Monday, July 19, 2010

Hyman, the ER doctor from New York who looks like a younger version of Dr Sanja Gupta on CNN, was at breakfast. He works for IRC--International Refugee Center in the summer. IRC is a big NGO with 4x4 vehicles and in-town offices complete with a cook, and no doubt their own clean water and electricity. They are not allowed to ride motorbikes for insurance reasons. CDC people are arriving this week to collect data on fatality rate in the under 5 age group so things will be busy for him. Interns however weren't impressed with large NGOs, citing waste and bureaucracy. They thought a small group like GAF was much more hands on and effective. No one asked me but I would take the car, the cook, and all the water and electricity.

Uncle Ben has a cavity so he drove me and Kulani to the clinic and he could be the first patient. Unfortunately one of the tires had a problem which was pointed out by someone on the road so he had to find a garage. I was late to work again.

Monday is the busiest day in the clinic and we hit the ground running. The demand for extraction was simply overwhelming with everyone pointing to one or more molars, take your pick. Inevitably some had to wait around for the proper forceps to finish boiling. The woman with the exposed pus oozing bone we saw the first day came in for a follow up as arranged. Pus was gone but the bone of course was still exposed. We referred her for surgery in Freetown again and I could only hope it would happen for her. I suggested that Sahr James keep her on his radar. A very overweight man could not move air too well, he was snoring just trying to breathe. The woman with the huge swelling still did not come in today so I asked if we could call her. Sahr James said she did not have a phone or other contact information. High blood pressure prevented a few from getting extractions. No children at all today.

I dicovered I was bad at telling people's age. A woman said she was 35 when I thought she was 60, a man was 32 and I thought he was 18.

We took a 10 minute break and I ate the half bun I had saved from breakfast. I asked Sahr James if he ate lunch and he said he was fasting, which meant eating once a day at 6pm. He did this during difficult times he said, he would fast and pray. He did not elaborate on the difficulties but said things were tough financially due to the small salary. A bag of rice takes 1/3 of his salary.

Nurse Andrew looked better today still recovering from malaria. I have to remember to bring the bottle of OFF for him. He told me he had heard some praises of our work around town, even the people who had to be referred for surgical extractions. Kaiba looked different today and I finally realized he had shaved his head. He will take a leave soon because the clinic no longer needs a driver since the clinic vehicle has been broken for a while. He has not been as smiley this week.

We finally finished seeing patients at 4 and Sahr James wanted to prepare for the radio interview. He wrote down things we were discussing--oral hygiene, good habits, bad habits---. I realized I was in trouble when we started talking about diet. He named 5 or 6 things ( one of them being palm seeds ) and I had no idea what they were. Everyone nurses the baby for a long time here, we definitely have to talk about that.

Ali, the mechanic/driver/and clinical assistant, took me home on the bike and he made an effort to drive "small small" and I told him I appreciated it very much. He asked me when I would go home and I said Thursday. He said oh we don't want you to leave yet, we wish you could stay two more months. I thanked him for that sentiment.

The radio interview was scheduled at the prime time of 6pm, but does it really mean 6pm?

GAF interns and Dr. Bailor Barrie

Princeton sent four students interning at the Amputee Clinic with GAF (Global Action Fund, goact.org) this summer working with Dr. Bailor Barri from SL and Dr. Dan kelly from US. Dan was here the last two weeks of June and Bailor is in Koidu with he interns.

Kulani, the only female intern, is everyone's favorite. Staff and town's people all know her and love her, their eyes light up when they see Kulani and they shout with delight or chase her down to say hello. When they dont see her they ask "where is Kulani". Kulani's parents were from Ethiopia but this is Kulani's first trip to Africa. She gets constant unwanted attention on the streets so she got a ring to wear, except the jeweler added a heart to the band and it now signals "searching for love". So she has to go back and get rid of the heart.

Kulani works with community health workers on HIV patients in the home care program. Part of her project is to create a stigma index about HIV. Her interviews take her all over the villages day and night, and she hears a lot of difficult life stories and very personal feelings. It is now the raining season when people are busy with planting, plus people forget or just no show. She often has to schedule several times for one interview. Some days she is just drained after a full day's work.

Raphi works with a Medical Anthropology postdoc Peter whom I met for a few hours before I left Freetown for Koidu. They study PTSD-Post Traumatic Stress Disorder among the amputees. Currently they have some difficulties with their questionnaires due to "lost in translation" type problems, but Raphi continues to gather data on chronic pains. He hopes to write grants this fall to bring funding for physical therapy, counseling, and prosthesis to the amputees. Raphi hits the "gym" after work to train with an ex RUF rebel to get ready for his wrestling career at Princeton. He often finds amazing papayas. Being popular at the camp he is often given oranges and ears of corn, which he hopes were not taken from other people's trees.

BJ is gathering data on blood pressure and diabetes, two common diseases in SL. After the initial drive of 1500 people, he now follows up with everyone taking new data on BP and blood sugar. For instance one day he held down the fort at a local tea shop most of the day so people in his group could come and get their BP and blood sugar checked, and have some tea or Turkish coffee. BJ is funny, outgoing, and friendly with a quick smile, drawing wanted and unwanted attention.

BJ and Raphi also has a pilot project they are excited about--to buy two goats for an amputee camp and see if they can raise the goats to produce milk as a source of income. If the campers do not lose, eat, or sell the goats, and can show responsibility about running the goat milk business, then the next thing maybe to get them two cows to raise and produce income for the camp. Bailor thought this might be a no return high risk investment but he is okay with it. Raphi and BJ have to front the cost of the goats and hope to get reimbursed back at school.

As BJ does the health servery, Michael is doing a wealth (well, poverty really ) survey trying to figure out average household income in the general population vs the amputee population. From that data, they hope to construct an income-based fee schedule for the services provided at the clinic to non-amputee patients. Michael is about to survey the general population. He also takes BP for people because otherwise who would want to sit around and answer a bunch of sensitive questions. Michael was hooked up with a local soccer team made up mostly of seemingly unemployed men, but he said anyone of them could be a super star on the Princeton Varsity soccer team. He has many friends through his translators and community health workers.

Bailor directly works with the interns while Dan works with them via email and phone. I have talked to Dan a few times on the phone about my trip and I hope to meet him some day. Both Dan and Bailor, founders of GAF(Global Action Foundation) and NOW(National Organization of Wellbody), are just 30 years old. With his young family living in Freetown Bailor commutes between Koidu and Freetown most weeks, not an easy task considering the bad road conditions. He sees patients at the clinic, runs all the projects with Dan and the interns, lectures in the US on global health, travels on GAF businesses--. I dont know how he does it. He certainly can move overseas and be part of the SL brain drain, or he can practice in Freetown and make big bucks, but he chooses to stay in war torn Koidu to work with the amputee community.

After the Sunday dinner, Bailor stayed to talk. Kulani was very worried with one of her HIV patients Molai who was in the hospital for transfusion, She has been visiting daily to check up on Molai. Raphi wanted to give blood but Bailor did not want Raphi's hemoglobin to get too low in case he should get malaria, which is still possible even though everyone takes a Malarone pill daily. Next Bailor talked to Michael about what questions should be on his survey to determine wealth, such as, do you use milk with your tea ( fresh milk is rare and expensive), how often do you buy meat, how often do you need to beg for good etc.

Bailor stressed that any questionnaire should not take more than 30 minutes to do. There were discussions on how best to ask people about the violence they had seen or suffered personally during the war. BJ thought amputees had been forthcoming with such emotional information while Kulani thought it could be hard to press them back to those painful memories. Bailor suggested that perhaps crying could bring healing and talking things out could be therapeutic. Bailor will work with each intern on their field work or routes this week, starting with Michael and his translators on Monday to start the surveys in town. To make it a random sample they should pick every third person to interview.

Bailor and I talked a bit about the radio interview on Monday to promote dental health. After all the talk on HIV, TB, high BP, malaria, malnutrition, amputees' hard life---, brushing teeth seemed trivial. But everyone insisted it was important business.

The nasty road to Koidu was the cause of an accident in 08 involving a GAF vehicle and 5 passengers including Bailor. One SL medical student died from brain injuries. Bailor recounted how he did the first roadside EMT work even though he himself was in the accident. I don't know how this came up but it affected me deeply. The interns pointed out that such accidents could happen on any US roads any day. I pointed out that emergency brain surgeries would have been much more available in the US.

There is plenty of hard work to go around here for sure, and this group is pressing ahead with dedication and compassion.

Sunday-- A Day Off, July 18, 2010

A whole football (soccer) team from Bo, 100 miles southwest of here, was staying at Uncle Ben's last night, which explained the late night party noises. They were in high spirit for today's game against Kono Lions; washing down their breakfast with beer. By 11AM the noise from the breakfast room sounded like a riot, and I decided to stay in my room and eat some bread, an orange, and water for lunch.

Michael came back with three teenage friends who lived in one of the amputee camps and we took some pictures. One of them rapped for us while the football team was in high gear getting ready for the 4pm game.

Then Kulani and I set out with Aisha for our shopping trip which did not happen yesterday. Women dress in very colorful fabrics here and it was eye opening looking through all the designs at the two stores that Aisha was friendly with. Then we went to the dressmaker to get Kulani measured for a shirt she wanted made. Three male dress makers work in a very small room way back in the ally, the shirt will be ready in 5 days.

We decided to walk back for exercise, which turned out to be a hot and dusty walk. I should have known better. As soon as I got to Uncle Ben's it was time to set out for the soccer game. Michael now had 6 or 7 friends in the breakfast room, some are his translators. One told me: "Michael's mother, you are very active", referring to the fact I had just walked back from the market.

Five of us started for the stadium. The locals knew short cuts so we followed them. Some of these paths were so uneven with rocks, roots, and ruts they would have been rated as "moderately difficult" in any US parks. One friend, Abu, told me I was a "strong" woman being able to walk so much. His own mother could not walk much anymore because she had to walk so much when she was young. Doesn't all that walking make her strong I asked, no he said, there was no medication for her all these years.

One boy in our group called a man some bad names and the man started chasing the boy who ran away fast but was later apprehended by the man who turned out to be the boy's teacher. There was commotion and I was told the man was taking the boy to the police. One said "We have to pay for the boy", looking straight at me.

Michael and company caught up with the man and started making a case for the boy's release, saying the boy was his guest and telling the man he had no right to arrest the boy. The man, middle aged and overweight, was profusely sweaty and arguing loudly that he was simply so tired, so tried of being insulted by this boy. He had had enough!! By this time a sizable crowd of more than 30 had gathered to watch, with all the shouting I was worried a fight would break out. In the end the boy apologized and the man walked away sort of deflated. One friend, Abu, said to me he had advised Michael not to get involved because the boy needed to learn to respect himself and others. I agree with Abu.

The stadium had no grass and no lines and the game was a friendly between almost-middle-aged men. Kulani predicted the game to be a joke based on what she had observed at breakfast, she was right. Nevertheless the game was fairly well attended and festive with loud music and commentating, plus two "comedians" who were actually clowns with white make-up. It was Kono Lions 0, Bo United Friends 2. The victorious team came back to the guest house singing songs and drinking more beers. Then they were gone and peace returned.

I had been walking in the hot sun back and forth three times and I was terribly overheated, like being on fire. The shower was luke warm from the hot weather-- it felt great!!

Soon it started to get dark, and for the first time I was cranky about not being able to see. When will the light come on? What a messed up situation. I went out to the little patio next to the breakfast room, the first star was just starting to twinkle. No matter how unfair things are on earth, the sky and stars are beautiful for all to see. Perhaps that is a reminder of the equality we hope to achieve.

As arranged Uncle Ben's wonderful daughter Alima cooked dinner for us tonight for a fee, I wanted all of us to have a "home cooked" dinner. Alima and I planned the menu in the morning before she went to the market. We had rice with peanut soup and chicken--a traditional SL dish, and casavva ( taste and looke like potatoes). Bailor joined us, and Raphi brought a huge papaya for dessert. Kulani said this was the BEST meal since she got here, Bailor said we should just eat here for the weekly meeting instead of going to the Kono Hotel and spend four times as much. We ate and ate, I was not only full, I was STUFFED!! Everyone was a bit surprised to be stuffed for once!! I thought about Michael's friends from the camp who had wanted to come back with us. We bought them water and bananas, and Michael gave some of them money as they asked to buy food. What are they having for dinner?

Saturday---Half Day, July 17, 2010

kaiba forgot to pick me up so I was late to work. He said he thought I would like to walk today, I assured him I never would want to walk before work so please don't think that. As a result we did not finish until way past noon the official closing time for Saturdays. But it was a great day because the new generator was running the lights and the ceiling fan, and the outlet was available for me to charge my cell. And Sahr James said we both would be interviewed on the radio Monday night to promote dental health for children. What more could I ask!!

Andrew the other nurse came in to say hello. He told me he was sick yesterday with malaria and could not be at work. He would get malaria about 2 times a year even though he uses a bed net; he did not want to take prophylactic meds for fear of developing resistance. I told him I would bring a bottle of OFF for him since he did not have any. It turns out Sahr James and Andrew share a house together because their families live elsewhere. They can't afford to see their families often because traveling cost too much.

In the middle of another patient a man came in saying " I just want to see her". He introduced himself as the "Chief", and I waved. Sahr James said Chiefs were elected local officials.

kaiba took me home through yet another short cut, going through back yards and under cloth lines . This apparent trespassing was business as usual as I found out later from the interns.

I got home to join Kulani for a shopping trip with Uncle Ben's wife Aisha. We waited but Aisha never came. Michael was out visiting friends at an amputee camp. Kulani then had to go to the hospital to visit a HIV patient who needed transfusion. I had a few cashews and a soda for lunch, listening to interns BJ and Raphi talk about the feasibility and funding of a plan to buy two cows for the amputee camp residents to raise as a self sustaining business. But maybe two goats would work better, so they set out to research the market.

Crossing the small courtyard from the breakfast room, I saw Alima and her mom Aisha cook rice and soup on their coal stove. My mother used to cook on a coal stove when I was very young; I remember her fanning the stove just as Alima was doing now. She gave me a taste of the soup---super spicy with very rich flavors!!

After a cold shower and a nap, I set out with Michael to find food. I decided to try the Philly Cheese stake look alike but it did not work, the meat was too chewing and kind of suspicious. I had three of the green oranges Michael was given at the camp, they were very juicy and sweet. This was my first taste of a fruit other than bananas since I got here.

The Basics

Friday July 16

Electricity-- Foremost on my mind, it is available at Uncle Ben's 7pm to midnight. At the clinic the generator only has one gallon of gas ( to avoid theft) at a time so it runs out a lot, when it is not broken. The town is dark in the evenings except for headlights from cars and bikes and the occasional house that runs a generator.

Water--Uncle Ben's has running well water. Faucets at the clinic and the UN compounds were all dry. People use well water to clean and cook outside. Bottled water was used to clean and recycle dental instruments. We drink small bags of purified water or bottled water. We all brought the water treatment pen to use too.

Sanitation--We use antibacterial wipes or sanitizers a lot especially when there is no water for hand washing. Baby wipes are used to wipe off sweat which helps us stay fresh longer.

Money-- $1=4000 Leones. I carry about $20 worth of Leones and my wallet was swollen with bills I could not close it. Credit cards do not work here. $100 bills get better exchange rates.

Laundry-- Alisame who gives us breakfast does bags of laundry for a small fee, hand washed and sun dried.

Internet-- The 4 interns and I share a USB stick for super slow Internet. To stay in touch I need the stick and electricity at the same time since my laptop's battery life is short. I will have to load photos after I get home.

Bathrooms-- Better just wait till returning to Uncle Ben's.

Showers-- Guests at Uncle Ben's have piped in cold well water showers. Staff has camp style stalls where they wash with buckets of well water, which is what the clinic has too. The key to cold showers is to start with extremities and just get into it slow. You should try it.

Religion-- Muslim or Christian, one of the two. If you don't belong no one will come to your funeral and your body will just be abandoned.

Language-- Krio. English is taught in schools and understood by most. Michael said most could speak better than they could spell.

Weather-- Hot and humid, but when the rain comes things can be cool for a while.

Cell phones-- Get a local cell phone and buy "units". I can call on my iphone for $$$ but it is not a 3G world here.

African Time-- All things tend to be late, if they really happen at all.

Third Day--Friday July 16, 2010

The woman with the huge swelling was the first patient and thank goodness she looked a lot better, we will evaluate her again tomorrow.

Sahr James now knew all the teeth by numbers, and he started to see the pattern of problems: always the molar numbers before the patients even opened their mouths. He threw up his arms and chuckled. He now knew about the six year molars and the care they need early in a child's life. I did have a 4 year old who did not need extraction. She cried initially but smiled after she got her sticker and a new toothbrush, just like kids back home.

The clinic generator was broken so it was stuffy and dark all day. The UN compound conference room was not available to us today so I just went home. My laptop and cell were both dead now and the power would not be on until 7pm at Uncle Ben's, not much I can do about any of this.

Dinner was at the Kono Hotel which was a bike ride away. Everyone was looking forward to this weekly ritual for the good food. After a delicious chicken pizza and a cold beer I was full--what a strange sensation. This was the only place with western style food and atmosphere of an open air bar.

Bailor talked about all the NGOs (none government organizations) he had dealings with, and the history of him and Dan, how they met in 06 and got the whole amputee community health program started. They got the clinic built in 08 which was jaw-droppingly amazing. He grew up poor, but refused to be part of the SL brain drain overseas to UK, Canada, and US. He stayed to serve SL's poor and sick. SL has a population of 6 million served by 87 physicians, 60 of them in Freetown. Bailor can be totally academic with the interns, and the next moment he is just a guy on the street in the real world. I did talk to him about getting the kids to the clinic for dental care, perhaps through another radio announcement.

Kulani and I doubled up on the motorbike ride home. Unfortunately we came to a checkpoint and our driver was in trouble according to the guy in uniform. After being paid some money he let us go.

The extra cold shower sort of woke me up a little. I thought about all the NGOs I had met at breakfast: the two SL women working on education outreach and women's awareness ( one of them was turned in to the village elders by a 9 year old girl when she discouraged FGC-female genital cincumcision), the New York ER physician in SL for three months doing evaluations for CDC on fatality in the 5 and under group, the two SL men doing evaluation of skills programs and surveys. I'd say the local economy is mainly NGOs. Well, let's not forget the "miners" who the interns say come and go in fancy cars. I have not seen them because they tend to stay at the more expensive Kono Hotel. The interns said I had just missed the two fun Californians who could soon retire from their diamond mining business. One used to work with the rebels to keep them funded, the other used to be a movie star in Hollywood.

Second Day--Thursday July 15, 2010

It was clear I could not walk 4 miles in the hot sun before work; too much sweat too early. I had to have transportation. The most common practice is to hire a motorbike. Michael thought it was dangerous and wanted me to use a real taxi which was impossible to get.

In the end Kaiba from the clinic came to pick me up on one of the clinic motorbikes on loan from UNICEF. Michael disapproved but I was doing it anyway. I said "small small" which meant "go slow". kaiba did not go too slow in the chaotic city traffic and the winding hilly village terrain. Next thing I know his bike ran out of gas and he told me to start walking. Just then another bike went by and kaiba arranged for me to get a ride with him the rest of the way. When I got to the clinic, I was a bit wind blown and wound up. But not sweaty.

Everyone wanted their teeth pulled out, some even made a pulling motion. After seeing the woman with the exposed jaw bone soaked in pus yesterday from a bad extraction, Sahr James was now on the same page with me about case selection. He was good at explaining things to patients by always starting with a soothing "You see", which I found out meant "she said".

We had one clinic staff giving oral hygiene instructions in the hall and two others keeping the boiling going to recycle instruments. Val had told me that was what they had to do in Haiti, and Sahr James followed the boiling protocol from his days at the Doctors Without Borders hospital.

So it was advanced decay with pain and swellings all day and I had to be the accidental oral surgeon as best as I could. I did have a 9 year old patient who was very good when he and his mother both got extractions. Sahr James said parents did not care about "milk teeth" because they would be changed; that was why there were no kids in the clinic.

Since I did have a 10 minute break to have bread and banana for lunch, I had energy to go to the United Nation compound for electricity and wifi after work. I was dying to go because the interns were saying the Internet was so much faster. Plus there was electricity ALL DAY!!

It was a walled structure with barbed wires and some buildings inside. The guard let me in and I got the password to get online. We quietly laptopped away sharing one outlet. The bathroom was bad but a bit better than the one at the clinic; still no running water though. This building was quite empty. Some say it is a good thing UN is not busy in SL nowadays, Some say UN people drive around in fancy SUVs but what do they really do. Right now I am just glad they have a building with power and wifi.

Next we walked to Dabo's ( one of the staff) house for dinner. Intern BJ had gone to the market this morning to buy 3 live chickens and gave them to Dabo so his aunt could cook them for us. We walked by village houses on dirt roads full of kids and adults leisurely hanging out or cooking on stone stoves.

Sitting on the porch of the small house we were each served a bag of purified water and a plate of rice with a piece of chicken and a piece of fish. Bailor and the staff ate SL style in a large communal plate. It was very tasty. When I was finished my plate was taken away by a teenager who gave it to 3 kids and they started on the leftovers on my plate. It was done casually and naturally, food was not to be wasted.

There was loud singing music; I was told it was the nearby church having a service from 9 to midnight. I went to check it out with three staff members who were attending the service. kaiba and Ali got permission for me to take a photo but by then all the kids and adults had spotted me and stopped singing. I was invited to church on Sunday 9am to noon. I left the guys at church but later spotted them on the street talking to girls, way before midnight.

Dusk gathered as we walked home. The Lebanese grocery store was a must so we all went. I found canned peaches this time, what a treat. The only girl intern Kulani decided to take a motorbike home so I joined her. We yelled " bike, bike" on the street and bike drivers stopped for us. I told my driver to follow Kulani's driver because I did not know my way. All of a sudden Kulani's bike stopped which caused my bike having to stop just short of running into them. Turned out the drivers did not know their way and Kulani had to stop and give directions. Riding on a hired motorbike at night in the dark on bad roads in dusty traffic is, ummm, not recommended.

Back to my room I was just grateful the lights were on and the water was running. I wanted to get some sleep but I kept thinking about the last patient, a woman with a huge swelling around her jaw and neck but could not afford the IV meds. Her face was tired and resigned. My friend Celeste once asked if Michael and I were ready for the suffering we were going to see in SL; we thought we were. And I have not even seen an amputee yet. I hope the lady shows up tomorrow as we asked so we can monitor her condition under oral medications which was free to her.