My first patient

She was an elderly women, most likely in her 60s (Many people have no idea what their age is. We must use some creative questions to get a good idea: How many harvests have you seen? Who was the chief when you were born? For children: how many moons have passed? How many teeth does she/he have?). Our lady had a leathery face that cracked whenever she smiled. She had very few teeth, but a beautiful smile. The elder, Coussa, took her blood pressure and recorded it on a crumbled, well-worn piece of paper she kept in a plastic bag. Evidently, they used patients logs to record their BP whenever they came in. Impressive I thought, they are more with-it here than some places in the states. She was here today because she had some headaches and she wanted a refill on her BP medicine. When I heard the words “BP” “medicine” “refill,” my heart sank a little. Huh? Here I am, in the middle of nowhere, and this lady needs her BP meds refilled? What about the weird tropical diseases? What about the different pathology I kept hearing about? I was dumbfounded. I quickly realized that everyone suffers from hypertension, even older women in Mali. Just do your job, and you will be fine. So, when I saw her medicines, I jumped a little. She was on Lasix and methyldopa, 2 drugs that are hardly ever used to treat hypertention in the US. I asked Maiga after she had left why those two drugs, and he said that was what they had available in the pharmacy in the clinic. I was floored. Every medical governing body in existence recognizes that hydrochlorothiazide is the first drug of choice to treat hypertension. It is cheap and very effective. Why was that not being done here? I had some work to do and some questions to ask, but after clinic.

The next stream of patients were pretty much representative of what I see everyday at the clinic: 6 month – 9 year old children with fever, headache, and weakness (signs of a malaria attack) compounded by some kind of upper respiratory infection or diarrhea. And what do we do to these patients you may ask? We pretty much get a thick blood smear on every child that comes in with fever or history of fever. Which makes sense as studies have shown here that 80% of the causes of fever in children are malaria. What does not make sense is giving them an anti-malarial drug before they even know if they have malaria or not. I suspect that about half to 3/4 of the patients we order a thick smear on have malaria and get the appropriate treatment. What about the rest though? They are told once they are seen by us to get the thick smear and get the medicine and that is it. No waiting around for the results to confirm if they have malaria. It really is rather sad and it frustrates the hell out of me. But what can I do? I can change the system. But that will take time, which I have a lot of.

There are some other problems I have with how the clinic is organized and run, which I will not get into here. Suffice it to say that the Craiger is on the case, and I hope to have a better clinic up and running soon.

First Day as Gone-Gougou doctor

9/5/05
Maiga and I had morning bread (no butter, jelly, jam, spread of any kind) and tea (some Lipton-like brand but with Arabic writing on it, with sugar), talked a little on how the clinic worked and such, and then we were off. I remember thinking “Holy shit, how does one use a stethoscope again??” as we walked to Maiga’s office to get our equipment. He had seen my short white coat, and said that wouldn’t do, and handed me a crisp, freshly clean LONG white coat for my use in Doneguebougou. I remember the first time I tried it on, I had these strange thoughts of “Holy Shit, I am a doctor now,” anxiety, and pure fear. I also remember thinking that John Carter would be jealous. Maiga had an extra stethoscope for me because like a dumbass I had forgotten my own back home in Hippodrome.

We walked the short 50 feet or so from the vaccinations clinic to the other clinic, and greeted a mob of anxious mothers and their babies. The scene was truly one of utter chaos. Mothers wearing one part traditional Malian garb (multi-colored sarongs with hair scarves), one part Western t-shirts that ranged from football (aka soccer) apparel to I Love New York to Best Grandma in Texas. Their children were either at their side, looking up at the Toubaboo (White Man) with a look of both fascination and fear, or on their backs, wrapped with a thin sheet-like material to secure the baby to the mother. The mothers looked at the two of us, and appeared relieved, but I had the suspicion they were not too sure about the Toubaboo. I received all kinds of stares: puzzling, infatuation, scorn, wonder, indifference. The clinic “guide” (aka the village elder who assists the clinic as a nurse and pseudo-purveyor of order while we are there) had already made a list of names, and handed it to us. We walked in, saying the traditional “Ini-Sogoma,” found our chairs, and started seeing the patients.

The clinic building could not get more basic if you tried. Imagine if you will a building made of concrete. The front area is the “waiting area”; there are a few benches that align its walls, and some scattered chairs. Directly behind that is the “treatment” room. There is a bed in the back left corner for patients that require procedures. A shelf and a metal closet is on the back right filled with medicines and basic equipment. I have not had a chance to explore what resources are at hand yet; that I hope to do soon. The room immediately to the right of that is part storage, part second treatment room. It is rarely used, which is a shame, because it has a lot of potential use.

The consult room is in the front right. It is exactly how I had pictured it. It is small, about 10 foot x 8 foot (aka 3 meters by 2.5 meters), and is rather spartan. It is painted a deep color blue, and dirt is caked on the walls in varying patterns that make it appear as if it were part of the design. There is a desk along the back left wall with various notebooks, stethoscopes, a BP cuff, a ruler, antibiotic cream, plain white paper, and other things which I have yet to really look at yet. There are two chairs on either side of the desk, and fan in the far part of the room near the door that leads into Treatment room 2/storage room. There is an exam table with a thin single foam mattress with a floral pattern on it, and a thin orange sheet that covers the mattress. The table looks and feels old, and it is too high up for patients to get on and off. We hardly ever use it, as the physical exam is a joke: quick listen to the lungs and heart, feel the belly, and order the usual regardless of what we find. I find the whole thing very frustrating sometimes.

Typical day at clinic

Up @ 7. breakfast at 7:30, initially only bread and tea. Now more fruit added, coffee occasionally.
8:00 clinic starts. Many patients wait in the small waiting area outside of the main consultation room, sometimes spilling out into the open area outside the clinic building.
8 – 1:00 see 40-50 patients between the Malian doctor, me who assists, and occasionally the aide (village elder/assistant to the elder)
Typical consult: Fill in graph paper book with information: name, sexe, age, race, village, occupation, temperature, symptoms/complaints, thick smear result, diagnosis, treatment given. Ask brief follow-up questions. Do a quick exam. Dish out meds. Call next patient.
1:00-2:30/3:00- lunch and downtime. Usually take hour nap. Write in journal if time. Read pleasure book or read medical textbook on patients I have seen.
3:00-7:00- travel to and from Bamako, getting provisions, and/or work on study at the site. Run and/or play soccer with the locals. Truly and unforgettable experience (see later posts)
7:30- dinner
8:30-10:30- work on protocol, clinic revisions, talk with study staff about questions
11:00- have beer and chat outside in the elements (usually Guinness. The first day I got there I asked for a Guinness, and they have supplied that for me for the past 2 weeks.)
12:00 or so- bed and read for a while.

Life is what happens. . . .

All-

So, recall in my last post that I had these plans to write a shitload of stuff into my blog, go the the pool, shop, etc.? Well, I think the old saying is correct which says: "Life is what is happening when you make other plans." Whether it was the long night partying on Friday (until 6:00 am) or destiny, I woke up with a fever, body ache, and general malaise. I somehow walked home from my friends house I crashed in, feeling like death. Go figure: I am in Africa, where diseases that have never existed in the U.S. or haven't existed for years, and what is the first disease I get: a common cold. The Peace Corps volunteers and other expats I have met have said that the colds here knock you on your ass for days. I am experiencing that now. There is a small chance that I have malaria, and I will get that checked out tomorrow.

So in the meantime, I feel a little better than yesterday, but still not 100%. I will try to at least post some more meaningful, heartfelt, gritty, no-holds-barred posts in the next few days, before I return to Gone-Gougou for work.

In the meantime,

Be good,

Craiger

Gone-Gougou or Bust

All-

I am alive and mostly well. I realize that is has been a while since I last had the chance to write. While it has been immensely liberating to not have the internet and phone at an arm's length away, it has been difficult to keep in touch, share my stories, and know what is going on in the world. It has been a mentally, physically, and emotionally challenging time, and one that I will never forget. I am finally getting used to the ropes, have my room in the Doctor's Quarters slowly pimped out, and living life Africa style. I will be in Bamako all weekend, so expect some posts real soon. I have some stories for you.

Craiger

Gone-gougou beginnings

I woke up on the Sunday I was to finally leave for Doneguebougou. Still heartbroken after what happened to New Orleans, I needed the respite. I was looking forward to settling into a place without a landline, without Internet, without sparse cell phone reception, a place to unwind and just be. I went to the Broadway for a good breakfast before I had to pack and buy some last minute provisions. What was initially supposed to be a leisurely breakfast turned out to be an hour and a half affair. Once I got my food, I woofed it down, as I was already running late and had to get back. I left feeling a little sick and pissed off, but I remember saying “What the fuck, this is Mali afterall.”

I packed up and my friend Maiga showed up just as I was finishing some emails. We loaded my stuff into the back of the driver’s car and off we went. Little did I know that during my rush to pack I forgot 3 of the most important items I needed: my watch, my white coat and stethoscope. Hello McFly???? Turns out they were "running late" and I would have to wait until later that week before I could get those provisions. Anyway, we headed out to the market to pick up some provisions (water, bread, the usual suspects). After about another hour or so of driving around, we were finally off. Just as we left Bamako, past Point G, I remember feeling a release of sorts: no more pollution, no more crowded, nasty streets, no more annoying people selling you shit. I was ecstatic. Just as we were about to pull off the main road to head to Donegue, we stopped off at a bar. It was a quaint little place, with a big tiki hut type roof and corrugated tin for walls. It was called the Rio Grande. I half expected to see little conchitas running around and such, a mariachi band, and Margaritas abound, but no. they had 3 beers (Castel, Flag, and Guinness) and some liquour. They ordered me a Guinness and a Castel for the driver, and we were off.

The Donegue road is horrendous. It is full of potholes, sudden drops, boulders; it is not really a road, more like a trail that can loosely serve as a road. The bumps seemed to become less of a problem as I slowly downed the Guinness down as we drove.

We finally arrived at the site right at around sunset. There were a throng of people near the car park, I thought to greet me. The were all sitting down. I thought, Gee, that is nice. Turns out they were watching a European Cup Soccer match, and I was just another researcher from Point G who happened to arrive during the match. I remember getting many weird looks from the 40 or so villagers who were there watching the TV, kids and adults alike. After I settled in to the sleeping quarters, I joined them watching the match. I forget now who was playing, but I remember rooting for the team everyone did not want to win. What a way to win the crowd, ehh?

The village itself is nestled on a hill that has a small river that runs just near it. The road that took us to the village runs West-to-East, with the village proper to the South and the NIH compound to the North. It is sandwiched in between the school to the right and the marche (market area) to the left. It is a fenced in area about a full football field in both length and width. There are a number of buildings on it:
Personal quarters on the left
Vaccine building in the middle
Clinic on the right
Kitchen and generator in the back.

I still cannot believe this compound exists here. It seems so out of place. Here you have this modern complex with electricity next to this quaint, clean, perfect little African village, complete with the huts and everything. It is just a weird dichtomy that I think I will never get used to.

My first meal at the site was rather familiar to me: Spaghetti with meat. While there was no tomato sauce perse, there was a small amount of spice added to it, and the meat was few and far between. It was edible, and I rather enjoyed it. Dessert was homemade tapioca (milk plus rice). Very, very good. After dinner, we all chilled outside, chatting and watching the stars. I have not seen stars like that in a very, very long time. Sitting there, in the pale moonlight, stars seemingly more abundant that the people on earth, hearing a language I could not yet understand, I felt at peace. I went to bed that night full of excitement, fear, and restless. I had a thousand questions spinning through my mind, but no answers to them. I finally drifted off to sleep, completely unaware of the emotional and physical roller coaster that would be the next week of my life.

Leaving for Gone-Gougou

All-

I am heading out to Doneguebougou tomorrow afternoon. I start my clinical work as a study clinician Monday morning (Gulp!!). Not sure what exactly that means, what I will be doing, how I will be doing it, but I will get by somehow. I am also in the process of planning a drug efficacy study (medspeak for how well patients respond to a drug) on a new antimalarial drug combination that the government of Mali recently adopted as first line therapy. The new combination contains a drug that has been widely used in Chinese medicine for centuries to treat fevers, and only recently isolated and used to treat malaria. This drug, Artemisinin, has shown to be very effective in other countries, and only limited studies have looked at its effectiveness here in Mali. It has also been shown to be even more effective when used in combination with other anti-malarial drugs, even some medications where resistance is high (e.g. chloroquine). It will be a relatively short study and one that will involve from my end: study design, IRB approval, clinical work, laboratory work, and learning about molecular epidemiology, which is a fancy way of describing how health is affected in populations at the molecular level. It is great for me because I will see the whole scientific process in action. A lot of logistics have to be worked out, but it is doable in the time frame I am here. I am very, very excited, about this opportunity, and will keep you updated.

In the other big news, the hurricane has come and gone, and the aftermath that has hit my beloved city is heartbreaking. Everyday I think about what is happening there and the possible short-term and long-term consequences. I guess I will just have to wait and see, and leave the rest in Gods hands. It is so easy at this stage, once the intial shock wears off (if it ever does wear off), to start examining the response and how our leaders are coping with the problem at hand, and putting blame on someone or something. My simple response to that is forget the past, learn from our mistakes, and focus on the living and the future. New Orleans and the entire Gulf South region will make it out of this, albeit at a pace that is congruent with the lifestyle in the Deep South (i.e. very slow). We just have to wait and see how things turn out.

Anyhow, gotta get packed and get ready for tomorrow, and have one last beer at the Terraza before I head out to the bush, where luxuries such as beer and music and everything in between do not really exist.

Love Life, Enjoy Liberty, and Be Happy.

Always,

Craiger