Sunday, November 18, 2007

We're on Flickr

I wanted to put up a really quick post to let you know that you can see a whole lot more pictures we've taken by checking out our Flickr site. Click here:

And you can still see a few videos on YouTube:


Thursday, November 15, 2007

Fire and Water

Lara had the quote of the year last night:

"You know, one of the nice things about Mozambique is the M&M's are always soft and squishy on the inside."

We'd just received a chocolately care package from her parents when this gem tumbled from her lips. And it's true, because its ridiculously hot here.

Have you ever been walking outside in the absolute heat of the summer and someone turned to you and said, "Gee, it's Africa hot out here"? Well, it wasn't. This is.

The only thing I can compare the Heat to is when you first open the oven up and the blast knocks you back a bit. When you walk outside at midday after being in the office all morning it feels like a normal summer day, except someone just pulled a wool blanket out of the dryer and violently wrapped it around your head and shoulders.

The Heat is different on the walk to work: not hotter, just slower. You start walking and you think you're gonna be fine. There's a breeze, you find the shade. But no matter where you go, there's always a long stretch of unrepentant sunshine waiting to coat you like hot caramel over an apple.

The Heat, for me anyway, starts at my neck. It's about halfway through my commute: a dull, achy warmth that just kind of reminds you that its there. It spreads first down your back, and the first trickles of sweat start to slide down you spine. Then to your shoulders where you first start to feel the real stuff: burn, like standing too close to a campfire.

If I make it to the office before it gets to my head I count my blessings. I haven't cut my hair since I've been here, so I've got a big mop on top to maintain gobs of humidity on my person. Once the heat gets to my head, forget about it. I arrive to the office looking like I was already wet when I put my shirt on, and I stay that way for the rest of the day.

All this, and it's just the beginning of summer.

At least that's what the locals tell me. They sure don't seem to mind the heat as much as I do. I can still get a bicycle taxi at 12:30 or buy a cell phone card from a guy on the street. And no matter how hot it gets there are still guys walking down the street wearing tobbogans.

But those are the people who have to work when I want them to. Demand requires that they offer their supply when I'm around. Most stores and businesses close from noon until 3:00, and I thought that was stupid before the Heat arrived. Now, getting to work at 4:30 and quitting at noon doesn't seem so silly to me.

But there is a flip side to the Heat. As Lara said, the M&M's that her parents sent are a perfect texture. Also, God had to grow mangoes and pineapples somewhere, and they wouldn't be as delicious if it weren't hot enough here to start a fire underwater. And we do get some relief: the Rain.

So far the Rain has only come a handful of times. It hits like a monsoon, and you can't see 100 yards ahead. The potholes become lakes and the roads with curbs become rivers for about an hour. But you can feel the difference immediately.

The Rain stops the Heat.

You get excited when clouds show up. On overcast days people walk around the office talking about it. The Rain brings relief, renewal, and the redemption of the air. When it rains life comes back to Quelimane.

The nicest days, for my taste, have been the weekdays after a big overnight rain. You walk to work and it's almost chilly, at least by comparison. The scent of a fresh rain means so much more when you know that the other option is 107 degrees.

The Heat lost the battle. The Rain, well, reigns. And maybe you can survive one more day in Mozambique.

My First Trip North, Pt. 1

Friday afternoon Lara was at a training seminar in Inhassunge while I was at the office banging away on my computer. Just after lunch Aguinaldo, sort of half-joking, invited me to go on a trip he was taking this weekend. He needed to go to Mocuba, Mogulama, Alto Molócue, and Íle (almost all of the outlying areas FGH serves). He was to leave at 6:00 a.m. Saturday morning and would return sometime Sunday afternoon.

At first I balked. It was short notice, and we had plans with a friend of ours Saturday night that I was really looking forward to, and plus I wasn’t too sure about leaving Lara in Quelimane by herself for the first time. I basically told him I’d have to think about it and talk to him later. He kind of laughed at me and said ok, sensing that I needed to ask the wife first.

Lara arrived back shortly thereafter and I told her what he’d asked me. She told me I had to go. I may or may not have that many chances to see the district sites, and she thought I should take every opportunity I could. So, next time I saw Aguinaldo I told him to pick me up Saturday morning.

That evening Lara and I went to a dinner hosted by our friends Matthew and Lorraine. He’s originally from Zimbabwe and she’s South African. They’d introduced us to “braai” a few weeks back, and we were totally hooked. Therefore, even though I knew good and well that I had to get up before 5 a.m. the next morning, we went. Arriving back home a little before midnight, I tiredly filled a bag with clothes, toiletries, a towel and sheets and crawled into bed.

4:45 came quick. We’d forgotten to plug in the hot water heater the night before, so I had an invigorating shower and made a French press full of coffee to get myself going. The car wound up being late, so I had time to check my e-mail and read a bit before they came. My eyelids were still heavy, but the coffee was kicking in and I fought to stay awake.

We leave our side door open with the screen door closed to get a little air circulation. Around 6:30 Aguinaldo popped his head around the wall and gave me a startling “ok!” Aguinaldo’s accent is awesome. The way he says “ok,” he sounds like a Greek who’s just set the cheese afire: “Opa!”

“Are you ready to go?” he asked. I said I was. Lara had made it up by this time, and while I carried my bags to the car, Aguinaldo was busy assuring her that he would bring me back in one piece: “You don't have to worry! I will bring him back in one piece.”

Aguinaldo treats me like I’m his little brother. He shakes hands with everybody else, but he high-fives me. Also, he kids me more that he does anybody. It’s been a great incentive for me to learn more slangy Portuguese so I can kid him back.

This trip was all about work he had to do: buildings that were being built, delivering salaries, computer outages, etc. So I packed like I’d have a lot of downtime: my computer, two books, my journal. Aguinaldo and Nazaré (the driver) didn’t say much, but they did look at my two bags with a little exasperation. They had brought one bag each, the combined volume probably not equaling one of mine.

So we started out on the bumpy roads of Quelimane with Aguinaldo riding shotgun and Nazaré driving. I had the back seat of our extended cab all to myself. It’s obvious that Aguinaldo and Nazaré enjoy each others' company. They were talking fast in Portuguese nonstop for most of the trip. I caught a lot of it, but they’d throw in what I could only imagine was Zambezian slang and I’d get lost. Every once in a while, after something particularly hysterical, Aguinaldo would turn around to me and explain the joke in English.

After about an hour we came to Namacurra. I’d visited here last week to work with one of our data managers. We stopped right at the square to buy snacks.

The way you buy snacks in Mozambique is to stop your car anywhere on the road and twenty roadside vendors run up to you and start hassling you, shoving peanuts, cashews, mangos, bananas, chickens, and anything else you can think of in your window. To date I’d only experienced this with other Americans in the car, and we usually bought something just to get rid of them. Aguinaldo takes a different approach.

We stop the car, he rolls down the window, and immediately a young fellow thrusts an entire basket of peanuts at him.

“What’s this?” he asks in Portuguese.

“Peanuts,” the guy says.

“How much?" inquires Aguinaldo as he takes a handful and tosses them in his mouth.

“Ten (meticais).”

“Ten?!” Aguinaldo protests, chewed up peanut flying from his mouth. He takes another handful.

“Ten,” confirms the vendor.

“Five,” Aguinaldo replies firmly. This time a bit of peanut manages to land on the forehead of the poor peanut hawker.

Meanwhile, Nazaré is talking with a couple I'd never met, and before you know it two people are piling into the back of the car. Until now I'd had the back all to myself, and I was a little less than excited about more passengers. It turns out she was a nurse that works for us, and she and her husband needed a ride to Mocuba.

As we all got packed in, Aguinaldo told the pitiful salesman that he had in fact changed his mind and no longer wanted any peanuts. Nazaré hit the gas, and we were off.

Honestly, the weakest part of my Portuguese is my listening. I can write and talk well enough, but I do have trouble understanding others (Lara would argue that I have the same problem with English). So now I was the lone americano in the car with four Mozambicans at full speed. It was dizzying trying to keep up. Our new passengers would try to include me, but seemed unwilling to slow down, so they left me in the dust. I held my head up and smiled along periodically when there was a big laugh. They used words in ways that had never made it into any of my Pork textbooks. I was tired, so I dozed.

We arrived in Mocuba at about 9 a.m. and we stepped out into the pressure cooker. There's a wonderful little food stand on the main street, but it's set down in a little hollow, so it felt like a hot tub in July. Stacey, one of the Americans that works for us, had already arrived. She was spending her day looking for a house there for her and her two daughters. Aguinaldo was going to help with the negotiations.

Stacey had been running into trouble. A Portuguese company had brought dozens of workers with them to help build a bypass from Quelimane to Mocuba, and they had been willing to pay any price asked for houses there. She had seen a few, but the fellow that owned her favorite was asking $1900 US for a three bedroom house with a scrap of a yard. As you would expect, she refused on principle and hit the streets again.

We headed to a nice, poured-cement (its the only way to beat the heat) house off the main road. There was a gate and a wall (a must have), with young chickens already running around the yard. There were guys in the back mixing more cement and cutting boards when we arrived.

I tooled around outside while Stacey and Aguinaldo went in to talk with the guy. Lourenço, the driver that brought Stacey, hung outside with me. Further inspection found that the house was really still being built, and this guy wanted to get somebody in it before it was done. Stacey said no thanks. We traded Stacey and Lourenço back in for the couple from Namacurra and got out.

On the way out of town we dropped the couple off at some hotel. A river makes the northern border of Mocuba. It's wide and low, and every time I've been there hundreds of half-naked Mozambicans were washing their clothes and themselves. Our colleague saw a pygmy hippo on the banks of this river, but we had no such luck this time.

We crossed the river and got back out of civilization. I nestled down amongst the bags in the back and just watched unrepentant splendor of the northern Mozambique roll past. We were going up a little rise when I saw the first real mountain I've seen. They are far different from any mountains that I've ever seen. We were up on a small plateau, and everything below us looked like West Tennessee low country. But the mountains, austere and solitary, stood each by themselves like giants around a campfire.

They're epic. You can't help but imagine waves of Bantu invaders pouring down them (though the Bantu invasion wasn't violent, I still like to think of some African chieftain leading his men in a charge down a mountain. Even if they weren't carrying anything more deadly than a goat). I don't know why I felt it so liberating, but I did. You know what you think of when you sing "from purple mountain's majesty/above the fruited plain"? That's what it felt like.

We drove up and down and up and down, the rattle of the mud-dirt road forcing me to shift constantly. Suddenly, at the top of another rise, we turned left. We'd arrived in Mogulama.

Mogulama is the first place that I've been that looks like what we all expect when we say "I'm going to live in Africa for a year." The road we were now on was lined with stalls, and the next road we turned on was full of mud brick houses leaning from where rain had started to erode them.

We drove until we came to a small clearing with a few old cement buildings and a fresh cement slab in the middle of it all. This was the hospital.

We were met by the nurse as soon as we arrived. She and Aguinaldo started talking, and that first idle moment has immediately hijacked by the vastness of where we were. I couldn't wait for some excuse to go wander around. Mogulama would come to be my favorite site we have.

Finally Aguinaldo told me he had to leave to pick up the construction folks.

"Do you care if I stay here? I'd like to have a look around."

"Ya, you can stay here," he said. They left, and I was alone in a fairly remote part of Africa by myself without a car, outside of cellphone range, and with no one who spoke English.

I told the nurse that I was going to go for a walk, and she kind of looked at me like I was crazy (it was getting near noon, and wasn't exactly cool), and went inside. I picked out a path that went downhill and around a wood into the middle of nowhere. I found this little house under a withered tree. No one was home, so I couldn't ask permission, but I snapped a shot anyway.

It was such a funny little path, but it ended quickly in a dry riverbed, so I turned around to find a new way.

This time, I went along the road. I was up on a ridge and could see down the highway for a quarter mile each way. The path was lined with mercifully shading mango trees that folks were picking as I walked past.

This path opened up into a little clearing lorded over by a large dilapidated structure. As I walked past I noticed little eyes darting out at me and turning away just as I saw them. When I stopped, uncontrollable giggles snuck out from the bush. A excited scurry later brought the mother of the Marcos' out, with nursing baby in tow.

The Marcos' were a family of at least seven (Dad was at work). When Mrs. Marcos came out children started crawling from every conceivable hiding place around their home (the dilapidated structure).

We talked a bit about Mogulama, she told me the name of the largest mountain in the distance (Hatui), and we talked about her family. Her husband was a car mechanic (which explained the worn drawing of a transmission on the wall of their home, even thought there was no way to get car anywhere near it). She introduced me to all her children, I asked her if I could take a picture of them, and then I headed back to the hospital.

Still no sign of Aguinaldo, and I was feeling bold. I took the main road leading away from the hospital and back through the market. There were lots of people there, and they were all very interested in the white man walking thought they're town. I try to just smile and nod, but sometimes people seem a little less than friendly. As quickly as I could I got off the main road.

In Mogulama, "off the main road" really means "off THE road." I stepped into a network of footpaths swirling around dozens of mudbrick houses. That's when I fell in love with Mogulama. The houses are built on a gentle slope that ends a mile away in valley. The valley is immediately interrupted by another giant mountain. The houses themselves eaach have their own personality. I know these shows how much of a geek I am, but it is exactly what you would think wandering around Kakariko village with Link (Google it if you don't know what I'm talking about).

The houses are so close, and the paths go right by front doors and windows. Mogulama proved to me that land ownership is not a human instinct but a learned behavior. Also, the houses are built around the wildest ruins left from days of Portuguese colonization. If I was here for longer than a year I'd definitely try to buy something like this and have it reinforced and renovated.

Saturday, November 3, 2007

So, what are you gonna do?

Before I jump into my latest entry, I wanted to share with you maybe the greatest picture I've ever taken. We met this fellow on an adventure we took a couple of weeks ago. I'll let you know more about this guy and what we were doing there next week. For now, onto the question at hand: what are you gonna do?

Depending on who we were talking to, this question was usually somewhere around the tenth folks would ask us after we told them we were going to Mozambique: “So, Kevin, what are you going to be doing while Lara is working in the clinic?” Generally my response went something like “Ha! Good question!” And it was, because I really didn’t know. Everyone would laugh, but occasionally someone would ask, “Seriously, what are you gonna do?”

As evidenced by a recent conversation I’ve had with our friend Jeremy (of the Vienna Wilsons), people obviously still wonder this a lot. Luckily, I think I’ve finally come up with an answer: information technology.

Yeah, that’s right, computers. Here in the third world. They’ve got them, you know. Some of them even speak Portuguese. And they go along way to helping people get better.

Here’s how it all works: everyone understands how medical practitioners (doctors, MAs, NPs, etc.) can help people. Also, you may be familiar with the role of community outreach. For instance, we have people here whose job it is to take medicine and food to people who aren’t able to leave their homes. They also go find people who haven’t shown up for their appointments for whatever reason (it’s too far to travel, they're too sick to travel, they died, etc.) Both of these direct-care roles are made much easier by what is known as a Medical Records System (MRS for short).

Let’s say you go to your regular pharmacy to fill a new prescription. After your pharmacist looks up your records on his computer, he types in the new prescription and a red light goes off: this medication will react with another medication you are currently taking. This simple example is how medical records systems can save a life.

MRS is usually a database technology that stores patient information and all of the definitions that are required to make sense of that information (i.e. patient x has y disease, we are treating him with z drug, he came here first on this date, and is due back on this date). So MRS can keep track of an individual patient’s records, but why does that matter in our setting? To understand that, you have to understand the importance of adherence in an antiretroviral (anti-AIDS) drug regimen. (big thanks to Lara for technical direction on these next few paragraphs)

Just like there are different bugs that are all “the cold”, there are different subtypes of HIV virus that are all “HIV” (“the cold” is actually different viruses, but this comparison works for us). Some subtypes of HIV are more common than others, and different types of HIV can be treated with different drugs. One patient usually will carry several subtypes of HIV that are in competition with one another, and all of these subtypes are constantly mutating in the body. A patient is generally given multiple drugs to attack various subtypes by various means, but as all of the subtypes mutate they can change in ways that can make them less susceptible to the drugs that currently exist.

When you treat someone for HIV (or any other infectious disease) you are killing the bugs you know how to kill but clearing the way for the bugs we don’t know how to kill. That’s usually not so bad because most drugs will have some effect on all of the HIV, and the patient will get better. However, when you stop taking that drug, the first bug to come back is the bug that hasn’t been directly suppressed (the mutated bug that is less susceptible), and restarting the drugs will have less or no effect on that subtype of HIV. Then we’ve lost that drug for that patient and we have to switch to different (and usually more expensive) drugs.

This is a particular problem for tuberculosis care. TB is really good at mutating. Whenever you let up on a treatment, the bugs that survived your last attack grow back fast. This is how nightmares like MDR (multi-drug resistant) and XDR (extremely drug resistant) TB get started. People start taking drugs, then stop, then start back and stop again. They continue down this cycle until the type of TB they have resists most (if not all) of the drugs we have. Then they give it to someone else and suddenly there’s a new TB strain that we can’t stop.

(PUBLIC SERVICE ANNOUNCEMENT: This is why your doctor always tells you to take all of the antibiotics prescribed to you. We don’t want a mutant pneumonia epidemic. Take all of your medicine! And don’t insist on taking antibiotics when you just have a cold, even if it lasts for 2 weeks. They won't help.)

How can technology help with this? Folks here are only given a limited amount of medication at a time, and they have to come back to the hospital to get more. If they don’t show up for their next scheduled consultation, our computers send up a red flag and we send a community outreach person to go find them and find out what’s going on. Often that leads to treatment, education, or home-based care, and we can keep fighting the bugs.

The other way to use an MRS is epidemiological information. If we have all of the information for all of the patients in the whole district, we can know what diseases are more prominent in that particular district and plan to get medications there for that problem. Also, we can keep up with patient indicators on a large scale and see if we are doing our job correctly.

One excellent example of MRS helping in the third world is the story of OpenMRS in Kenya. It’s a magnificent program. You can watch a video about it by clicking here. It’s a 50-minute PowerPoint presentation that gets a little technical towards the end. Don’t watch it all, but please take a look because it goes a long way to explain what people like me can do in the third world.

OpenMRS ss great because it’s open source. This means that it’s free in both meanings of the word: free like free pizza and free like freedom (thanks Eric). This is great for two (duh) reasons: first, we don’t have to pay to install it or pay licensing fees. Also, it’s free in the sense that you can change it to suit your needs (which you’re not allowed to do with proprietary programs like Microsoft’s Access). So if you want to have a feature that doesn’t exist, we can alter the program itself however we want it. For example, it could know patients’ families. If your aunt has TB, your doctor will ask you when the last time you visited her and get you tested.

Speaking of changing the program, the spirit of OpenMRS falls directly in line with our mission here. Coming to Mozambique and fixing their problems for them is fine, but what are they going to do when we leave? Not only was OpenMRS written to be rewritten for specific needs, it’s meant to be changed and managed by the people it serves. Relief organizations always strive for sustainability; the success of the project shouldn’t depend on the presence of the organization. What better way to involve and empower the educational infrastructure of Mozambique than to have them write and maintain their own MRS system?

Now all of these ideas are wonderful, but as it stands right now we have some health posts that don’t have electricity or running water. That makes it kind of hard to implement a network-based MRS, so Friends in Global Health is getting these places wired up. For instance, we’re talking with a company that can supply solar panels to charge car batteries that run the lab machines and computers out in the districts. In the most remote places, we’ve met with companies that can provide satellite Internet at DSL speed. It’s really expensive, but it could allow a medical technician in Gíle to send a patient’s X-ray to a doctor at Vanderbilt for a second opinion. It’s called telemedicine, and it rocks.

My own work is based in this system. Since there are going to be computers in every health post we operate in, why not get all the folks who work there on them? I’m developing a simple version of what’s known as a Learning Management System (LMS). If you’ve ever taken an online class, you’ve used one. It’s essentially an online training program. We’ll be modeling ours after the continuing medical education programs that health professionals in the US use. All the local people who work for us (nurses, technicians, lab folks, data managers, etc.) will have an account and they will be assigned digital classes they have to take. The doctors that we send out there will be able to create new classes when they see a need and upload it to the system. We’ll give tests and evaluations, and those scores will be available to our administrators anywhere they have Internet access.

So that’s what I’m doing here, and that’s why I haven’t blogged for a month. I’ve latched on to the IT guys and I'm keeping myself busy learning computer languages. It’s incredible how much you can find out on the Internet. I’ve been reading about eight hours a day all month. It’s a lot of work, but it will hopefully be something that can impact healthcare in this region for a long time.