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Kevin Starts His African Tour

2008-04-25T23:31:00.000-07:00

Finally, after 6 months of asking everyone I knew, I found a band to play with.
We were having dinner the other night with Janeen, Troy, Eric, and Silverio (who knows everyone in Quelimane). We were talking about why I hadn't brought my guitar to any parties recently. I told them now that I had an electric bass here (I brought one from home over Christmas) I didn't really want to play guitar. This is a constant struggle for me: I'm a bass player, but I can play a little guitar. It doesn't make any sense to play the bass solo at a party, so if I'm going to perform I have to perform on the guitar. I don't really like playing the guitar. I always play it too hard (like I'm playing a bass) so that the sounds too percussive

Kevin's Moz Gig

2008-04-25T22:52:00.000-07:00

Kevin finally got hooked up with a band! They're called Saldicos and are very popular in Zambezia. Dates for rehearsals got pushed back and never done. Until one night, we walk over to "Sporting" the local crumblimg discoteque, gym, night club for the buffet dinner and musical entertainment. $4 all you can eat. Xima and fish.

They finally called Kevin to the stage. Keep in mind, they still haven't practiced, given Kevin music, nada. He walked up on stage never having played this stuff. There wasn't even a drummer he could follow. Needless to say, he was a bit nervous. And he did awesome! He followed along and even threw in some solos that got applause.

You can see some pictures on our Flickr account: http://www.flickr.com/photos/kevincreedharvey

What Happened to the Prayer Shawls?

2008-04-19T23:44:00.000-07:00

A couple of weeks ago, I went to start the TB project I'm doing in Lugela, another of our rural sites. I went with a driver up to Mocuba and met Stacey, our clinical advisor in Lugela. From there, we caught a dugout canoe across the wide river.

Right in the middle, a drenching, cold rain decided to soak us as we sat helpless in the canoe. I curled over the top of the lab equipment I was hauling in an attempt to keep it dry. It may be the first time I've had goosebumps in Africa. We arrived on the other side dripping and climbed into the FGH truck for another hour down a dirt track to get to Lugela. The hospital, like all our rural sites, is in the middle of gorgeous but completely empty country. There were tons of people milling around in the hospital's yard.

I was introduced to the hospital staff and we made plans for the Tb training the next day. Right before we left for the afternoon, one of the staff asked if we could transport a patient to the larger hospital in Mocuba. She was a young woman in labor who had cephalopelvic disproportion (baby's head too big for pelvis). When she stumbled out of the maternity ward supported between two family members, I could see why. She was tiny, the size of a child, and in obvious distress. She was just wrapped in a one thin capulana and after the sudden downpour, it had actually gotten a bit cool. It was starting to rain again. She had a long way to go and had to be transported across the river in a canoe in the cold rain. Remembering how it was chilly for a healthy, non-laboring, North American woman, I had a flash of inspiration and pulled a shawl out of my backpack and wrapped it around her. There is a group of ladies at our church in McMinnville who knit and crochet beautiful shawls for people who are ill, bereaved, etc. Before we left for Africa, they gave us two to give away here. I had been carrying one around in a ziploc bag in my backpack for awhile, looking for the right opportunity and it presented itself in Lugela. I hope it's wrapped around a healthy mom and new baby right now.

After spending the night with Stacey and her two cute daughters in Mocuba, we got up early and caught a motorcycle taxi down to the river (I thought it was going to be the end of my life when the driver sped up and passed a gas tanker on the rutted roads. He seemed amused by my panic attack). We crossed again in the canoe and headed back up to Lugela where I did my training with the lab guys.

After that, I saw a man I had seen yesterday. His wife had recently given birth and apparently hemorrhaged. She was very weak, vomiting frequently, and her tongue was almost white. I've never seen anemia like that. Chronic anemia is a common problem here due to malaria and other diseases. She may have had chronic anemia anyway and the loss of blood in labor put her over the edge. Since there isn't a good way to store blood in electricity-free Lugela, patients who need transfusions have to find a donor themselves. (Which can be difficult since many people, as in the states, are afraid of donating.) She didn't have family willing/able to donate and her husband was desperate. He haunted the medical staff, always in sight, trying to find someone who could give blood to his wife. I was nervous when they drew blood for the pre-tests but carefully inspected all needle packaging. It was near the end of the workday, so the lab was winding down. I ended up having to do many of the required pre-tests myself (that is an odd situation, but the lab guys watched and confirmed the results). I'm glad to say I'm free of syphilis, HIV, hepatitis, malaria, and have a Hg of 17mg/dL (the lab guys did that one. I'm pretty sure I don't have a hematocrit of 51. Whatever it actually was was sufficient because I didn't pass out). I asked Stacey to actually be the one to collect the blood after I saw the lab guy donning a giant plastic apron in preparation (you shouldn't actually need that right? I mean, nothing should be spurting.) I hated to be a chicken, but I would much prefer an American nurse practitioner to collect it than a lab guy with one year of education past high school. We actually did it in a supply closet, because there was no other free space.

I didn't see them give the blood to the patient, but Stacey did and said it went well.

RETRACTION: Big News...

2008-04-19T22:44:00.000-07:00

We're less than a year into this blog and we're already printing our first retraction. My great-grandfather Porter would be ashamed...

Turns out we're coming home in June. Lara's abstract was accepted to a conference in Uganda and we'll come home right after she presents. The cervical cancer project is starting a bit more slowly than anyone had anticipated and so it looks like the best thing is for us to come home and Lara to start 4th year.

As a side note, Lara's abstract was also accepted to the 17th Annual International AIDS Conference in Mexico City. Of course, I'm going along for moral support (by climbing pyramids while she's listening to other presentations).

I know this is a surprise to everyone. We're surprised too. We're going to have to hit the ground in Nashville running. If anyone has apartment ideas within walking distance to Vanderbilt or can volunteer to put us up until we have an apartment, send on an email! We will stay in Nashville until our housing situation is resolved.

Can't wait to see everyone and hit up some Steak and Shake!

Tourism campaign

2008-04-10T05:21:00.000-07:00

I've been seeing this new bag around town with a tourism slogan and it is my absolute favorite. There's picture of the world and the text reads, "Africa. You are Welcome. We wish you good luck." 'Cause you're gonna need it! HA! (interpretation of sub-context my own)

Gile

2008-04-06T02:30:00.000-07:00

A couple of weeks ago I traveled to Gile to start the TB project I'm working on there. It was a 6 hour drive over bumpy roads. We had the new gestor do dados for Gile and her two kids (surprise!) in tow, so it was a bit cramped in the back seat of the truck. After stopping in Mocuba a couple hours into the trip, I watched with misgivings as she poured a bottle of thick fruit juice in her toddler's mouth. Sure enough, the inevitable result of combining bumpy roads, toddlers, and lots of fruit juice occurred, necessitating a stop on the side of the road. The mom ran to some nearby huts to change clothes after wiping off the kid. She gave him to the other kid, a tiny girl, maybe 5, to hold. She looked likely to topple under his weight so I swung him up and addressed the damage with my water bottle and an old shirt.

We rolled up in Gile with Mt. Gile in the distance. It was a tiny bit cooler than low-lying Quelimane. Emilio is our physician there. He's Spanish impossibly energetic, and hugely friendly. He took me on rounds at the hospital. The different wards are in tiny round concrete buildings, shaped like traditional homes. The design idea behind this is mystifying because only three beds will fit in each building and none of the square furniture fits. The pediatric ward had patients with marasmus and kwashiokor. Lacking any capability for G-tubes, IVF, or other interventional feeding, they were doing frequent milk feedings in the hospital. We saw the TB ward. We saw a young woman who had initially come to the hospital to be dewormed, but was epileptic, had a seizure and fell into a fire. She was laying on her stomach under a net in a crudely built structure with stick walls. Her back was pale pink and covered in iodinated bandages. Emilio told that she was lucky and will do well because she really wanted to live. He had a cheerful word and pats or handshakes for everyone and it was clear the patients all like him. We visited the maternity ward where he told me that 2 women had died last week of uterine rupture. He introduced me to the on-duty nurse who came forward and vigorously shook my hand when he told her I was going into OB/GYN.

A walk before dinner led Emilio, Daniel (who works in community action for FGH), and I through the market where people sold cooking oil in little plastic baggies and goat meat on the freshly butchered skins and then down a dirt road littered with sparkling chunks of green quartz (or something) to the river. Emilio had his camera and took pictures of the little gangs of kids that gathered to watch us. When the flash went off they would scream, laugh, run off, and congregate further done the road to wait for us. A sly young man joined our walk and asked if we wanted to buy gems. The area around Gile is famous for gem mining, though little of the profit seems to be returned to the local community. However, the reputation makes it a good environment for hucksters looking for someone to cheat with a hunk of quartz. The river was full and fast from all the recent rain. It ran right by the imposing Mt. Gile in the distance. We could see storm clouds gathering around it. As the evening wore on, a lightning storm danced in the clouds in an impossibly huge sky.

We had dinner with Emilio, prepared for us by the amazing Sergio. Emilio, who has lived in Mozambique for 10 years, hired him away from another employer in Maputo and brought him to Gile to do the cooking and cleaning. He is a fantastic cook. I heard stories from Daniel about eating difficulties in Gile without a restaurant that could even make some beans and rice for you. He usually brought cans of tuna, but now that Emilio and Sergio were there, we were in luck. I had brought a bunch of fruit along the road as a host gift as it is hard to come by in Gile. The first night Sergio made some delicious rice and sauce. Next he brought out a large bowl filled with a bright green pudding substance. I took a taste. It was avocado, but mixed with lemon and sugar. Avocadoade. It was kind of ice creamy and actually really good once you got over the surprise. “Sergio,” I asked “What is this?” “Avocado.” “I know, but I mean, what is it called?” “Avocado.” “Does the dish have a name?” “Avocado.” He's a man of few words. After that he brought out REAL coffee. Now, we have been having a coffee shortage in Quelimane (more specifically a ground coffee shortage). Kevin and I had been sipping weak tea in the mornings for several weeks. No offense to the British, but it wasn't cutting it. Apparently Emilio has an Italian importer friend from whom he buys some really good stuff (cheese, coffee, pasta, etc.). Here I was in the middle of nowhere, enjoying better coffee and Parmesan than you can get in Quelimane.

A flash light would have been a good thing to remember on my way to a place without electricity or sell phone service. Emilio lives in a house powered by a generator for a few hours each night. Outside the rain fell into blackness. He let us borrow his head lamp for the walk back to the pensão. We could only see a few feet ahead of us at a time. Because of the storm there was no star or moonlight. It was truly black as pitch. We could hear voices of people laughing and talking in their homes as we passed. Some had candles or kerosene lanterns. Back at the pensão, Daniel waited with the flashlight while I lit the 1 candle provided by the pensão. He went to his room and I stood in the middle of mine, a bare candle in my hand listening to the rain and thunder. The rain was coming in the window screen. I decided to leave it open anyway, because I knew the heat would become insufferable with no air movement. There was no holder for the candle, so I dumped my cashews out of an old olive jar I brought and leaned the candle in there. Then I took my first bucket bath! I set the olive jar with my only light on the non-functional sink and surveyed the bath situation. There was a plastic bucket of cold water on the bathroom floor and a plastic dipping cup. I pulled my soap out of my back pack and started at my feet, figuring that would be easiest. I decided to leave my hair until the morning. Bedtime! I tried to maneuver the candle as close to the bed as possible without igniting the mosquito net. I moved too quickly and the flame wavered ominously. If it died now, I was in trouble because I wasn't sure where I had set the matches. I quickly arranged the box of matches in a corner with palpable landmarks and settled in to read a bit. I brought Crime and Punishment. I was not exactly feeling turn of the century, despondent working class Russia. Originally, Kevin and I thought we'd bring a lot of classic books to Mozambique, thinking we'd have time to appreciate and discuss. This turned out to be not as good an idea as I thought. Many of these books address serious social issues, failings of civilization, or universal questions about human nature. Sometimes these topics, while poignant, and can also be rather depressing. It was actually getting kind of difficult for me to see sick, starving, and dying children and adults all day in Mozambique and then also feel guilty about never having lived in a Hooverville like in The Grapes of Wrath or forced to march across the dessert like in What is the What. It's harder to see the redeeming and hopeful parts of these stories when you're surrounded by living examples of the misery described. Anyway, after a passage describing the main character's garret lit by a stub of candle began to seem strangely familiar, I worked up the nerve to shut the book and blow out the candle. Actually kind of hard to do through the mosquito net. Utter pitch dark blackness swallowed the room. “Don't be a baby, Lara,” I admonished myself. No reason to freak out. All the same, I stuck a hand out of the net and felt for the matches. Good. Easy to reach.

My sleep was interrupted by only one bedbug/rat nightmare. This seems to happen in every new bed I sleep in in Mozambique. It's pretty obvious what I have anxieties about. The next morning I addressed the hair issue. Getting my hair wet all the way through with the bucket was actually pretty difficult, especially since it has grown out some. Finally, I just dunked my whole head in the bucket and then soaped it up. Upending the rest of the bucket of cold water on myself definitely got my blood pumping.

On the last day, at the lab, Dr. Kizito came in to ask if we could do a gram stain on some “liquido cephalo-something” It was a new term for me, but I was pretty sure I knew what the combination of “liquido” and “cephalo” would entail. I asked the laboratorians if they had the reagents for a gram stain. “No” they replied unequivocally and Dr. K went away. Remembering to myself that Emilio had mentioned something about a gram stain, I instigated a search and found 4 dusty, filthy, browned bottles labeled “crystal violet,” “sarafina,” etc. They looked ancient. I searched for an expiration date on the bottle. June 2003. These went out of date before I entered medical school. Would they still work? How does a dye go out of date? I didn't think any of these were particularly volatile compounds. Did the lab guys know they were there? Hard to tell. I ran after Dr. K. and explained that we'd give it a try but I couldn't promise anything cause the reagents were ancient. He brought a syringe of crystal clear (Nice tap!) fluid. That boded better for the patient than cloudy fluid anyway. I put on a mask (no sense in being colonized with a meningitis bug) and put a few drops on a slide. There no instructions on the bottles. Should I leave the dye on a long time because of the age? I had no idea so I did a few minutes with the dyes and less with decolorizor. When it was all done, I took it over to the solar microscope. I had never seen one of these before. There is a mirror where the light source normally is and you direct sunlight onto the plate. Looking through the eyepieces, it was pretty dim. I couldn't see much on the slide. Either the dye hadn't stained, there weren't many bacteria to begin with, everything had washed off the slide, or I couldn't see anything because of the low light. I could hear the cries of a patient brought in the day before. A woman whom a homemade brick wall fell on. She was paralyzed from the waist down and terrified. Emilio had given her anti-inflammatories and put her in a brace in the hopes that the paralysis was due to swelling and inflammation around the spinal cord and not due to permanent damage. Without any way to image the spine or spinal cord, that was all that could be done.

Emilio popped into the lab where I was dealing with TB project training with the lab guys and told me the patient we heard about last night had arrived. Umbilical cord prolapse. She needed to come the night before but one of the ambulance drivers had gone with visiting Ministry of Health dignitaries to outlying areas and the other one no one could find, even after checking with all his friends. (There's no phone service, cell or otherwise, in Gile.) The nurses helped her out of the ambulance and into the treatment room. Poor woman was heavily pregnant and stumbling. On exam, the umbilical cord was visible and pulseless. One tiny hand was projecting into the birth canal. Emilio listened for fetal heart sounds and didn't find any. A craniotomy was briefly discussed, but finally it was decided it would be better to send her to Alto Molocue where there is sometimes a surgeon. The woman was already feeling warm so he gave her antibiotics and sent her another several hours down a bumpy dirt road.

We left by noon on our last day, aiming to squeeze in the return 5-6 hour drive back to Quelimane before dark.

Inhassunge

2008-03-28T01:52:00.000-07:00

Rough day in Inhassunge. Our truck was hailed by one of the outlying health posts as we drove to the main sede. They had a patient that needed to go to the main center and the ambulance was far away. Nurses had been sent to wait in the road until we came by. They ran back to get the patient. She was woman maybe in her 20s with the horrible skeletal look of end stage AIDS. She couldn't sit up so she was loaded in the back of the truck with relatives. I hoped she wasn't too uncomfortable as we bounced along the dirt track. We arrived at Inhassunge and she died just a few minutes later. I hate the thought of her last moments being in that truck, but maybe she was looking at the sky. Inhassunge also has a new skeletal baby and have not much to offer but milk. I saw the father holding it while I was working in the lab. He was trying to bottle-feed it, but was interrupted by teensy coughs. I'm worried the baby may not be strong enough to eat the amount it needs.

BIG NEWS!!

2008-03-23T02:21:00.000-07:00

Okay everybody, if you haven't heard yet, here's a real bombshell: Lara and I have decided to stay another year.

I know, I know, crazy right? Another year. It was hard to decide. I think I might have given myself an ulcer in the two weeks between them asking us and actually saying yes. Truth be told, I get more excited about our extension with every passing day. Lara has a fantastic project that she'll be working on, and I'll continue working and learning with the computers we use. It's going to be great for both of us.

More great news: our moms are coming to visit! We've booked a safari/tour through South Africa in late May and early June. Peggy's cousin Leslie and her son Dag are coming as well. We promise to put up lots of pictures of, you know, elephants and stuff.

Speaking of pictures, take a look at the new Flickr widget to the right. You can click on it and you'll be whisked away to our Flickr page, which has lots more pictures than we've put on this site.

And last but not least, I've got a gig on Friday! Our friend Silverio is introducing me to a band here called Saldicos. They put out at least one record, but have since more or less disbanded with members moving to Maputo and Europe. The guitarist and drummer have remained behind, and I'm playing with them on Friday night. We're supposed to get together at least once this week to rehearse, but whether or not we do it will still be a fly-by-the-seat-of-your-pants kind of show.

(Note to the Nashville IGH office: Katie has the Saldicos record, but I don't know if it's properly labeled. It's 17 tracks long, and the first track is called "Zambezia". The chorus starts "Essa terra mãe, essa terra jovem".

I like Ike.....

2008-03-06T00:07:00.000-08:00

We went to the beach at Zalala last weekend for the first time since October. It was a beautiful and hot day. The water was particularly dirty, I suppose from recent storms, but the beach was as empty and beautiful as usual. We set up capulana camp and read and swam for a few hours, getting instant sunburn despite compulsive sunscreen use. Then we headed to the little restaurant where they grill fish and shrimp outside on a patio. After a yummy meal, we walked back through the pine strand to the beach. A little boy came up to us holding a small hawk with its wings pinioned behind its back. We asked how much it was, feeling bad for the bird. “Fifty metacais!” (About $2). We decided to buy the poor thing and let it go. I gingerly took the bird by its wings from the boy. The hawk/eagle was heavier than it looked. It seemed very uncomfortable to be dangling by its wings so I started to put my finger under his feet so he could support his weight. However, after noting the extremely sharp-looking, curved talons, I re-thought that idea and asked Kevin to get a stick. We untied the black string around his leg and set him on the stick, expecting him to fly away at any moment. But he didn't. The bird curled his feet around the stick and we got a good look at him. He was beautiful, white and gray with clear, fire engine red eyes. He was maybe a foot tall. He intently studied each of us in turn with those eyes. I stroked his back and he turned his head all the way around to watch me, which was a little unnerving. This bird looked you full in the face, fearlessly. The boy was still hanging around, suspecting we were going to release the eagle and I'm sure he wanted to catch him again and resell him. We continued our walk to the beach with the bird on the stick. We decided to name him Ike (we considered Sam, Wilbur, Eggbert, Charlemagne, Truman etc.) As I walked, I would glance over and see the bird staring at me or Kevin or Troy. He stayed on the stick for the whole walk. We were beginning to think we would have to take him home. Sophie, a French employee of Save the Children, called the boy back and demanded to know if he had hurt the bird. The boy said that of course he hadn't hurt him, just thrown rocks at him until he fell out of the tree. We sent him off again. As we crossed the dunes, the sea breeze picked up and Ike took wing. He flew to a pine tree and settled only about half way up the tree. The tree was immediately encircled by little boys and Troy went back to negotiate hostilities. Unless Ike learns to roost WAY up in a tree and fly far, far from little boys, I'm not sure he's going to have the longest life.

This was the week of birds. At the lab in Inhassunge this week, a baby bird fell out of a tree. Unfortunately for him, the lab technician caught him and brought him into the lab. It was a tiny little bird I have never seen before. Iridescent blue and purple with a gold tummy and bright orange feet and beak. The beak was really long, so I'm guessing it was the type that eats bugs. The Mozambicans weren't better informed. When I asked what type it was they said, “It's a small bird.” Very helpful, thank you. We ooohhed and aahhed and I suggested we put him back in the tree. The lab guy had another idea and over my increasingly frantic protests, he took scissors and clipped the poor animal's wings. After that it could only flutter a couple off the ground. It would careen about in panicky bursts and hide behind glass jars and boxes in the lab.

FYI: Podcast duel report. I'm the victor! Although truly, one would have to say that NEJM is the victor. No one takes themselves lightly at the NEJM. It's the most puritanical of medical journals with zero cover art, pictures, catchy graphic design, or any of the fluff like poems about cancer that other medical journals (I'm looking at you JAMA) prefer. Stay tuned for next week's duel. Kevin's digging up new boring computer stuff.

Podcast Duel....

2008-02-26T07:00:00.001-08:00

So...there's not much do after work around here. The 8 movies we had on the laptop and old paperbacks are running out. Even for a med student, there's is only so much studying that can be done. The TV (sporadic at best) has been out for a couple weeks. The mileage on our evening runs is increasing. Often, we entertain ourselves with podcasts while we make dinner. God bless BBC Africa. You would be amazed at what's out there. Unfortunately, we don't always agree on what to listen to. So tonight Kevin and I have decided to hold the first ever Bratcher-Harvey Podcast Duel. Whoever can stand the other person's podcast the longest without falling asleep or talking wins. Kevin just downloaded 1 hour and 10 minutes of 2 English web developers talking about "HTML snippets, pros and cons of version typing, and a featurette on javascript techniques." Scary. However, I will unleash the New England Journal of Medicine February 21st. Highlights include: "Featured are articles on aprotinin during coronary-artery bypass grafting and risk of death, the effect of aprotinin on outcome after coronary-artery bypass grafting, surgical versus nonsurgical treatment for lumbar spinal stenosis, hepatitis E virus and chronic hepatitis in organ-transplant recipients, and scientific and legal viability of follow-on protein drugs; a review article on lumbar spinal stenosis; a case report of a woman with renal failure and stiffness of the joints and skin; and Perspective articles on quality-improvement research and informed consent. " If y'all are smart, you'll bet on me. Results to follow.

Bringin' Home the Bacon....and melancia

2008-02-21T06:34:00.000-08:00

This is some of the strange new fruit we're enjoying on regular basis, a purple olivey/grapey thing, yellow mangoes, tiny bananas, and a "melancia" which is like honeydew with red seeds. I'm getting very good at eating things first and asking questions after. Kevin brought all this home from travels to district sites. Every time the truck stopped, they'd be swarmed with people selling food from the roadside. One of the nice things about being married, I'm discovering, is help with bringing home the edibles (and if he brings them home in a cute new straw bag for me, all the better!)

Update

2008-02-21T06:18:00.000-08:00

There's a cholera outbreak in Quelimane right now, likely related to the amount of rain we've had lately. 75 people have been hospitalized and while the hospital is full, it seems they have a handle on the extra patient care. We'll be really careful with our water in the meantime. In other news, Hurricane Ivan has been in the Mozambique channel, but Quelimane has luckily not suffered any serious storm related problems. We'll update more later....

The Lab...

2008-02-12T23:58:00.000-08:00

Frequently, we have to test little kids for HIV and malaria. It's a simple fingerstick rapid test, but I hate doing it. I get the kids to sit on their mom's laps. I smile and coo at them in Portuguese and English; most understand neither since they aren't taught Portuguese until they're in school. But they look at me with interest. Curiosity is the only emotion on their faces as I take a little hand and clean a finger with alcohol. They have so little experience with medical systems that they don't know to be scared when someone comes at them with a lancet. At this point, while the kid is still smiling at me in ignorance, I ask the mom to help me hold their hand still. “I'm going to pinch your finger a little,” I say in Portuguese, with a friendly look. I prick them with the lancet and see the inevitable, heartbreaking result. The first look is one of absolute surprise and betrayal. The nice lady who was talking and smiling just hurt their finger. Then they realize I've still got their finger and they can't get away. Panic sets in. They scream and cry, and try to twist into their mother's arms or stiffen their backs to slide off her lap and run away. Sometimes it takes me, the mom, and other lab guy to hold them still enough to get a drop of blood into a capillary tube. When it's over, I wipe the sweat off my brow and say to the lab guy, “Esse e porque eu nao sou pediatra.” I thought it was the worst...until the day I tested a child who lay limply in her mother's arms and never even blinked when I pricked her. I had been holding her hand tightly in anticipation of the battle to come, but she didn't move. Since then, when a child comes in who looks too thin or feverish, I find myself silently begging as I do the test. “Ok Mom, if you could hold her hand still please.” Kiddo please cry. Please react. Try to hide behind your mom. “Ok, if you'll hold this cotton on her finger until the bleeding stops.” Try to run away. Something. Anything. So many of them test positive for HIV.

At the lab yesterday, I was talking with the lab guy about a tray of sputum samples and I caught some motion out of the corner of my eye. One of the samples moved. I looked closer and realized it was full of worms crawling around. Someone coughed up a load of live maggot-looking worms. I'm proud I didn't faint into a sweaty heap in the dirt. I need to refresh my differential of COUGHING UP LIVE WORMS!! Some nasty parasite. Ascariasis? Between brushing tse tse flies off my face and out of my ears while I try to use the microscope and spiders leaping out from behind the sharps box, sometimes the bugs are just too much.

The Prey and the Bandito

2008-02-02T05:22:00.000-08:00

Last night we went to eat at Nauticos, the restaurant at the end of the marginal. Since Christmas they’d put in a patio that connects the main dining room with the riverbank. It’s the first place in Quelimane that takes full and unashamed advantage of the beauty of the city’s waterfront. There were maybe 20 of us in our group so we effectively took over the entire staff and facility.

But I’m not writing about what we did last night. Today, I’m writing about a crime. A shocking trespass against humanity that will change the way you look at southern Africa. It involves deception, intrigue, violence, ransom, and just enough sex to ask that parents read it in its entirety before deciding whether allowing the kids a peek. Also, it’s hysterical.

Truth be told, this is all hearsay. Troy told us this story as his guard told it to him. It all happened late one night on Troy’s street when he was asleep. Long-time readers will remember that Troy’s street used to be our street.

Jacinto, Troy’s guard, had been noticing some peculiar activity as of late. Apparently, a young woman was luring men down the dark alley at the wee hours of the morning with the chance of taking part in the oldest economic activity in the world. Her victims would saunter down the end of the alley and find a nice comfortable spot. What he didn’t know was that his companion’s bandito accomplice was hiding in the shadows near the site of the illicit transaction.

At the moment at which her victim was most vulnerable (usually with his pants around his ankles) the accomplice would jump out of the shadows. In mock fear, the young lady runs off. Flashing a knife, the bandito shakes down the victim for all the money on his trembling body. Later the pair split the booty at a separate location.

Remember, the source of this story is a security guard. Why didn’t he help the poor fellows? Didn’t he feel bad for them? As it turns out, he is only responsible for malfeasance within the boundaries of the property he protects. Luckily (for the purposes of this story), he is required to thoroughly observe any crimes committed nearby in case he has to report anything to the police.

On one particular night, Jacinto saw our antagonist up to her same tricks. But this time she had picked out a prey that was larger than your average Mozambican. One can only imagine the sinking feeling in the bandito’s heart as he saw a lion caught in his rabbit snare.

At the appointed time, the bandito sprang the trap. However, much to the evil-doer’s dismay, the prey did not frighten, and instead decided to stand his ground. In the ensuing scuffle, the prey quickly gained the upper hand, our lady friend long gone.

According to Jacinto, the prey had wrestled the bandito to the ground near a mud puddle. With one arm around his neck and the other on the back of his head, he forced the bandito’s face into the mud. He held him there for a moment, and when he allowed him a breath the bandito’s first utterance was a call to his gang.

His face was back in the mud when his gang finally appeared. Seeing that he was larger than any two of the gang combined, the prey immediately recognized his continued advantage.

“If you want your friend back,” said the prey, “bring me 500 meticais.” An ambush had been parleyed into a hostage situation.

500 meticais is a lot of money in Mozambique, and the gang didn’t have nearly that much on them even after rifling the bandito’s pockets. The prey callously insisted that they go find it while he waited by the bubbling puddle of muck and the bandito’s face. After what must have been an agonizing wait, the gang returned with the ransom for their comrade.

This, I feel, is good news and bad news. Yes, there is petty crime in Mozambique, but most of it is perpetrated by small-minded, small-bodied idiots. I guess that’s the same anywhere. And, as in this example, maybe every once in a while the criminals get what’s coming to them. But I know that I’ll never look at a Quelimane mud puddle the same way.

Domestic Life

2008-01-30T03:05:00.000-08:00

Nothing about running a household here in Africa is easy. There aren't any easy meals. You can buy dry rice and beans, oil, fruits, vegetables, eggs, sugar, bread, flour, tea, and coffee. The rice and beans have to be soaked, the vegetables chopped and cooked. There's no bagged salad, frozen meals, Wendy's frosties, pre-made pie crusts, pre-made pasta sauce, sliced bread, granola bars, soup, chocolate chip cookies, lattes, string cheese, yogurt smoothies, or any of the other things I'm realizing made up the entirety of my diet in medical school. On the other hand, one of the true benefits to living here is the tropical fruit. I have never eaten such delicious mango, banana, pineapple, litchi, and papaya. They're little fruity miracles, fresh and sun-warmed right off the tree. There has been many a night Kevin and I stuffed ourselves with pineapples and mango and called it a dinner!

I tromped to the outdoor market a few days ago in search of food. Since the onset of the rainy season, the collection of thatch huts that make up the market have been swimming in a sea of mud and muck. As I waded through the stalls, my feet sank up to the ankles in sludge (Thanks to Mrs. Harvey for the cute galoshes. Boy was I grateful for them right then). I stopped to buy some onions and tomatoes. Women called to me from their stalls, “Senora, don't you want some couve? Amiga, don't you need garlic?” I lingered by the spice man's stall. He has little packets of powdered spices laid out in a rainbow of colors along with bouillon cubes and dried bay leaves. The intermixing smells of all of them is intoxicating. I always pause, but never know what to buy. I don't know their Portuguese names of the spices or how to use them. It could be curried crack for all I know. I recently bought some “chicken spice” that smelled good. I assume that it's for chickens and not somehow made from chickens, but I haven't yet tried it out. On the way out of the market, men were hawking pineapples from the small mountains of produce that lined the main entry. Other men were roasting ears of corn over tiny charcoal fires. I took particular note of this since I hadn't seen corn eaten here yet. I dragged my galoshes through the giant puddles in the streets trying to get the mud off on my way back to the office.

Back at home for lunch, I searched for the avocados and mangoes I had left on the counter that morning. Not finding them, I asked our new empregado if he had seen them. He proudly opened the door of the freezer and shown me that he had frozen all of our produce. I was at a complete loss for words. I guess that might seem like a good idea to someone without the personal acquaintance of freezers.

As Kevin and I tried to make dinner that night, I was discouraged by the sight of the melting fruit disintegrating in front of me. We were also boiling some corn we had excitedly bought from some street children earlier. “Can you eat it?” we had asked them eagerly. They looked at us with surprise, curiosity, and a touch of disdain, but replied “Yes, you eat it.” “Who are these stupid people?” their eyes seemed to say. I was so excited by the thought of some yummy corn on the cob. But as we continued to boil it, we noted something odd. It was still rock hard. “How long does it take to boil corn?” Kevin asked. I was pretty sure it didn't take more than 10 minutes. Since neither of our mothers was around for us to ask, we decided the best course of action was to keep boiling it. After half an hour, we poked it with a wooden spoon. Yep, still rock hard. We boiled it some more. After three-quarters of an hour we decided the corn was not going to get softer. But what can't be improved with butter and salt, right? We pulled it out to try. Definitely very hard and oddly chewy. I was mentally running through possibilities. Was this type of corn only good for making meal? Was it infected with some weird fungus with neurotoxic properties? So far I wasn't experiencing any ill effects, but I voiced this concern to Kevin. Kevin, by now used to my starting sentences with “I remember they told us in medical school about this weird but lethal fungus/poison/bacteria/disease...” noted that it tasted like popcorn and kept munching complacently. I caved and opened a bag of Valentine's M and M's Granny gave us before we left. I had carefully guarded them during our voyage from prying airport security officers who wanted to know “why I needed a whole backpack of candy on the airplane.” Turns out I needed them for just such emergencies.

We have a friend here who has been working for FGH since it started. She's a Nurse Practitioner from a small town in Tennessee (and therefore knows what good corn is) and has lots of African experience (ex Peace Corps). I asked her what the deal with the corn is. She told me that it is indeed, “just really hard for some reason. But you can still eat it.” She related a similar experience of boiling corn for an hour in confusion before giving up and eating it. At least it's not a neurotoxic fungus.

An aside from Kevin: One thing that will always be fabulous about domestic life in the Moz is the fruit. I could, and usually do, eat between 3 and 6 mangoes daily. Until recently this fact accounted for a considerable part of my waking hours. However, thanks to a lovely gift from Mr. and Mrs. John Egerton of Nashville, Tennessee, I now have my life back.

They gave us a mango slicer. Everybody's got one of those apple slicer thingies, right? That you push down over the core? This operates on the same principal, but only extracts the one giant seed in the middle of the world's greatest fruit. Before you'd spend no less than 10 minutes delicately slicing the Prime Meridian, peeling the skin back like the petals of a lily, and then making a mess of your entire face trying to eat a mango like an apple. That's not to even mention the fibers that get stuck in your teeth. Now I just push the all the best meat falls perfectly on my plate.

Our first experience with this device didn't go so well. We'd purchased a half dozen ripe mangoes, but had decided to dine with friends at the last minute. The mangoes had to wait. The next day, Lara tried the mango slicer on a now very ripe mango. The result could only be described as a mango smoothie. We'd abandoned this technology like Beta VHS until I was faced with a dozen fresh mangoes to slice. I decided to give it a chance myself, and now I am grateful: what would have taken me a half hour was done in 3 minutes.

I know a lot of people who are addicted to Africa, and the reason is plain and simple: mangoes. They are a coy fruit, promising so much flavor but requiring an incredible effort. Men are turned to mindless drones, forever searching for the dissection technique that will yield true. Do yourself a favor before your next trip here: pick up a mango slicer.

Selections

2008-01-27T23:47:00.000-08:00

Here are several "mini-blogs" I've been writing that I haven't had time to post individually. Also, all our luggage finally arrived as you may have read along with all the medical supplies, thankfully. The pediatric BP cuffs are going to be a welcome part of the pediatric HIV treatment roll-out. I delivered the masks and gloves to some very grateful lab staff here. They will make their difficult jobs safer. The cute card from the United Methodist children is in our FGH office! Thanks to everyone for their generosity; these things will go a long way here.

Adventure in Namacurra: Last Thursday I went to Namacurra to check on the lab there. It was a somewhat slow day with few requests for lab tests and still fewer TB samples. After spending a few hours in the lab I realized I had neglected to bring water. I headed out to find our driver and get some water or Coke in town. We found a little stand and I had my Coke and we got some water to take to Dr. Paulo. We stopped in the market so I could buy some white sweet potatoes for Kev's and mine dinner that night. In Mozambican markets, you buy things by the “lugare” or place. They build little piles of produce on the ground and that's the unit of sale. I asked the vendor how much each lugare of potatoes was. He replied “10 contos.” That's about 20 cents. By this time, our driver had gotten out of the car and started berating the vendor. “Ten contos! You know it's 5! You're going to charge this Doctora 10?!” The vendor sheepishly agreed to 5 contos for each place. Our driver collected the 2 places I asked for and I gave the man 10 contos. Back in the car, the driver chided me, “This is why you shouldn't go to the market alone. These guys will try to cheat you!” I didn't have the heart to say that whether my huge bag of sweet potatoes cost 40 cents or 20 cents didn't make much of an impact on my financial life. I'm well aware that I get charged more in the market than anyone else (you'd have to be entirely stupid not to catch on to that.) But, I felt kind of bad for the guy who worked hard growing those potatoes in the field. Produce costs so ridiculously little (a pineapple right now is between 10 and 20 cents) and these farmers labor so hard to scratch out an existence that I don't really mind paying extra sometimes. Still, I appreciate the driver looking out for me.

On the way back, we saw FGH's Mozambican social assistant and 2 Peace Corps volunteers that are working with us, so they hopped in for a ride back to the hospital. I was in the front passenger seat, talking to our other passengers when one of them gave a gasp. I had just time to turn my head and close my eyes when I heard a loud pop and safety glass from the windshield burst all over me. The driver slammed on the brakes and I looked out the cracked windshield to see a small man stalking away and scowling at us ferociously over his shoulder. The large chunk of rock or metal he had thrown slowly slid off the hood of the car. My heart nearly stopped as I looked at his twisted expression; thinking this was my first experience with someone truly hating foreigners. But the social assistant said, “No, I recognize him. He's maluco.” He's the local mentally ill resident. Turns out he frequently throws rocks at women, children, cars, animals, whomever momentarily offends him for whatever obscure reason. We went to the local police building to make a report. They wrote out a description of the accident by hand and stamped it. They told our driver, “Yes, we are familiar with this man. He's crazy. We tell people to stay away from him.” Apparently that's all that can be done. There is no place for him where he can be kept from harming other people. (And a rock of that size thrown at a child's head could easily be lethal.) There is no treatment for mental illness, even severe mental illness and psychosis like this man may have. For most of Mozambique, the physically ill have trouble enough getting care, but the mentally ill are truly out of luck.

Patients: A young woman came in the Inhassunge lab with her sister and a small capulana wrapped bundle and handed me a slip for an HIV test. I introduced myself and told her to please sit in the chair by the testing materials. She sat the bundle on her lab and unwrapped it. Inside was a tiny, scrawny baby. He could not have weighed 6 pounds. On every limb, bones, joints, and ligaments stood out in a most unbabylike way. I've never seen a baby's patella before. I tried to think of the Portuguese words for “Was he born today?” but could only manage, “How many days old is he?” The mother replied, “He's one month old.” It's times like these that I'm grateful for the practice my medical training gave me in controlling my facial expressions. She was anxiously watching me as she said this. I nodded and picked up a tiny foot, no longer than my thumb. I cleaned it with alcohol and stuck the poor thing with the lancet. The baby let out a tiny mew and tried to kick. I gingerly kept a grip on the foot and ankle and squeezed a drop of blood into the little capillary tube and put it on the rapid antibody test strip with reagent. Thankfully, it was negative, one of the few that day. So what was the problem? Intrauterine growth retardation? Congenital metabolic disorder? Congenital malformation of the GI track? Allergy? Continual infections? Diarrhea? Abuse? Difficult to know here.

Colors: Mozambique is a jewel toned country, especially now during the rainy season. The sky is an electric sapphire that can't be relegated to the background of the landscape. It has a presence. You feel the brightness of this sky and the sunlight that pours out of like heavy gold. You can't ignore that either, especially if you're standing in it. It will fry your brains (that's a medical term). I had to wait sitting in the sun on the boat coming back from Inhassunge one day at about 1pm. I felt I better understood tales of people losing their minds from wandering around in the sun. When I got home I realized that my legs had gotten sunburned in splotchy places through my pants. The plants on the ground are vivid green from soaking up all the tropical rain and even the dirt is rich black or blood and rust red, never pale clay. There are tons of little birds I've never seen before, bright gold, ruby, and iridescent green that swoop through the bushes. Some have long sweeping tail feathers and some hide in little twig houses that hang from yellow-green tree branches. There are flowering trees so covered in vivid red-orange blossoms that from far away you would say they are on fire. While we were home over Christmas, lots of people commented on the bright colors worn by people in our pictures. I hadn't really noticed that before, I guess because the bright colors people wear seem to fit into the landscape somehow. They belong more than pastels would. Many clothes come from second hand markets. People at the market shop with a taste for the bright and flamboyant, with no knowledge of the designer's original intent for the garment. So occasionally you see a man sporting a woman's red satin button down or one of those crinkly shirts with lace trim. It's kind of refreshing really. The pointier the shoes; the orangier and more Hammer style the pants; the more covered in butterflies the shirt the better. They walk proudly in their finery, calling to mind the bold, brightly colored birds and butterflies native to this country. It's pretty clear Puritanism would not have gone over well here. Actually, it's hard to imagine Puritanism being popular anywhere but under a gray, cloudy sky isn't it?

Rain: The heat had slowly increased throughout the day in Inhassunge until it reached a truly suffocating level. The staff told me it meant the rain was coming, even though I could see no clouds in the sky. I was in the lab when the rain began to fall softly. It was the first time I'd seen rain there. It pattered pleasantly on the tin roof of the building. I smiled in relief at the sudden coolness and went to the screen door to watch. Suddenly, the pitter of the rain on the roof turned into a startling and deafening roar. It became hard to see people across the courtyard as sheets of water fell from the sky. The drainspouts started to gush and the water exiting them sprayed 1 or 2 feet before hitting the ground. Small rivulets in the sand turned into rushing gullies. This went on for about 20 minutes. It looked to me as if the whole hospital would be washed away. I began to look around at other people to see if anyone else was concerned. Everyone had stopped working since no one could hear and was watching the rain. Some were rushing to put out containers to catch the clean rainwater. But no one looked particularly worried. Then, as suddenly as it started, it stopped. You could see the last sheet of water hit the ground and then no more. The sun came back out and clouds of steam rose from the wet sandy ground.

That afternoon, as we headed the 18km back to the dock in the truck, we crossed the flat expanse of rice fields near the shore of the river. You can see for miles in this particular spot because there aren't many tall trees. There were billowing piles of angry storm clouds that towered into the blue sky, but that weren't very wide. Across the horizon you could see three or four cloud columns and the rain falling beneath them. In between the columns, it was sunny. This is an odd thing about rain here. The rain comes down like someone overturning a giant trough in the sky, complete with thunder and lightning, for 30 mins or an hour in a very contained space. Then it stops and moves on. Rarely is the whole sky covered with clouds. The one time this happened, I noted it because it was the first time I've felt all the muscles around my eyes relax when I was outside. Once in Namacurra I saw it rain across the street but not where I was standing.

Poultrygeist

2008-01-21T01:11:00.000-08:00

Slowly but surely, we are bringing our house to order. As of last Thursday (one week after we arrived), we have received all our bags. My bass came in on the 6 o’clock plane from Maputo after many poorly Portuguese-as-a-second-language phone calls and extra work from FGH staff in Maputo.

I’d always heard about musician’s getting a sign from God either to pursue music professionally or not. All guitarists have a story like this:

“I’d thrown out my back playing two-bit parts in kung fu B-movies for the last time. That’s when I decided to devote my life to my guitar.”

I figured this could be my sign to stop. I’d nearly resigned myself to 5 months in Mozambique without my instrument. However, in one final effort, I asked our friend Heather (a former Peace Corps volunteer whose Portuguese is much further advanced) to call the Maputo airport for me. She said they had it and she had them send it on the next plane.

I reserved my celebration until I actually saw my bass case on the tiny carousel at the Quelimane airport. Relief washed over me like Zambezia rain after a 5k up and down the marginal.

After we got it, we asked the security officer if there was a room that I could examine it in to make sure nothing had been stolen. He showed us to a room with a table and an ominously still pile of feathers on the floor. What better way to sum up Quelimane than a dead chicken on the floor of the security office at the airport?

The security guy totally ignored it. “What dead chicken?” he seemed to say. He regarded the carcass as if it were totally normal. Meanwhile we tip-toed around it like, well, like it was a dead chicken in the middle of the floor.

That poultry gave me pause: after all this effort to find my wayward bass, could God have put a dead chicken in between me and my dreams? Or maybe the customs agents had simply denied someone their patently third-world carrion carry-on. We checked my case quickly and went home. I have since dismissed it as someone else’s sign to stop whatever he was pursuing and do something else.

Taking stock of our luggage, we only found a few things missing. Lara brought a tiny sampler vile of perfume as a gift; some security person somewhere decided she needed it more than Lara did. Most oddly, of the entire 5-pack of toothbrushes we brought back for Troy, four of the compartments were opened and vacated. Only the fifth remained untouched.

With our final bag in our grubby little paws, we’re finally starting to feel settled in again. Our apartment is the best we could have expected in Mozambique. A one-bedroom flat-style furnished apartment above a delightfully tiny bar-restaurant called Pica-Pica. Since we’ve been here we’ve discovered three new places to eat, including the new Chinese restaurant. The spring rolls are exactly like they are in the U.S., and all the dishes have numbers instead of names.

The weather isn’t so bad. All but one day since we’ve been back have had a solid drenching around 1 p.m. that staves off the most intense heat. There is one drawback, however. To get to our apartment, there is only one narrow driveway to the back of the building where our gate is. After intense rains we have to walk through an ankle deep wall-to-wall puddle to come and go.

The city itself seems cleaner. The white walls of most of the buildings seem brighter, and to our eyes there is less dust in the street. Relating this last night, a friend corrected us. She’d had the same impression after returning from a long trip. She said that we’d only remembered it being filthier than anything she’d ever seen, and the city didn’t live up to the pigsty our imaginations had created. We decided she was right, but that hasn’t kept us from feeling better about Quelimane.

So we’re in and we’re safe. My days are filled with work, books, Mozamblog, and my bass. Lara is traveling to her research sites almost daily and comes home exhausted. Back to business as usual in Mozambique.

Seven Connecting Flights Later....

2008-01-17T01:13:00.000-08:00

I’ve got a new favorite quirk about Mozambicans: they congratulate you on getting fat. We’ve been back in Mozambique for three days now, and every time I run into one of my native friends, it’s always the same thing.

“Oi Doutor Kelvin! Fique gordo!” (You got fat!)

This is not abnormal conversation in this part of the world. First of all, most folks mispronounce my name in the same way, inserting an l. Secondly, they almost always assume I'm a doctor, as all the other people in our organization are. Thirdly, obesity is celebrated, and they are not at all afraid to talk openly about it. Usually, the Portuguese word for "fat" and "strong" (forte) are used together to describe people.

So I put on a few pounds over the holidays? So what? I hadn’t had any of my mom’s desserts for five months, so she made all of them for me over the break. It was fabulous. Combine that with Peggy Bratcher’s Thanksgiving extraordinaire to make up for our being out of the country and I’m lucky to have escaped McMinnville with only ten extra kilograms (don’t do the math).

We arrived in Quelimane around 3 p.m. last Thursday. None of our luggage did. None. In an incredibly convoluted effort to save some money, we took two round trip return flights to get back to Africa. We started out in Nashville with fours bags and a plane that was an hour and a half behind schedule. Only by the grace of God did we make it to our connecting flight in Philadelphia. Twelve hours later we’re in Paris at the luggage carousel looking at Lara’s red rolling suitcase, wondering Ought that not be on a plane? Unfortunately, we decided to leave it.

We flew to Vienna where we had to check-in again (this was the end of our first round trip return) with only two of our four bags. Lara’s red bag was still in Paris. I’d decided while I was home that four more months without a bass of some type would be unbearable, but I may have seen my Epiphone for the last time when we checked it in in Music City.

Down but not out, we headed onward. We had to fly to Frankfurt to get on a plane to Johannesburg. I’d barely had time to examine the seat back pocket in front of me when weariness finally caught up. I was on another intercontinental trip. Needless to say, the fourteen-hour trip to Johannesburg had me crossing my eyes, plus we arrived late there and had to run to catch another plane to Maputo.

With three days’ worth of dried sweat, we finally landed in Maputo, only one more flight to go to get to Quelimane. I don’t remember if we spoke Portuguese or English to the customs official. The luggage carousel in the airport was tiny, and only a few bags had come around before they announced that most of the bags were still in Johannesburg. All we had for five months in Africa were our laptops and a backpack full of books and Christmas candy.

We went to report our lost luggage. I can assure you that nothing seems more futile than dealing with a Lost & Found agent in a third world country. I told him about the bags in Johannesburg which he assured me would be sent on the next flight to Quelimane.

It was 11 a.m., and our flight to Quelimane was scheduled for 2 p.m. Eduardo, the driver for the FGH office in Maputo, met us at the airport to give Lara some lab supplies and pick up some things we needed to get to Maputo.

Eduardo fills an interesting role in our lives here. He is the yardstick for our Portuguese skill. When we first came here, he was the first person we met that didn’t speak English. Conversation was difficult but manageable, and he was a very patient teacher. Promises were made that we’d be a lot better when we came back through in December, and those promises were filled. Now, however, after a month away, we were all surprised how we struggled for words that we hadn’t used to. I try to keep telling myself that it was because I was exhausted.

Eduardo was kind enough to pass by the Lost & Found desk to ensure our requests had translated, and he left. We checked in for our flight to Quelimane and went through security into the gate area only to be greeted by what was left of Maputo’s Christmas decorations. They have the most precious and pitiful Charlie Brown Christmas tree you’ve ever seen at Gate 6, complete with precarious lean and insufficient tinsel. You can’t say they didn’t try.

On to Quelimane, where for the first time in my life we didn’t have to wait at the baggage claim. We were ecstatic to see Lourenço, one of FGH’s drivers, waiting for us in the parking lot. He drove us back to the office to pick up the key to our new apartment, and we dizzily hugged everyone. An hour later (around 5 c’clock), we were asleep in our first home as a married couple without a roommate. Pictures of the apartment to come soon.

I promised myself I would never say this after I started this blog, but here it goes: sorry I haven’t posted more recently. I’ve got a backlog of stories to tell a mile long in my journal, and I’ll be trying to get some of them up, as well as whatever else happens over the next five months. Thanks for reading!

Adventure in a Crumbling Cathedral

2007-12-04T23:14:00.000-08:00

There is a beautiful old church on the marginal in Quelimane. It was built by the Portuguese in the late 1700’s and is one of the oldest buildings in Zambezia. It has two bell towers, a tiny garden, and crumbling wooden front doors. It is truly in the midst of a slow collapse to the ground. There are large cracks in the walls where vines have slithered in and silently carpeted the floor. Parts of the ceiling are missing and the rubble lines the old aisles. I explored the inside of this place on an afternoon walk. The silence and coolness of the inside were so remarkable; I brought Kevin back another afternoon.

We walked up and entered an opening on the side of the church where a door once was. We were awed into a whisper by the combination of beauty, antiquity, and creepiness the place had. There was a marble basin by the door that once held holy water. We wandered further in and I looked up at the ceiling. At that moment I felt Kev’s hand pressing my back and heard his urgent mutter, “We should go. Now. Quickly.” I wheeled around and saw what he saw. My heart leapt into my throat. A small, shoeless man was standing in the doorway we had just entered, scowling, holding a machete upright in the air and looking at us.

Now, it is a personal rule of mine to run from men with machetes in this country and in fact, in any country. I don’t ask questions. I just go. Kevin shares this philosophy. I was not happy about being in a secluded, enclosed space with a man with a machete. So without further discussion, we began to make our way across the sanctuary to the only other exit, at a very high rate of speed.

The man started after us. We had cleared the doorway and were leaping down the steps that circled the outside of the church when we finally heard him. “Wait! Wait! It’s okay! I’m the gardner!” We stopped, confused, and turned around. The man very deliberately laid his machete down outside the door and trotted up to us. “Hi! My name is Artuli. I take care of the garden of the church.” He grinned up at us. We shook hands, feeling a little sheepish. “Do you want to see the inside?”

He led us back inside (leaving the machete where it was) and took us over to a marble plaque on the back wall. It was engraved with names and dates of people involved with the building of the church (commissioned by the high lord so and so, completed by so and so the 5th district governor or whatever). It was amazing to know that people began construction on this place before the American Revolution. Artuli showed us marble slabs that marked where people were interred around the altar of the church. One was a woman from Portugal who was married at 13, brought to Mozambique and died at 16. Another interment, placed in the wall of the church, was of a three year old boy who had died in Zambezia. Artuli next took us up a stone spiral staircase to the bell tower. You could see the whole marginal and the Bons Sinais River from the top. The two bell towers connected with a wooden loft area at the back of the church. Artuli warned us not to step on anything wooden. “It’s dangerous, you could fall.”

When we finished the tour of the church we went outside to see his little gardens. He kept the grass and tiny bushes around paths trimmed with his machete. We praised his work. It was a small place, but not a weed in sight. I thought it was sad he took such care with the small grounds while the church was left to fall apart. Artuli didn’t know who was responsible for the church or why it wasn’t renovated. He said “a padre” arranged for him to care for the garden. We suspected that responsibility for the church had slipped into some kind of bureaucratic no man’s land between the Portuguese and Mozambican government and the Catholic church during the war or maybe even earlier. We thanked our new friend for the tour, slipped him a few coins, and headed on our way.

We're on Flickr

2007-11-18T12:52:00.000-08:00

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:

http://www.flickr.com/photos/kevincreedharvey

And you can still see a few videos on YouTube:

http://www.youtube.com/kevincreedharvey

Enjoy!

Fire and Water

2007-11-15T20:23:00.000-08:00

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

2007-11-15T20:14:00.000-08:00

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.

So, what are you gonna do?

2007-11-03T13:16:00.000-07:00

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.

Inhassunge

2007-10-23T04:49:00.000-07:00

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