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  • Writer's pictureVanessa Valenti

30 days as a volunteer nurse in Tanzania: from my travel diary at the Bugando Medical Center

For the first time on this blog, in this post you will not find travel advice and information, so if what you were looking for is some advice for a trip to Tanzania please READ ALSO: A perfect guide to plan a trip to Tanzania on your own - everything you need to know But let's get back to us... this time I decided to do something different, risking that these lines will remain read by few, but I think it's still worth making an attempt given how much I care and the importance that sharing this experience has for me. Here you will find some pieces extracted from my travel diary that for a month I tried to compile assiduously and punctually... a totally free, unedited and liberating stream of consciousness, from which I will now take some lines that I will elaborate minimally to make them readable. Doing this I hope to get to anyone who wants to take a few minutes to read this at least a little of what I have experienced this month and what this magical land has given me and for which I will be forever grateful.

Asante Sana Tanzania

Now, let's start with a little introduction. For those who don't know, when I'm not traveling or writing about travel, I'm a nurse who deals with Palliative Care at the Romagna Cancer Institute IRST IRCCS. IRST has supported and collaborated with the Bugando Cancer Center in Mwanza (Tanzania) for years and and, thanks to this collaboration, I was able to spend the month of March as a volunteer nurse in the oncology department of the Bugando Medical Center.

So far, I published travel articles about this experience, about our life in Mwanza, about what we ate and the places we visited in our free time.

READ ALSO: What and where to eat in Mwanza, in the heart of Tanzania - where Africa and India meet After much reflection and indecision, I decided to also share the most health-related and impactful part of this experience, hope to raise as much awareness as possible about the situation in Africa, what happens in one of the most advanced hospitals in East Africa and what to expect from this type of experience, in case someone on the other side of the screen is now reading me who wants to undertake the same path. P.s.: I apologize in advance for some technical nursing terms or purely healthcare details but above all for some crude descriptions and perhaps a little too much for the more sensitive stomachs.

"Suffering exists. For everyone, no one is excluded. The only aspect that men of every culture and religion have in common is that they suffer, some more and some less. So let's deal with this, because it's real. Let us be a refuge for ourselves and then be a refuge for others."

Today is finally the first day at the hospital: I'm very nervous, I don't know exactly what to expect and I'm afraid of not being up to it, but I steel myself and set off towards the Bugando Medical Centre. The new building, the one that houses the Bugando Cancer Centre, is not yet operational so we go up to the old department at J4: there is no real oncology department, we are inside the dialysis and ophthalmology department. The oncology "ward" has 3 rooms: one with 6 beds, one with 12 (which would fit 4) and one with 2 for VIPs, i.e. paying guests. The patients are mostly young people, even children. The impact is truly very strong and the first impression I have is a huge sense of helplessness and desperation. I look these people in the eyes and I really don't know how to help them.. I know perfectly well that even at home, perhaps I couldn't save them but I could certainly alleviate their pain a lot and make them feel better.. but here there is very little. I see nurses doing what they can with what they have.

I immediately try to get out of my Italian mentality, because otherwise you'll have to tear your hair out: it's all so unhygienic, non-sterile, not according to procedure... but there really is no other way. They disconnect the drips, they don't wash out, the infusion sets hang encrusted with blood from the poles next to the stacked beds. I shudder. But then I realize that perhaps there isn't an IV infusion set for every drip for every patient, a syringe to do a wash every time. But these nurses must be good: having little or nothing certainly allows you to be creative and give/do the best with what you have. I saw a patient with a peripheral venous catheter in her finger, and all I could wonder was how the hell they managed to get a vein in her finger. Then it was time for the dressings... God! The first was to a 26-year-old albino girl with parotid cancer. While the nurse removed the old dressing I was already shaking. There are no words to describe the devastation I witnessed on my first morning working in Africa. A face totally devastated, disfigured by disease, deformed. The jaw bone was completely eaten away with a giant hole from which you could almost see the inside of the mouth. It's impossible to even remotely imagine the pain of that poor soul, yet I never heard her complain. I observed her and only the noise of the injustice of this life echoes in my head. Being born an albino in Africa is already a sentence, add to that being a woman and then having such a tumor.

I try to put these thoughts aside and look for the right way to approach myself to help the nurse who, very awkwardly, tries to treat that monstrosity. In my heart, I know perfectly well that this medication is useless and that this girl's days are numbered, but doing this medication makes me feel better, especially taking her hand and holding it to try to take some of her pain.. but also to make her understand that I am here and give her comfort, because this is the only way I have to make myself understood. Here almost no patients speak English and I don't understand them the same way they don't understand me. And this is another of the difficulties: not being able to understand and make yourself understood. The only means are gestures, glances and the few smiles that manage to shine through the mask. In fact, I immediately realized that it was all a game of looks, expressions, smiles and touches The patient we treat next is called Angela, she is a 16-year-old girl, or perhaps I should say child. Osteosarcoma in her leg, tomorrow she will go to the operating room and when he comes out her leg (from mid-thigh down) will no longer be there. Yet Angela has one of the most beautiful smiles I've ever seen, so much so that I wonder if she doesn't know about the surgery that awaits her. We treat her leg where she has had an external fixator for 4 endless months, but she doesn't bat an eyelid.

Today is my second day at the hospital, Angelo and I go up to the ward in a different mood than yesterday: now I know what to expect and I am much calmer and eager to get involved. There are two Dutch girls in the ward and the first thing I think about is that the more people there are, the less opportunity I will have to do concretely but I immediately try to banish this thought: we are in Africa, and nothing or no one will ever be enough to fill the gap of this place. Angela's amputation has been postponed... I don't know yet but this will happen about every morning for the next 2 weeks.

Today, I observed nurses for the first time during a blood draw: they use syringes or PIVCs (peripheral intravenous catheters), the butterfly valves are not there. Even tourniquets are a big absentee in the ward, gloves are used instead... I feel a little sad because if we had known this we could have brought a lot of material. During the visit with the doctors, while some nurses take care of the blood samples, a patient squats on a metal pot and poops and pees in the middle of the room with 12 patients, 10 family members and 5-6 healthcare workers... I'm shocked, and the most shocking thing is that no one seems to notice. It seems clear to me that I am no longer in Italy but on the other side of the world, almost in a parallel universe. The morning is rather quiet and feels a little useless: even getting involved in work isn't easy because you're not really supported by anyone specifically and there doesn't seem to be a clear plan of the activity. At a certain point, however, a nurse calls us to help him with the medications and we return to Ashana (that's the name of the albino girl with parotid cancer). Today he seems more agile and at ease, he gets along well even without the assistance of a second operator and I take the opportunity to shake the girl's hand who today, due to a change in the disinfectant used, is more visibly distressed.. For a few moments I lose contact and I realize that that little snow-white hand, with very long and thin fingers, is looking for mine.

In an instant my heart is full, overflowing, and the feeling of uselessness that I felt until about ten minutes before suddenly disappeared. This single moment is enough and justifies everything: the journey, the entire month here... even if this were just the only moment, it would be enough. It doesn't matter if in practice I can do little else, if I won't do much in nursing... this really has to be enough.

For the first time today, we are treating a girl suffering from retinoblastoma: I have heard a lot about it, also because of the clinical study I am contributing here, but it is the first time I have seen one live. Angelo and I were unable to understand whether the eye was surgically removed or whether it was eaten away by the disease, but we are more inclined towards the second hypothesis. What we see under the bandage is horrifying: the pus bleeding from the eyebrow, a nauseating smell... it's hard to report on these pages the things I see these days.

While we go back to Ashana for her usual medication, we are called by the patient's family who is next to the window. At first glance we immediately realize that the situation is critical: the lady is unconscious, clearly gasping (4-5 breaths per minute), radial pulse lost and extremities of the limbs frozen. My palliative heart would sedate her and allow her to leave in peace, in tranquility, surrounded by her family. The reality, however, is very different: we are in the room with 11 other patients and as many family members competing to see who can crane their necks the furthest to witness the macabre spectacle unfolding in front of them. The truth is that palliative care here is just a mirage and I find myself dealing with one of the best nurses in the department, who is busy administering cortisone and physiological solution for hypovolemia, trying in vain to detect the vitals signs and desperately calling the doctor for help... as if there really was something that could be done. Angelo and I are still, and we observe this frenetic and senseless scene in silence. We can't do anything, not even indulge this delirium, while I see the desperate nurse frantically searching the drawers of the "emergency trolley" for adrenaline... but fortunately (and I realize the contradiction in my words), all the medication carts are open and used, there isn't even one usable.

The lady dies, she has finally stopped suffering in front of our eyes and the most absurd thing is that the doctor and nurses are struggling to explain to me and Angelo that unfortunately there was nothing that could be done, that the lady had widespread metastases even in the brain and therefore it would have made no sense to practice cardio-pulmonary resuscitation... it seemed like they were trying to justify themselves to us as if they felt guilty for not having been able to save her... how could we explain to him that it was right like this, that it couldn't have gone differently? That it's not their fault? Indeed, that they should have let her go much sooner? That she would have died in Italy too. It's hard, really hard, you have to completely detach yourself from the Italian mentality. And maybe I'm finally starting to become aware of the gap, of how lucky we are at home and don't realize it, of how much we have to be grateful for. We also treat Angela, who should finally be operated on tomorrow, and at the end of the round, the nurse thanks us so much for our cooperation and help. Actually, it's me who would like to thank him from the bottom of my heart for his courage and the dedication with which he works every day without losing heart in such a context. It must be demoralizing and devastating to know that you can only and exclusively plug and patch a sinking coffin with water coming in from every hole. It's time for lunch and I'm tired, literally distraught and drained of all physical and mental strength: a few hours in here feel like days.

Today I wake up feeling exhausted: it seems to be getting hotter and hotter, the humidity is devastating and I'm starting to feel its effects... standing up is very tiring but we still complete the bed tour and dust all three rooms. Oh yes, because here, after the handover between those who leave for the night and those who start the morning shift, first thing, the beds have to be made. The dirty sheets are removed and replaced with clean ones: clean so to speak because they are all torn and stained. There are no pillows. And then we go around all the rooms to remove the dust with very old, worn and black rags which are passed in a basin with soap and water and perpetually rinsed in the same water which after two beds is putrid. These steps are part of an ingrained meaningless routine that nurses must practice every morning.

Today there are a few patients in the ward: Ashana has been discharged... she will continue the medications at home - that is, no one will treat her and in a few days she will be dead. But hey, this is normal. I try to repeat it to myself: there is no wound care team that goes home to treat these patients, it's difficult even in the ward. Even today Angela doesn't have surgery, she keeps waiting on her bed. For the first time, there is a tiny patient: a little girl of just 6 months. It's difficult to explain the trauma of having a 6-month-old girl hospitalized in oncology in a bed next to a 70-year-old lady. It all seems wrong and impossible, yet this is the reality of things. There is no pediatric oncology, patients are all cared for in the same way, in the same place, and with the same medications and materials used for adults. Unthinkable in Italy, right? Yet, this is it…This little girl is beautiful and chubby with two round and full cheeks, giant dark and super-expressive eyes... she seems like the picture of health, yet she has a hepatoblastoma and is undergoing chemotherapy. I'll talk about it with Angelo... it probably won't arrive at Christmas. I look at the mother who gives her water and lets her play, and I wonder if she knows that her little girl's days are counting. She doesn't seem to know, or maybe she just accepted it... I can't figure it out. How do you see children and elderly people dying next to each other? I can't understand it and I have the feeling that I will never succeed, while for everyone here it seems normal.

At the end of the morning, around lunchtime, I head to the research office to get to grips with the database for the study of retinoblastoma, a longer and more complex job than I would have imagined. Patient records are paper-based, incomplete, full of inaccuracies, discarded, and half the information is missing. How do you treat patients whose date of birth is not reported? How can you make a diagnosis without diagnostic imaging tests, and administer chemotherapy without a histological examination? Realizing the lack of accuracy with which everything is done is shocking.. Vanessa you are not in Italy, you are not in Italy.. this is my mantra, the chant that I repeat to myself all day in here.

Today begins our second week at Bugando: the department is full again but now there are more men and no medications to do. On the other hand, I help for the first time in administering chemotherapy and changing some needles. I don't even know where to begin to list the myriad of things that upset me:

  • there is very little material and of very poor quality, which makes the nurse's work difficult, tiring, imprecise and risky for both the professional and the patient. There are no tourniquets (replaced with gloves), butterfly valves do not exist so to take samples you use syringes or PIVCs whose tip is almost always blunt and piercing the skin is a challenge;

  • chemotherapy is taken from the pharmacy and paid for directly by the patients who bring it to the ward in bags. When it is time for administration, the nurse goes to the patient's bed, collects the drugs, dilutes them at the bedside (without any special mask, and gloves, or infusion tubes with valves and anti-spillage material... they don't even know what the hood is) and administers them;

  • there is no order, a work plan nor the slightest sense of priority, of how to work sterilely, of how to optimize time and resources.

It is very difficult to realize all this and not be able to say anything, help, teach and contribute to improving... because as Angelo, who has more experience than me, confirms to me: you have to be very careful about how you pose and what you say otherwise you risk to offend your colleagues and that they no longer speak to you. It's hard to realize that you leave Italy fully loaded with the conviction of coming to Africa to help, teach and change things and once here you have to come up against the reality of the facts that you are the white man who occupied them for centuries. Your ancestors enslaved them and made to feel inferior for hundreds of years and it is not possible to think of imposing yourself as if you were the most intelligent, capable one and bringing your knowledge as if it were better. You have to enter the team on tiptoe, observe in silence and blend in humbly, and once integrated, wait for them to ask you for advice, help, an opinion on how to do a certain thing, or an idea on how to certain procedure is done in Italy. And that's when a small window opens up in which to insert yourself and give some advice, but even here you must always do it by remembering where you are and what you have. There's no point in explaining to them that blood samples are taken with butterfly and not with PIVCs because they don't have them anyway, so what would be the point of my indication? It's useless to tell them to change the infusion set after the transfusion, to do the washing so as not to block the PIVCs or to close the accesses with caps... anyway the material isn't there and they could follow your advice for 3 days but then they would be left without everything and they would no longer be able to assist other patients. No, the difficulty of this experience is precisely being able to help them and give constructive, feasible and repeatable advice here in their reality, being able to enter this world and improve by dealing with the reality of the facts. Otherwise, it's all useless. We need concrete changes adapted to the context, repeatable and above all, continuity; because I have noticed that they put things into practice, but for two days, then everything goes back to the way it was before. Continuous reinforcement is needed.

In any case, compared to last week, today the nurses seem more expansive and confident, more inclined to ask and collaborate and I feel satisfied even if a little discouraged: I have just less than 4 weeks available in the ward and it took me a whole week to begin gaining their trust and some respect.. imagine how long it would take to fit in and to really make an impact. After lunch, I get to work on the retinoblastoma database and continue to leaf through files of children who arrive at their first visit in monstrous conditions, often after months or years of full-blown and symptomatic oncological disease, which has deformed their face and skull. I wonder how a parent can entrust their seriously ill child to the care of a shaman and to natural and spiritual therapies to reach this point... a point in which even having the best medical therapies any intervention/treatment is totally useless and palliative I think that not even in Italy with the best technologies it would be possible to do something. Leafing through these folders but also these few days spent in the ward were enough for me to understand how much we should invest in prevention and in spreading health culture and controls rather than in medical innovations and treatment materials.

Today we finally remembered to bring Angela, who obviously hasn't had the operation yet, a small beauty kit that Angelo had brought her: some nail polish and some perfume samples... I'm looking for the words to be able to put her smile on this paper, but it was truly indescribable. I think that for a few moments, we actually managed to make her the happiest little girl in the universe... with what? With a couple of Euros. Truly incredible how with so little you can really make a difference here. It was a moment of pure gratitude and joy, a feeling more fulfilling than years of working in Italy. I'm very sorry for bringing so little from home: now that I'm here I can realize that I could have brought so much more that would have made a difference, even in the ward... But I'll write it all down for next time so as to be more prompt and efficient. One thing that I notice today that particularly strikes me at work is the extreme dedication and care that family members have towards the patient - family members of any sex. Not only mothers towards their children but also fathers or children towards their parents... much more important care and presence than in Italy, which I was not used to. Actual physical care: here the family prefers to take care of the person directly... it is really rare to see a nurse washing or changing a patient. I have witnessed a love and dedication that in Italy is truly rare, incredibly intense and which slightly changes the perspective with which we approach African patients even at home: I think this is an immense and unrepeatable opportunity to get closer to this culture and to improve assistance for this population in Italy too.

Even today, I try collecting a few blood samples: it makes me laugh a lot to see how in just a few days I have totally adapted to this reality and I do things that if they had told me a week ago I would have categorically refused in horror. If after an attempt to take a vein you are not successful, you reinsert the needle into the cannula and start again... hole after hole, even 6 or 7 holes with the same needle re-cannulated time after time... the risk of getting stuck is very high and sterility doesn't exist here, the risk of infection is sky high. Once you have taken the vein and removed the needle, where should you put it? Inside the needle-box? Absolutely not, it sticks into the mattress used like a pincushion.. so when you make the bed you have to pay a lot of attention to needles coming out of all the corners.. this last thing is unrepeatable, just beyond any thought for any European nurse, but the issue of using the re-cannulated needle... alas, what alternatives are there? There aren't any PIVCs for everyone and you can't afford to use a new one every time, so I too had to adapt and did this, something I never in my life thought I could do. But for extreme evils, there are extreme remedies.

This working day begins with the urgent placement of a chest drain on a literally dying patient, perhaps already more dead than alive. The drain was inserted by the pulmonologist without echo guidance, with a 20G PIVCs, obviously making two attempts with the same re-cannulated needle and then connected to an IV infusion set for the leakage of the liquid which ended up in an urinary catheter bag... there is no need for me to comment because I think that the madness of this maneuver is in itself already sufficiently explanatory of the medical level -welfare.

The girl with the retinoblastoma that literally ate her eye has returned and she promptly, proudly shows the receipt attesting to the payment of the service that the nurse will have to perform before being treated: 20,000 TSZ, around 10 €. Here practically everything is paid for, unless you have health insurance, which however is very expensive... so you can get treatment as long as there is money, when the money runs out, patients start skipping treatments.

Then we treat a new patient with breast cancer: she certainly underwent a mastectomy but now she has a recurrence with a very ugly cauliflower lesion and a deep ulcer that exposes a nice piece of raw flesh... I swear I feel pain just looking at it. Instead, she is impassive and proud, she holds back the pain as long as she can but then a few grimaces appear on her face without ever losing her composure. I find myself admiring this woman of just over 40 years old, at a glance, and I try to help her as much as I can to give her strength but unfortunately, my language doesn't help me so I resort to the only universal language I know and I hold her the hand. At first, I notice her surprise: she is a little disorientated but then she looks at me gratefully and holds me in turn, repeating "Asante Sana" a thousand times (thank you very much in Swahili). At the end of the dressing, I help her get dressed and I shake her hand and she looks at me and smiles at me and repeats "Asante" one last time. I know it's impossible but it seems to me that in these almost 30 years of life I have never known true gratitude and that I am learning its true meaning now. In the eyes of these people I am learning so many things that I didn't see before or perhaps didn't pay notice to, and I understand that here to lend a hand you don't need degrees or particular skills... anyone can make the difference simply with their presence, kindness and humanity.

Today begins our last full week of work here at Bugando: time is flying, it seems like yesterday that we arrived. We don't know if we will still be in the old building at J4 or if the department has finally moved to the new Cancer Center building. Last Thursday Angelo said that he helped start the move while I was in bed recovering from fever and vomiting and they assured him that the new department would be operational today, but we don't really believe it... in fact, the first thing we do is head to J4 where, however, a nice surprise awaits us: it is completely deserted! They really moved! I would never have believed it and I feel very lucky: I managed to see both the old department and the new one!

We can't wait and run to the new building to see how they have settled in... we are super curious to see if the guys will work in the same way or, as Angelo hopes, there will be improvements encouraged by the new environment. I highly doubt it! But in the end, I was right... the same chaos that until a few days ago reigned in the old department has already invaded the new one too: everything is already dirty and messy... Resources and instruments are the same so it was impossible to expect anything of different!

Today there are a lot of medications to do and when Marco's turn arrives, a 15 year old boy, I feel like I can't breathe... I think it's the worst case I've seen so far. Marco is totally disfigured by a parotid tumor that has grown enormously, deforming his neck, shoulder and shoulder blade. Marco is doubled over in pain and crying... I don't know if he's crying for the physical pain he feels, for the shame of what has grown on him or because he knows he's dying... Inside I keep wondering how a parent can wait for their child to get to this point before showing him to a doctor... I've been asking myself this question for two weeks and I swear I can't find a satisfactory answer or one that can justify what I see. This dressing is entrusted to me as the first operator and my initial enthusiasm is immediately dampened as I remove the old bandages and I realize the enormity of the mass which was previously partly hidden or at least camouflaged and which now emerges from the neck of the boy, totally deforming it. The view is frightening and I really can't understand that a child, because yes at 15 years old in the end he is nothing more than a child, has to deal with this image in the mirror in the knowledge that his days are counting. The pain he feels must be excruciating because he is on all fours in bed with his head on the mattress while I am treating him. The lesion is immense, full of pus and infected tissue, the smell is terrible and I don't know what to do. As with every dressing, they use sterile kits (which they sterilize manually with various passages in buckets of disinfectant...) and a myriad of sterile gauzes and gloves: as I have now learned, I don't say anything and I leave them to do it... it would be useless to explain to them that the lesion it is infected and absolutely dirty, there is nothing sterile and therefore they are just wasting material unnecessarily. I try to clean the lesion as best I can and apply the bandage as best I can considering the protuberance and extent of the wound.

After an exhausting tour of the beds in which we changed only 1 bed in 3, since it has been raining for days and the sheets are missing (well yes, since they hang the sheets out to dry in the courtyard when it rains a lot there are no clean sheets), we set off again with our medications and we went back to Marco. Although I have already seen his illness, today it is another blow to the heart and I prefer to help in the room opposite where only children are hospitalized.

Now that we are in the new Cancer, the inpatient department welcomes both pediatric and adult cancer patients. I adore children and pediatric departments and as wonderful as these little ones are, after the first impact of total adoration, the awareness that almost all of them will not make it to the end of the year hits the heart hard. There are very small ones, even just a few months old, and the majority are affected by hepatoblastoma, nephroblastoma, retinoblastoma, brain tumors or haematological diseases. Children are treated with the same drugs as adults, just at reduced doses.. and you think that while you fight the disease you are actually damaging the marrow and they will most likely die from the side effects. Even the material with which you assist them is the same as for adults: you do not have the pediatric instruments for detecting vital signs, the PIVCs are adult-sized and with the same needle that you insert into the veins of an adult, you take the veins of a 1-year-old baby. Yet these children are all fantastic, no one sheds a tear while they are pierced over and over again with these gigantic needles... they undergo bone marrow biopsies while sitting on their mother's lap in the guardroom and you don't hear them say a word. Like the adults, also the children here in Mwanza are proud, true stoics.

The thing that fascinates me is the composure of the parents of these children: in Italy, parents with children in these conditions would not find peace, they would be exhausted and desperate, while here they really don't bat an eyelid. Perhaps because losing a child is an ordinary event, very probable at the moment the child is brought into the world, these parents pass in the corridor and assist their children impassively, as if it were truly something natural. I saw devastating parents incapable of dealing with the imminent death of their child and I observe with amazement these mothers whose lives continue almost impassively. It's a really distant reality that I struggle to understand.

Today is the day I met Caroline: an 8-year-old girl, all smiles and big dark eyes, with a multiple-operated brain tumor. "Caro", as we call her, finds it difficult to walk, and clearly has some brain disorder and psycho-physical slowdown, especially in speaking, but none of this affects his smile... I have seen a smile like this only a few times in my life. I don't know what it is about this little girl that struck me so much but she just got into my heart and I wish I could do more. In fact, I plan to buy her some games at the market and bring them to her.

Caro is here in the hospital with his super old grandfather, because mom is at home with another little son and dad abandoned the family when Caro started his oncology journey.

I pop downstairs to the radiotherapy area where Enrico works to take a look at the machinery: after Enri's various stories I'm very curious. I manage to enter the room with him and I am shocked by the fact that they don't tattoo patients, but to mark the point to be irradiated they apply a tiny piece of tape with a cross made on it with a marker. The question arises spontaneously: as soon as you wash or change the tape it falls or moves, so how do they do it? They simply irradiate the chosen area a little approximately.

Me and Caro

Today, after almost 3 weeks of service at Bugando, in the heart of Tanzania, I - Vanessa Valenti, Palliative Care nurse - cried for the first time... I gave in to emotion for the first time since I have been here and what broke me was a tiny little girl of just 2 years old. Even now, as I write these lines, I find myself teary-eyed thinking about it and I believe that the eyes of that little girl looking at me asking for mercy are the thing I will think of every time I search for this experience in my memories. The symbolic image of the situation here in Tanzania, the one that will always move me and that will make me come back to do more.

The little girl in question is just 2 years old, a small skeletal body eaten by the choriocarcinoma she was suffering from... this immense mass in the pelvic area had grown externally, creating a gigantic protuberance above her bottom, and internally filling her abdomen with cancer and ascites. Her belly is typical of Biafran children, very swollen and tense, making her slender figure incredibly disproportionate and of which she was clearly ashamed. Yes, because she lay covered with one of their colorful sarongs, and when her mother tried to uncover her to check her catheter, drainage from which yellowish material was coming out, or her diaper, she hid. The same thing happened when the doctors tried to examine her... she covered herself with her sarong to hide that immense illness and started whining. I saw her cry a few times even though she was in incredible pain with every movement, and she struggled to breathe, certainly due to the abdominal encumbrance of all that mass. At the end of the rounds, she looked me in the eyes for the first time, after not allowing herself to be examined by the doctors, and I swear that in that look I saw all the resignation, despondency and awareness of imminent death. At that precise moment, I felt helpless, useless and incredibly empty. She knew it, a 2 year old girl knew perfectly well that she would soon die and it seemed she just wanted a little peace. Instead he was in the room with 5 other small children and their mothers and siblings. There was no talk of peace, not even a shadow of relief from pain.

I never saw her again, when we came back the next day the little girl was dead.

Last week, when I went to work with the toys to distribute in the ward among the little ones, I had with me a rather ugly doll (but the only one I had found) to give to Caro, but she had already been discharged. I had brought it home and placed it on the desk together with the last things purchased to give to the nuns to distribute to the children at the school where some of them teach. Every time I looked at it it reminded me that I would not see Caro again and she would not be able to have her doll.

Today was also our last day at Bugando so I had lost all my hope. I can't describe my joy when, upon arriving at the ward, Angelo and I saw Caroline in a wheelchair next to her grandfather, while they waited patiently. At this point I rushed home, not even 5 minutes from the hospital, to retrieve that blessed doll that I had kept aside and fortunately, until then, had refused to give to any other child. I packed a nice bag with that horrible doll, some toy cars, soap, toothbrush and toothpaste, and even some little girl's t-shirts and ran back to work.

I thought Caro's smile when she saw us again was the most beautiful of my life but nothing beats the moment she saw her doll, the first of her life, and named her Sophia. Seeing Caroline play with that doll filled and emptied my heart at the same time, if that's possible. The only thing I could think of was how she could do more with the little time she had left. I gave her my necklace, so that a little piece of me would always remain with her. A very simple necklace, made of pink beads, worth a few coins... yet when I put it around Caroline's neck, for a few moments, I'm sure I made her the happiest little girl in this world. And she made me the happiest girl in this world, because those moments and those smiles are among the most precious and dear things I have ever received, priceless and irreplaceable.

Before leaving the department for the last time, after the little party that Joyce organized for us together with the guys from the department, after eating the splendid cake and unwrapping the gifts they had given us, I left Joyce around 100,000 STZ to pay for Caroline's chemotherapy and pain treatments. I gave everything I had in my wallet to him. A small drop in the ocean, but I hope they are useful to you and can give you some relief in these last months.

So we left this hospital, these wonderful and courageous nurses, guys I deeply admire because being a nurse in these conditions is truly a battle, which they do to the best of their ability. I challenge many of my colleagues to live up to them. Here we felt truly welcomed and part of the team, after the first days of initial and understandable distrust, they let us into their lives and I will be forever grateful to them and I hope with all my might to be able to see everyone again as soon as possible.

I think that there is no need to add anything else, other than a huge thank you to all the people who contributed to making me experience all this, to Angelo and Enrico who accompanied me on this adventure, and to this land that welcomed me and made to feel at home.

If you read this far then a huge thank you to you too, I hope you won't be bored. For any questions, I am available as always, in private or in the comments.

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