Tuesday, October 23, 2007

Inhassunge

So, I've been traveling out to the district of Inhassunge where the TB project is hoepfully going to fly. Inhassunge is an island, near Quelimane as the crow flies, but relatively isolated since the only way you can get to it is by boat. For my first visit, I went with Dr. Paulo Pires, about whom you've heard a bunch already. We bought a ticket for the ferry at the dock in Quelimane for 5 metacais (about 20 cents). We walked down to the dock in the press of a rather big crowd and clambered down into a wooden boat with benches for seats across the middle. And then others climbed in. And then a lot more people. The staff guys were encouraging people to move farther and farther back in the boat unitl they were practically in each others' laps. Then they started loading bikes onto the wooden hutch over the boat and I started watching the water level rise against the side of the boat. Then they loaded a motorcycle on the front. Then another. People began to yell, "Chega!" (Enough!) Finally they started an old engine on the back of the boat and a rudder guy pointed us across the river. We arrived at another concrete dock about 20 minutes later. We climbed off into a ring of small thatch huts and waited for the Inhassunge ambulance to pick us up and carry us 25 or so more kilometers to the clinic. It came flying over sandy hills at an incredible rate of speed. I hopped in the back on a bench (noting the complete lack of medical equipment, unlike our ambulances which are mini-ERs). We covered the coconut palm covered terrain on a rolling dirt road at a speed that made me feel like I was tubing on Centerhill Lake back home. It was difficult to talk! We passed a few homes and other buildings made by the Portuguese years ago in a style that looks very old world European with cascading staircases, verandas, and French doors. Now they have fallen into a state of picturesque disrepair, abandoned, creepy and beautiful, covered in vines. For most of the drive we saw just sporadic thatch homes. We finally arrived at the clinic and we hopped out. Paulo made introductions. The staff there is very young. They don't have staff doctors that work there regularly. Most staff are tecnicos de medicina, which means they had a couple years of health training out of high school. The chief of the clinic is about my age (what a thought). He's had a few years post high school training and now runs this center with HIV treatment, pediatrics, maternity, and a lab. I met the lab guys and the TB program manager, all of whom were very nice and seem excited about this project. We talked for awhile and then they had to get to work on the line of patients outside the lab door. It was blood drawing day for CD4 counts, which happens only once a week. The samples had to be taken to Quelimane to be run. I met the guy who ran the pediatric portion of the clinic. He was working on a big outdoor porch weighing and vaccinating babies. I watched in fascination as he put kiddies into a little sling and hung it from a scale, just like in a supermarket. He noted their weights in their growth charts then puntured an iodine oil capsule with a needle and squirted it into the kids' mouths. Which they did not appreciate. He gave the mothers three capsules each and they swallowed all of them whole with no water, unquestioningly. Sometimes this guy was a bit harsh with them. He didn't explain why he was giving the meds, he berated them for leaving vaccination cards at home, he wouldn't look them in the face. I don't know how much was a cultural difference, how much was influenced by my presence, or how much was due to the fact that was incredibly overworked and paid pennies by the Ministry of Health. He was actually a bit brusque with me, so I gave him the winningest smile I had and thanked him profusely for teaching me about health care in Mozambique. At that point he opened up and asked me to pitch in. I was weighing babies and writing the weight on a little piece for cardboard for the mothers. They would put their kids in the sling and hurriedly wipe their faces with their capulanas so no one would have a snotty nose while being weighed. This touched me, like being weighed was really a momentous event. Another striking difference, on the height and weight charts, the top line is the 50th percentile. They don't measure any higher. There are lots of categories of underweight marked, but it appears that the attitude is, "If a kid is above the 50th percentile, good for them. We won't think any more about it." I weighed one baby so young he couldn't hold his head up. I had one hand under his head and one under his rump as he dangled from the scale, so he got underweighed a bit. One child was maybe 4 or 5 and severly malnourished. Paulo said that they had seen him before and hospitalized him for re-feeding. He malaria at the time and they suspected HIV as well, but he tested negative. Everyone agreed that it was odd for an otherwise healthy kid to get so malnourished when the rest of the family wasn't. When asked how often they fed him, the family replied that they fed him when asked for food. Something was odd about the situation but no one had the answer. At Inhassunge, he was lying limply in his father's arms and the father was staring at us with a desparate look. The boys hip bones and ribs stuck out and his eyes were huge. Was this kid abused? Starved by a second wife of the man? Victim of a rare genetic disorder? No one knew.

After a while, the tecnico asked if I could vaccinate. He showed me the supplies (yikes, no alcohol pads! They just stick the needle in!) and we went to town. We squeezed open little babies' mouths to drip in oral polio vaccine. There are few things so satisfying to me as vaccinating a child, despite the fact that they hate it and cry. I love giving a huge line of kids vaccine and thinking, "Polio won't get that one and polio won't get this one! Take that polio!" Vaccines are one medical intervention worth their weight in gold. (Note for scientific accuracy: Vaccines aren't 100% effective, but they really load the deck in a kid's favor). Then we took BCG vaccine and vitamins to the maternity ward. Three tired women were lying on cots with rubber sheets with their infants, born earlier that day. I think all were younger than me. The tecnico wore gloves as he gave them vaccine because the babies had not yet been bathed.

While this was going on, Paulo was seeing consultations. There was a woman with HIV that had suddenly become paralyzed from about the hips down. Likely, the cause was a CNS infection like toxoplasmosis that was allowed to run rampant in her body as her immune system was destroyed. Nothing could be done for her at Inhassunge so she was loaded into the ambulance for Quelimane. A relative of hers came, and the lab guys with CD4 samples, Paulo, myself, the driver, and 1 other person who needed a ride across the island. I was perched in the front middle, trying to keep my feet away from the various gears and shifters on the floor. I could hear the woman crying in the back. I'm sure she was terrified. When we arrived at the dock, several men jumped out and carried her on the stretcher pad to a wooden blue boat, the river ambulance, waiting at the dock. She continued to cry. I'm sure being carried over water and jostled when you've suddenly lost the use of your legs is a frightening thing. We made it across the river and the woman was laid in the back of a truck and we drove to the hospital. Men came out to carry her in when we arrived and that was the last I saw of her. I wish I knew how things were going with her, but since I don't work in the main hospital, I'm not sure I can find out. I remember her family member, an older man, digging in a basket tied with a capulana for her ID papers at the hospital. Also neatly packed in the bag were some mismatched dishes and aluminum containers of food. When this woman had left home that morning she had obviously realized she was going to be away for awhile.


One of the rusted hulks next to the dock in Quelimane. The pic below that is of the clinic at Inhassunge. I found this building on a walk around the clinic during the lunch hour. The blue boat is the "water ambulance" that carried the paralyzed woman across the river to the main hospital in Quelimane

Saturday, October 20, 2007

Going to the mall.....

This is the Feira de Fi, a large shopping area for Quelimane. There used to be an old electricity company located here on big plain, but it went out of business years ago and now there is a maze of thatch stalls with second hand clothes and plastic house stuff from China . It's very easy to wander in and get totally lost because there is no logical organization to anything. We went to try and find some shirts for Kev and a mat for our room. It was really, really hot so I stopped to get one of my favorite treats, a "lanhe" (a young coconut with water inside instead of milk) at the "food court." This was a guy sitting on the dirt road with a big pile of these coconuts. I asked how much they were. "Cinco contos," he replied (about 20 cents). "Faz favor, Podia abrir meo lanhe pra mim?" (Could you open my coconut for me please?) The guy whips out a machete and gives the coconut four or five good whacks and the top comes off. (I'm always impressed by that. You can see young kids whacking these things open. Kevin and Troy and I tried it one afternoon with a kitchen knife because it seems like such a cool skill to have. I was afraid someone was going to lose a finger.) He handed it to me, edges dripping. I wish I could describe the taste of these when they are fresh and you have been walking in heat and dust for a couple hours. First of all, it's always about 60 degrees inside a coconut. The water is clear, cool, and a little sweet. I drank the whole thing as we walked, avoiding the hairy edges. We passed an older man while I was taking a big swig. He laughed and yelled, "Lanhe, gosta n'eh? Mozambican food!" When all the coconut water was gone, I found some concrete steps and tried to bash it open and scrape out the coconut meat with the little top. I was pretty ineffectual, so I asked Kev to smash it. When we had nibbled it clean, we dropped the shells on the ground. It feels weird to do that, but there are no trash cans anywhere. I don't think there is much of a trash collection program in Quelimane. In some areas, there are huge piles of shells laying by the side of the road.

Coconuts and politics: There is a company called Madal with a coconut plantation outside of town. We met a consultant and his wife (wonderful people) recently hired by this company; who told us about their efforts to make charcoal out of these shells with kasava paste. Many people here have tiny metal stoves and you can buy tiny piles of homemade wood charcoal for them and cook outside. Their plan is to reuse the coconut shells as a sustainable fuel source, so people don't cut down more trees. They used some at a cookout at their house recently and it worked beautifully. They took us on a drive through the plantation recently, which is gorgeous. The palms grow enormously tall and pineapples are grown in between them. As we drove through, we would see people among the trees that would duck down as we passed. We learned that about 50% of the crop of coconuts and pineapples is lost to theft every year. What a problem. One the one hand, people are hungry and the crop is a source of food. I don't know how the local populace approaches this situation. Maybe they feel that after years of colonial exploitation, part of the crop should be theirs. On the other hand, 50%. Yikes! How does the farm, which employs many people, stay financially afloat?

Kevin got a shirt and we bought the mat for about a dollar from a huge pile of them on the side of the road and lugged it the mile or so back home (well, ok...Kevin lugged it.)

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Friday, October 5, 2007

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