues.

In years past, Muhimbili had been “paper based” in their record keeping but have now moved to computerized records. This would seemingly be great progress for a country in the pursuit of improving care. The infrastructure has not kept up, however, and the computers lose power every 10 to 15 minutes. They have to be rebooted, and the record keeping takes twice as long. No one complains.

 

Washing Cement

In my last blog, I referred to the campus maintenance legion who does their work all day. When we are walking to rounds at 6:45 am, the hospital is getting scrubbed. The dirt paths, dirt parking areas, and public spaces have already been raked to clean the leaves and overnight debris as well as trash. There must be a mile of concrete walkways that are actively being washed, mopped, and swept every morning. Dust blows all day so this is an endless task, but their commitment to this effort has paid off. Maintenance of a clean space is easier than achieving that first clean transformation. The hospital corridors are protected in the same way. Yes, it might be cosmetic, but there seemed to be a real sense of pride in the end result. The patients and their families are the ultimate beneficiaries. They have done the same with the campus gardens, but they are, unfortunately, cordoned off with barbed wire and are off limits for sitting. Too clean to use…

 

What’s In a Name?

When we arrived at Muhimbili in October 2014, we were perplexed by what they decide to call us and how they refer to their own colleagues. They called Bill Schecter “Prof” as a sign of respect. They referred to me as “Dr. Grey” and called Craig Lubbock “Dr. Craig” — no explanation, no reason for this difference. During this trip, it became evident that there was this inconsistency even within their own ranks. They would refer to each other by either their first, middle, or last name only, about a third of each, and not refer to any as “Doctor”. Today the explanation: their society chooses to take the simplest name – either the first name, middle, or the last name – and that becomes their name to all employees and patients. “Bosco” is the name of reference of John Bosco Ngendahayo ; “Kitembo” is the reference name of Kitembo Salum. They take the easiest name of the three and that becomes the reference name for all. Makes sense. Mystery solved.

– Doug Grey

Too Few ICU Beds in Tanzania

The following entry was written by Dr. Doug Grey, former MedShare Board member and current Western Council Member, who is on a medical mission trip in Tanzania.

I began my fourth medical mission trip to Dar es Salaam just before the New Year in 2016. Having a number of home renovation projects finally finished, the travel was a welcome relief.

When I arrived in Dar I met Dr. Craig Lubbock who is also retired Kaiser surgeon and had been on our trip in October, 2014. We stay in the Kalenga House, a UCSF-sponsored house with rooms for eight, a common kitchen, and convenient proximity to the Muhimbili Hospital, the largest teaching hospital in Sub-Saharan Africa. It is a bit like being in something between a dormitory and a fraternity house. Cooking duty is shared, but there are those with culinary skills, and then there’s me.

The first weekend was dedicated to combating jet lag, getting the house provisioned for the month, and making initial contact with our Tanzanian colleagues with whom we will be working the next several weeks. Our new Pediatric Surgery colleague, Dr. Henry Lau, is a retired Johns Hopkins surgeon who is spending the year under the aegis of the US Peace Corps performing Peds Surgery at Muhimbili. He provides some consistency to the exchanges and efforts to assist with care at Muhimbili. He has taken a great interest in teaching the Tanzanian surgery residents basic surgical skills like knot tying, suturing, and some of the “craft” of surgery. One of the hazards of spending a year in any one place is you inherently feel much more ownership for both the problems as well as responsibility for solutions. Inherent in any medical mission is “doing your best with what you have in the allotted time.” There are advantages and disadvantages to almost any effort to help.

Our first day at the hospital began early. We passed the Baptist Chapel that finishes its morning service with a singing round by the parishioners snaking out of the chapel. The harmony was angelic and contrasted with the stillness of the hospital grounds. During the day, the hospital campus is over-run with humanity, but in the morning hours the corridors are empty and the gardens quiet.

We begin with rounds in the Intensive Care with the Chairman of Surgery, Dr. Ali Mwanga. This is a six bed ICU with the sickest of the sick, most on ventilators, and either trauma cases or patients with surgical complications. It is evident that the Muhimbili staff’s dedication and commitment to getting these ill patients better is exemplary. Intensive Care Units are complex. Getting some of the patient data is difficult to sort out in the bedside records. The patients can’t be weighed every day and some of the decisions are made with gestalt and not data. But this is not necessarily bad. Strain occurs in this limited resource environment when all six beds are filled and a new case is contemplated. The safety net of an empty ICU bed isn’t always available and patients can suffer because of the lack of resources.

One of the system improvements that has been introduced for the Surgery Department is a Morbidity and Mortality Conference, the standard forum for discussing complications due to lapses in care or unavoidable circumstances. The Residents presented several cases where this ICU bed shortage had led to delays in necessary operations. This was referred to as a “System Problem”. Those bad outcomes due to bad judgment or bad decisions were called “negligence”. The stark candor is both alarming and enlightening as now there has been a tangible increase in everyone’s awareness (and responsibility) for the need to improve care. This level of frank discussion was impressive and has already led to good decisions and discussions from the younger surgeons.

Four years ago the hospital campus was like an abandoned movie set. The hospital wards were concrete barracks. There would be areas of used medical equipment, almost like randomly occurring “equipment graveyards ” of old white iron beds, stainless steel, broken furniture, etc. This happened in a society where almost nothing is ever thrown away, but rather re-utilized in a lower tech manner.

Through government jobs programs newly introduced by the Prime Minister, the hospital now has several different categories of workers that are improving the physical plant. There are security guards, both male and female, who circulate on all the corridors outside and provide a feeling of safety. There are people assigned to raking leaves and picking up trash in all the gardens and public spaces. There are construction projects throughout the campus with rich red soil being dug by hand in several different areas. Many of the gardens have been finished and are now like public parks. The plumeria trees are in bloom and the fragrance of jasmine is pleasant. We no longer get the feeling of crumbling desperation that we had three years ago.

But that feeling of thriving culture disappears when we enter the wards where the patients are cared for. There would be 50 patients in a room otherwise designed for 30 patients. The rooms, which would usually house three beds in parallel, were now housing one bed, followed by one patient on the floor, then a bed, floor, bed, floor and so on. There were also patients in the corridors. There is no patient privacy.

Walking across the campus, I came across an extremely idealistic medical student who was going into Internal Medicine. She was proud that MUHAS was the most difficult medical school to gain entrance to as well as the most difficult to stay enrolled in and succeed. She was optimistic and happy with her decision, which was not based on reimbursement potential, something that she thought motivated her fellow students. She was grateful to meet a happy retired surgeon who shared her same idealism.

Again on this trip, the engagement of random passers-by with solid eye contact is alarming at first, then very reassuring. “Mambo Poa” is the standard “How are you?” And their response can be many variations of “fine” (“Poa,poa”, “Poa” , “Nzuri “). It certainly makes the walks more enjoyable.

– Doug Grey