September 1st: I have completed many preparations for the trip. I started my anti-malarial meds today. Reading the list of possible side effects had scared me somewhat, and I had wanted Ed to be around in case I started hallucinating. I’d rather not have to see Gene Kelly in miniature dancing around in the kitchen sink tap dancing “Singing in the Rain” if I can help it. At least Ed could slap me back to reality before I try to flush Gene down the drain with the sprayhose.
Ed has assembled a kit for me: Swiss Army knife, insecticide impregnated mosquito netting, industrial strength insect repellent in sticks, wipes and sprays, bottles of water purification tablets, small maglight, spare batteries, army surplus rain poncho, a capacious rucksack with frame and padded compartment for my laptop, and a nifty small digital camera that uses the same size batteries as my maglight.
I will be busy the next couple of days, so I might not get to blogging again until after my departure.
September 5th: I arrived in the Republic of West Africa (hereafter RWA) after 26 hours of travel, New York to Amsterdam, then Amsterdam to Nairobi, Nairobi to Capitol City, RWA. I am staying in a guest house tonight, very nice, the family that runs it very friendly, they have six rooms here, furnished with very basic furniture, but all of it sparkling clean. My single bed has a mattress that has seen better days, but it is brightened up with Star Wars sheets. There is a convenient hook over the bed for my mosquito net.
I had my first sample of RWA food: some form of meat in thick gravy, served over a starchy paste that had a yellow color to it, very, very spicy hot! It really cleared out my sinuses and brought tears to my eyes. Later I had another version of this, but with rice instead of the starchy paste, and if possible, even hotter!
Water comes in little plastic bags instead of bottles; you nip off a corner and drink.
Cell phones are huge here, probably because there is no need for the infrastructure of poles and lines. There are little kiosks and stores everywhere that sell top off minutes, as prepaid service is the only game in town. Minutes of time are surprisingly cheap. Service is a variable thing, you often get cut off in the middle of a call.
September 6th: People here are very religious: All the taxis have “God Bless”, or “Jesus Saves” painted on them. Stores and businesses have titles such as “Fear God Cell Phones”, “God Is Good Fashions”, “With God All Things Are Possible Tire Repair”. Repair shops are common, unlike back in the States, it is more economical to repair things than buy new. Repairs are often marvels of ingenuity and improvisation, as spare parts are scarce, and when available are often cannibalized from the unrepairable. There is almost no litter here, as cans, bottles, cardboard, etc are all looked at as materials to be used. I bought a model helicopter for Ed made from scavenged wire. There is a lever on the side, and if you push and pull on it, the main and tail rotors spin. Aluminum cans are prized for the parts that can be made from them to repair things, and for all the things that can be made from them. I also bought a beautiful candle lantern made from a soda can. A popular toy here is a car made from soda cans that is about the size of a shoe box. It has a stiff wire that sticks out the top to about two and a half feet, with a circle of wire at the top making a steering wheel. When you turn the steering wheel, the front wheels of the car actually turn. The children “drive” these beautifully made cars all over town.
It is hard to say who is more influential here, Jesus or Bob Marley. Pictures of both are everywhere. Reggae music is the soundtrack to everything. It often seems to me that the whole country is bopping along to “One Love”, the music perfectly in tune to the laid back life style. I have to explain about RWA time, or it is more probably just African time. Among westerners, there are many jokes about this. If someone says “five minutes” they really mean “an Hour”. I had to wait two hours for food at a restaurant. But on the other hand, you do not have to rush for anything, there are no deadlines, and your lunch break is a s long as you want.
September 7th: People here are warm and friendly. English is theoretically the official language, but many other local dialects and languages are spoken. Everybody has some English, although individual words have novel meanings. It was an amazing experience to ask directions and then be led for fifteen or twenty minutes through a maze of narrow streets to the tro-tro station, then to exactly the right tro-tro for my destination, and then my offer of a small cash reward refused. I have to explain about tro-tros.
A tro-tro is a van outfitted with seats. They are uniformly in deplorable condition, rusted and paint peeling. They are the main conveyance for people and packages, all crammed in to fullest capacity. Private ownership of cars is rare here, so tro-tros are the way to go.
The roads here are another thing, with as many holes as a Swiss cheese, and that’s the paved ones! The drivers of the tro-tros must dodge and weave to avoid the largest ones, often into the face of oncoming traffic. After about twenty minutes of sheer terror, your adrenaline level comes down to just higher than normal. At every stop a crowd of people swarm to the windows of the tro-tros hissing at you (the way you get someone’s attention here) selling a bewildering array of things, bags of water, plaintain chips, toothpaste, batteries and other food products.
My seatmate is George, a medical student from England, on the way to the same provincial hospital as me. He has been here the past two summers and has picked up some of the local language called Twili. At a stop just outside the city, a man dressed in a black suit climbed aboard. As the tro-tro moves off, he gets up and starts speaking rapidly in Twili. I asked George who he thought the man was. I had guessed a preacher by his black suit, and the general level of religiousness I had seen in the country. George said he was a patent medicine salesman, and did his best to translate and summarize the pitch. He described the miracle spices in the tin he was holding up. He passed out little cards, like business cards, that listed all the things his medicine would cure. Diabetes, hypertension, stroke, headache, malaria, dementia, heartburn and indigestion to name a few. He was very entertaining and I was reminded of the TV infomercials back home (But Wait! There’s More…..). Next he pulled out a box of toothpaste with a picture of a pack of cigarettes on it. It was supposed to make your teeth shiny white. I hope it didn’t taste like cigarettes.
September 9th: We encountered heavy rains part of the way to the provincial capital, our destination. I had not considered that: dirt roads + heavy rain = mud. Our driver chooses to drive through a large puddle rather than around it and we get stuck. The water is so deep it begins to flood into the tro-tro. We all get out and after about twenty minutes of pushing, manage to free the tro-tro. Of course, it then refuses to start. And no bother about the mud and dirty water we were covered with, the rain washes it off. The sun comes back out and we wait in the shade of some trees for about an hour while the driver summons a mechanic on his cell phone. Thank god that was working! The mechanic arrives, does something under the hood, the tro-tro starts, we all pile in and we are off.
I am staying with a host family. The husband has a business manufacturing cement blocks, and selling lumber and other building supplies. She is a school teacher. They have two children who are away at a boarding school, which is the norm here for the wealthy. Their house is one of the more upscale in the town, made of stucco and cider block with a tile roof. The interior is very nice, well furnished with a modern western kitchen and electric ceiling fans in every room. Unlike in the west, there is no separate neighborhood for the more affluent. Next door is a mud walled shack with a thatched roof and no electricity. I am given a very comfortable room. My hosts speak very good English, the King’s version, as both have been to university in England.
September 12th: About technology: Africa capriciously decides when it will work, and when it will not. In a town you may have electricity to run technology, such as the internet café I am sitting in right now, the only internet access for this whole provincial capital. Like most of Africa, the power only works when it wants to. Half the time the power is out, so you get by with candlelight , and you don’t buy more food that needs refrigeration than you can eat in a day or so. This is also true of the water as well, so when you get in the shower, you fill a bucket with water first, so if it goes off before you finish, you can still rinse off. I was in surgery at the hospital this morning, a myomectomy (removal of uterine fibroids) when the power went out. The procedure had to be finished by flashlight, and suctioning had to be done with a foot powered pump. The hospital does have a generator for back up, but it steadfastly refused to start. They are used to things like that here
The hospital is a cluster of small buildings made of cement block with corrugated metal roofs and covered verandas on the side that faces into the yard that the buildings enclose. Everything is whitewashed, but the rains have given the lower portions of the walls a red-brown color from splashed up dirt. Patients see a clerk in one building, a doctor in another, get their prescriptions in a third, and then go to a fourth to get a bed. There are three buildings that serve as wards. One for men, one for women and one for children. If you do not have family or friends, you are out of luck, as the hospital does not provide food or linens. Family members provide the everyday care. Everything is done to conserve supplies. For example, gloves are very scarce, so they are only worn when absolutely necessary.
There is a secretary who does all the typing and filing of records, with a meticulous efficiency. The typewriter is missing the type bits on the end of the type arms for the letters “h”, ‘’e” and “s”. When she finishes typing a document, she goes back and fills in these letters with a fine point pen. Her draftsmanship is so good that her hand written letters are indistinguishable from typed ones. The documents are very easily smudged however. This is because the typewriter ribbons are re-inked with soot from the kerosene lamp chimneys.
September 18th: I have been so busy that I have a lot of catching up to do. As I expected, there is a very high incidence of malaria here, it is the leading cause of childhood mortality. Hypertension, cardiovascular disease and diabetes are also high here, even more so than in the states, the diet (high in salt, low in vegetables and a low level of exercise) is most likely to blame, but there appear to be genetic factors as well. Typhoid and tetanus are common as well, things almost never seen back home. There are cases of HIV as well, but due to the huge stigma attached, testing is mostly not done. As a rule, people do not seek attention until there is no other alternative, so most cases that come to the hospital are in advanced stages. I have seen some very advanced cases of anemia and malnutrition, especially among the children.
Clinical tests, like technology, are a sometimes thing. Maybe there are no testing reagents at the moment, or the equipment is broken down. Despite malaria tests coming back negative, doctors still prescribe anti-malarials on the basis that the symptoms are there, and the test results may be unreliable. As a result there are problems with drug resistance here.
September 22nd: Yesterday we went on a community outreach to a nearby village. It was obviously a much poorer place than the provincial capital in which we have been staying. There is very little car or truck traffic here, but there are bicycles. Goats and chickens forage everywhere. There is almost no western style clothing here, most are dressed in traditional clothing, brightly colored long skirts and full sleeved blouses for the women, trousers and brightly colored shirts for the men. Mothers carry their babies in shawls on their backs, the babies fast asleep. I almost never heard babies crying. The women and a few of the men carry large loads on their heads, sometimes heavy and bulky items. I even saw a heavy foot powered Singer Sewing machine carried in this manner.
There are many stalls in the market place, most made of plywood and brightly painted, the names of the stalls reflecting the religious nature of the culture, such as God’s Bounty Vegetables. Almost everyone seemed to be engaged in some sort of business in order to bring income for their families. No one was idle or just sitting around under the trees.
First we went to the school. Under the direction of the teachers, the children raced to set up tables and chairs in the courtyard of the school. We were directed to chairs and were not permitted to help. The children obviously knew from prior visits how to arrange the tables and chairs and seemed very happy and excited. The teacher then got the children lined up, and things got started with a triage at the first table. The other tables were set up for vaccinations, wound care and the last table for screening for TB, Sickle Cell, Malaria, etc. I got the wound and skin care. Many of the children have infections of simple cuts and scrapes because a common folk remedy here is to rub mud into wounds to stop bleeding. So I clean the wounds and dress them as needed, and try to teach them not to put mud in the wounds. The kids love bandaids, especially the colored ones, and will ask for a “plaster” as they call them even if they do not need one. There were one or two that I referred to our doctor for antibiotics, as they had more advanced infections. Everything is done without gloves as there are none to spare, but we had lots of soap and water to wash between patients.
After we finished at the school, we went back to the market area and by this time, our crew had set up a couple of tents and a canvas awning, and we had a clinic for prenatal, mother and baby care. I dispensed oral polio vaccine drops. Because of the lack of gloves, I was instructed not to touch the babies, just get the mothers to get the babies mouths open to receive the drops. One must not use the left hand. It has some connotation of insult; even beggars will refuse money offered with the left hand. Another volunteer entered the vaccination in the patient record carried by the mothers. One or two of these were very tattered, and these were sent to our clerk for replacement. Most however had been carefully folded and then placed inside a piece newspaper or other salvaged paper to keep them clean and intact. There was also screening for hypertension and diabetes, and appointments were made for follow up as needed.
A district Nurse then conducted a class where she covered a whole variety of subjects from breast feeding to basic baby care. She used stories and songs, humor and repetition, much in keeping with the traditions of oral history and culture. I couldn’t help but think of this as the African version of the pamphlets and flyers that are passed out at clinics back home. Though we were tired from a long day of it, we loaded up our van and boarded in good spirits for the trip home.
September 24th: I am writing from The Tall Horse Café. “Tall Horse” refers to a giraffe. This is the one place in town where there is some western style food (pizza, french fries and coca-cola). It is also a place of refuge from being the major side show in town. Western white people really stand out here, and everything we do is of great interest and a subject of much conversation, a major source of entertainment. There are a couple of things I want to write about before we leave in a few days, as this will probably be my last chance to post.
The Brain Drain. The Republic of West Africa loses a lot of the nurses and doctors they train to other countries, especially England. There are a couple of reasons for this. A nurse can go to England for two years and come back with enough money to buy a house, set up a business for herself and/or her family. Secondly, many nurses are assigned to positions by the government with little regard for or choice of location. Because of the brain drain, the government closely watches nursing students and graduates, and they may be refused visas for foreign travel.
Politics. Political influence peddling and maneuvering results in a far less than optimum allocation of the available resources. Some is also lost to bribery and corruption, although the RWA is reckoned to be one of the least corrupt in this area of Africa. The government tries to keep as many people as possible employed in the public sector, albeit at very small wages. This is part political patronage, part works program.
Ed, I have used everything in your kit many, many times, especially the Swiss Army Knife and the water purification tablets. You should market the kits to those traveling to Africa.
The people here are really lovely, and I will always remember them with great fondness. I hope I can come back again next year, and maybe bring some of you with me. See you soon!