Signing Off..

Well Guys, I don't know where the last few months have gone at all! The best things in life always go so quickly I guess, but it's all over now.. And I have had an amazing time! I would recommend all of it to anyone..

• Going to a third world country to experience their healthcare system
• Using Work the World as a company, they are truly amazing, they sort everything for you and the staff in the Dar house were the best and nicest people I think I have ever met, they really did go above and beyond! I can't speak highly enough of them!
• Tanzania as a country is awesome, even if you're just travelling there is so much to see and to do, you could easily spend a month and more just going around as it is a huge country

If you ever get the chance to do any of the above, just do it! You never know what you might find, who you will meet and what's in store for you. I thought I had a pretty good idea of what to expect, but at the end of the day I didn't really and I had some of the best experiences of my life and meet some of the lovliest people I think I ever will.

Thanks to everyone who has been following me, I hope it hasn't been too much of a bore and I've managed to keep you all a little interested in my goings on. If you do want to know anything more or have any questions then drop me a line and I'll be happy to help.. Whether its about the hospital, Work the World, Tanzania (or Kenya) or anything related!

Cheers everyone! :)

Kwaheri!

Statistics...

Whilst in the department the staff gave me statistical information for between 2006 - 2012 about the country and different regions and the variation between the different regions is vastly different, let alone compared with the UK.

Cervical Cancer is the most common cancer (as already known), with 955 cases being treated in '06 rising to 1896 in '12. Patients treated for Prostate cancer in '06 was just 51 and last year 101 were treated. The incidence of Kaposi's Sarcoma and other skin cancers is quite different, Kaposi patients treated last year were 789 and for other skin cancers 147 were treated.

Breast Cancer - 667
Oesophagus - 573
Head and Neck - 386
Lymphoma - 295
Leukemia - 252
Bladder - 168
Eye - 131
(As of 2012)

These relate to the type of cancers I saw and the quanitites I saw them in too.

The number of these patients that came from Dar es Salaam was nearly 10,000, from other regions less than 1,000 were treated. This is as Dar holds the only radiotherapy centre, it is hard for most people to travel this distance; especially if they live in Arusha which is at the northern end of the country. The region of Manyara has the lowest number of patients being treated with cancer.

These statistics don't really have a baring on how many people with cancer there actually are in Tanzania, as most people probably ignore their illnesses anyway. A couple of the staff that I talked to were very keen on travelling around to the different regions and educating their people on their health and cancer. There are lots of things that the staff would love to do to help their people, like creating a charity for those patients they have to help them with travel, food, expenses, etc. - which is lovely, but they are finding it hard to start as they need to get sponsors first.

My Saddest Cases..

I saw a lot of pretty horific cases, but a few stuck out for me specifically that I don't think I will ever forget!

1. Anal Carcinoma

This case was one of the first I saw and I only saw it once - after this the patient was too ill to attend.

So in the UK anal cancer is assosicated with the older population (along with most others), however, the population in Tanzania is obviously a lot younger than ours so cancers develop at earlier ages. But I did not expect to see that this man was just 25 when I looked through his notes. He was so frail he did not have the energy or life to lift himself out of his wheelchair, let alone get on to the bed! His father had to lift him up onto the bed. It was so sad having to watch his father care for his ill son knowing that he hadn't got long left.

2. Brain Tumour

This case was pretty similar to above in the respect that this young boys father had to do everything for him as he had no life left in him - he couldn't open his eyes and had to be carried everywhere. This young boy was about 6 and had to be transferred from another hospital everyday to have his treatment. I'm not sure what type of tumour he had as it wasn't recorded in his notes, but his treatment was not nessercary as it was not helping the little boys condition at all - in the UK he wouldn't have been started on treatment.

3. Pituitary Tumour

I watched this lady from the beginning of her treatment to near enough the end as she started when I started my placement.

At the beginning she was so chatty and trying to teach me Swahili and always laughing, but she deteriated a lot and quickly! By the end of three weeks she could hardly put one foot infront of the other, let alone walk in a straight line! Her eyes were hardly open and speech slurred. What struck me was how little care she was given still in this condition! She could hardly get herself on the bed, yet the staff all just left her to it.

I was asked what we would do in the UK, when I said that the technique would be completely different to start with they didn't understand that using right and left laterals was treating too much brain and meaning that the side effects she was having were horrific! I said that if she was in this state, we would have stopped her treatment as we were doing more harm than good to her obviously.

After this day, she didn't return for treatment whilst I was there as she was too ill.

4. Xeroderma Pigmentosum

This was something I had never heard of before I saw this patient. It a genetic disorder than basically means that you're allergic to sun and any exposure to UV leads to skin cancer.

This little girl was just 7 and had skin lesions all over. In her notes it read how she had had lesions on her back when she was younger and a few on her chest. But from that point, she had progressed into a state that was beyond repair and her treatment was very palliative. She had deep lesions all over her scalp that were pusey and scabby, her nose was none exsistant and had been consumed by cancer along with her right eye which she could no longer see through. Her mouth and lips were filled with ulcerative lesions which made eating a struggle. And this little girl was terrified!

On the first day she was too scared to get on the bed and was crying her eyes out! The radiographers had little sympathy with her and it just sounded like they were shouting at her. I felt so sad for her. The next day she hid behind her mum up against the wall, then she saw me and came over and held my hand and then walked with me over to the bed (I don't think she'd ever seen a white person before). On her third day I took some stickers in with me to give to her and when her mum gave them to her, she was extatic! She was smiling with all her might and wouldn't stop playing with them!

The even sadder thing was that her mum still held out hope that she was going to be completely cured soon, but her case was so that even the radiotherapy she was having wouldn't have made too big an impact on her situation.

It's hard to convey just how sad these cases were, without being there I think. But I've done my best for you guys!

The Staff..

So my placement is now over, the last four weeks have flown past and I have no idea where! It's been amazing working there and hasn't felt like work at all! 

The staff have all been lovely, there was only one woman in the department and she only works with the caesium machine really. There attitude is so laid back and there is no rush about anything. It's nice in a way, but can sometimes be annoying when patients are waiting around and left on the bed or waiting for their treatment for ages. 

They have a poor opinion of UK radiotherapy and the staff. It's been said to me that we don't talk to patients at all, whereas we talk to patients a lot more than they do and have much more of a caring nature. Most of the time all they ask them is for their name and to go into the room and to leave the room. So I'm not sure why they think that their much more patient orientated! 

Another statement has been made that we don't talk to each other at work or use our phones. I tried to explain that we do talk to each other and they said no you don't talk about things outside of work, they didn't understand that we did. And the fact that we don't use our phones was a professionalism thing, they didn't grasp that concept either. 

They've made a big effort with me though asking lots of questions about the UK and how we do things. Most of them know how we do things though, as the sad thing is that their education at university is the same as ours, but everything is theory as that just don't have the equipment to practice how we do. One man told me how they got told they would get a chance to go to another country to practice, but they never heard anything else about it sadly. 

They would all love to see how we did it and come over, but they can't get anywhere as its just too expensive and they have commitments here. 

This week a lot of the staff have been off, due to the red they received at the end of last week. There were 7 interns working and 4 jobs were on offer to start when they are qualified at the end of the year. However, none of them were offered the jobs as they decided to offer them to diagnostic technicians and then train them up as this way is cheaper. This means that they know have nowhere to go as there are no other centres in the whole of Tanzania, so the last 4 years of their lives have been with no reward. It's very sad and they were very demoralised, so have not been in to work. 

It will be sad to leave them, but I've got their emails and intend to keep in touch and see what's happening our there in the future and if things are changing like they all want it to! 

Set Up..

Patient set-ups are all pretty similar out here and easily picked up. 

So, the staff will tell the patient to enter the room and then give them a few minutes before entering again. ive been told two reasons for this, one because of the radiation protection and the other because of patient dignity. The patient will get on the bed by themselves, sometimes struggling and I've seen blind people with little assistance trying to get on. They all have to lay their individual kanga's on the bed for their treatments before getting on. 

Sometimes they are moved to make sure that they are straight but they are mostly just given directions as to what to do to get themselves in the right position. Sometimes I disagree with what they are doing because they can move their ankles and legs after the field has been positioned, altering the position of the field possibly. 

For cervix patient anatomical surface markers are used for the set up on every patient; as I blogged in my last post. 

For other patients most of them have plaster markings around the edges of the field so that their is some guidance as to where to go. Although this is a good idea, the plasters are often put on by nurses outside of the treatment room. This means that the field light is not on the area and the patient is in a different position, therefore it can be non-representative of the actual treatment field. Another issue is that they do not stay on very well after washing etc. so if they fall off and patients re-position them (like they often do) it is hard to know where the exact place is. For patients having lateral fields treated the field is only marked on one side so this too can make the positioning hard as the bed can be unreliable with the measurements and movements. Obviously no movements are made from these plasters as they represent the actual field that needs to be treated. 

The accuracy is better than what I thought it would be, even if it is a bit dubious sometimes! Most of the time I feel comfortable to set up and switch on with the set-up they have done as it is all that can be achieved with their equipment. To start using tattoos would require a large change in the department and a lot of time and money; but hopefully in the future. 

Techniques..

Explaining the techniques used in ORCI will not take me long as they are very basic and all very much the same. Not because they know no different, because they all get taught the same things as us (but their knowledge is just all theoretical rather than practical), but their techniques are the way they are because of the equipment that they have sadly. 

As there sinulator is a bit tempormental and most techniques are just done by the book and with surface markings, after a few days picking the set-up was easy. 

For cervical cancer - most of what I see - they are mostly late stage and the technique used is SSD100 (or SSD80 if you're on the other machine) and a field arrangement of anterior and posterior parallel opposed pair. Field sizes have to be large to encompass the large extent of disease (which you can often see bulging and can smell from a distance sadly for these women). The general field size is 15 x 15cm, which is sometimes coned down to 10 x 10cm or 12 x 12cm after their initial 25 fractions and review by their doctor. As these patients don't have marks on their skin, surface anatomy is used to position the field. The lower border is the anterior commissure and the upper is just below the umbilicus, to position the lateral borders the Sagittal laser is positioned running through the middle of the vulva. 

For almost every head and neck cancer right and left parallel opposed fields are used. The field size for these is not as predictable and will vary depending on the extent of the disease and where exactly it is obviously. Some may be 8 x 5cm for example, while others 12 x 10cm. The decision on field size is made by the radiographer a treating the patient on the first day and their knowledge on the cancer and patient; so this can be very subjective. But their textbook knowledge is very good so they know how it should be. 

Some lymphomas of the head and neck and other more superficial cancers are treated with direct single anterior or posterior fields - also varying in size depending on the tumour. 

As you can see, the techniques are very much palliative in their style and although the majority of patients are very late stage it is not ideal. But Asides from these three techniques anything else is very much impossible due to their lack of equipment and money and the fragility of the equipment; I have been told by one that they don't like moving the jaws of the machine too much as it makes it very tempormental, like i wrote in my last post. They would all love to be able to move on to greatest things, but right now they are doing the best they can for their patients. 

Their technique for breast is however nearly identical to our technical, the only difference being that they used an SSD of 100 as they don't have the facilities for planning obviously. So the standard treatment is medial and lateral tangentials; they were surprised when I said we were doing the same in the UK! They even use half beam blocking for the medial border, but not for the superior border of the field where it mets the supraclavicular field. There is a difference with the patients too. Because the majority are caught late stage this means they have all had mastectomies, I don't think I have seen one patient without one. As this is the case, it also means that they all have supraclavicular fields too - with the exception of one patient I have seen.

Apologies..

Sorry I haven't been here in a while my last couple of weeks have been so busy exploring I've ran out of time to get down to updating you all on what is going on in the hospital! I think this week may be my last post/s while I'm out here too, as I'm off on safari on Saturday - no idea where the last four weeks have gone its very scary! 

Hopefully I'll be able to catch you up on everything within the next few days though and if not then will do when I get back. 

The Hospital..

The hospital isn't very big as its purely specialised for cancer and it's treatment, so my orientation around didn't take very long at all. It's different from what I thought it would be like! It's all on a campus with different buildings that are all white and look very modern, but aren't! One of the building contains all the wards and clinics, which is really new but the others containing a canteen, church, mosque, chemo day unit, diagnostic imaging and radiotherapy is not as new. 

There are lots of wards which are all full as most of their patients are admitted. This can be due to their poor health, late stage of disease, the poor healthcare system that they have near their homes or the distance that they have to travel from home for their treatment. For patients that are Tanzanian this is free as the hospital is government run, but for those who do not originate from this country only abide here, they have to pay a fee to use the ward. I'm hoping to spend a day there during the next three weeks, but have been warned that I will probably cry! 

The clinics there are all very over-run and very non-confidential! There are many people spilling out into the corridors waiting to be seen by doctors, some very ill! It is very strange because when I was being shown around, the doctor I was with would just walk into clinic rooms without knocking and with no regard for the patient in there. The staff and doctors would then all ignore their patients and just talk to each other and me then, I felt very awkward about it and very sorry for the patient, but this is just how their country is - there is no privacy or dignity for anyone! 

The diagnostic facilities are better than I imagined and the equipment looks surprisingly like that I have seen in the UK! They are equipped with 3 X-ray units, 2 ultrasound units and 2 gamma cameras - no CR or MRI. The gamma cameras are very new, but the rooms are very dusty and still remain looking a bit like a construction site. Privacy in this department is like the clinics too and I ended up walking in on a lady with her skirt around her ankles, they all acted as though it was just the norm though! 

In chemotherapy I didn't get to see much, but I'm hoping to go back again! There was a fume hood being used by nurses with masks on and aprons, but no gloves?, to prepare and mix chemotherapy agents under. All the needles with the drugs in were being re-sheathed after being prepped, so it wasn't actually very safe anyway! In the corner next to this there was a nurse sat in the corner and then two lines of plastic chairs where people were queuing to be cannulated before being hooked up to there drugs. There were a few beds and a line of chairs across the wall, which were all being shared by numerous people. The queue outside was very big, with the courtyard outside the door full of people waiting for their treatment! I don't think that their organisation provides that best efficiency and time management. 

The radiotherapy department isn't very big, but does provide a massive service to the population, treating upto 150 patients a day with hours between 7 until they finish, which can be at 2 the following morning! (Which makes our country seem very lazy, as we complain about 1 hour over time, whereas these guys don't complain about 5 hours overtime they just want to help all their patients!) So they have two machines like a knew, along with a simulator and brachytherapy equipment. 

Both machines were in use when I first arrived last week, but one had a very broken table that they were trying to utilise to cope with the amount of patients. It has now been completely taken out of use, so all the patients have to treated on the one working machine. Although I had been told one of the lasers on the working machine was broken, it is actually working so this is functioning the majority of the time. Although the bed cannot be lowered completely, so a wooden step has to be used to get on and off the bed and the X2 jaw has been very tempormental over the last few days, with the engineers having to be called a couple of times. The machine also completely broke down on Thursday, so not all the patients could be treated! The source got stuck in the open position and the jaws got stuck again too. 

Going into the room there is a 'maze' so to speak, but it is more just a straight corridor down to the room. The door in is very heavy and very big with a red and yellow light outside the room, the red is on when the radiation is on - like in the UK. In the room, the cobalt-60 machines are huge! So much bigger than linacs, there is a tennis racket section of the bed and the handset is hung on a metal pole over the head of the gantry. Along one wall are two very dirty and dusty tables which have all their immobilisation equipment on. There is no organisation though and barely any equipment. They have headrest A to F, a plastic plate with two Velcro straps across and a very old breast board! Most patients have a headrest, with the straps being used for whole brain treatments. The breast boards is positioned on a plastic slant which isn't indexed and then one arm is elevated, which ever side is being treated as the arm cup moves from both sides. I have seen a leg support being used just once, for a very very ill young man in a lot of pain! 

The computer system outside the room is very very simple! There are three monitors in total - one general computer used most of the time for watching films, safari documentaries and a but of Kenan and Kell! Another monitor is not used because the camera inside the room is broken so there is no need for it. The third controls the linac! So there is a section where the parameters for the individual treatments are entered and that is all! No patient information is stored on there and the only record of the patients treated that they have is a notebook with all the patients names from that day written in. On the control panel there are auto-set buttons which I was surprised about, but they no longer use them as one time when no-one as paying attention (which happens 97% of the time!) the gantry head crashed into the wooden steps used to get on the bad and there is now a big hole in the top of it!! 

I'm yet to take my camera in, but will be a few times over the next three weeks, so either when I get back or whilst I'm out here if the Internet allows it I will upload them all so that you guys have a better picture of what it's actually like, as I don't think my descriptions are very good and pictures will be much easier to understand!  

Jambo!!

Jambo everyone at home! So I've been here for nearly a week now and lots has happened and is going on!

My flights were very good although long! The airline Qatar is lovely and they treat you really well and feed you lots of lovely food, I was surprised how good is was for airplane food. When I arrived in Dar es Salaam it was already in the high 20's at 8 and I was boiling! Work the world picked me up and I went back to the house to be shown around and meet everyone.

The house is very nice. There's a living room, dining room, kitchen, garden, swimming pool and then bedrooms coming off of these as well as a couple of chalet type outbuilding rooms. I share my bedroom and bathroom with three others - two medics and a physio! I get given breakfast and tea and can help myself to food from the kitchen during the rest of the day. So far, I've had pancakes, eggs, sausages and home made doughnuts for breakfast along with a lot of fresh fruit, like mangoes, bananas and pineapple. For tea I've learnt that they love their carbs! For example one night we had rice and mash in the same meal! There's a lot of chicken and beef dishes and also a lot of bean curry, but always a lovely lovely selection and it all tastes lovely! Tried banana stew last night and as horrible as it sounds it was actually very very nice! However, the one thing I do miss I sweet things as there are not many of these. It's a good job I brought gingerbread men and sweets with me!! 

I've explored the local area and it's very nice. I'm staying in the posh part of town, where all the government members and the prime minister lives (obviously it is not like in England, but the houses are very big and very lovely!) the shop opposite where I am sells everything English which is nice, but I haven't yet brought anything as I'm loving everything African at the moment. It is all so cheap too! For example, I've just had a chocolate ice cream milkshake which cost 5,500 Tanzanian shillings, which equates to about £2?! There's a local post office, market which sells local crafts and paintings that are painted outside our house, a liquor store, ATM and air conditioned shopping centre where we can get wifi (where I am right now!). 

The transport is very interesting! I have only got a daladala once, not because I haven't wanted to but because they are very rare in our part of town due to the caliber of people that live here which means the majority of them have their own cars to use. The one I got was fine and I even got a seat! However, most of the ones I see on my way home from work have people hanging out of the windows and doors and people say on eat other an pushing each other to get on and off, it is very chaotic! Taxis are common, but with no AC they can be very uncomfortable if there are too many of you in them - but they can work out cheap, as the drivers are not fussy about how many people are in their cars. An alternative to taxis seems to be hitching lifts which is very common too and I have participated in. Cars pull over at bus stops all the time offering lifts and they will squeeze as many people in as possible too as it means more money for them. They were only four in the back of the one I was in, but I have seen more squeezing in! The most common method that I have used is a bajaj. This sounds and has the front steering of a quad biker has a cover on the back - it's very cool. They are really small so can squeeze in between little gaps and are breezy too which  is good in this heat! You have to haggle over the price as they see a Mzungu and immediately put the prize up loads! But I've pretty much sorted out how much most journeys should cost (and if you walk off they normally call you back saying you can have it for the price you asked!)

I'm loving the laid back attitude of everyone out here, the culture and everything new and all the locals are so friendly! They also say hi and are very impressed when you reply in Swahili. I think mine is getting a bit better and we have casual lessons at the house in the week too which is very helpful just to help with the basics.  I'm hoping that in a few weeks I'll have picked up a lot more. 

I think that's about it for now, but I will be back on at the beginning of next week to tell you all about what the hospital is actually like!

Kwaheri! 

All Packed.. Am I Ready To Go..?!

It's been a pretty busy week for me really and I'm very glad that I managed to get it off placement as there has been lots to sort!!

Monday was spent sorting out all my many documents.. And there are a lot! I've got flight tickets, safari tickets, hotel tickets, insurance documents, professional indemnity insurance documents, my yellow fever vaccination certificate - very important else I won't be allowed in the country!

Tuesday I started sorting out what clothes, etc. I needed to take. So my bedroom looked like a bomb site! I had piles everywhere, of everything I thought I may possibly need, these had to be sorted out and minimised, as I had way too many items to squeeze into my 23kg, let alone my backpack! Also ordered my US dollars for my safari, visa and CTA permit whilst I'm out there.

Last minute shopping was done in Exeter on Wednesday with my brother and boyfriend.. All important jami's were purchased, along with batteries for my torch (for when there's no electricity in the house!), and a journal to help me remember everything I need to. And I also enjoyed my last subway for at least six weeks!

Yesterday I had to go to London for the day, which was lovely! I went to be videoed for a 'YouTube' blog by 'YourWorld Healthcare'. This was more than scary, but once I'd done it I felt much better. I've also got to do a couple of blog posts for this company about the comparisons between here and there. Once I've been sent a link for the video, I'll pop it up here so if you fancy a look you are more than welcome!!

And today has been very, very stressful sorting everything out.. But I think I'm finally there now! Anti-Malaria tablets started, hand luggage packed, lunch sorted and backpack packed, although I needed a lot of help packing it and trying to squeeze everything in. It's only 16kg of stuff, but that's all my backpack will take (leaving a little bit of space for anything I want to bring back - although I have been told that I will not be allowed to take a giraffe through customs sadly!)

I'm a little nervous about getting the plane now, as I've never caught one alone before. But I'm so very excited to get out there and enjoy everything the country has to offer me! I was however very annoyed to hear that the weather was showering over there today as apose to the glorious sunshine over here (it was still 30 degrees though!)

Now it's time to relax and get a good nights sleeo before a long day of travelling tomorrow!

Next time I get a chance to update you guys, I will be in a very different country experiencing very different things.. So Watch this space to see what happens and what I get up to in Dar Es Salaam!

Hospital Swahili..

So, A week and more has passed since I was last here and my Swahili knowledge has not improved drastically.. But I have picked a few more useful phrases that I can use in the hospital and with patients.

When asking about symptoms and side effects, useful phrases could include:

Umetapika? Have you vomitted?
Umetapika damu? Have you vomitted blood?

Unakohoa? Do you have a cough?

Una homa? Do you have a fever?

Unaumwa? Do you have pain?
Unaumwa wapi? Where do you hurt?

Umeharisha? Have you had diarrhoea?
Mara ngapi? How many times?

Instructions to patients that may be needed are:

Fanya hivi. Do this.
Tulia. Relax.
Usisogee. Don't move.
Subiri. Wait.
Kaa. Sit.
Inuka. Sit Up.
Lala kwa mgongo/ubavu/tumbo. Lie on your back/side/stomach.

However, although these words may be needed if techniques and practice were the same as in the UK, I'm unsure of just how necessary they will be whilst I'm in Tanzania. I will have to wait and see in just a few days..!

Learning The Basics of Kiswahili..

Swahili comes from the plural sawahili, a derivative from the Arabic Sahil, which means boundaries or coast. With the ki- in front, kiswahili literally means coastal language.

Swahili (or Kiswahili) is a bantu language that is the national language of Tanzania, Kenya, Uganda and the Democratic Republic of Congo, (Coastal Countries) along with being a means of communication through much of East Africa. Some of the language is derived from Arabic due to the years of Arabic-inhabitants, but there is also some incoorporation of Portugese, German, French, Persian and English due to contact with traders and slavers over the years. 
So, I'll start somewhere simple that everyone loves.. The Lion King! As it uses a few Swahili words that I've picked up on:

Hakuna Matata - No Worries!
Simba - Lion
Sarabi - Mirage
Pumba - Careless; to be a fool; to be bewildered!
Rafiki - Friend
Banzai - Skulk/Lurk
Upendo - Love
Shenzi - uncouth, savege, demon, barbarous

Some Swahili words are incorporated into English:
Safari - Journey/Travel
Jenga - From 'Kujenga',which means to build
Tote - Possibly derived from 'Tuta', meaning to haul

There are also some English words that have been incorporated into Swahili Too!!:
Polisi - Police
Boksi - Box
Hoteli - Hotel
Televisheni - TV
Baiskeli - Bicycle
Hospitali - Hospital
Soksi - Socks
Picha - Picture
Muziki - Music
Redio - Radio

Here are some general, basic phrases that I've picked up:
Jambo - Hello (Mambo is the more informal version of this)
Shikamoo - Greeting to an elder, which originally meant literally 'I touch your feet', as a sign of respect
Kwaheri - Goodbye

Habari? - How are you? Or literally, 'news?'

Variations on this include:

Habari yako? - What's your news?

Habari za leo? - How are you today?
Habari za kazi? - How's work?
Habari za nyumbani? - How's home?
Habari za asubuhi? - How are you this morning?
Habari za usiku? - How are you tonight?
Habari za mchana? - How are you this afternoon?
Habari za jioni? How are you this evening?

(I am yet to fully master all of these variations - and am still working out the correct pronouciation!)

An informal version is, 'Mambo Vipi' - How's it going?

Responses to these can be:
Nzuri - Good
Njema/Mzema - Fine
Poa/Shwari/Bomba/Mzuka - All meaning 'cool', which can can be doubled up, ie. poa poa

To ask in response you would say, 'Za Kwako?'

Asante - Thank you
Asante Sana - Thank you Very Much
Tafadhali - Please

Karibu - Welcome/You're Welcome

Samahani - Sorry (Forgive me)

Apparently, this is a word that I will hear a lot, not in an offensive way, but just as a statement - 'Mzungu' meaning foreigner!

Jina langu Ni.. - My name Is..
Ninaitwa.. - I am called..
Jina lako Nani..? - Your name is..?
Unaitwa..? - You are called..?

Ndiyo - Yes (Or just raising both eyebrows!)
Hapana - No

There's a lot to learn and I am trying my very hardest! I'm working on body parts and phrases I will use more in the hospital at the moment, so when I've got a better grasp of those, I will let you know and post some of them up here too!

Safari..

I looked at so many different safari's when I was browsing.. Ranging from a weekend to three weeks.. All going on different routes to different national parks. Whatever one I chose I was intent on going to the Serengeti and Ngorongoro crater! When I found this one with STA travel it sounded perfect and means that I can travel around to a few parks and have a nice relaxing few days to finish it all off..

I finish my placement on the 28th of June, so on the 29th I'm meeting my boyfriend and then we're flying upto Nairobi, Kenya early in the morning where our safari starts the following day. When there for the day, we intend to do a bit of exploring and there's a giraffe centre, run by a charity, that I would love to visit where you can feed the giraffes.

On Sunday morning we have a pretty early start at 8am where we head off through the Great Rift Valley to the Masai Mara, where we camp on the reserve edge for two nights and explore the park during the day looking for the big five and other wildlife! With the possibility of encountering some of the great migration of wildebeest, zebras and other grazing animals. Also, we are likely to encounter the red robed Masai warriers (who can be very scary on there approach)!

Great Rift Valley

On our third evening we head back to Nairobi to stay, before heading out on Wednesday to cross the border back into Tanzania. We go to Arusha - known as the safari capital - and explore here for the afternoon, with the possibility to visit the Meserani Snake Park and maybe Mt. Meru.

We will then have a two night/three day excersion to the Serengeti and Ngorongoro crater. On the first night we camp on the Serengeti planes after having game driven all day; the name Serengeti is derived from the Masai word siringitu meaning 'the land moves on forever' as the planes are endless! After our second day we will camp around the rim of the crater at 2400m above sea level, where we will be surrounded by wildlife for a second night, before descending down into the 326 square metre World heritage site on our last day here; where the only animals that can't get down here are giraffes due to the steep descent. After this we will drive back to Arusha to stay the evening.

Ngorongoro Crater









On day eight, we visit a local Masai village to get an insight into everyday life and the culture there. Then heading south via Moshi, we will pass Kilimanjaro and camp on the banks of the Pangani river, below the Usambara and Pare mountains in the Eastern Arc Range of mountains.

Day nine involves the journey back down to Dar es Salaam, where we camp on the beach before our trip to Zanzibar!

From day 10 we spend our time on Zanzibar, where we have no specific plans, but lots that you can do! It's known as the spice islands so you can tour around to see the exotic spices being grown, in Stone town the markets are bustling where you can explore and see what's on offer, white sand beaches encase the island for a relaxing day, there are snorkelling and scuba diving opportunities, along with the chance to swim alongside dolphins! So with all that choice, I'm sure there will be something that we can agree on to do!

It's an overland safari, in two-man domed tents, which means that everyone has to pitch in when it comes to setting up camp, cooking (although we have a cook who comes along with us) and shopping, so it can be a great experience if you have a good bunch of people!

It's all very exciting and I can't wait to get over there and see all the beautiful landscapes and wildlife! It really will be an amazing experience, with an amazing man!

My Preparations..

Getting ready for this trip has been a massive whirlwind, what with having revision, exams and placement to do too! But I think I've finally got there.. I hope I have, because if I've forgotten anything, it's getting a bit late now!

It started back in March when I had to arrange everything with Work the World, which was no problem at all! It was so easy, I basically just had to tell them where I wanted to go and when and then they accomodated me as best as they could. I recently found out that I will be definitely staying in Oyster Bay House, with lots of medics, nurses, physios, a couple of midwifes and a few diagnostics.

Work the World also offer a travel insurance package especially designed for their placments through Endsleigh, so I decided to use this for the entire 6 weeks as it seemed to be the best thing. I also had to ask SCoR for proof of my professional imdemnity insurance so that if anything were to go wrong then I would be ok and covered.

Once my dates had been confirmed, I started thinking and looking into what I could do post placement to make the most of my Summer and time out there.. After searching everywhere and asking many questions to lots of people and companies, I decided to book a 2 week safari with Acacia Africa, through STA! I also booked my flights with them as It was easy. I'm flying with Quatar airlines, with a stop-over in Doha, before landing in Dar es Salaam - the journey time overall is about 15hrs; so I will be bored.

To make sure that It was safe for me to travel out there I had to have quite a few injections, much to my dismay as I am really not a fan.. Hep A, typhoid, meningitus ACWY and yellow fever. A couple of these were quite expensive, but had to be done because you're not allowed entry to Tanzania unless you have a special certificate to say that you've had yellow fever! Anti-Malaria tablets were also a must and buying 6 weeks of Malarone is not a cheap purchase.

Due to the strong Muslim culture in Tanzania and therefore, having to keep my shoulders and chest covered and have shorts that come down my thigh, as mentioned before, I've also had to do some shopping for new summer clothes that fitted these criteria and were also lightweight and preferably cotton (but lets face it, not many girls would be disappointed with having to go clothes shopping - and I wasn't either!) I also needed to buy clothes that weren't too bright (blue, yellow, etc.) for safari, as these colours attract insects which can give you dengue fever - not very nice as it can make you very delusional, sadly there isn't anything you can take to protect you from this. Another item the safari compant recommend, although I thought this very strange it does kind of make sense (if you need it), is a sports bra?! Apparently because the roads are very bumpy, the truck ride can be very uncomfortable!

I didn't really know what to do about my phone because I didn't want a massive bill when I come back, but I did want to be able to send the odd text home. I got recommended to suspend my contract and get a pay as you go sim card instead, so that's what I did. It's not too expensive, 50p to send a text and free to recieve and it's £1 a minute to recieve a call and £1.75 a minute to make.

There's also been all the general holiday stuff to buy too and it's been quite hard to figure out what I'm going to need for 6 weeks, as I've never been out of the UK for more than 2 weeks at a time before! Sunblock was a definite need of course - both factor 30 and 50 (if I burn with this still, my skin must be paler than I thought!), along with new sunglasses and of course insect repellant, which had to have 50% DEET in (not really sure what makes DEET so good, but it was recommended, so thought it best to have!) and then all the shampoo, shower gel, moisturiser etc. etc.!

One thing that I've been trying to do since Work the World confirmed my placement, is learn Swahili. It's very interesting, but when It's a language that you've never really heard before, it is hard to know whether you are pronouncing the words correctly at all. I'm still trying my hardest so I know at least the basics when I get out ther, but am not really a language person, so it is very trying at times!

I think that I've now got everything in place that needs to be sorted, I've just got money to get and then the packing to do.. And at the moment I'm feeling that 20kg is not a lot for 6 weeks, but I'm sure it's probably more than I think.

Radiotherapy In the UK.. VS.. Radiotherapy In ORCI..

Radiotherapy in the UK is all about accuracy. Without this who would know where we are treating?! To achieve this there are many different procedures put in place for each and every patient.

Patients will have CT scans done, in a CT Simulator, prior to treatment in order to plan there treatment so that we're in exactly the right spot and the cancer is getting the exact dose needed. For the CT scan a patient has to be comfortable and immobilisation equipment is used in order to keep them still and in the same position - this sounds like an awful term, but basically all it is is something like a head rest and something to support under their knees, for head and neck patients they will also have a shell made to keep them in the exact position.

 A CT Scan and Breast immobilisation

Example of A Head and Neck shell

The plans created using the information provided from this scan can range from two different beams of radiation treating the patient.. To five or six (Intensity Modulated Radiotherapy - IMRT) creating a very precise dose distribution around the cancer target.

A Two Field Plan

 

An IMRT Head and Neck Plan

The patients have to be in the same position as they are for this scan when they come for treatment. To make sure this happens, the same immobilisation equipment is used, and permanent marks (aka tattoos, but no I'm afraid we can't give pretty butterflies as many patients ask!) are given to the patient during their CT. These marks then have to be aligned using lasers in the treatment room.

X-Ray images are also  incooporated into the treatment machines - linac's - that we use, and are taken when the patient has been positioned on the bed correctly, another method to ensure that the patient is in the correct place. If not initially then alterations to the patients position will be made to make sure that they are.

In Tanzania however, the situation is very different - with little accuracy compared to practice over here!

The department was donated two Colbalt-60 machines (the older version of a linac, which uses a live radioactive source - and can be dangerous if this source gets stuck in an active position and will not return to the safe) and a simulator (the older version of a CT simulator, still used in some centres in the UK, but not as much as they once were). This was great.. However, the last that I heard one of these Colbalt-60 machines has broken down, along with the simulator and one of the lasers used to align patients in the working Colbalt-60 machine is broken too! So equipment wise the insitute is in a very poor state sadly. 

 Example of A Simulator

With no simulator, this means no initial immobilisation (head and neck shells are reserved for the 'VIP' patients) to get patients in exact positions and no images to plan the treatment with. Therefore, there is a lack of accuracy before the treatment set up even begins! No tattoo marks are given to patients, and reference points are often just plasters stuck onto patients skin, which could easily come off - leaving the radiographers with no idea about where they are treating!

As they have nothing to plan with, basic techniques are used - those seen for palliative treatments in the UK - Single direct fields or parallel opposed paired fields, all of which are very large, leading to bad side effects; which are poorly managed.

Infection control is poor in ORCI, with there often being no running water let alone soap! As this is the case touching patients is a no go, so even if reference plasters are on the patient, they are unlikely to move the patient anyway!

The fact that the centre is working with only one Colbat-60 machine influences the throughput of patients too. As the pace in the country is slow, even in the working environment, days become very long for staff, often treating patients from 8 in the morning until 10 at night!

As you can see, the situation in Tanzania is very far from perfect and for a country with such a huge population is no-where near what is needed. I'm looking forward to going out there and experiencing all of this with my own eyes.. And seeing if there is any little thing that I could do to help!

The Hospital..

The other day I got a call from Work the World to finalise more of my trip and the hospital I'll be working in,Ocean Road Cancer Institute (ORCI). So I thought I'd do some more research into this hospital and find out more of what I'm in for..

ORCI is the only specialised cancer institute in Tanzania, along with one of the oldest institutes in the country, located along the Indian ocean about 200m from the beach. It works under the ministry of health, so is funded by the government, but works along side the Tanzanian community to offer the services they are in need of most.

The hospital is a referral insitute for about 3,500 patients a year and follows about 10,000 patients through in a year. The services it offers includes:

• General laboratory services

• Diagnostic imaging including X-Rays, Ultrasound, Mammography and Nucleur Medicine

• Chemotherapy delivery

• Radiotherapy treatment - Treating 150-200 patients a day, over 24 hours

• Outpatient cancer patient clinics

• Inpatient services

• Palliative care services - The delivery of oral morphine, counsilling and spiritual services

• Cervical and breast cancer screening outreach programme and screening itself - ORCI is the only hospital that offers this service in Tanzania, they use exsisting family planning clinics and reproductive health services to integrate this into practice

• HIV/AIDS care and clinic

• Offers teaching programmes for undergraduates and post graduates in medicine and other healthcare courses

Hopefully whilst I'm out there I'll have the opportunity to experience all that this hospital has to offer so that I will get a full picture of the management of cancer in Tanzania.

THE BIG 'C WORD'!!

The Big C Word (cancer) is a bit of a taboo subject in the UK, with people avoiding the subject totally in a lot of cases. But in Tanzania the situation is worse still as it is under recognised and over shadowed by HIV and AIDS. Although cancer can have a good prognosis, local doctors missing early signs and giving incorrect diagnosis' due to their limited knowledge of cancer and the public not being aware of what they should be looking out for, leads to cancer being picked up at a late stage and sadly with a much poorer end outcome to cancers in the UK; with the majority of patients dying withing a year of diagnosis.

In the UK the most commonly diagnosed cancer in females is Breast, followed by lung and bowel. In males, prostate is most common followed too by lung and bowel.. In Tanzania the common cancers are very different..

Whereas cervical cancer is the 19th most common cancer (Cancer Research, 2010), it is the most prevelant cancer amongst women; especially common in areas of non-circumsised men - a causal factor of the disease, along with the HPV virus. It accounts for between 35-40% of all cancers in Tanzania.

With men, the most commonly diagnosed cancer is Kaposi's sarcoma (a skin cancer) something relatively rare in the UK. It is caused by the Herpes virus and there are two types that affect the African population - AIDS related and African endemic, which are much more aggressive than the type that affects the UK. Numbers of this disease are so high due to the incidence of AIDS in Africa and it is considered to one of the AIDS defining diseases.

Other common cancers include skin cancer, primary liver cancer and Burkitt's lymphoma.

Although skin cancer is easily treatable, it is much more noticable in caucasian people due to the colour of skin. In coloured people it is often assumed that they are immune to the disease, therefore diagnosis is late when disease is advanced and potentially fatal.

Primary liver cancer is a disease rarely seen in the UK, whereas in Africa it is common due to Hepatitis B and C which are causal factors.

Burkitts lymphoma is a disease which was discovered in equatorial Africa and is divided into three categories. One category is classed as non-African, the other two are very commonly seen late stage amongst African children. It is related to the Ebstein-Barr Virus (EBV) and also HIV/AIDS (leading to it's high incidence).

Although the cancers prevelant is Tanzania can be life-threatening their lack of knowledge, late presentation and lack of money in the country mean that education, control and treatment of the disease is hard. And means that the majority of cases I will be seeing will be palliative to improve quality of life rather than obtain cure.

As you can see the cancers I will be experiencing will be very different to anything I have ever seen in the UK and at times I imagine it will be very trying and I will experience some very tough and sad situations.. it will definitely be an eye-opener in more than one way!!

The Country..

When in Tanzania, located on the East coast of Africa, I will be staying in Dar es Salaam which is the largest city and political capital. It has a hot and humid climate and when there in June it is considered the coolest and driest month, just after the rainy season, with average temperatures of between 25-30°C! (I don't class this as cool! And having very pale skin this will probably not mix very well - so I can imagine some sunburn!)

English is quite widely spoken, but the main language in Tanzania is Swahili or Kiswahili; which is part of the Bantu group of African languages. As most of the patients I will encounter will know little English, I've got to get my head down and learn some general words and phrases before I go - But more on that later!  

The general religions are Muslim and Christian, so although having four weeks of sun will be nice, covering up will be a must to avoid unwanted attention from the local men and unwanted looks and remarks from the local women. 

To travel to the Radiotherapy department; Ocean Road Cancer Institute, I will have to use the local form of travel - the 'daladala', there version of a mini-bus, which can get very crowded and with maniac drivers and no air conditioning I've heard that the experience is definitely something very different!

As well as work, I also intend to experience as much culture and do and see as many different things as I can!

I've heard very good reports of the variety of foods in Dar and the prices for food and drink are very, very cheap! The local dish of Ugali (a dish of maize flour served with a meat or vegetable stew) is just £1, a beer is 75p and a soft drink just 25p. Konyagi is there local spirit which is 35% and this is cheaper still!

Kariakoo is a district in Dar es Salaam that is most famous for it's extensive market which offers a thrilling, authentic shopping experience! It offers cheap souvenirs including jewlery and African drums. However, being a muzungu (foreigner) means that traders try to charge way over the actual price, so haggling is a must and it's recommended to take someone who knows the market and how it runs if you're a bit unsure.

Kilamanjaro National Park is located in the North of Tanzania, but I'm afraid I do not have the stamina to climb Kilamanjaro - as much as I would love to! As well as this park, there are also a lot of others - some of which I will be visiting. They include:

• Mikumi National Park; which is famous for it's tree climbing lions!
• Ngorongoro Conservation Area; a large volcanic crater, which is a UNESCO world heritage site
• Lake Victoria
• Selous Game Reserve; one of the largest faunal reserves in the world
• Serengeti; extends into Kenya and is well renowned for hosting the worlds largest terrestrial animal migration in the world - one of the 7 natural wonders of Africa.

The Big Migration!








Zanzibar is another must, just a two hour boat ride away! t's a semi-autonomous part of Tanzania which consists of numerous small islands and two larger one; known as the 'spice islands'. It's capital, 'Zanzibar city' is located on Unguja island and is known as the 'Stone town', a UNESCO world heritage site. It is one of the only places where saffron is grown, along with many other Middle Eastern spices. There are beautiful beaches to explore, the possibility to swim with doplphins, open air markets in the Stone town and a seaweed centre; where soaps, etc are all made using seaweed an natural products.

Another beautiful area, just a boat ride away from Dar, is the Bongoyo Marine Reserve, a secluded area where you can picnic, swim or snorkel amongst the diverse marine life amid the coral!

This touches on only a few of the many opportunities available whilst in Dar es Salaam, so as you can see I will definitely not be getting bored on my weekends off and intend to take full advantage of the beautiful country whilst out there. This includes a cheeky 12 day overland safari post placement, for which my boyfriend is flying over to meet me.. Details of this will follow shortly!

Diagnostic In Tanzania..

For the Diagnostics amongst you (the majority I imagine!) thought I'd link this up for you..

My fellow winner +Richard Betteridge is also blogging about his journey to Tanzania to work in a diagnostic department, if you're interested in hearing about his preparations etc. here's his blog - A Student Radiographer goes abroad!

Thanks guys!

Hello..

So, being a bit of an internet novice and having never written a blog or anything similar I'm very unsure of how this whole thing works - Apoloigies for any clumsiness and such, but here goes!

Firstly, my name is Kimberley Balsdon (Kim please!) and I'm currently a second year student at Cardiff University studying Radiotherapy and Oncology. And the reason I've decided to start this blog is due to my recent success in winning the Society of Radiographers (SCoR) International Elective Competition!

Being a student member of SCoR means that I have the opportunity to tap into loads of different resources, including journals, conferences and weekly newsletters to keep me up to date with the world of radiography. When I saw this competition in StudentTalk advertising a prize of a 4 week elective placement in a third world country it sounded like an amazing experience! I've always been interested in travelling the world, experiencing new cultures and having lots of amazing adventures, so being able to combine this love with my love of radiotherapy seemed to be perfect! To enter I had to write an 800 word personal statement about where I wanted to travel to and how I would benefit from the experience.

Having not heard anything by the end of Decemeber (when I thought winners would be announced) I assumed I had not won; I was disappointed, but I had expected not to. So I forgot about it really..

Then at the end of January, I had just finished Uni and got a phone call from SCoR saying that I'd won!! I was in complete shock and amazement and was sooo excited!It then became official.. And me and +Richard Betteridge could begin our journeys across the world :)

The society work with Work the World to offer this opportunity and since I won I have been working along side them to plan my trip. Originally, I had written in my statement about how I wanted to go to Ghana for my four weeks. However, the links that Work the World have in Ghana for radiography are diagnostic, but not radiotherapy. Therefore, I had to change my plans and am now off to Tanzania for four weeks! I wasn't disappointed about the change as both offer amazing opportunities!

I'm flying off to Tanzania on the 1st of June - less than a month away?! - and leading up to this date I will be regularly posting and keeping you guys up to date about the country, the healthcare, the hospital I'm going to, the culture, the language, my preparations and then my experiences whilst I'm out there (although internet connection can be very dodgey I hope to be able to keep in contact as much as I can!).