29 October 2005

Ramadan- Week 3

A few updates from my last entry on Ramadan:

The entry “The Best Meal Ever” happened the weekend before Ramadan started, so I have been pretty much faithful to the fast thing (See other post on Segou).

Today marks 3 weeks of Ramadan.  Only 7 more days to go.  I have never felt better.  I am able to concentrate more and get more accomplished as I have become more accustomed to the fast.  However, depending on the quality of the meal the night before, I have good days and bad days, just as the cook seems to have good days and bad days.  I have had only one “holiday” from the fast (my 2 days in Segou) and surprisingly I did not put on that much weight from the experience.  

I just weighed myself a few minutes ago after clinic, and I am now at 76.5 kg (~ 168 lbs).  So in the 3 weeks I have done this fast, I have lost a total of 7 kg (~ 15 lbs).  This is the lowest I have weighed since my Freshman year in college, 1994).  Now, I will say that the scale I am using probably has not been checked or re-scaled in a while, so I am not sure how accurate the reading is.  But my initial weight of 83 kg was made on that scale, so I am using that as my point of reference.  

I started to read the Koran to fully get the Ramadan experience.  It truly is an inspirational book.  I have only covered the first 20 pages or so, and it kind of reads like a morality tale.  I will fill you in one more as I read it.

The foot infection has now healed up.  I think I also have an alternate explanation for its occurrence.  According to some of the Peace Corps volunteers I have met, cracked heels and soles are a common occurrence in West Africa.  People don’t really wear shoes in the village, they mostly just wear cheap sandals.  Thus, the feet are constantly dry, and thus crack.  Since I have been in Mali, I, being a HUGE fan of sandals, decided to adapt to the local customs.  Suffice it to say that I wear sandals pretty much every day.  So, hence the cracked heels and soles on my feet, and the infection.

I have done some reading online about the physiology of fasting.  Suffice it to say that all of those old wives tales about starving yourself to loose weight as being bad is actually not all that true. While fasting, your body is forced to rely on its own stores for energy: fat, glycogen, protein.  The initial weight loss you see in any diet is predominately water weight.  After that, you start to loose body fat, as that tissue type has the greatest amount of energy than protein and sugar.  In this type of fast, you are losing water and fat, as you are using up your water stores to stay cool throughout the day and you are burning your fat stores after your body has already used up the nutrients and energy from the meal you ate at night.  This is just basic info from what I have read, and I continue to read more, so stay tuned for even more info.

I am not sure what this whole Eid al Fatr thing is about at the end of Ramadan, but Maiga and I have already spoken about it and we will experience Eid al Fatr in Bamako with his family, which from previous experience, means delicious food from Timbuktu. Yes, indeed.

28 October 2005


It is a little after 9 pm, and I just finished dinner. I just got back from the Malaria training center, waiting for a ride to Doneguebougou and having to wait according to the Malian Mathematics I have alluded to earlier. I am rather exhausted from the weekend, and for good reason.

I decided a few weeks ago that I wanted to get out of Bamako for a while and see another part of Mali. I consulted my guide books for a small town, on the Niger River, that would do well as a visiting spot. One of the researchers I worked with recommended Segou, Mali’s second largest city. It is nestled about 230 km from Bamako and sits right on the Niger river. From what I had read in the guide books, it sounded like a jewel that is overlooked for her more popular cousins Mopti and Djenne. I decided then that Segou would be my destination.

I was all set on arriving to Segou alone and checking it out on my own when a chance encounter with a Peace Corps volunteer this past Friday night who had worked in Segou mentioned that her friends were all there this weekend, and that they would serve as great hosts. Not one to overlook a chance to meet some new people, I got her friends’ numbers and gave them a call. I agreed to meet up with some of them for lunch on Saturday right after I arrived. Perfect. . . .

Well that chance encounter ended up becoming a late nighter as we met some other Americans and enjoyed the local night club on the Bourbon St. of Bamako. Surviving on 4 hours of sleep and fasting for Ramadan did not make the morning any easier. I ended up rolling out of bed around 8, somehow packed a small bag, and made my way to the main road to get to the bus station. Naturally, I thought the station was somewhat close to the downtown area, but I was wrong; it was on the other side of the river. I arrived, not really sure what the hell I was doing. This was partly due to the lack of organization at the bus station and my hangover which was in full effect at that point. I found the main terminal and paid for my ticket to Segou for the 9:00 am bus: only $6!! At that point, a few strange occurrences bode either a good omen or bad karma about my trip. First, I saw a man wearing a New Orleans Saints sweatshirt. He was standing near what I assumed to be his shop (aka informal shack selling trinkets). I approached him and asked to take his picture, but he refused. Then a few minutes later, I saw a man wearing jeans with the New Orleans Hornets emblazoned on the front thigh. Given the reaction the previous guy made, I did not ask for his photo. I could not believe my eyes: 2 different Malians wearing paraphernalia from my city at the bus station in Bamako, Mali. What are the chances? The third happenstance was perhaps the most weird for me: I was sitting down on a bench in the open air seating area (there was a roof over our heads) and noticed a small frog hopping right towards me. He stopped right between my feet and, I kid you not, pissed and shat right there in front of me and then kept hopping along. I will leave that one alone for you all to ponder.

So, as I alluded to in a earlier post, time in Mali tends to run on its own schedule. I factored in that we would not leave the bus station on the 9:00 bus until about 9:45 or so. Well, surprising enough, we started to board the bus at 9:15. I couldn’t believe it. The bus was interesting: It looked something right out of the 70s: brown upholstery, red, brown and yellow curtains on the windows. There were air conditioning vents along the sides, so I figured there might be a chance for a little A/C. I found an empty seat, hoping the bus was not full; of course, it was. Perhaps one of the only large women in Mali happened to sit right next to me. She carried her bag on her lap and her Carmen Miranda sized bunch of bananas under the seat in front of us. Needless to say, I had a tight fit. By about 9:30 or the bus was pretty full, and I had anticipated that we were ready to go. I was wrong. We sat on that bus until 10:30, with no A/C (apparently those vents are for show only), no windows. It was like a sauna in there. And, in case you don’t know, African’s aren’t known for their use of deoderant, so you can imagine the smells eminating from the bus. I kept telling myself as I tried to ignore all around me: this was the experience I was looking for, and that it would be something interesting to share one day.

So finally at about 10:30, a pudgy Malian with a cigarette in his mouth sauntered on the bus and took his seat at the driver’s chair, making sure to hike his pants up before he did so. He reminded me of a New York cab driver lost in Mali. Finally we leave. Even some of the Malians on the bus were complaining, and the bus driver shouted back in Bambara some kind of invectives to them. We were finally on our way.

The guide books said to expect a 3 hour drive to Segou; given what I have thus learned in Mali, I was expecting something more of a 4 hour drive. The landscape is not much to be desired. It is the start of the dry season, so a lot of dead brush along the road and a lot of browns and tans creeping up alongside the few remaining green patches of shrubs and trees. We were traveling on the only main paved road/highway in Mali, the same road that I am sure I will be taking to head up to Bandiagara and Tombouctou. There were a number of small village alongside the road that I am sure sprung up after the road was developed. It seemed like we stopped off at each road side village, and the villagers there scrambled to the bus, shouting and screaming at us to buy something they had to sell: water in sealed plastic bags, fruit, trinkets, soda, etc. We also seemed to be supplying enough charcoal to supply the Malian army, because at each stop, we seemed to accumulate more and more, to the point where the aisle was stacked with 50 pound bags of charcoal. If an accident had happened, I am sure it would not have been pretty to escape.

After a 4 hour bus ride, we arrived in Segou. I cannot tell you how happy I was to be there. The view from the bus showed it to be a smaller version of Bamako, but a lot less busy and more pleasant. The French influence was evident everywhere: the streets, the houses and buildings, everything had the stamp of a French colonial town. We arrived at the bus station, and I walked the 4 blocks over to the Hotel Djouliba where my Peace Corps acquaintance was waiting for me. I looked and felt like hell, so after I freshened up, I joined her and her friend for lunch. (Side note here: I had fully intended to keep the fast thing going, but there is actually a stipulation in the Koran that allows you to break the fast when you are traveling as long as you add on more days to the end of the month to make up for lost time: Ummmm, I don’t think I will take this whole fast thing THAT far). I had an incredible lunch: Exotic salad (chicken, tuna, mangos, papaya, lettuce, thousand island type sauce) and a Castel. My Peace Corps colleagues were going down the street to the Hotel L’Auberge swimming pool. I had yet to check in to my hotel (Hotel Esplanade), which was on the river and not far from the action. After checking in, I joined them poolside (Following their suggestion, I said I was a Peace Corps volunteer, and got a mad discount on the price of drinks and the pool). What a pimping place. There were already other Peace Corps volunteers there, enjoying a much needed respite from village life. After a few Bili Bili Castel’s (aka 32 oz. beers) my hangover was definitely gone.

We decided to freshen up and move the party to the Hotel Esplanade bar on the river for a sunset beer. This bar was a small place right along the banks of the Niger. It had ample seating for the 6 of us (myself and 5 Peace Corps women) and the beers were very, very cold. We saw some of the sunset, but clouds obstructed a clean view. It was very peaceful and relaxing, and it reminded me of many a sunset evening spent along the Mighty Mississippi, the Big Muddy, in Uptown New Orleans, post-medical school exams, sipping cold Abita Ambers and hanging out with friends.

The party continued back at the Hotel Djouliba, where it was Pizza Night: you make your own Pizza in a brick oven. I dined on a Hawaiian style pizza and a small carafe of cheap South African wine, which was the staple alcoholic beverage for the whole group. We then explored one of the local Malian bars, The Tempest. It was just like the seedy Malian bars I have been in Bamako: dark, a few lights, cold, cold beers, and little seating. After that, we went to the only night club in Segou: The Mobasa. Pretty much the same fare as the last bar, except outside and with more seating. Ramadan kept the local crowd at home, but the place was kicking with the Peace Corps regulars and the random medical student from Tulane.

It is really hard to describe “The Perfect Day.” Different people have different definitions of what it means for a day to be so: chilling at the house, visiting friends, good day at work, etc. For me, The Perfect Day was on Sunday in Segou. The Peace Corps girls had convinced me to stay an extra day as the “newbies” were coming in that day to check out the area for the first time (the new class of volunteers had just arrived on Sept 23) and they had planned a party for them complete with dinner and a local band. I woke up feeling surprisingly spry and good for the number of beverages we had consumed the night before. Plus, it was 8:30 am and I had the whole day to play. I met up with some of the ladies for breakfast at the Djoliba (see a pattern developing here. . . .). Again, incredible: yogurt, mueslix, orange juice and coffee. Fantastic!! I then borrowed one of the Peace Corps bicycles and took a bike tour of Segou.

Truly, a beautiful town. I started out by the river front, rode past my hotel and made it to the pottery section. There were easily 1000s of pottery pieces for sale, and more arriving as I perused their stock. Low on cash and with no easy mode of transport, I opted out of buying something, promising to return later to purchase. The architecture around that area was quite stunning: Neat little Sudanese houses made from the red clay of Mali, classic French style architecture, Arabic-influenced, mud houses. It was rather incredible. I continued along the river and made it to a main road of sorts. Huge, French style mansions rested on both sides of the road, upon which huge trees created a canopy of sorts for the street. I swear it reminded me of somewhere I had once lived. Hmmmmm. . . You decide.

After the street, I made it to the main road and continued to the downtown area of sorts. This is where Segou becomes Mali’s second largest city: traffic, markets full of vendors and buyers, small banks and government offices. I decided that I had seen enough and decided to venture back to the Hotel Djoliba to drop off the bike and somehow make my way onto a pirogue (aka canoe) to cross the Niger River. I ran into the only Peace Corps guy there that weekend and asked him to introduce me to one of his shady friends who had connections. I somehow was able to con my way onto my own private pirogue for only $6!! I made it down to the water front with one of the shady friends and found my equally shady boat. It looked sturdy enough from the outside at least. We set off with myself, the pirogue driver (Fa-Fa) and his little brother (Amadou). The current is strong even as you get out about 20 from shore. Even though our destination, a small fishing village, was directly across from the port, we had to go upriver about ½ mile and then attempt to cross so as the current would help us a little. Overall the trip was about 45 minutes. We got to the other side and walked around a bit. It was oppressively hot then, so we sat in the shade and enjoyed some Malian tea with the pirogue driver and his family. While the family invited me to stay with them for the night, I politely said no, and made the long trip back to the other side. Not one for being passive on a boat, especially on a canoe, I asked the pirogue driver if I could help him paddle. He said yes. The 45 minuted trip over lasted only 17 minutes coming back. As we pulled in, the entire port seemed to stop and watch the Toubab paddle, something I think they have never seen before, as most tourists prefer someone else paddle for them.

I then hiked back to the hotel and jumped in the pool with some of my Peace Corps friends and some of the new volunteers. The Bili Bili ba Castels sure went down well after a long day. We then all met up for dinner back at the Djoliba, and went to hear a local drum band at the sketchy Malian bar we had frequented the night before. The sounds and the feel of the band reminded me so much of New Orleans. We ended up shutting the place down, and I crashed hard back at the hotel. It was tough saying goodbye to my new friends in Segou that night, but something told me that I was to return very, very soon.

16 October 2005

The best meal ever

The best meal ever

So on a recent lazy Sunday afternoon, after a small breakfast of tea and French cookies, and reading “The Life of Pi,” I got a phone call from Maiga. He was returning my missed call from earlier.  He said he was going over to his Uncle’s house in Bamako, and wondered if I wanted to go.  One of the senior researchers who helps run the Fogarty Fellowship was in town for the week on a site visit, and he was already on board with coming.  His uncle was on his month vacation from work as a WHO officer in the Comores (an island nation sandwiched between Madagascar and mainland Africa) so there would most likely be many, many people there to meet and hang out with.  It sounded awesome, an experience that I could not pass up.  He showed up at the house in a yellow Mercedes Benz taxi, and off we went to pick up P., the Fogarty guy, at his hotel.  When I asked Maiga where in Bamako his uncle lived, he said it was near the river.  Hell, everything here is near the river.  After a long ride on our side of the river, we crossed the river to the other, newer side of Bamako.  Bamako is essentially 2 different cities.  On one side, the more traditional, older, more polluted city (that’s where I live, go figure);  The other side, newer, more modern, cleaner air, “better” living. After about a 45 minute cab ride, we finally reached his uncle’s house.

It appeared small from the outside, but once we entered the front gate, it grew exponentially in size.  There was a good sized courtyard with some children’s toys, a few palm trees, and some motor bikes. We entered the main house, which was full of people.  The men were all seated on small mattresses, some covered with brightly covered cloth, others with light pastel colors.  They were talking amongst themselves, and dressed in the traditional Malian garb typically reserved for family gatherings and special events.  They were talking in a different sort of tongue that I was used to, one that sounded rather Arabic.  They were speaking Songhay, the Malian dialect from the North of Mali (think Timbuktu), the epicenter of the Maiga clan.  I could smell something cooking in the courtyard in the back that made my stomach growl and snarl something fierce.  We sat down after some basic introductions, and talked like men.  More like they talked, and P. and I pretended to know what they were talking about.  After a while, I zoned out.  

2 of Maiga’s little cousins were there.  They treated him like their own personal jungle gym.  Evidently, they are all real close.  Maiga regards his Uncle and his family like a second father, as they took care of him while he underwent his extensive education to become a physician.  The room was decorated spartanly with artifacts from the north of Mali and some pictures.  It was rather roomy and I really felt like home there.

After about an hour or so, they called us to dejeuner (lunch).  Most of the family meals in Mali involve small circles of men arranged by pecking order in the family.  The elders and the main bread winners in one, the next younger ones, and on down.  I think most Malians believe that westerners must eat at a table, with a fork and spoon and knife, proper-like, while the Malians eat sitting cross-legged using their fingers to eat.  They offered to have us sit at the table, but both P. and I decided to eat as they did (After a while, P. decided to go with the plate and fork).  

So where are the women you might ask?  Seated away from the men, in a different room, eating what they can while they clean up and prepare the dessert.  Hmmmmmmm. . . .

People, this was perhaps the finest meal I have had in Mali, perhaps for a very long time.  It was a relatively simple dish, according to Maiga.  Chicken falling off the bone in a stew/sauce sort of dish.  The sauce had carrots, potatoes, onions, some pepper, and the best spices I have tasted in a very long time, along with a hint of lemon.  I was very impressed.  At first, before I took my first bite and was sizing up what I was about to eat, I thought it would be very similar to everything else I had eaten before: rice with sauce with little taste.  The first bite was nirvana in my mouth.  Spices I have not tasted in months tickled my tongue and the back of my throat.  Taste spread over my tongue and my mouth, awaking taste buds that had lay dormant for weeks.  I continued to eat and devoured everything in site.  I felt like I had finally reestablished the avorous appetite for which the Craiger is known.  I began to eat like a man possessed.  Maiga could not get over what he was seeing.  We had eaten many meals at Doneguebougou, and never had I eaten like this.  

Soon after, dessert came out.  It was a very simple dessert, fruit: oranges, banana, watermelon, and some mango.  I devoured those like a champ, and rested afterward.  I was very, very content.  After the meal, we rested on the floor with the other men, drinking the traditional Malian tea.  It truly was one of the best meals I have had in a very long time.  

Malian Math Made Easy

The book “Life, the Universe, and Everything” states that the answer to said title (aka life, the universe and everything) is 44.  Well, one can ascribe a similar mathematical model to Mali.  I have found that I can figure out 2 main aspects of life here by applying a little 4th grade math (thanks to Mrs. Roach at St. Ann’s) and a little algebra (thanks to Mrs. Sapporito at Gilmour Academy).  The examples given all ascribe to the same pick up and drive from Bamako out to Gone Gougou.:

I had an excellent Sunday morning and early afternoon, walking around Bamako and its markets, swimming in a hotel pool, catching a movie, and simply, living.  Maiga had called me around noon and said he had arranged for the driver to pick me up “in the afternoon” at the Malaria center here.
“About what time do you think?”
“Oh, I don’t know.  I will let you know.”
So does that mean 1 hour or 4 hours?  I have learned from talking to Maiga and other Malians that there is a simple equation to derive what time they actually will do something from the actual time they say it will happen.  The equation is thus:

Actual time = time stated + 4-5 hours (Equation 1).

Equation 1 has been tested about 10 times, and it has not failed.  So, after getting off the phone and as I tried to plan out my day, I figured the driver would pick me up at around 4:30.  I arranged for a taxi to take me up the escarpment (bluff) to Point G where the Malaria center is located.  I did email for a while, figuring the driver would arrive around 4:30 or so.  I finished my work at around 4:25, and waited outside.  At 4:45, he showed up.  I love math.

We had 4 errands to run before we were to go to Doneguebougou:
  1. Pick up my bag from my house

  2. Buy gasoline for the generators

  3. Stop at the drivers house to pick up some of his things

  4. Buy beer, bread, and watermelon for the group

So, time for the 2nd Equation that explains all Malian life.  This one derives how long it takes you to run errands from a starting point (i.e. ones house) to and end point (i.e. back to the house or to Doneguebougou) based upon the number of things you have to do.  The caveat to this is that this equation is irrespective of the type of errand: running to the store, waiting in line at the bank, getting gas, etc., all receive the same weight.  The equation is thus:

Time to complete an errand = # errands x (45 minutes - one hour) (Equation 2.)

With this said, from Point G to Doneguebougou (factoring in the extra 30 minutes from Point G to Doneguebougou), one would expect our errands to take minimum 2 hours 30 minutes to a maximum of 3 hours and 30 minutes.  This would mean in real time, that if we left at 4:45, we would arrive in Doneguebougou between 7:15 – 8:15.  Sure enough, after running all 4 errands and after finishing the last errand near Point G, we arrive in Gone Gougou at 7:45.  Who says you can’t use math in your everday life. . . .

Craiger does Ramadan

Ramadan, the Muslim holy month of fast and introspection, started on Oct. 4.  I was unsure what it exactly meant, and how I was to react to it.  I had never really thought about the muslim religion, so I didn’t really know what to expect.  Initially I thought that I would not fast, as I was not Muslim, and thus had no reason to do so.  A chat with one of the Americans who works at the MRTC who was a former Peace Corps volunteer here changed my thinking.  She said that it built a sense of comraderie with the people of her village who were muslim, and it allowed her the chance to experience  and understand the Muslim religion.  I thought about her words for a while, and then decided to go for it: I decided to fast.  

Oct. 5th was the first day I fasted.  The fast works like this:  You wake up around 4:15 or so and have breakfast with some tea, bread, fruit (sometimes), and water.  You stop eating at 4:45 or so and are not allowed to eat or drink ANYTHING until 6:20 in the evening, or for roughly 13 ½ hours.  At that time, you break fast with a small bit of tea (aka Lipton bag tea) with lime and sugar, dates, and raisins.  You then gradually sip cool-to-warm water and then gradually eat larger and larger amounts.  You also continue to drink water throughout the night to replenish what you missed during the day.  Of course, the muslims also pray 5 times a day like normally, but during the month a little bit longer.  The process repeats for the entire “month,” or better said the cycle of the moon from the New Moon of Ramadan to the next New Moon.  At the end of Ramadan there is a huge feast and party called Eid al-Fatr.

So, I decided to try this whole thing out.  The first day was hell.  We had a “good” dinner the night before, and I went to bed feeling a little nervous.  Waking up at 4:15 in the morning to eat is not easy, and it is nearly impossible to go back to sleep.  What follows is a description of my first day doing the fast (recall, no food or water during daylight hours):

“Clinic just finished, and I am tired.  43 patients between 8:00 am and 12:30.  I only got about 5 hours of sleep (4 hours between going to bed and breakfast, and only 1 hour from about 4:30 to 8).  It is hard to concentrate.  I am very thirsty, and I have slight hunger pangs.  My thoughts are fuzzy, and my ability to type is definitely diminished.  

It is now 4:00 pm.  I woke up from an hour nap as a way to kill time, to avoid thinking about food and drink, and lastly to catch up on sleep.  I am now trying to read an article I downloaded the other day on malaria vaccines.  It is very, very hard.  Words seem to mix together, concentration is at a minimum, and my typing is even worse than before.  Thirst is the hardest part.  My throat is dry, as is my mind.  I have a slight headache, like that of my hangovers (a sign of dehydration).  I cannot wait for 6:20.

It is now about 7:30, and I feel alive for the first time all day.  I had tea with sugar and lime, dates, raisins, and small amounts of water.  About half hour later, we ate dinner (some meat with a ton of French Fries, some rice with sauce, and some oranges I had bought the day before).  There is nothing like breaking the fast after about 13 hours of NPO except some water.  You feel alive again, as if you awoke from a deep sleep, and are finally aware of what is around you. You feel alive during that half hour or so after you eat. Your body then gets back into your usual state.  You can write again, speak again, think again, be again.”

So this same cycle of no food and water during daylight hours continued for me for 2 more days.  On Day 4, at around 1 o’clock in the afternoon, I got up from my chair, and fainted.  This has happened before to me when I was younger, but not in a long time.  The doctors there said I was out for only a couple of seconds, and I regained full capacity shortly thereafter.  They thought well of me for trying the fast with them, but they thought it was better that I not do it.  I told them I thought it was rather important, and that I would make an amendment: no food, but some water during the day.  They were skeptical, but agreeable.  

After my fainting episode, I decided to approach this whole thing methodically:

Breakfast at 4:30: orange, banana, bread/croissant, water, and half a granola bar that my parents sent from the states.

During daylight hours, one 6 oz. cup of water in the morning and one 6 oz. cup of water in the afternoon.  NO FOOD at all.  Half hour to an hour nap to kill time and catch up on lost sleep after breakfast.

6:20- break the fast in the traditional way: tea with lime and sugar, dates, raisins, and sometimes oranges.  To replenish my water stores, one 8 oz glass of water every half hour for the rest of the night.  

This regimen has suited me well for the past 10 days.  It is hardest when I am in Bamako for a day or two, and staying at my free room at the office with no one to share in the misery of the fast.  But, somehow I do it.

Health wise, I feel great.  I weight 84 kilos when I started (about 184 pounds).  After 14 days, I weight 80 kilos (about 176).  With means I have lost 9 pounds.  Not bad at all.  The only other issue is that I have this nasty foot infection on my left foot.  I think it is a nasty case of athlete’s foot that caused cracking and blisters to form.  It first started on my right foot, and now my left.  My right foot is essentially healed after about 10 days of treatment, but my left foot is worse than the right ever was, and there are about 5 blister-like sores there.  So I am now walking with a slight limp.  It looks like they are healing well, but slowly.  Otherwise, no issues.

Probably the biggest gain I have received is the comraderie from my fellow researchers in the village.  I live with about 10 other researchers: some doctors, some lab technicians, some clinical coordinators.  When I first arrived to the site in early Sept, there were some growing pains and some funny looks here and there.  I felt isolated from them.  As it became apparent that I could not work on the trial that was ending there and I worked vigorously to change that, my isolation increased.  Compound that with my less than adequate clinical experience there, after a month, I was at wits end with them.  After a while, they grew on me and I on them.  However, it took the experience of Ramadan and fasting with them to really change their conception and thoughts about this American living amongst them.  I have noticed completely different reactions to me now.  We are like a fraternity so to speak of researchers living and working in a spot that is close enough to civilization that we can get provisions when we need them, yet isolated enough that we feel we must rely on each other to get by.  

I have 14 or so more days of Ramadan remaining.  I have become accustomed to the fast, and now am able to function better than at the beginning.  I hope to learn more about the muslim faith during this time, and a little more about myself and what I am made of.  I think I will somehow make this a yearly thing, like a cleansing of sorts.  Of course, if this were a true cleansing, I would do this thing sans alcohol.  But, as the Bambara saying goes, Doni doni ne tere geh. (Little by little, my friend).  

Sundown prayer

The eeriness of the Sundown chant calls to everyone, whether you are Muslim, Christian, or pagan.  It’s a haunting sound; guttural, melodic, and yet soothing.  You are instantly drawn to it, like a bug to light.  You feel its power deep within you.  You are forced to introspect about life and everything in it; you find yourself pondering, questioning, wondering. You are forced to think of things larger than yourself.  It’s power, it’s center, it’s meaning becomes you, even if but for a moment.  

Followup to previous post


Perhaps the hardest part for me happened next.  After we saw 10 more patients, clinic was done for the day.  We ate lunch, and didn’t talk about the incident at all.  It was very hot that day, and I decided to take a nap.  I woke up about an hour later, and began to write about the incident in my journal.  At about 4 or so I walked out of our house and saw some of the Malian researchers sitting near the same tree a few hours earlier I had sent the patients waiting to be seen.  Maiga, the Malian Fogarty Fellow, had arranged a meeting that afternoon with the village chief, so I was ecstatic about that.  H. was sitting hearby, and I told him that I wanted to attend the little girls’ funeral.

“I have already do that.”
“What do you mean?” I asked.
“The funeral happen after lunch while you nap.  I attended for two of us” he said in his broken English.

I sat dumbfounded, speechless.  With tears in my eyes, I started to yell at him, telling him that I was just as much a doctor for that little girl than he.  I actually tried to save her, while he sat by and did nothing.  I cursed at him for what he did, and got up and walked away.  I felt like running away, never to return.  

A few seconds later, Maiga and H. approached me, and H. apologized to me in French.  Maiga, translating, said he did not think about the situation with the funeral the same as me and nor did he think of me as a doctor at that time.  After seeing what he saw in the clinic, he now thinks of me as a colleague, and he apologizes procusely.  I accepted his apology, and that was that.  I asked if I could go to the cemetery and say goodbye.  I was told that in Mali, you do not go back to the cemetery to visit the dead after the funeral.  Like most things I have learned here, I accepted it, and moved on.  

It has been exactly 37 days since this happened.  I still think of S. every day I see a little baby in her mother’s arms in the waiting area at the clinic in Doneguebougou or on the streets of Bamako.  I look at each face to see if looks similar to the one that I saw that day, to be sure that I never let one like that slip away again. Now that I have had some time to reflect on the experience and seen how medicine is practiced here, I question if I was the one who was wrong in how I treated S.  Life is precious anywhere, but death is accepted differently in different cultures.  In addition, I realize that my initial reaction to my colleague was overly harsh.  He was practicing medicine according to the type of medicine available to him.  He is a good physician who I still work with at the clinic, and someone who I trust infinitely.  He and I are rather close friends now, and we never speak of the incident, like it never happened.  

From time to time when no one is around after clinic, I find myself searching for the page with her name on it.  S.’s name still has an asterisk by it, and is one of a thousand other names in a ledger on a desk in a small medical clinic in West Africa.  But for me, Souleymane is more than just a name; she is a real person, a little patient that I could not save.  I am haunted by her.    

Everyone Knew But me

The following story happened on my first day at the village clinic where I am working on the vaccine trial.  It has taken me a while to come to grips with it, hence the delay for posting.  Not a day goes by that I don’t think about the patient in this story.  I picture her face every time I see another one like her, wondering if it is her and that what had happened was some sort of bad dream or story I had read that happened to another doctor who had worked in Africa.  While the following story may seem frankly formulaic, like it was an amalgam of stories that you have read about elsewhere or had heard about on an infomercial for African children relief, it actually happened exactly as described.  I have often heard doctors describe that certain patients will leave an indelible mark on their lives, both as physicians and as humans.  For me, one of those patients will be Souleymane.  

Patient #43 was a beautiful young baby girl, swaddled in colorful Malian cloth and lying rather quietly in her mother’s arms when they entered the small clinic room.  We had already seen about 40 other infants and young children just like her that day, my first in Doneguebougou as a “doctor.”  They all had the same complaint – fever – usually mixed in with some other common complaint (headache, diarrhea, cough, etc.)  In this clinic in this little corner of Africa, this meant malaria.  There was nothing to suspect that there would be anything different about this little baby girl.  

You could tell the mother was very proud of her baby in the way she held her head high up near her shoulder and cradled her carefully in her arms.  You could also sense that she was rather worried about her recent infection from the quiet concern I read from the mother’s face.  I remember the infant’s small, angelic face, her seemingly perfect dark skin, and the pink dress she was wearing.  I also remember seeing many small, handmade bracelets and anklets on her wrists and ankles, a sign that she had visited the traditional medicine healer in her village.  When I saw this little “perfect” infant as she lay in her mother’s arms, I knew something was very, very wrong.  

Her mother said her name was Souleymane (S.) and she was 9 months old.  They came from a village about 10 km (about 6 miles) away called N’gara.  She said S. had a bad fever and chills for a couple of days, and suddenly this morning was not responding to her when she tried to wake her. So, she begged her husband to accompany them on the walk to the clinic in Doneguebougou.  Neither the mother nor I have any idea what time she arrived at the clinic that morning, but it was already about 12:15 when we saw her, and we had been seeing patients since 8:00 am.  

At first glance, S. was not acting like the other babies I had seen before her that day and for that matter ever before.  She just laid in her mother’s arms, not moving and staring off into space with these deep, big, brown eyes that resembled those of a doll.  Within the first minute of arriving, the Malian doctor I was working with that day (H.) and I immediately had the mother lay S. on the exam table, the same table that was covered with an orange cloth that had already been drenched with the sweat, dirt, and some urine from the 42 earlier patients.  I recall thinking that it was not right that we place something that seemed so perfect on such an imperfect spot, but this was not the time to worry about perfection.  After we removed her dress to examine her, we took her temperature (40.5 degrees C, or 104.9 degrees F., a dangerously high fever for an infant) and did a quick physical exam, knowing full well that we probably would find nothing of significance but still suspected the worse.  We also noticed that S. was flaring her nostrils and using her chest more than normal, a tell tale sign that little S. was in respiratory distress.  I also moved her head from side-to-side to see if her eyes stayed fixed looking straight ahead (which is normal) or followed the direction I was moving her head (which is not normal); her eyes followed my movements, a very, very bad sign.  

H. and I had the same reaction to our brief exam and he anxiously told the mom to quickly go outside and wet her head wrap with the cool water from the spicket a few feet away from the clinic.  As she returned, H. called in the father to tell both he and the mother that their baby had to go to the hospital immediately because of the possible drastic consequences of cerebral malaria, of which this was most certainly a classic example.  

While he was doing this, I attempted to wrap S. in the cool head wrap.  As I supported her little head in my left hand and tried to wrap the cool cloth around her with my right, S. stopped breathing.  I felt her pulse and couldn’t feel anything.  I startled a bit and H. instantly looked at her and in a weak attempt at CPR, awkwardly pushed on her chest a few times, and weakly blew out air through his mouth in a way that made his lips putter, as if to help her breath from a few feet away.  He knew what had just happened.  The mother and father, watching everything we had been doing to their daughter, somehow both knew what had just happened, and started to wail.  For those first few seconds, I had no idea what just happened; everyone seemed to know but me.  

A few seconds passed before my instincts finally kicked in and I thought of the steps of CPR.  I knew that they had emergency drugs and oxygen in the clinic building next door that was to be used in case one of the vaccine trial recipients went into anaphylactic shock after receiving the vaccine.  I asked quickly if we could use that equipment to revive her, and H. told me no, that “There was nothing we can do.”  After he said this, I pushed him rather briskly out of the way so I could get near S., almost knocking him down.  My instincts now were in full gear, and I started CPR for the first time ever in my life on a live patient.  I had no mask to cover her face to prevent me from getting any infection she might have, but I ignored that small detail.  I put my lips over her little mouth and nose to help her breath, and did the breaths and compressions in the order that I had practiced up-teen times on a plastic dummy.  

At this point I was a machine, immune from everything occurring around me.  Neither the mother or father’s wailing nor H.’s staggered look fazed me.  I remember thinking “I don’t give a fuck if you say I can’t use the emergency equipment, I am going to use it anyway.”  After about a minute of altering breathing and compressions, I felt a tap on my shoulder.  It was H. telling me to stop.  I remember turning around and staring at him, tears slowly welling up in my eyes, tears of both anger and sadness.  The machine suddenly stopped whirling, and the human returned; I then realized that my attempts were futile.  Everything that I had ever been taught up to that point no longer mattered; I now knew what everyone else in the room had already known for some time.  

I looked down to the floor, and then back at S.’s naked body.  She still had the face of an angel, and the appearance of a life-like doll.  Her big, brown eyes were still open.  I will never forget the way she looked just then: at peace.  I reached up, and closed her eyes, like I had seen done so many times on TV and in movies, and never on a real person.  I remember her face and forehead were still warm, full of the warm blood of a life that was now suddenly and prematurely gone.  

The mother and father continued to wail hysterically.  H. scolded them (I think) for crying, and I yelled at him for yelling at them.  The tension and the utter reality of the situation hung thick in that small room for a few seconds.  I felt I had to do something.  So I brought the parents to the treatment room, and sat them down.  I then picked up S., wrapped her up in her mother’s cool, colorful cloth and carried her into the next room and handed her to her father.  I saw the father first proudly look at his daughter and then start sobbing hysterically.  Feeling invasive, I walked out quietly and closed the door, which shut with a loud thump, providing a rather grim tonality to the situation.  H. was silent, looking off into the distance.  I looked at him for answers, expecting my colleague to console me and tell me that I had done a good job.  Instead he looked at me and said “Wow.. . . .   Wow, wow, wow.”  

I was beyond myself at that point, and walked out the door of the exam room into the outdoor patio that serves as the waiting room for the clinic.  There waiting for me was a crowd of about 10 mothers with their children, every single one absolutely silent, looking at me in a way as if I were to blame for what they knew had just happened.  There I stood, in my newly ironed long white coat, as helpless as the little girl that had just died in my arms.  Not being able to communicate to them in their native tongue, I looked out across the dirt of The Compound and pointed to a tree that was far away from the clinic building.  They somehow understood, and one by one got up and walked in silence to the tree I had pointed to.  

After the last perspective patient had left the patio, I walked to the side of the clinic building, hidden from sight from everyone present.  I dry heaved, and then again, but nothing.  Tears welled in my eyes as I leaned against the side of the building and bent over, struggling to make sense of what the fuck just happened.  I began to curse my colleague for not allowing me to do more with the emergency equipment.  I cursed him again for what I perceived as his lack of judgment.  I cursed the family for not bringing their daughter in sooner.  I cursed the whole country for being so backwards.  And finally I cursed myself for agreeing to come to this fucking country and in thinking that I could actually make a difference; who the fuck was I kidding?  What the hell was I doing?  Why did I come here again?  Why did this happen at this time, in this place, to this child?

I sat there for what seemed like eternity, but in reality was more like a minute.  I got up, wiping my face as I walked back to the clinic.  While I was gone, H. had arranged for a relative of the family who lived in Donegue to come help them.  After about 5 minutes, the family left out the front door of the clinic and down the steps toward the main entrance.  The relative was in the lead, followed closely behind by the mother and father.  The father walked with his head down, holding his little baby girl tightly against his chest with both arms, her limp body covered from head to toe in the wet cloth that usually adorns his wife’s head.  The mother sobbed as she walked next to her husband.  I stood watching the unfortunate triangular group from the window of the very exam room where that family’s world and my world were forever changed.  

I stared at the family as they walked out the main gates and disappeared into the small mud brick huts of the village.  I saw the workers of The Compound gathered near the entrance look back in my direction.  I saw the looks of the mothers and of the infants and children who I had just instructed to move away from the clinic stare blankly back at the strange white man with the long white coat that was looking out the small window of the clinic.  To this day I can only imagine what they were thinking.  

When I turned around, H. was writing down S.’s information in the book that we use for record keeping.  I looked over his shoulder as he wrote.  When he finished, it looked like every other entry in the book, with the exception of an asterisk by her first name.  Dumbfounded, I asked what would happen next.  He said he would tell the team later what had happened, and that would be that.  I asked him if anything like that had ever happened before at the clinic, and he said no, that was the first time ever.  

We sat in silence for a few more minutes, both trying to make sense of what had just happened.  I breathed in deeply and let out a deep breath, and asked him: “Ready for the next one?”  

“Yepppp,” his lips puttering slightly.

Patient #44 was a . . . . . .

05 October 2005

A little Malian tea for your hangover?? Seriously, the most addicting substance on the planet: Malian Tea taken in 3 doses. These are 2 of the doctors that I work with (Guindo on the left, Kimate on the right) on the vaccine trial. Posted by Picasa

The Self-Proclaimed-Craiger dancing much to the amusement of the children of the village. Posted by Picasa

Some of the kids from the village down below and the researchers strutting their stuff to the music. Posted by Picasa

Malian Independence Day at The Compound in Doneguebougou. Notice the Guiness-in-hand. Posted by Picasa

Holy S--- I'm in Africa moments

So many times I find myself having these “Holy Shit, am I really in Africa?” moments.  From walking the 3 blocks from my house in Bamako to the main road, looking at the goat and sheep yard where they sell the animals.  Watching people carry chickens upside down by the feet while maneuvering their moto through the insane traffic of Bamako.  Another example deserves some more explanation:

It’s Friday, 23 September.  It is the day after Malian Independence day.  Still recuperating from a nasty upper respiratory infection, I pretty much sat on my ass all day, learning how to do “The Stare,” an art that my Peace Corps friends here told me that I was sure to master before I left Mali.  Basically, you are so bored and/or non-committal that you stare off into space looking at absolutely nothing.  Adding to the excitement of Doneguebougou today was the oppressive heat: it was fucking hot out today.  Thus, it was ripe conditions to practice the art of The Stare.  I was just kidding about all of that staring off into space stuff.  I did some reading, both for work and to finish a book I had started the day before about some secret organization that ruled the world and wanted to buy a small nation so they could have a seat at the UN (It was called “The Business” by Iain something and was OK and brought up a couple of interesting points), some work with Maiga, and some cataloguing in the pharmacy for my upcoming, self-proclaimed and self-acclaimed take over of the medical operations here.  

So, after finishing up said work and as I started to read under the shade of one of the small trees by our house, I saw one of the helpers in the pharmacy help wash this goat (mouton) with Bafily, the local young man who helps out around The Compound.  I thought it was one of those random things  that I see everyday that I question for about a second and then dismiss it as “Oh yeah, I am in Africa.”  To me, I thought the goat was a pet, as there are freakin’goats everywhere on The Compound grounds, and they were simply giving it a wash like they would wash a dog.  Well, a few minutes later, Maiga says: “OK, time to go kill the mouton.”  I jump up like a kid at Christmas, grab my camera, and am determined to watch this whole bloody process and catch it on film.  I will spare you the gory details, but I will share some of the 38 moments that I caught for eternity on digital film.  It was a pretty gruesome site to watch, especially the actual blood-letting part.  But after they started to skin Mouton, I was instantly transplanted back to my 1st year anatomy lab, trying to make some anatomical sense to this animal: the multiple levels of fascia, a muscle here that looks and functions like the rectus abdominus, the aorta, the liver, pancreas, etc.  It was incredible.  Then watching how they used every part of the animal for cooking, except the distal part of the legs (i.e. the wrists and hooves).  They had a big pile of Mouton parts, and subsequently spread it out amongst the people at the camp: the headmaster of the school, the cook’s family, the guard’s family, a little to our village elder who helps us, and the rest (about 1/3) of the muscle and innards we kept.  

Soon after, they made a small charcoal fire, and grilled a half slab of ribs, the rump, and one of the thighs.  They then spread this spicy bouillon/salt mixture on top of it while it BBQ’d.  The smell was incredible.  I could not wait to dig into that damn Mouton.  With much aplomb and after cooking the shit out of that meat over the charcoals, they cut it up, and added a different type of salt concoction and we dug in.  It was truly THE gastronomic feat of my trip to Mali thus far.  Luckily, there were still some beers left over from the celebration the previous night .  There is nothing like eating free-range goat, freshly-killed only a few hours earlier in somewhat “sanitary” conditions, and sipping on cold beer with your friends and co-workers in the front yard of your compound in the middle of nowhere in West Africa.  “Holy Shit, I AM in Africa.”  

Malian Independence Day

22 September is Malian Independence Day.  That day, 45 years ago, Mali became independent from French rule.  The day itself has a feel that combines Thanksgiving Day, the Super Bowl, and our own Fourth of July all into one.  Usually people are spending the day with their family and friends at their homes.  Since we were all far away from that, we had our own celebration of sorts.  

The night before Malian Independence Day is the big celebration as far as alcohol and going out is concerned.  Since I was recuperating from my Upper respiratory infection, I was in no mood to go out and so wanted to get the hell out of my house in Bamako that I had just spent the last 4 days recuperating from.  Maiga had called and said that he was heading out to Doneguebougou and that he would talk to me in a couple of days.  I asked him, rather begged him, to take me with him, as I was feeling better and had to get out.  He reluctantly agreed, and he came to pick me up around 8:30 or so.  As always, we had a few errands to run, which included picking up some alcohol for the group back at The Compound.  That turned out to be an hour and a half ordeal as we waited at the bar right before the turn off to Doneguebougou for some friends of the guys.  Well, there was alcohol there, so why not partake.  Usually this bar is dead whenever we stop by to pick up “provisions” for the group.  This night it was far from dead.  There were motos everywhere, every table was full, and there was much merriment.  According to Maiga, many of these people were devout muslims who allow themselves a little merriment once in a while.  There was definitely much merriment to be had.  I laughed a little at what I saw: normally subdued Malians dancing about, enjoying the effects of the evil alcohol; emphatic conversations in Bambara that some could consider to be yelling, but most likely chit chat about the government or football; Malians dancing to their jazz- and blues-infused local music.  After a while, we were finally on our way to The Compound.  Once we arrived, there was already much merriment afoot.  They had a table set up on the mini-porch outside the front door with a boombox playing all sorts of toons.  About 10 of the villagers were there dancing away.  We showed up, and the party really got started.  The beer was flowing, the music kicked into high gear.  I was still feeling a little worn out from the past week, so the Craiger took a back seat much to the dismay of my co-workers there.  I did dance to a few songs, but not with the same fervor that I usually partake.  It was hilarious to watch my co-workers not only drink alcohol, but dance and enjoy the moment.  After being there about an hour, it seemed the entire village showed up.  I think I counted about a hundred people: from kids to adults, dancing, enjoying their Independence day.  At about midnight, I called it a night, but a hard core group of about 20 decided to keep the party going, and keep it going they did.  The stereo for some reason, could only play music at the loudest setting, which permeated into every room in the house.  It was tough to get to sleep.  They kept playing the music until about 6:00 am the next day!!  Talk about hard core huh?  

In the morning, the hard core and the soft core stumbled out of bed and slowly made it to the television which had been set up in a small courtyard with shade.  By the time I showed up, about 75 people were already there watching the festivities that takes place every year in one of the major cities in Mali.  This year, the president and the whole country it seemed was in Sikasso, about 200 miles to the Southeast.  There was a big parade with all of the cultural groups of Mali, musicians, various ethnic groups, etc.  It reminded me a lot of the Macy’s Thanksgiving Day Parade that I have watched part of every year as far back as I can remember.  While there were no floats, there was some colorful commentary in West African French, cultural discussions and demonstrations, and of course, the coup de gras, the military parade.  Mali is very proud of its military. It has an Army, small, small Air Force and, well, that is about it.  No Navy (it is landlocked don’t forget), no Marines (I can’t really picture Malian Marines yelling Hoo-Ahhh), no Coast Guard (see the landlocked thing again), and no Office of Homeland Security (Hmmmm).   After the parade, people usually feast for the whole day with their family and friends, trying to nurse their hangovers from the night before.  

Well, after the parade, it is eating time.  We had little food, and we had to wait until that night to have our dinner anyway.  The one big event that night was the Super Bowl of Mali, the final deciding game of the year for the Malian Cup of Football (Soccer).  Literally, I think the entire village showed up to watch the match.  I strolled in a little late, but as always, was able to find a seat right up front, as the Malians insist the Tobaboo gets everything (I am really, REALLY getting used to this treatment here!!).  You could tell by watching that the 2 teams were incredibly talented, but they were not exactly World Cup quality, nor even major European Club football quality.  I was impressed by their play, but they made some mistakes.  It was obviously a rather heated match, as both teams had their staunch supporters who hooted and hollered throughout, wore their teams colors, etc.  It was a hell of a game.  It was 0-0 after the first half, then both teams scored a goal within 5 minutes of each other, and the score was knotted at 1-1 after regulation.  The score remained tied after 2-15 minute overtime periods, which left it all to shoot-out.  Both teams missed at least one, so it was then up to the goalies.  The yellow team goalie scored, but the red team goalie shanked it left, ending his teams hopes for the championship.  Half of the village erupted in thunderous applause, the other half left in disgust.  I could also hear pockets of applause from elsewhere (supposedly there are some folks with power in the nearby area that have black and white TV; ours is the only color).  Some were ecstatic, others felt each others pain and walked away.  I, the only white person out of about 99 other denizens of Doneguebougou, watched with amazement at my little pocket of the world, and couldn’t help but take part in the revelry.  

Typical day at Donegue clinic

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: Graph paper book with lines drawn to separate the columns: name, sexe, age, race, village, occupation, temperature, symptoms/complaints, GE result, diagnosis, treatment given.  No other record.  Difficult to follow-up with care.
1:00-2:30/3:00- lunch and downtime.  Usually take hour nap. Write in journal if time.  The first 2 weeks were pretty much spent in Bamako every afternoon working on the study, so journal writing took a back seat.
2:00-7:00- travel to and from Bamako, getting provisions, and/or work on study there.
The 2 days we did not go to Bamako the first 2 weeks, we played soccer with the locals.  Truly and unforgettable experience (see later posts)
7:30- dinner
8:30-10:30- work on protocol
11:00- have beer (Guiness.  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