Kwamasimba, The Place of Lions: Tanzania Week 6
“Field work begins today. Your two research assistants will help you find your participants and schedule times for focus groups and interviews. You will start collecting data tomorrow. We can polish the proposal and budget later. Good luck.”
These were the first words Edwin, my supervisor, said to me Tuesday morning. Filbert, the data manager and statistician who was trying to help find participants, found that there wasn’t satisfactory information to find the children listed as having febrile convulsions, let alone track down their parents. I had a meeting with my preceptor, Dr. Lusingu, about the problem and we decided to try a different approach. “I am officially freeing you from using the pediatric ward data to find your study population” he said.
However, we didn’t completely stray away from using past-study related information in our search for participants. The NIMR research site in Korogwe has had a long and proud history with malaria research, and has been integral in the continuing clinical trials for a new malaria vaccine in partnership with GlaxoSmithKlein (GSK). Two villages in Korogwe District, Mkokola and Kwamasimba, were two of the first villages involved and therefore had experienced CORPS members, which would be extremely useful for our purposes. Also, Kwamasimba means “Place of the Lions” in Swahili, which is pretty cool even if there aren’t any lions there anymore. CORPS stands for community oriented research personnel. CORPS members are respected, mostly older, members of their villages who have in-depth knowledge of and ties to their community and its members. They were given basic health worker and research related training and have a dual role: serving the village community as first line of access to health care and serving the research community as monitors and field guides.
So, it seemed that all roads ran to CORPS. We would conduct a focus group discussion with CORPS members from both study villages at NIMR Korogwe Site, and they would refer mothers, health workers, and traditional healers to us for interviewing from their respective villages. I would also interview a doctor who worked in the Korogwe District Hospital Pediatric Ward and had experience in our study communities. That interview I would conduct alone in English. I went back to my desk to refine my focus group discussion and interview guides, a process I finished Tuesday.
That night, I had dinner with 4 Danes. Christenze, the doctor, Katherine, the master of medicine student, Cecile (Cessie), the bachelor of medicine student, and Rune, the volunteer physiotherapist. We had a little family dinner at Christenze’s house which was a nice change of pace from eating dinner by myself and gave me a nice opportunity to frankly discuss my experience living and working here with people who were also foreigners. I could be honest about frustrations as well as the pleasures without worrying about offending anyone.
The focus group discussion with the CORPS members seemed to go very well on Wednesday. Edwin actually helped conduct it, along with Tesha and Tilaus, my research assistants. The participants seemed very involved and afterwards Edwin and the others told me that they got a lot of good information, though it was hard for me to know for sure since I understood so little of the discussion. I felt kind of useless over the next few days as we visited both of our study villages, and this feeling will probably continue over the next few weeks as all of the recordings are transcribed and translated, but I have confidence that all of the work will be done well and that I’ll have plenty to work with once I start doing the analysis.
I was pretty entertained by how concerned Tesha was about how comfortable I would be in the field. I assured him that I would be fine and that things like using the bathroom behind a bush really weren’t going to bother me. If anything I was uncomfortable with how hard it was to communicate. The depth of these conversations were well beyond the trivial ones I was used to, and some of the Swahili they used, even for greetings, seemed different than I was used to and more peppered with Arabic loan words. These were people opening up their homes and offices, their experiences, and their beliefs to me yet all I could do was sit there quietly and record the conversation.
I’m used to being very friendly with people, and lending an ear in many different situations, so the language barrier was kind of tough for me when I could still sense the mood and intensity from body language and tone. I really wanted to hear the words as they said them, really get into their heads, and have the ability to respond or ask follow up questions on the spot. I tried my best to greet our participants and their families as warmly as I could, laugh when I understood some of a joke, apologize when they told us something sad, and thank them as best as I could. I do believe they at least appreciated the effort, finding butchered Swahili more comforting than silence. At the minimum, they found my attempts with Swahili funny and one of the mothers was excited to point out that her grandson had the same name as me. Though, funnily enough, one of the traditional healers was adamant for a very long time that I was faking and actually spoke Swahili and that I was from Pemba (a part of Zanzibar) and would not back down until I showed him my identification from the US.
Again, all of the interviews conducted for me in Swahili seemed to go very well. One of the mothers gave us a plant to take with us, one that she apparently had used to treat her own child when he had convulsions as a toddler. Unfortunately, she couldn’t tell us a name besides “Duka ya Degedege”, which literally means “medicine for convulsions”. It will be interesting to see if we can identify it.
Many Tanzanians put heavy stock in traditional medicine in healing, with about 60% of the population still relying on traditional healers in some capacity. Though many western-trained practitioners scoff at the practice, there are some things they have been doing right (or close to right) long before modern medicine caught up. For example, about 37% of the herbal remedies used by traditional healers here show strong antimalarial properties. Or in the case of convulsions, even if an herbal bath is meant to scare of spirits, it still lowers the child’s body temperature, acting like a sponge bath. Of course, there are also the other 63% of those remedies, and cases where even a proper treatment is used in a harmful way. For example, at the clinic there was a patient who had a bad cut that was stitched up (very well for that matter) by a traditional healer. But on closer inspection, they found that under the stitches were stuffed herbs that had rotted and had probably contributed to the nasty infection she now had.
Though, there are certain practices that are not unique to the traditional healers but definitely rubbed me the wrong way. Namely, the way some practitioners interacted with their patients. When we conducted our first traditional healer interview, he had a lot of patients in back rooms as well as one sitting on the couch in the entrance room. She was extremely thin, angular joints jutting out frighteningly underneath her skin. She looked like she was in a lot of pain, but it didn’t seem to be localized anywhere. She sobbed quietly, cradling alternating parts of her body: elbow, knee, back, stomach, collar bone. The healer came out from the back and plopped down right next to her on the couch, jolting her almost off of the couch cushion. He was ready to start the interview. I asked Tesha if we should move somewhere else, or if the healer should attend to her first, and he seemed uncomfortable asking as he didn’t want to compromise what he saw as surprisingly compliant behavior from the healer, but he did. The healer told us she would be fine, he already talked to her, and to continue on with the interview. We did. She never stopped sobbing.
Even the modern practitioners are pretty rough. I understand very little of the conversations, but local health workers seem to speak very condescendingly to patients, a feeling that others who could follow the conversations backed up. In the district hospital, nurses would routinely do things in a crowded ward like point at a patient and loudly exclaim “Oh that one? Yes, that one has AIDS.” Obviously, this isn’t universal. I’ve seen extremely compassionate and considerate care in Tanzania, and I know there are extremely abrasive doctors in America as well, but it just seemed much more extreme and accepted here.
My last interview for the week with the doctor never happened. I waited for him Friday evening but he never showed up, and was not answering his phone. Tesha and I decided we would just try and reach him again next week. In the meantime, I spent the weekend reading and watching soccer at a pub with Mahunda and Wilson, two Tanzanian friends I made who unfortunately will be moving back to Dar to continue their university studies.
Once I interview the doctor, the true waiting game begins. Everyone here is going to be extremely busy as monitors for the clinical trial are coming this week and there is a big conference in Dar es Salaam the next, which will delay the translation process. But if everything goes according to plan, by the time I return from climbing Mt. Kilimanjaro on October 24th, it should all be done and ready for analysis.
Though, things could get interesting that week. The national elections are October 25th, and no one is sure who will win or what the reaction will be. Either way, we will have front row seats for history.
Tutaonana Badai.
