On Friday, March 1st Kendra and I will begin our trek up Mount Kilimanjaro. The itinerary says we start at Machame Gate (1800 meters) and walk through a rainforest type environment to the Machame Hut camp (3000 meters). The next day, we leave Machame to get to Shira camp (3840 meters). This is a 4-5 hour hike in mooreland. Sunday is an important day for acclimatization, as we will go as far as “the junction of Lava Tour” at 4600 meters before returning to Baranco camp at 3950 meters. Monday we “ascend the great Baranco wall” which is reported to take 1.5 hours (is that just the wall, or the whole day’s hiking? I don’t know) and then end in Karanga Valley (4100 meters). Tuesday we leave our camp in Karanga Valley and arrive at Barafu hut (4600 meters) in time for lunch. Hopefully we will be able to go to bed and sleep early in the night, because in the wee hours of the morning we will get up to make the last leg of the journey to the summit. The schedule I have says we will go via Stela Point to reach Uhuru Peak at 5895 meters. Take some pictures! And start the trek down…
It goes much faster on the way down. We will have lunch at the same camp as the day before (Barafu) and then descend to Mweka camp at 3200 meters. The last day (Thursday), is only a 3 hour walk in the rainforest to get from Mweka camp to Mweka gate. A car ride back to Moshi will complete our Kilimanjaro adventure. What next?
*- Safari-*
Our plan right now is to meet the DMU students that arrived on the 17th of February for a 4 day safari from March 8-11. We will definitely go to Ngorongoro crater, and hopefully we will be able to get over to see the Serengeti in that time as well. After that, Kendra and I catch a bus back to Dar where we will spend the night before flying home. Natalie and Eva, the other students, will have a few more days at Gonja before continuing their 4th year adventures in Uganda. I’m betting that I won’t be able to get on the internet again after we leave Gonja, so this is goodbye until I see you again back in the states! Thanks for paying attention to all my ramblings!
Thursday, February 28, 2013
Monday, February 25, 2013
Tanzania OB and HIV
It is the end of week three here in Tanzania, and I’m going to try and describe a few of the highlights from my time at Gonja Lutheran Hospital.
One of my favorite parts of medicine is delivering babies. Probably this is because it is generally a happy and exciting thing and also because you get to see the results of your work right away. I already described the first delivery we saw, and I’ll briefly mention the other obstetric events I got to participate with.
The day after the high intensity resuscitation efforts, Kendra and I were present for a vacuum assisted delivery. The young woman delivered a healthy baby girl who cried almost immediately after being born (both are in picture to the right). The interesting part of that delivery was to see the vacuum/suction device they use here. It is not a hand held self pump, but rather a rubber apparatus that has a head like a plunger. Instead of a wooden handle there is a rubber tube to connect the cup to a mechanical suction machine. Dr. Amini cut a mediolateral episiotomy (cringe!) to help place the cup on the baby’s head. Once placed, he asked the nurse to turn on the suction, and then waited a couple minutes for it to form a strong seal. After a few attempts – the seal kept breaking and he would have to replace the cup, waiting each time for a new seal– the baby was born. I delivered the placenta, and let the OB nurse stitch the episiotomy.
One week ago, I saw and scrubbed for my first C-section. There have been plenty of c-setions, but for whatever reason I never hear about them until they are already underway. In this case, Dr. Lusingu is my neighbor and this is his week of call. I asked him to get me on his way to the hospital for c-sections, and so around 2 in the morning I heard him calling for “Doctor Kendra” (Kendra is currently away, but it is not uncommon for our names to get switched here. I guess it is the similar –ndr– in the middle of them that get people confused?). I yawned all the way down to the hospital, and all the while that they were setting up. I was awake enough once the surgery started and I first assisted Dr. Lusingu. Dr. Yona did anesthesia. The surgery went smoothly and the baby was healthy. They cut a vertical incision into the skin, fascia, and peritoneum. Then a horizontal incision into the lower uterine segment.
The night after the c-section, there were 2 deliveries back to back; the second one I was in charge of guiding the baby out. It was pretty exciting to have my first hands on delivery in Tanzania. The woman did have a 2nd degree laceration, and when I was recording in the chart afterwards the nurse told me I should write episiotomy. I still don’tknow if that is because they only understand episiotomy, or if there is another reason that they want to report iatrogenic injury to the perineum instead of trauma from delivery. Whatever the reason, I refused and wrote “2nd degree laceration” because that is what happened!
On Sunday, February 17, two new DMU students arrived. They will be here for 4 weeks and are living in the same house as me and Kendra.Their names are Natalie and Eva and I have enjoyed their company. We have fun talking about things we have in common, as well as sharing about our different experiences and knowledge. For example, Natalie grew up in Key West, and recognizes many more of the plants here. She has been sharing some of their names with us. Eva grew up on a farm in Oregon and did goat and pigs for 4-H. She has educated us some about goats, since we see them frequently grazing by the road/path.
Last Thursday night, there was another vaginal delivery. We were called at 2 am and all 4 trooped down to participate as we could. I felt that I shouldn’t hog all of the deliveries, so Natalie delivered the baby. It was her second time delivering a baby, and the first time repairing a perineum. She did a good job, and asked at times for advice/suggestions. It was strange to be helping her, because I feel like my training or experience isn’t that much more than hers. I guess I have sought out more OB experiences than she has, because her particular interest is in HIV care and treatment.
Because Natalie is hoping to care for HIV patients in the future, she is especially excited for Thursdays here at Gonja, when there is an HIV clinic in the Care and Treatment Center (CTC). This week was actually my first time in the CTC and it was interesting to see the routine in clinic. With every patient, they go through a questionnaire to screen for tuberculosis, as well as asking about other signs of opportunistic infections or medication side effects. They have a flow sheet that makes it easy to compare symptoms from previous visits as well as weight gain or – more likely – loss. Most patients seemed healthy by just looking at them, but one woman had lesions that were very clearly Kaposi’s sarcoma. She also had a lot of swelling in her right leg only, to the point that we got worried about elephantiasis and felt the need to think about tropical medicine and clarify the filarial diseases in our heads.
I think that for awhile, the people at Gonja considered HIV to be a disease of the cities and if a patient was positive it was because they had traveled to Dar Es Salaam, or Moshi, or some other big city.That it no longer the case. We have seen many patients with HIV; some patients are new diagnosis and others are known cases that come in because they are very sick. One HIV positive man in his 30’s or 40’s came in with severe shortness of breath. He had a serious case ofheart failure – not only was his JVD the most prominent I had ever seen, his anterior jugular was also distended, and the small thyroid veins were clearly visible. He did not live 24 hours after being admitted, and the doctors attributed his heart failure to the virus (I think dilated cardiomyopathy is a known complication of HIV, maybe that caused his decline). Another patient was brought in with altered mental status and cranial nerve findings (left sided facial droop and disconjugate gaze). His “blue card” that the government gives to all HIV patients indicated that he hadn’t been taking ARV therapy since 2010. That meant that he could have a number of infections affecting his brain, and Gonja doesn’t have the diagnostics to determine which organism is most likely. Instead of diagnosing, apply the shotgun approach – the patient got antifungals, antibiotics, and of course was restarted on antiretrovirals!
The topic that merges HIV and OB is Preventing Mother To Child Transmission (PMTCT). They are very careful about checking a new OB’s HIV status, even requiring both husband and wife to come to the first OB visit together so that both partners can be screened. The charts have a number designation written on them to communicate the HIV status. If the result is not known, the woman is PMTCT 0. If the result is positive, she is PMTCT 1, meaning she has HIV and needs to receive ARV therapy. If the result is negative, the woman is PMTCT 2. There have been a few PMTCT 1 deliveries, but Kendra and I always missed them because they happened in the night or they didn’t tell us they were going to C-section. However, we did see that they are careful to document delivery of the correct medication to both mother and baby to prevent transmission.
One of my favorite parts of medicine is delivering babies. Probably this is because it is generally a happy and exciting thing and also because you get to see the results of your work right away. I already described the first delivery we saw, and I’ll briefly mention the other obstetric events I got to participate with.
The night after the c-section, there were 2 deliveries back to back; the second one I was in charge of guiding the baby out. It was pretty exciting to have my first hands on delivery in Tanzania. The woman did have a 2nd degree laceration, and when I was recording in the chart afterwards the nurse told me I should write episiotomy. I still don’tknow if that is because they only understand episiotomy, or if there is another reason that they want to report iatrogenic injury to the perineum instead of trauma from delivery. Whatever the reason, I refused and wrote “2nd degree laceration” because that is what happened!
Last Thursday night, there was another vaginal delivery. We were called at 2 am and all 4 trooped down to participate as we could. I felt that I shouldn’t hog all of the deliveries, so Natalie delivered the baby. It was her second time delivering a baby, and the first time repairing a perineum. She did a good job, and asked at times for advice/suggestions. It was strange to be helping her, because I feel like my training or experience isn’t that much more than hers. I guess I have sought out more OB experiences than she has, because her particular interest is in HIV care and treatment.
I think that for awhile, the people at Gonja considered HIV to be a disease of the cities and if a patient was positive it was because they had traveled to Dar Es Salaam, or Moshi, or some other big city.That it no longer the case. We have seen many patients with HIV; some patients are new diagnosis and others are known cases that come in because they are very sick. One HIV positive man in his 30’s or 40’s came in with severe shortness of breath. He had a serious case ofheart failure – not only was his JVD the most prominent I had ever seen, his anterior jugular was also distended, and the small thyroid veins were clearly visible. He did not live 24 hours after being admitted, and the doctors attributed his heart failure to the virus (I think dilated cardiomyopathy is a known complication of HIV, maybe that caused his decline). Another patient was brought in with altered mental status and cranial nerve findings (left sided facial droop and disconjugate gaze). His “blue card” that the government gives to all HIV patients indicated that he hadn’t been taking ARV therapy since 2010. That meant that he could have a number of infections affecting his brain, and Gonja doesn’t have the diagnostics to determine which organism is most likely. Instead of diagnosing, apply the shotgun approach – the patient got antifungals, antibiotics, and of course was restarted on antiretrovirals!
The topic that merges HIV and OB is Preventing Mother To Child Transmission (PMTCT). They are very careful about checking a new OB’s HIV status, even requiring both husband and wife to come to the first OB visit together so that both partners can be screened. The charts have a number designation written on them to communicate the HIV status. If the result is not known, the woman is PMTCT 0. If the result is positive, she is PMTCT 1, meaning she has HIV and needs to receive ARV therapy. If the result is negative, the woman is PMTCT 2. There have been a few PMTCT 1 deliveries, but Kendra and I always missed them because they happened in the night or they didn’t tell us they were going to C-section. However, we did see that they are careful to document delivery of the correct medication to both mother and baby to prevent transmission.
Friday, February 15, 2013
Tanzania Part 2
Hello All!
I forgot to mention one aspect of the set-up here that is fairly important. In addition to the staff here, the hospital is currently hosting 10 Tanzanian students from Kilimanjaro Christian Medical University College. They arrived a few weeks before we got here, and will leave one week before we do. They are third year students, having their first clinical experiences. As part of their training, a resident comes from Kilimanjaro Christian Medical Center (KCMC) to teach them for a week in their specific discipline. They had OB/Gyn before we arrived, a pediatrics resident last week, and this week is a resident in internal medicine. I really like having the university-minded resident here – it allows me to see how the healthcare services provided are different even within this country because going on rounds with the resident is a different experience from rounds with the Gonja doctors. For example, he clarifies to the students that although the young woman likely does have somatization disorder, ideally we should check for organic causes of her behavior and the diagnosis of somatization disorder is one of exclusion. Another example is a type I diabetes mellitus patient that was admitted before Kendra and I arrived and is still here. The first day the resident saw him on rounds, he asked if they could do labs to check for end organ damage from the disease – how are his kidneys? His eyes? These things were not considered by the providers here – or at least not mentioned to me. Perhaps they didn’t mention it because they know they cannot carry it out. Which brings up the issue of resources.
One resource is doctors. When we talked on Tuesday, the resident described a familiar problem – doctors (especially specialists) finish their training and want to stay in the big cities. Even young adults who grew up in a rural area, once they go to a big city for training and get used to living there, do not want to return to the rural area they are from. Another resource is equipment, and I don’t think you will be surprised to hear that the hospital here lacks many diagnostic tools we take for granted at home. They have an x-ray and an ultrasound, but no CT. Also, I don’t think they have anyone here trained to use the ultrasound machine, which they need in order to really take advantage of what they can do with it. We went to the lab one day to learn what they can do here, and I still don’t think I know for sure. However, there are definitely blood tests that they cannot do here. As for treatment, we’ve had a number of patients that need one antibiotic, but can’t have it because it is out of stock. I am not sure they even stock other things, like dextrose solutions in higher concentrations than D5 (important for hypoglycemic patients), or small enough gauge IV’s for neonates. Of course, they do have medicines that I bet I couldn’t find in Clarion (mostly anti-retroviral medications for the HIV patients). Maybe it comes down to priorities and where they can spend money to benefit the most patients.
One last comment on resources; my friend and classmate had an experience with a patient in the hospital who had a terminal cancer and also a drug-resistant infection that was only susceptible to one antibiotic. When they ordered that antibiotic, it just so happened that they got a warning saying there is a (national?) shortage of the medicine. They went through the extra paperwork required and got the medicine for their patient. I heard about it because my friend brought up the ethics of using a limited resource for a patient that is going to die no matter what. In this case, the hospital/state/country is so big that the physicians treating the terminal patient will not actually feel the shortage or have to compromise care of another patient. At Gonja Lutheran Hospital, however, it is a different story. Choosing to treat an HIV patient with an opportunistic infection that they likely won’t be able to fight off might take antibiotics away from an infant later. Just a thought.
Probably I thought about this scenario because in our first week here there was a 5 day old baby boy who died of septic shock due to cord sepsis. The pediatrician from KCMC was here that week, and he had initially written for ampicillin and gentamicin to cover the possible organisms. The hospital didn’t have either of these, and instead they started injections of ceftriaxone. The baby got 1 or 2 days of antibiotics, but didn’t make it.
Just 2 days after that baby died, Kendra and I attended a delivery of a baby girl. She was born around 11:00 am and looked terrible. She didn’t cry and was blue and limp. I grabbed the bulb suction and tried to clear any secretions, but she still wasn’t breathing. Every once and awhile her mouth opened and closed in a way that reminded me of a fish out of water. There are many details to the resuscitation that I won’t describe because I’m not sure I can do it accurately. Mostly, the resuscitation was slow to be initiated and lacked many of the tools needed to do it correctly. Also, when it became clear she was having more prolonged trouble that stimulation and suctioning wouldn’t cure, Kendra and I had to really push to order diagnostic labs. Really, all we got was a glucometer that showed her to be hypoglycemic (this was about 2 hours after she was born). Although we were trying to get her to nurse at this point, mother and baby weren’t connecting. We ended up giving the baby 15ml’s of D5 solution (remember, D5 is the highest concentration they have) and we gave it orally because the smallest IV catheter they have is 24 gauge. Luckily, later that afternoon the baby started nursing. She stayed at the hospital for 5 days or so to receive antibiotics in case an infection was the cause of her hypoglycemia. There were a lot of things that could have gone differently, but maybe we wouldn’t have had to fight with her so much to start breathing if we had known we needed to correct her hypoglycemia and done that earlier.
Baby Girl (I can’t remember what they named her) has had the biggest impact on us so far. It plays right into Kendra’s project as well, as she was hoping to do some teaching about newborn resuscitation for her global health project.
 |
| the KCMC students packed up and ready to go home |
One resource is doctors. When we talked on Tuesday, the resident described a familiar problem – doctors (especially specialists) finish their training and want to stay in the big cities. Even young adults who grew up in a rural area, once they go to a big city for training and get used to living there, do not want to return to the rural area they are from. Another resource is equipment, and I don’t think you will be surprised to hear that the hospital here lacks many diagnostic tools we take for granted at home. They have an x-ray and an ultrasound, but no CT. Also, I don’t think they have anyone here trained to use the ultrasound machine, which they need in order to really take advantage of what they can do with it. We went to the lab one day to learn what they can do here, and I still don’t think I know for sure. However, there are definitely blood tests that they cannot do here. As for treatment, we’ve had a number of patients that need one antibiotic, but can’t have it because it is out of stock. I am not sure they even stock other things, like dextrose solutions in higher concentrations than D5 (important for hypoglycemic patients), or small enough gauge IV’s for neonates. Of course, they do have medicines that I bet I couldn’t find in Clarion (mostly anti-retroviral medications for the HIV patients). Maybe it comes down to priorities and where they can spend money to benefit the most patients.
One last comment on resources; my friend and classmate had an experience with a patient in the hospital who had a terminal cancer and also a drug-resistant infection that was only susceptible to one antibiotic. When they ordered that antibiotic, it just so happened that they got a warning saying there is a (national?) shortage of the medicine. They went through the extra paperwork required and got the medicine for their patient. I heard about it because my friend brought up the ethics of using a limited resource for a patient that is going to die no matter what. In this case, the hospital/state/country is so big that the physicians treating the terminal patient will not actually feel the shortage or have to compromise care of another patient. At Gonja Lutheran Hospital, however, it is a different story. Choosing to treat an HIV patient with an opportunistic infection that they likely won’t be able to fight off might take antibiotics away from an infant later. Just a thought.
Probably I thought about this scenario because in our first week here there was a 5 day old baby boy who died of septic shock due to cord sepsis. The pediatrician from KCMC was here that week, and he had initially written for ampicillin and gentamicin to cover the possible organisms. The hospital didn’t have either of these, and instead they started injections of ceftriaxone. The baby got 1 or 2 days of antibiotics, but didn’t make it.
Just 2 days after that baby died, Kendra and I attended a delivery of a baby girl. She was born around 11:00 am and looked terrible. She didn’t cry and was blue and limp. I grabbed the bulb suction and tried to clear any secretions, but she still wasn’t breathing. Every once and awhile her mouth opened and closed in a way that reminded me of a fish out of water. There are many details to the resuscitation that I won’t describe because I’m not sure I can do it accurately. Mostly, the resuscitation was slow to be initiated and lacked many of the tools needed to do it correctly. Also, when it became clear she was having more prolonged trouble that stimulation and suctioning wouldn’t cure, Kendra and I had to really push to order diagnostic labs. Really, all we got was a glucometer that showed her to be hypoglycemic (this was about 2 hours after she was born). Although we were trying to get her to nurse at this point, mother and baby weren’t connecting. We ended up giving the baby 15ml’s of D5 solution (remember, D5 is the highest concentration they have) and we gave it orally because the smallest IV catheter they have is 24 gauge. Luckily, later that afternoon the baby started nursing. She stayed at the hospital for 5 days or so to receive antibiotics in case an infection was the cause of her hypoglycemia. There were a lot of things that could have gone differently, but maybe we wouldn’t have had to fight with her so much to start breathing if we had known we needed to correct her hypoglycemia and done that earlier.
Baby Girl (I can’t remember what they named her) has had the biggest impact on us so far. It plays right into Kendra’s project as well, as she was hoping to do some teaching about newborn resuscitation for her global health project.
Wednesday, February 13, 2013
Tanzania
Hello from Gonja Lutheran Hospital, Tanzania!
Kendra and I arrived here a week ago, on Tuesday, February 5th after traveling for two days. We felt very welcomed by the people here and were immediately shown around the hospital by Sister Dora, the matron of the hospital. The hospital is built on two floors, and each floor is divided into North and South sides. The doctors’ offices are all located on the first floor, (south side) and this is where the outpatient department is conducted. There are four doctors total, and they take turns being the doctor on call and taking days off. As far as I can tell, the doctor on call has to round on the inpatients in the morning, okay admissions to the hospital, and be available for deliveries and surgeries. There are four doctors, Dr. Lusingu, Dr. Amini, Dr. Yona, and Dr. Mary – and even though everyone calls them doctors, they are technically Assistant Medical Officers. Our first week, Dr. Amini was on call. He is very expressive/animated and seems to have good rapport with his patients. This week, Dr. Lusingu is on call and Dr. Amini is gone to do things in town (down the mountain).
The other half of the first floor (the north side) is where the delivery room, main OR, and minor OR are located. So far, I have not seen a surgery, but we did have two very unique experiences in the delivery room that hopefully I can write about later. The minor OR is more like a procedure room and is used for things like ultrasound, setting a fracture, or proctoscopoy.
Upstairs is mostly inpatient. The south side of the upstairs is all wards. They are divided into male and female wards, and they group pediatric patients together but there hasn’t been enough for them to have their own ward. The nurse tells us during morning report there are somewhere between 30 and 40 patients in house, including the 7 women on “antenatal” who are really just waiting to deliver their babies. They are all have big bellies and share a room with beds like a ward, but it is on the north side and it is more colorful because they use their own brightly printed sheets. Also on the north side, second floor, there is the CTC where they have clinic for HIV patients on Thursday and the Maternal Child Health clinic, where they see well children under five and women for family planning and prenatal visits. The MCH clinic is open every day except for Wednesday when they go to do outreach clinics. The nurses at the MCH clinic also offer patient requested HIV testing/counseling and they said they see 3 or 4 people every day who are worried about having HIV – usually teenagers/young adults.
Our house is across the road and a little bit up the hill from the hospital. It is one building with two houses. The other half of the house is occupied by Dr. Lusingu and his family. I think Dr. Lusingu is the doctor in charge of Gonja. In our half of the house, there are three rooms. Kendra and I share one room, and the other room will be occupied by 2 DMU students on February 18th. The third room belongs to an employee of Gonja who is frequently gone, traveling for work. The house is neat and well kept, though not bug proof. We are currently scheming about how to solve an ant problem that has developed next to our front door. The ants have built a sort of highway from the corner of the “picture window,” down and across the wall, to the corner of our door. We also have lots of little lizard housemates and a constant stream of moth friends coming in to hang out and bounce off the walls (or our faces).
There is running water in the bathroom, but we can’t figure out how to make it run into the toilet tank. Therefore, we fill a bucket from the sink to flush the toilet. The sink and shower have cold water only. I hoped I wouldn’t mind, but it is hard to get under that cold shower. Lucky for me, Kendra hasn’t complained when I decide to forgo the shower for an extra day.
More than the cold shower, my biggest frustration with the house is that I am sleeping in a queen bed and the mosquito net won’t fit all the way around the mattress. It is a nightly struggle to arrange the net, and I still end up with it only over half of my body (so you can imagine how good the seal is).
That is a brief sketch of the layout here. We have had a few interesting patients that I can tell you about later, or maybe I’ll tell you about new patients I see this week!
Thursday, February 7, 2013
Tallinn Time
I spent yesterday in the capital of Estonia - Tallinn. The town is known for its Old Town which is, you guessed it, old. There are buildings dating back to at least the 13th century. It's also not very big, which makes it great for a one day adventure.
After breakfast at a locally famous pancake house, I went with others from all over the world on a free guided tour of the Old Town. In our small group, there were people from the UK, Spain, Moldova, Argentina, Russia, and myself. The tour was nice because the guide was able to explain a good bit of Estonia's complex history (which is essentially a revolving door of occupiers from the 1200's on, including Germany, Russia, Sweden, Denmark, and a Polish-Lithuanian kingdom.) Only for a handful of years have the Estonian people really controlled their own destiny.
How about a brief history of Estonia? It's quite fascinating to me because I knew next to nothing of Estonia's history (or of Scandanavia for that matter). There are several major wars that I was completely unaware of. Anyway, the documented portion of Estonia's history started when German crusaders invaded the territory in the first decade of the 1200's. Around a decade later, Danish crusaders attacked from the North at what is present day Tallinn.
There was a major Estonian uprising in the mid 1300s, the Danish were forced out in the 1300s, and there was a Russian attack in the 1400's, but from the time of the crusades to the early 1500's, German nobles of one order or another held the majority of power and wealth in Estonia. Indigenous Estonians were treated as serfs (at best) during this period. The next stage is way more complicated, but the gist of it is that there were significant internal rivalries between different nobles and religious leaders holding the power in Estonia and the territory had very complicated relationships with surrounding Kingdoms as well. What seems to have been a tense peace fell apart in 1558 at the beginning of the Livonian War. Russians (led by Ivan the Terrible) invaded present day Estonia and fought, over the next 25 years, with varying combinations of the Kingdom of Sweden, a Polish-Lithuanian Kingdom, and the Danish/Norwegians. The Estonians themselves remained relatively subservient to whichever army was occupying the territory. The best they were able to do seems to have been to pull for the least offensive occupier, which was the Swedes. The Polish-Lithuanian Empire and the Swedes fought in the early 1600s after the Russians had enough and Estonians were treated rather well under the rule of the Swedish people.
And it goes on and on...the Russians fought the Swedish again in the Great Northern War of the early 1700s and won Estonia back. The Russians retained control over Estonia until the early 1900s with significant German influence. In 1918, they gained an independence (though the Soviet Union seems to have continued to be a significant influence even then, despite the wishes of the Estonians) that lasted for 22 years. In 1939, the Germans and Soviets signed a secret pact to essentially divide up the countries between them. Estonia tried to remain neutral in the war, but the Soviets threatened to invade if they didn't accept military bases and troops on Estonian territory (solely for the Estonians protection of course). Thus Estonian became occupied once again. In 1940, the Soviets left their military bases and formally took over the country, forming the Estonian Socialist Soviet Republic, which was never formally recognized by most of the Western world. The U.S. kept communicating with a true Estonian government that had no power. For a time, the Germans advanced and took control of Estonia, but were eventually pushed pack and Estonia remained rather forcefully controlled by the Soviets until the late 1980's and early 90's when Estonia gradually and incredibly, without violence, gained their independence.
In an interesting side-note of history, Estonians, Lithuanians, and Latvians formed a 360 mile long line through the three countries, joined hand to hand and singing as a protest of Soviet occupation of their countries. You read that right, 360 miles. Wow.
That's probably the most interesting part, but a quick run through of the day after the tour...a couple Moldovans from the tour and I went to this little medieval themed cafe in the bottom of the town hall. A sassy woman served us pastry pies and elk soup. She warned us that we should remember to bring our own "weapons" next time. You know, swords and silverware. It was good, but mostly I was glad it was warm. Afterwards we walked through an old Soviet style market that had a reputation for being a very shady place in its day. We continued on to see an old Soviet prison. We only got to see the outside, but the inside is supposed to be pretty dreary. It remained open all the way until 2005.
The final part of the day was a visit to Estonia's maritime museum, Seaplane Harbour. It's a very modern museum with diverse descriptions of maritime history from iceboats, to buoy styles through the years, to submarines and coastal defense. The highlight is a WWII era Estonian submarine that you can look through. There was also an icebreaker in the harbor available to walk through. The giant steam engines buried deep in the hull were pretty cool. Unfortunately, I have no pictures, because the batteries on my phone died at the prison. Too bad. The rest of the night was low key back at the hostel and I got up early in the morning to catch the ferry back to Finland, where I went to visit a 250 year old island fortress called Suomenlinna. I'm staying in a hostel on the island at the moment. More about Helsinki later!
How about a brief history of Estonia? It's quite fascinating to me because I knew next to nothing of Estonia's history (or of Scandanavia for that matter). There are several major wars that I was completely unaware of. Anyway, the documented portion of Estonia's history started when German crusaders invaded the territory in the first decade of the 1200's. Around a decade later, Danish crusaders attacked from the North at what is present day Tallinn.
There was a major Estonian uprising in the mid 1300s, the Danish were forced out in the 1300s, and there was a Russian attack in the 1400's, but from the time of the crusades to the early 1500's, German nobles of one order or another held the majority of power and wealth in Estonia. Indigenous Estonians were treated as serfs (at best) during this period. The next stage is way more complicated, but the gist of it is that there were significant internal rivalries between different nobles and religious leaders holding the power in Estonia and the territory had very complicated relationships with surrounding Kingdoms as well. What seems to have been a tense peace fell apart in 1558 at the beginning of the Livonian War. Russians (led by Ivan the Terrible) invaded present day Estonia and fought, over the next 25 years, with varying combinations of the Kingdom of Sweden, a Polish-Lithuanian Kingdom, and the Danish/Norwegians. The Estonians themselves remained relatively subservient to whichever army was occupying the territory. The best they were able to do seems to have been to pull for the least offensive occupier, which was the Swedes. The Polish-Lithuanian Empire and the Swedes fought in the early 1600s after the Russians had enough and Estonians were treated rather well under the rule of the Swedish people.
And it goes on and on...the Russians fought the Swedish again in the Great Northern War of the early 1700s and won Estonia back. The Russians retained control over Estonia until the early 1900s with significant German influence. In 1918, they gained an independence (though the Soviet Union seems to have continued to be a significant influence even then, despite the wishes of the Estonians) that lasted for 22 years. In 1939, the Germans and Soviets signed a secret pact to essentially divide up the countries between them. Estonia tried to remain neutral in the war, but the Soviets threatened to invade if they didn't accept military bases and troops on Estonian territory (solely for the Estonians protection of course). Thus Estonian became occupied once again. In 1940, the Soviets left their military bases and formally took over the country, forming the Estonian Socialist Soviet Republic, which was never formally recognized by most of the Western world. The U.S. kept communicating with a true Estonian government that had no power. For a time, the Germans advanced and took control of Estonia, but were eventually pushed pack and Estonia remained rather forcefully controlled by the Soviets until the late 1980's and early 90's when Estonia gradually and incredibly, without violence, gained their independence.
In an interesting side-note of history, Estonians, Lithuanians, and Latvians formed a 360 mile long line through the three countries, joined hand to hand and singing as a protest of Soviet occupation of their countries. You read that right, 360 miles. Wow.
That's probably the most interesting part, but a quick run through of the day after the tour...a couple Moldovans from the tour and I went to this little medieval themed cafe in the bottom of the town hall. A sassy woman served us pastry pies and elk soup. She warned us that we should remember to bring our own "weapons" next time. You know, swords and silverware. It was good, but mostly I was glad it was warm. Afterwards we walked through an old Soviet style market that had a reputation for being a very shady place in its day. We continued on to see an old Soviet prison. We only got to see the outside, but the inside is supposed to be pretty dreary. It remained open all the way until 2005.
The final part of the day was a visit to Estonia's maritime museum, Seaplane Harbour. It's a very modern museum with diverse descriptions of maritime history from iceboats, to buoy styles through the years, to submarines and coastal defense. The highlight is a WWII era Estonian submarine that you can look through. There was also an icebreaker in the harbor available to walk through. The giant steam engines buried deep in the hull were pretty cool. Unfortunately, I have no pictures, because the batteries on my phone died at the prison. Too bad. The rest of the night was low key back at the hostel and I got up early in the morning to catch the ferry back to Finland, where I went to visit a 250 year old island fortress called Suomenlinna. I'm staying in a hostel on the island at the moment. More about Helsinki later!
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| Toompea Castle - Home of Estonia's parliament. Every ruler since the 1200's has used the castle as a seat of power. |
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| St. Nicholas' Church in Tallinn. Originally built in the 13th century, the vast majority of the church is now much newer because it had to be reconstructed after a Soviet bombing near the end of World War II. |
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| A section of the old defensive wall of Tallinn. Legend has it (apparently with some legitimate historical basis, though it probably didn't fall from heaven as the legend goes) that this is the site where Denmark's flag was first created. |
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| The Alexander Nevsky Cathedral across from the parliament building. Built by the Russians in the late 1800's, many Estonians despised the church as a sign of the forced occupation and "Russification" of Estonia. |
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| Old Soviet-style market near Old Tallinn. They say that you used to be able to buy AK-47s and passports here only a little more than a decade ago. The picture doesn't do it justice, but the "booths" are many small corrugated steel buildings. It definitely has a sort of ominous Soviet feel. |
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| View of the Old Town from the town wall. |
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| Tallinn's town square |
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| Former Soviet Prison, "Patarei." Along the coastline of Tallinn. |
Wednesday, February 6, 2013
European Beginnings
Back after a long hiatus...Andrea and I were much busier during our month studying Spanish in Riobamba and Andrea didn't have wifi in her house (clearly she's the real driver of the blog), but I'll add a little about the first few days in Scandinavia. Wishful thinking perhaps, but maybe I'll work on adding some details about the last month in Ecuador soon too...or you'll just have to find one of us to hear about that part.
I went to bed at 6 PM and slept till 4 AM when I had to get up to get to the airport and catch a 6:30 flight to Helsinki, Finland. Really I spent most of the day traveling, as I also took a 2 hour ferry ride across the Baltic Sea to Estonia. In between the flight and ferry, I asked one of the workers at the ticket booth for a good local restaurant and went and found myself a Finnish buffet in a cozy little place. The coziness was welcome, as it was cold, windy, and snowing outside. The ferry was huge and quite comfortable. It had 9 floors, which included a 3 level bar with giant windows in front of the ship. It also has its own "mall," and dozens of cabins. Not to mention the semis that it hides away in its belly. All in all, it was an uneventful trip and I found my way to my hostel in the Old Town of Tallinn, Estonia easily. It turned out to be a little wilder hospital than I'd prefer, but the 3 very drunk Englishmen and 1 Australian kept it from being boring.
I arrived in Europe this past Sunday afternoon when I landed in Copenhagen. Then it was a quick flight to Stockholm, finding a hostel for the evening, and hunting down a grocery for some supper, all of which were quite easy. One of the first things I was struck by in Stockholm is that everyone speaks English, but you'd never know it if you didn't strike up conversations with folks. No one speaks anything but Swedish to each other, even though virtually everyone speaks English fluently. Everyone is very friendly and doesn't seem to mind speaking English, but I feel a wee bit of shame every time I make someone use it. No matter where I am, I always wish I could speak the local language.
That evening, I got a couple hours sleep and then, in good American fashion, woke up to watch the Super Bowl live online. Normally, I don't care so much, but the 49ers have been my favorite team since childhood. Tough loss...oh well...moving on. Maybe not quite yet...watching the Super Bowl by yourself at 4 in the morning in a place where no one else cares makes you realize it's not very important, but still rather fun. I was glad my body was still on U.S. time or I wouldn't have made it through the game.
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| Random street in Stockholm, not far from the Karolinska hospital where I'll be rotating in a couple weeks. |
The next day was spent getting things arranged for my stay in Stockholm. I bought a SIM card, so that I have phone and internet service here, rounded up some more Swedish Krona, and picked up the keys to my apartment. It's a small, but nice, place and the floor is filled with other international students. I don't remember all they told me, but there's a Spanish medical student, a South African doing research on diabetes (In Sweden? The obesity problem is so much less there that diabetes must be far less as well. It seemed like an unlikely place to go to study diabetes.), and a German girl studying public health. They were all very friendly and I look forward to getting to know them more.
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| Helsinki is significantly colder than Ecuador. |
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| The cozy little Finnish restaurant, near the West Harbor of Helsinki |
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| Finnish food. Lots of meat, potatoes, bread, and cabbage. |
That's enough for now. Today was much more interesting checking out sights around Tallinn, but I'd like to write a little about Estonia's complicated history and that will take more time than I have now!
Michael
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| This doesn't do justice to the size of the enormous ferry. |
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| Every ferry needs a 3 story bar, replete with giant windows and a live stage. |
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