Sunday, June 28, 2009

Goat or Sheep

Liz came with me on a PMI trip week before last, and I invented two new games to pass all the time we spent crammed in the front seat of the hospital van trying not to get thrown around every time we hit a bump.

The first game is called "Goat or Sheep". Oddly, the goats and the sheep in Gabon look almost exactly the same. Liz inquired about this one weekend while we were visiting a nearby lake, and a villager explained that the sheep have tails that hang down, while the goats have tails that stick up in the air. Now, as we pass by villages and the animals scurry to get out of road, we yell "Goat!" or "Sheep!" It's more challenging than you would think.

The second game doesn't have a name, but it goes something like this: We survey the scene for things which, at one time, would have seemed completely bizarre to us, but which are now perfectly normal, mundane, even. I describe the situation, and I then add the word, "Check" to the end. For example: "Dude walking down road holding giant machete? Check." Or perhaps "Little kid holding pole on his shoulders with bunch of fish hanging off the end? Check." Or even, "Giant python, antelope and monkey displayed on roadside stand? Check."

These games mark what the passage of time has done to us here in Gabon, how even the strangest situations now seem commonplace, and how yet, somewhere in our consciousness we know that at one time we might as well have been on another planet while witnessing these scenes. At the same time, just when I begin to think I have seen everything I can see that would ever shock me, something new comes out of the clear blue sky to remind me that I am not living in the same world in which I was raised.

Just last week, for instance, I was on morning rounds in the Pediatrie, lulled into the monotony of the daily routine, halfway listening to one of the physicians talking to a patient about something, when I heard a thwacking noise coming from the corner of the room. Now, keep in mind that there are three beds to a room, and that everyone was sitting quietly on their beds, within my sight. Within seconds, I registered that the thwacking noise was coming from a plastic bag on the bookshelf in the corner. As there are certain situations in which I don't feel the need to hide my surprise here, I felt that a live animal in the plastic bag of an inpatient's room was indeed in such a category, and I exclaimed "What IS that?!?!" Everyone started laughing, and I learned that it was a fish that had just been purchased, and which, evidently, had not quite yet finished dying. Several minutes went by, and as the physician worked his way around the room examining the other patients, I ended up right in front of that same bookshelf. And then, nearly five minutes after the initial thrashing of the fish, it suddenly came to life again, right behind my head, and I nearly jumped out of my skin. These, my friends, are the kinds of things that will never happen on rounds-as-usual in the U.S. Live fish trying to escape from bag in corner of hospital room? Check.

Monday, June 8, 2009

Current Events

For those of you who are not well-versed in Gabonese political history (or who are wishing that I had already posted a map of Africa on this blog so you could figure out where the country is actually located), Gabon has had the same president for the past 40 years now: Omar Bongo surpassed Fidel Castro last year to become the longest ruling president of any country. Bongo has actually been around since Lyndon Johnson was in office, which is kind of trippy when you think about it.

President Bongo has been sick in a hospital in Barcelona, Spain, for the past few weeks, and this morning it was widely reported that he died last night. For some reason, however, the Gabonese press and those who control it felt the need to cover this up; As if we don't have the internet, people! In fact, a Gabonese minister reported that he personally, along with 5 other ministers, saw the president alive this morning. (Insert Liz picturing, out loud, all these ministers standing around Bongo's hospital bed poking him to see if they could ilicit a response.) Other reports said he was planning to come back to the capital tomorrow. Finally, some time this afternoon, the Gabonese press admitted what we all already knew: Bongo is, in fact, deceased. I am mildly relieved that they didn't attempt to keep up this charade for much longer, but I think the attempted cover-up reflects how much fear there is here about the potential consequences of a power vacuum.

There seems to be some debate about who will succeed Bongo. Evidently the military favors one of his sons to take his place, but there is some chatter that France doesn't agree. Clearly there are many puppets on many strings in this whole charade. In the meantime, however, the country has just closed its borders, and as of tonight there is an 8PM curfew. This means that my wild nightlife here is clearly going to be stifled for awhile.

I would just like to take a moment to point out the extreme unlikeliness that I would choose one of the most peaceful, stable countries in Africa to go live in for three months, right at the moment when its president of 40 years passes away with no clear successor.....But wait, I beat the odds and I DID do that!

I actually feel very safe here at the Schweitzer Hospital. Furthermore, someone told us today that if anything were to happen (i.e., if the country were to descend into some kind of civil unrest) that the French military would send some troops down here from the capital to protect us. (Prompting Liz to comment that the French have never been known for their military prowess....) Seriously, though, the chickens and the roosters here don't seem to have noticed the curfew, nor the border lockdown, and neither have I.

I usually cut straight to the worst case scenario, because I figure that once you have gone there in your mind, nothing can phase you. In my worst case scenario today, we get stuck on the hospital compound, and when our food supply runs out, we get to eat the roosters that won't stop crowing outside our window. It turns out, the worst case scenario is REALLY not that bad....

Wednesday, June 3, 2009

All-Star Bev

A word on the morning commute....But first, I should mention that Liz and I started taking Snake Alley a mere 4 or 5 days after arriving here. Yes, Snake Alley is, in fact, the shortcut across the hospital grounds that is allegedly home to small, deadly, green snakes just waiting to eat American medical students. We were eventually informed by multiple Gabonese people that this path is frequented by enough humans to be snake-free. It is hard to tell whether that whole story about the path being snake-infested was simply the Europeans here freaking out a bit, but ultimately I was very tired one afternoon after a trip with the PMI and Maman Sophie insisted that this path was safe. From that time on, Liz and I have been using it regularly, and we have informally dubbed it as mentioned above. We do have some limitations, however, and we avoid Snake Alley at night. To paint a picture of how routine our lives are here, one morning Liz and I stepped outside to walk to the cafeteria and both exclaimed, basically at the same time, "They mowed Snake Alley!" The less foliage on that path the better because we haven't totally let our guard down about the snakes and it is therefore good to be able to see where you are putting your feet.

Getting back to the commute....It never gets old how much stuff I see while walking the paths around the hospital. Not long ago, I paused on Snake Alley to allow a hen and her little brood (?) of chicks to cross the path in front of me. I keep at least one eye trained on the ground at all times, not only to look out for snakes, but also because one has to be very careful to step over the parades of ants crossing the path. They really do follow one another, in an unbelievably organized fashion, and you do NOT want to be the person to cause them to become lost and confused; This results in ants, ants, everywhere.

One morning during my third week here, I was sitting in the PMI office with Marie-Benoitte when she suddenly exclaimed "A millipede!" I looked at the sidewalk just outside and saw a giant black THING moving along the ledge. I hopped up to go take a closer look, but didn't get very far before she screamed "Don't touch it!!!" Now, do not ask me what made her think I was even contemplating touching a millipede, but when I asked her why not, she told me that they are extremely deadly when they bite you and that there is no cure. Naturally, this made me even more curious, so I went to the doorway to watch this thing, which actually looked like a train with rolling wheels for feet. Even more exciting than the mere presence of a bug so enormous it might as well have been an animal was the reaction of all the passersby. Gabonese natives on their own morning commutes exclaimed "Millepatte!" and swerved to avoid it. Better yet, it wasn't going anywhere anytime soon. It wove in and out of the brush next to the sidewalk and crossed the dirt path twice before deciding to come back again. We finally hopped into the van to head out into a village and Hortense cried "Oh! It's still there!" I turned around and noted that it was actually still visible 10 feet away through the back window of the van. I then asked Hortense in a low, dramatic voice if she knew anyone who had been killed tragically by a millipede and she responded that no, they were not really that dangerous. I said, "Really, not even if they bite you like this?" I gave her a little pinch on the leg, and she screamed. To this day, I don't really know why Marie-Benoitte thinks the millipedes here can kill you, but I am finding that it's hard to get the real skinny on a lot of the dangers here (Case in Point: Snake Alley.)

Just when I start to think the ant trails are getting commonplace, something new pops up. Several days ago, I was on a jog and a CHIMPANZEE walked in front of me. I teetered between wanting to pet it and wondering if it had rabies, because it was sort of just meandering aimlessly across the road. I suddenly had this flashback to high school, when my dad drove me to school in the mornings on his way to work. We had a pretty spectacular commute, driving through the hills of Marin, across the Golden Gate Bridge, and into the city of San Francisco. The only thing we ever saw that came close to an animal, however, was this lady with HUGE hair and giant sunglasses, driving a red convertible (always with the top down), with a vanity plate that read "All (STAR) Bev". She was there nearly every morning, passing us at the same spot on the bridge, and just like with the millipede, I felt compelled to look at her until she was gone from sight. There are some things on my morning commute that I will just never get used to, no matter how many times they appear.....

Thursday, May 28, 2009

Out Into the Jungle

Well, my apologies. Girl in Africa has not had much time to post on her blog in the past few weeks. But that only means more stories!

I promised to talk about the PMI, and oh, do I have stories about the PMI. I have to say, however, that one thing that is kind of fascinating about my time in Africa is that the things that seemed so alien to me about this place when I first got here now seem halfway normal. I am..... ADJUSTING. Gasp.

Two days a week, I work with the Protection Maternelle Infantile (PMI.) This is a public health program here at the hospital, staffed by nurses, which aims to provide basic medical services to women and children. The ladies of the PMI and I travel to surrounding villages where we weigh children to chart their growth, update their vaccinations, examine pregnant women and any sick children, and prescribe any necessary medications.

Every Wednesday and Thursday, we "part en brousse", an expression I really appreciate because it literally translates as "go out into the jungle." It kind of makes it sound like we're hacking our way through the underbrush with machetes in order to save women and children. Not quite, but a little bit.

I did not realize initially that medical students typically wait until they have been here for a few weeks before going out on trips with the PMI. I was also unaware that the doctor who goes with them no longer works here. So please, picture little pale, blonde me, in this insanely hot climate to which I am completely unaccustomed, out in a village in the middle of the jungle, chickens clucking right beside me, fielding visits with 15 sick children in one afternoon. That pretty much sums up my first week with the PMI.

I arrive at the PMI office in the mornings around 8 or 8:30, which is when they tell me I'm supposed to arrive, and then we wait until 9 or 9:30 for the truck to come pick us up, because this is Gabon and time is fluid. The nurses in the PMI....How can I describe them? I LOVE them. Maman Sophie is the head nurse, and she is this wonderful mixture of motherly warmth and I-do-not-take-crap-from-anyone-ness. Marie-Benoitte never smiles, rarely looks at me, and is all business, but then when she says "How did the day go for you, Elizabeth?" I pretty much melt, because, well, that's the best you're gonna get from Marie-Benoitte. I have more or less made it my mission to crack her, and it seems to be going well. Hortense is 34 years-old, with 7 children, and giggles a lot. Filomene also seems young and though she smiles a good deal she is also quite reserved with her physical affection, which is why I was pleasantly surprised when she more or less chest-bumped me yesterday morning upon my arrival at the office. My favorite thing about these women is that, even though half the time I spend with them they are completely lost in their own conversations and I don't always follow what they're saying, they periodically say my name and then laugh hysterically. This happens at random, during lulls in the conversation, and when they say it, it sounds like, "AY-leez-ah-BETT"! I translate this as, "You crazy little pale, blonde American who sweats a ton and tires out really easily, we love you anyway!"

When the the driver finally decides to bring the van over to the PMI office, we get started loading things in. If I can ever get a decent enough internet connection to load photos, I will have to post a picture of the equipment we bring along with us, because it is fantastic; An amalgam of old, weathered medicine trunks with little metal handles, nearly all of which are falling off, some large tin boxes which also look like they came out of World War II (both the era, and the war) and, quite randomly, what appears to be a giant toolbox on wheels. Once all is loaded into the truck, we take off on a ride that feels very....Outdoorsy; I usually have the sense that I'm getting both sunburned and windburned in the van, and pretty much like I'm bumping up and down in a little red wagon, to quote that childhood song. I actually did come back with a sunburn from the van one day, which confirms that this is not just my imagination. I am getting to know the road into these villages pretty well now (there is really only one main road in all of Gabon, anyway.) We typically pass through miles of jungle, punctuated by wood huts with tin roofs, goats and chickens milling about in people's front yards, as well as children who mostly seem to run around in their underwear because it's so hot here that clothing is really just an accessory.

That incredibly bumpy, windy car ride always makes me feel somewhat sleepy (Mom, Dad, did you used to drive me around to get me to fall asleep or something?), but I always know when we've arrived because we drive through the entire village honking the horn to let all the women know that "we're here, and you need to bring your children over pronto."

The PMI carries out all its activities in the village "dispensaire", which seems to be a clinic of sorts. The dispensaire is virtually always one or two rooms made of concrete, with a table and a few chairs. Every now and then they have some supplies that look halfway decent, but usually not. Notably, I try not to have to go to the bathroom on these trips. More than once, I have found myself peeing behind a hut where I can only hope no one is watching, or into a hole in a concrete floor if I'm really lucky. Now, I'm not a snob, and I can assure you that I don't mind where my pee goes, but I do mind if some crazy jungle insect bites me in the butt. On the topic of jungle insects, these dispensaire buildings are home to some very large species of spiders. The other day, I spotted a large one moving so quickly across the wall that I couldn't even tell what it was. I turned to Maman Sophie and said, "What IS that?!" She just laughed and broke into a song about spiders.

Nzoghe-Bang: My first day with the PMI had me exhausted from being out in the heat, but we were in a village that is only 15 minutes from the hospital, so there wasn't much work to do. We weighed and vaccinated children, and Maman Sophie said something about there not being any consultations because most sick children in this village had easy access to our hospital. We lay out a table cloth at noon, ate the lunch we had brought with us in a giant cooler, and made it back to the hospital by 1 PM. I spent the rest of the afternoon hanging out on my balcony reading, and thought to myself, "I could really get used to this PMI thing."

Benguie-4: My second day with the PMI was in a village much farther from the hospital (roughly 30 miles.) After we have weighed most of the children, Maman Sophie suggests we start the consultations. I want to say, "But we have no doctor!" It turns out that the white chick with the stethoscope around her neck and the green scrubs is the doctor. Oh, shit, that's me. So, I start doing "consultations" with sick children, which involves me sitting in a chair in a corner of the dispensaire, facing a mother and child in a chair two inches away from me. I find myself praying before each patient comes that the complaint will be something I can manage. For the most part, this is the case in Benguie-4. And fortunately, Maman Sophie sits beside me that day, making sure I know what medications we have available and what doses we give. Also invaluable is her knowledge of the diseases that commonly plague children in this region. Yes, medicine is medicine wherever you go, but common things are also common, and you simply cannot just show up in some random part of the world and expect to know what maladies you need worry about the most. I can assure you, for instance, that we do not empirically treat every child in New Hampshire who presents with a fever for malaria.

I keep thinking we are going to be eating lunch soon, just like the day before, so I don't bother to eat the Clif Bar I had brought with me that day. The consultations just keep coming, one after the other, and I pretty much feel like I am withering. I drink nearly a liter of water and still feel weak and thirsty. My last consultation is a little 6 year-old boy who breaks my heart. His mother tells me he has developed a fever and cough 1 week prior. Then, out of left field, when I ask if he is peeing okay, she replies, "Oh, sure, he pees a lot. But he pees blood." A little taken aback that this wasn't the FIRST thing she wanted to mention to me, I ask how long this has been going on, and she replies, quite nonchalantly, "Oh, for about a month." So then I look at this boy, who has his head down and is staring at the floor, and I ask him if it hurts to pee. Without lifting his head, he raises his eyes and nods slowly. I am literally wanting to take him home with me, and I am also kind of wishing I could call Child Protective Services. Little do I realize, this is the kind of situation that is going to become commonplace for me here. I treat him for malaria, a UTI, AND schistosomiasis, because out here in the jungle, with virtually no diagnostic tools other than my stethoscope, I simply cannot know for sure what is plaguing him. I try to get the mother to bring him to the hospital, but she doesn't want to have to pay for the consultation fee there, so I give her a laundry list of things to look out for, followed by, "and if that happens, or this doesn't get better, you MUST. BRING. HIM. TO. THE. HOSPITAL." I then spend the next two days replaying the scene over and over in my head, wondering if I should have insisted, no demanded, that he come in, pouring over his symptom complex and asking myself if I had treated him for everything that could possibly kill or scar him.

We ate lunch at 4 PM that day, and rather than feeling satiated, as soon as I had finished I felt sick to my stomach, as if my body had worked so hard in the heat that it couldn't muster the strength required to digest my meal. I got home and went straight to bed, without dinner, at 6PM.

Ebel-Abanga: I am dreading Week 2 with the PMI. I am not only remembering how tired and nauseated I felt at the end of my last trip with them, but I am also dreading being the person making medical decisions about these children with no supervision, or at least with no follow-up. I hate not knowing if the treatment I prescribed for a child worked. I hate not knowing if a parent will really bring their child to the hospital if his condition deteriorates. I know that Ebel-Abanga is way farther from the hospital than Benguie-4, and I am worried that there will be even more consultations that there were last week; I am wondering if my body can actually handle that.

There is no actual dispensaire in Ebel Abanga. We weigh and vaccinate children in an outdoor hut. Maman Sophie sets up my consultation "office" in the sand underneath an adjacent tin roof overhang. We see pregnant women in the village chief's house next door. Maman Sophie has left me on my own today, which I feel is a measure of trust I have not yet actually earned.
Fortunately, the number of consultations that day is not unmanageable, but as the sun moves overhead in the sky, the shade above my imaginary office begins to disappear. I keep moving my chair closer to the side of the house, which means I am moving steadily up a sloping surface. My bottle of hand sanitizer keeps falling over into the sand, so that I am eventually cleaning my hands between patients with sandy alcohol. I also drop my pen repeatedly, to the point where it stops clicking open because the tip is clogged with sand. I am marveling at this entire scene as it is happening. Am I really HERE? Doing THIS?

All the while, I am doing what I have always vowed I would never ever do as a physician, prescribing antibiotics and other medications empirically because I feel that if I don't, worse things than the development of resistant bacterial strains may occur. I am still feeling the mild panic and loneliness of being in a chair in the sand making medical decisions not only all on my own, but also without any of the tests and equipment that could at least tell me whether or not I am on the right track. I have loaned my oto-opthalmoscope to the Pediatrie for the week, so I am peering into children's throats with my keychain flashlight. I have my stethscope, my eyes, my ears, and my hands, and that is pretty much it for my diagnostic tools.

After the pediatric consultations are done (there are about 10 total), Maman Sophie tells me she wants to teach me how to do pregnancy check-ups. We head next door into the village chief's house, which is a very basic structure that is plastered with posters of Omar Bongo, Gabon's only president for the past 40 years. We lay a plastic tablecloth on the dirty concrete floor, which will serve as our "exam table" for the pregnant women. The five women file into this makeshift exam room, and Maman Sophie outlines how the exam works. First, I will measure the fundal height (size of the uterus), then I will listen to the heartbeat, followed by a determination of the orientation of the baby's head if the woman is somewhat close to delivery. Finally, I will take a blood pressure. I am pretty excited about this heartbeat thing: "We have a Doppler machine?!" I am thinking.

Maman Sophie then completely takes off to do something else, so I start my exam. Only, I can't find the Doppler; All I can see is this wooden, trumpet-shaped thing sitting on the table. So, I actually have to ask my PATIENT if this is what I am supposed to be using to listen to her baby's heartbeat. She confirms that, yes, that wooden cone-thing is, in fact, what I will be using. The open-end of the cone goes against her belly, and the close end is sealed against my ear. I kneel on the floor and I get the cone in position, pressed against this poor woman's large, pregnant belly, the other end squished against my ear. I feel like I am playing telephone with a cup and some string. Remembering how much one has to search for a fetal heart tone, even with a Doppler, I start moving this cone around. To position it on the opposite side of this woman's belly, I have to basically suspend my entire body across hers, so that finally I am hanging over this very pregnant woman with a piece of equipment which I am trying VERY hard to take seriously, wiping sweat off my face with the sleeve of my scrub top. I leave the chief's house and yell for Maman Sophie. She comes in and tells me I have to press HARD with the wooden cone, so that the baby will start moving. I do this, and I periodically hear what I THINK sounds a bit like that far-off ocean sound you get when you hold a conch shell to your ear; It seems just as likely that I am creating this sound all on my own the harder I press the wooden cone to my ear. I look up at Maman Sophie and tell her that, as much as I would love to be able to tell her that I am hearing something, I really got nothin'. When I stand up from the floor, the baby is moving so much inside this woman's belly that it looks like that scene from the movie "Alien" where the alien is trying to break out of Signourney Weaver's stomach. I feel reassured that this baby's heart is beating, and I remind myself that I wouldn't be able to get the fetal heart rate anyway with that wooden cone, so knowing the fetus is moving will suffice. From that point on, during my PMI obstetric consultations, I periodically test out the wooden cone but finish by asking the patient if she can feel the baby moving inside her.

I have no appetite when we finally get around to eating lunch that day, and I still feel exhausted when we return from Ebel-Abanga, but I don't feel nauseated, so I take this as a sign of progress. On the way home, the nurses stop in the village to buy produce, and right there on the side of the road is a meat stand featuring an entire antelope, an alligator, two monkeys hanging from a pole, and the arm of a gorilla, hand still attached.

Bifoun, Tchad, etc, etc: I have now visited a total of 8 villages with the PMI. I am getting used to the crowd of young mothers with babies strapped to their backs and toddlers wandering around on their own. I now practically tune out the cries of "Mamans, Oye!" from the nurses giving the health lectures to the mothers, as well as the chorus of "Oye!" they shout in response; I am engrossed in the consultations.

I have seen more than one case of chicken pox, and diagnosed what I am virtually certain was a lobar pneumonia, using nothing but my stethoscope and my fingers; Yes, I actually PERCUSSED, something I'm not sure I have done since first-year of med school in On Doctoring, and also a skill I never thought I had mastered well enough for it to be useful.

I now know that I have to drink a can of Orangina or D'jino at exactly 11 AM if I plan to consult for a long period of time. I am adjusting to the fact that no matter how tired I am at the end of the day, I have to expect that we will stop multiple times on the way home so the nurses can buy bananas and manioc from vendors on the side of the road. I know that sometimes we will then stop again to drop these purchases off at the nurse's homes.

At the end of my third week with the PMI, I am leaving the office at the end of the day, and Hortense says to me, "We really want to thank you for the work you're doing here. Maman Sophie is so much less stressed out now that you are here doing consultations, and you are so quick and efficient." I more or less skip out of the PMI office that day. They like me! They trust me! I am HELPFUL! Then I think about her last comment, and I start second-guessing myself again. I am quick and efficient....Am I too quick? Too efficient? Have I missed anything? Ah, the torture of practicing medicine "en brousse." It really does feel like I am hacking my way through the jungle with a machete.

Saturday, May 9, 2009

La Pediatrie

Yesterday evening was the official end of my first week in pediatrics at L'Hopital d'Albert Schweitzer in Lambarene, Gabon. I spent Monday, Tuesday and Friday in the Pediatrie (the pediatric hospital) and Wednesday and Thursday working with the Protection Maternelle Infant (PMI) out in the jungle.

I arrive at the Pediatrie at 7:30 every morning dressed in scrubs, a stethoscope hanging around my neck. I greet S.P., the charge nurse, and M.R., the nurse who rounds with us. We push a large cart that holds all patient charts and any lab request slips we might need, as well as our bottle of hand sanitizer. The Pediatrie itself is one long hallway with white tiled walls, white linoleum floors and 24 inpatient rooms on either side.

The first thing that strikes me when I enter the Pediatrie in the mornings is the heat. I would definitely be embarrassed if I had sweat dripping from my face on rounds in the U.S., but here I make no apologies for the fact that I am already perspiring by the time we make it to the second patient room. It almost feels hotter inside the Pedatrie than it does outside, and yet the native Africans working in this hospital (which means everyone except me and one German pediatrician) don't even seem to notice. Furthermore, I have noted on more than one occasion that while they are all wearing more layers than I am, none of them appears to even break a sweat. The two rooms containing the three functioning incubators we have available to us are, ironically, air conditioned; Suffice it to say that I love visiting these patients. However, I still haven't quite worked out in my head how it is possible that the ambient air in the hospital is not already at the perfectly steamy 37 C necessary for those premature babies. My only consolation at the end of the day is the Dr. Scholl's Odor Destroying Spray Powder that I had the extravagance to bring with me. Believe you me, at the end of the day, my scrubs are so sweaty that they go straight into the laundry, but my feet are dry and my shoes and socks smell fantastic.

The patient rooms are fairly small and each one contains three patient beds, one against each wall. Because the hospital requires that every patient have a guardian who cooks and cares for them here, it is not unusual to walk into a room and find that, in addition to the patient, there is also a parent, grandparent, and a few siblings. I am not only sometimes confused as to who the actual patient is, but also as to who the parent is. The guardians perform much of the work that U.S. nurses would normally do, which is actually not such a bad idea, as caring for one's family members is a very natural part of the social fabric in this country. However, imagine trying to ask an illiterate mother to record how much breastmilk she has fed her premature baby, and then to aspirate and record the residuals. Needless to say, this can be frustrating.

This is not the sterilized hospital environment I am used to, but I am not so confident we are doing any better at conquering germs in American hospitals, given the prevalence of hospital-acquired infections there. The first spinal tap I witnessed here this past week involved a premature baby and nothing more than a mask, gloves, a few cotton balls, some iodine, and a sterile needle. It was, however, the quickest LP I have ever seen, and it did make me wonder about that LP I did just last month, gowned up in completely sterile surgical garb, having just draped my patient with sterile covering and at least 7 towels; Yet another reason that this place is kind of making my head spin.

Each guardian here has a thermometer, and is required to take the patient's temperature at designated intervals, but we don't have much else available in the way of vital signs. The IV poles look a bit like something I have seen in movies that are based in the 1950's, with glass bottles of fluid hanging from their hooks. As far as I can tell, we don't have any way of measuring electrolytes, and I still can't quite figure out what the strategy is for giving IV fluids, though whatever it is it seems to be working.

I say "Bonjour" to all the patient's and guardians when we walk into the room. The adults greet me as if I am someone they should respect; They seem to think I am a physician, which appears to be an instantaneous measure of important status here. The children behave differently in our presence, depending on how old they are. Most of them are frightened into silence Dr. B, the Gabonese physician I work with, who they seem to view as a stern but friendly father figure. I, however, with my pale skin, blond hair, and bright green surgical scrubs, have an entirely different effect on these children. The infants old enough to have developed stranger anxiety are often immediately driven to tears, and seem to be inconsolable until I leave the room; The same is true for the younger toddlers. The older the children are, however, the more they cannot seem to stop staring. Even if I smile, they will often continue to stare, expressionless but curious, as if watching an animal in a zoo. I won't even get into what happens when I try to examine them, but it has quickly become obvious to me that some of these children have never seen a white person in their lives. I often find myself wishing I had stickers, balloons, pens, stamps, anything that could serve as a peace offering to a child; It is becoming clear that my smile and friendly demeanor will do nothing for me here.

There are many young mothers here, and I have even met several women with 8 or 9 other children at home. Breast-feeding is so normal that the women don't cover their breasts when we enter the room, and I have noticed that the breast seems to serve as a pacifier. Even among many of the toddlers I have seen, a fussy child immediately quiets once offered his mother's breast.

The diseases here are not only clinically new to me, but the exam findings can be unfamiliar as well; Virtually any dermatologic finding looks completely different in a black child than it does in a white one. Even body habitus here can throw me off sometimes, and I cannot say that I would have instantaneously diagnosed the child I saw the other day who had, among other things, a mixture of Kwashiorkor and Marasmus (both forms of malnutrition.) During my first week here, I have already seen at least 15 cases of sickle cell, including several inpatients with acute crises. In clinic yesterday, I met a woman with 5 children, 4 of whom have sickle cell (SS.) Dr. B tells me that most of the carrier parents he encounters separate after having just one or two children with sickle cell, to avoid the risk associated with continuing to roll the genetic dice. Malaria is so prevalent here that we test every inpatient, as well as any child who presents with a fever. One our inpatients this week was sweating so profusely that he had soaked through his bedsheets, only to return a malaria parasite level that was about 6 times what is considered to be severe.

And that is the debut of my work in the Pediatrie....More to come on my jungle village visits with the PMI!

Sunday, May 3, 2009

Nature Wins

In the U.S., we have more or less conquered the wild. We decide what can grow inside and outside our homes. Our lawns are perfectly manicured, and we plant our flowers neatly in boxes and rows. Here in tropical, equatorial Africa, we humans are merely guests of nature. Liz and I have decided that the sooner we give in to this reality, the easier life will be for us here.

Nils tells us as we walk to the pool yesterday that one cannot enter the jungle without a machete; It is simply too dense. Furthermore, wherever there is not enough foot or auto traffic, even when paved, foliage will quickly begin to overtake the road.

The hospital compound is definitely more farm than hospital to me as of right now; I have only been here for two days, and I don't start working in La Pediatrie until tomorrow, so as far as I can tell there are no patients here, only animals. Cats and dogs roam freely, and no more than a half hour ago, a goat watched me write part of this blog entry as I sat on the patio outside the laboratoire with my computer. There are chickens and roosters everywhere, but it is obviously the roosters that are the most noticeable; They are incredibly noisy. There is one that hangs out right by our house, and Liz remarked yesterday that that rooster is sadly unaware of how much he is incurring my wrath. Arnaud, a French doctor living next door to us, and I, have agreed that we will be getting together sometime soon to enjoy a nice "coq au vin" for dinner. I am not sure to what degree we are actually kidding.

Liz and I are not just sharing our house and yard with roosters and hens, but also with bats and bugs. The bats are nesting right by (in?) our bathroom. We hear them squeeking all night long, and the medical fellows who lived here before us were obliged to duct tape sturdy plastic over a hole in the bathroom ceiling through which bat poop falls continuously onto the water heater below. The bat guano is still collecting into that plastic bag, and would make fantastic fertilizer but is undoubtedly very bad for the lungs.

As I mentioned previously in this entry, Liz and I had determined on Day 1 that we would never win the battle against the spiders, the mosquitos and the roaches, and so we therefore planned to instead strive towards acceptance. I thought we were doing famously until last night, as we were walking back from dinner, I heard a tremendous crunch under my foot. I turned with my headlamp to look at the path (Nils says you can always tell who the Americans are here because they are the only ones wearing headlamps) and saw what was, quite possibly, the largest snail I have ever seen in my life. "WAS" being the correct term, as part of it was now on the bottom of my sandal. For some reason, Liz and I had an awfully hard time that night upon returning to our house. Almost immediately, she discovered a giant lizard behind her window curtain, and the only thing I could suggest was that she just pretend like she had never peeked behind that curtain in the first place. A few minutes later, she asked if I wouldn't mind helping her duct tape some of the holes in the screens and walls the next day, just as a small measure towards keeping some of the wildlife out of her room. I replied that yes, I would be happy to help, and would it seem like a fair trade to ask her to assist me in getting rid of some of the dead roaches on the floor of my bedroom?

Even more interesting is the threat of snakes here. Although it would be decidedly faster for us to cut across a large, grassy field to get from our house to the cafeteria, we have been advised to remain on the dirt roads that wind around the long way. I had been expecting to hear that there were giant, tree trunk-sized pythons waiting for us, but soon learned that the snakes in that field are tiny green snakes that can kill you within minutes to hours after biting. In short, we stick to the windy dirt roads. This field, booby-trapped with its deadly little green snakes, instantly made me think of the house I lived in for 3 years back in Hanover, NH. It was far quicker for our undergraduate neighbors, seven or eight of whom shared a house, to get to their place by cutting across our front lawn. This meant that they always walked right underneath my bedroom window. Our landlord had placed a tiny sign on the lawn that said "Private Property--no cut-throughs" and I finally took my roommate's giant "Save Darfur" sign and planted it right near my window where the trespassers would exit. Neither of these measures ever deterred anyone, and it occurs to me now that all we needed to do was post a sign warning of poisonous snakes....

Saturday, May 2, 2009

You are very, very white....

I realized how little of this world I have actually seen with my own eyes the first (and second, and third) time I saw the Sahara Desert. Liz, the other American medical fellow who will be here in Gabon with me, tapped my shoulder and told me to look out the window of the airplane, and there it was: The vastest expanse of desert I have ever seen looming below, with mile upon mile of what I could only imagine was just sand, punctuated by tiny mountain ranges or perhaps large dunes. It was right then that I understood why reading about something and seeing it in person are two very different things. I can only say that the same has been true about everything I have encountered thus far in Gabon.

Liz and I arrived in Libreville, the Gabonese capital, on Thursday evening. Miraculously, Nils, a Swissman on his way to Lambarene to repair the hospital lab equipment, had found us in the airport in Paris. He arrived at our gate shortly after our realization that between the two of us, neither one really knew exactly how we were to get from the airport to the hotel or when the driver was coming from Lambarene to pick us up the next day. To be honest, we didn't even know that there would be anyone else on our flight headed to the hospital. Fortunately, Nils seemed to know all about us, "les deux filles americaines" and he undoubtedly had no trouble identifying us when he overheard us speaking our mashed potato English. (For those who are unfamiliar with this concept, it is often said in Europe that Americans speak as if they had mashed potatoes in their mouths.)

From that moment on, Nils has pretty much saved our lives on numerous occasions. To be certain, we would have gotten by without him, but he is constantly offering us information about the culture and customs here which we would have otherwise learned more painfully.
Furthermore, Nils is incredibly cool, with a very California surfer appearance and attitude. He comes to Lambarene once a year to make sure all the blood testing equipment is working, but he has already also managed to get my mosquito net up (okay, it wasn't that complicated, but I was tired) and he plans to repair the toaster in the cafeteria, too. Just a few minutes before writing this, I watched him rig some crazy homemade adapter to his computer cord, as he had apparently forgotten his.

We spent Thursday night at the Hotel Tropicana, a place whose name seems to suit it perfectly, as it possesses what can only be described as a kind of tacky charm. Situated right by the airport but on the beach, the hotel exterior looks rather dilapitated and quite uninviting, but then opens into a large, airy lobby constructed of dark, rich wood, separated from the adjacent beach by nothing more than tiles and its roof. The actual guest rooms adjoin each other motel-style, and I tried to forget what I had heard about prostitutes frequenting this hotel with their clients when I first sank into my dippy mattress. That evening, the group of us European-Americans sipped cocktails and Gabonese beer at blue tiled tables under thatched roofs while just beyond the palm trees, waves lapped against the shore. The scene was marred only by the occasional plane taking off overhead. While trying to fall asleep in the sweltering heat of tropical Africa later on that night, I found myself longing for an East Coast winter. I then chastised myself with a reminder that just a month prior I had wished for the exact opposite.

We spent nearly an hour on Friday morning trying to extract ourselves from the city via a very slow road, 10 of us packed into a rather vintage van with the Schweitzer logo printed on the front. The drive out of the capital yesterday was like something out of a bizarre dream that is nothing but a series of illogical events. The only thing missing was that feeling of relief you experience upon awakening with the realization that it didn't need to make sense because it was only a dream. Everything in Libreville seemed to be for sale. At one major intersection, men and women milled past our van trying to sell us Kleenex, hairbands, some of the most random assortments of goods I had ever seen. We passed shops of every kind, with an overwhelming number of them selling furniture, pristine leather sofas sitting out in dirt driveways as if they were being sold at a garage sale. Statuesque women with enormous loads of vegetables and bottled water on their heads sashayed past our car. I wondered why we don't ever carry things on our heads.

There was such a panoply of people and shops and things in Libreville that it was impossible for me to delineate any meaning, and though I saw many things for sale, I never actually witnessed a purchase. Furthermore, the heat in the van began to take its toll; When we were finally bouncing down a seemingly endless, paved road through the jungle, Liz and I both nearly got whiplash trying not to fall asleep.

On the 4-hour drive to the hospital, we stopped several times in small villages to stretch and to buy something to drink, and it was during one of these stops that I saw the most adorable little Gabonese boy. He was holding his father's hand, and though he couldn't have been more than two or three years old, he clutched a bag of something fried in his other hand as if grocery shopping were just an old habit of his. I smiled and gave a little wave, but instead of acknowledging my greeting, he stared at me in shameless wonder, never averting his gaze. I'm almost certain that if he had spoken, it would have been to ask his father, "What IS that?" Ah, my first experience as, not simply a minority, but a tried and true alien species.

Arriving at the Schweitzer hospital compound in Lambarene 4 hours after our departure from Libreville was something of a relief, not only because it meant a reprieve from being jostled around in a sweltering van, but also because the hospital grounds are decidedly more tranquil than the streets of Libreville. We were greeted almost immediately by Le Directeur, Mark and La Directrice, Valerie, both of whom are French. Mark instantly commented on how pale Liz and I were, "Vous etes tres, tres blanches!" Here in Gabon, it seems that there are only black people, and tanned, leathery-skinned white people. Liz and I are neither. We are just pale, pale Americans, though Liz definitely cheated by vacationing in Florida several weeks prior to coming here. That leaves me as the one truly pale American.

On Saturday, Nils, Liz and I walked an hour and fifteen minutes outside the hospital compound to go to a decidedly murky hotel swimming pool, the one body of water here in which we are safely permitted to swim. It was so hot that day that I thought my sunglasses were going to slide right off my face. On our long walk, we passed a number of children playing, but by far my favorite scene was that of a little girl who looked to be about five raising her hand to greet us while calling out "Salut, les blancs!"....Translated as, "Hey there, White People!" Even in that insufferable heat, I could not stop laughing.