Saturday, February 11, 2012

Pebbles in a well

The stoic TFG forces warmed considerably as the hot dry day progressed. Initially flat, icy black eyes and motionless faces met my smiles and greetings. I felt a need to connect to thank these men for the protection they were giving. If anything happened, they would be the ones to put themselves between the danger and my sweating pink face. Hours passed and eventually they were smiling, shaking hands and looking for eye contact. These hardened militia fighters are still people after all. As we part ways at the Kenyan/Somalian border, I watch and smile as ten skinny fierce warriors clutched their AK-47s between their knees or in a free hand and were waving goodbye from their cramped perches on the back of their small pickup. Mostly broad smiles but a few remain sullen. I wish I would have had time to learn more about individuals, their families, beliefs and opinions about what they were doing and why they were doing it. Do they see a future for their Somalia? 

Clinic in Dhobley was good, it is organized, and like I mentioned previously, held in a building that was finished only a few weeks ago. My interpreter today was very skilled and that makes a huge difference when taking a history and explaining to a patient how to get better. Days that I have a beginner interpreter can be frustrating as I am trying to communicate with only a few hundred words, often only a handful of those words anatomical or medical. I was able to offer some instruction to clinic staff which was hopefully helpful. While helping individuals is important, teaching the existing staff is paramount. 

Sadly, today there were five rape victims. Training for medical staff on PEP (HIV prevention) for rape victims is to be arranged.

Dhobley is still not secure. It is on the border between Kenya and Somalia and sees a tremendous traffic of internally displaced persons (refugees) moving in either direction or staying. Al Shabaab is still active with local sympathizers. I noticed halfway through my clinic that the metal shutters were perforated and the indoor wall behind my patients was cratered with bullet holes. Many of the buildings in town are pock marked from rifle fire, collapsed or burnt. There are intermittent gunshots to be heard, mostly celebratory. While we are there, the TFG forces secure the entire area around the clinic, clearing the streets and redirecting traffic. Patients are searched and held distant to the clinic prior to admission to be seen. It is an interesting environment to see patients in. There is no concept of medical confidentiality, several patients lined up on a bench, able to hear each others issues plainly. Abruptly before clinic ended today, we were told it was no longer an option to remain in Dhobley and left quickly without incident.

In Kokar, a bundle of miraa is passed into the cab. Miraa (Qat) is the stimulant plant used by so many here. Curious to taste it, I choose a small leaf and chew it. It tastes like lawn, not bad but not particularly special or yummy. I chew it for a few minutes. If I was experienced with miraa, I would spit. I am not experienced and I was in an enclosed vehicle so spitting was not an option. Eventually, I notice my gums, tongue and lips tingling a little bit. The chewed wad of miraa leaf is provided an exit out of the landcruiser window.

We continue to drive back to our compound at Dadaab, bouncing out of the bush and returning to my temporary home. I am jostling in the back seat, sweaty and pressed against my team of the last weeks. A dry tree with hand sized umber flowers zips by the window; absurd in its beauty. Herdsmen slow our return as a sea of white goats flow down the soft sand trail we call a road. They evaporate by scattering, tails raised, into the brush. Camels sway by and look down aloofly, imagining what it would be like to spit on us. Around a long neck, an unobtainable wooden camel bell is fastened,  clacking unheard as we cruise by. My mind wanders to the stew of humanity I've been treating in Africa: bright eyes, swollen livers, honest smiles, coarse wet lungs, snake bite punctures, untreatable fractures, bones worn from unendurable work, amazing infectious laughter and humor in spite of the heat, the dust and the suffering. The suffering and the happiness. Seeing both married here makes me believe suffering and happiness are not mutually exclusive and perhaps, like a good marriage, give meaning to the other. The laughter erupting in the midst of poverty and famine and indignity is the most magical and true laughter. The cup of chai offered after prepared on a dirt floor and sipped from a cracked mug is the sweetest. Holding hands with a brother is a deeper love than my heart is accustomed to. These genuine gestures startle  my heart like dropping a stone into a deep well- a pause and a splash and maybe, just maybe, ripples that shimmer on the dark sweet waters. I watch the lazy white clouds crowd and boil in the impossibly blue unforgiving African sky and I am filled completely with gratitude and blessing for the opportunity to share my skills as a physician with my fellow humans (my brothers and sister as spoken here). I shift my sweaty leg and sweaty arm against my seat-mate and am reminded I am not alone in this service and look from face to face of our team. Some eyes closed, some smiling, some focused in their own self. Together we alleviated some suffering, perhaps saved a life or more and offered a small but real step for Somalia. As my heart and mind is filled with these things, I grin and am teetering between tears and laughter. 

I do chortle to myself when the cynical voice in my head says the miraa is speaking. It's not though (I didn't taste enough for effect). 

Gradually the road widens and the antennas of the UN compound come to view. We are almost back from our last day in the field.  We share heartfelt goodbyes and a goat dinner.  As I type this, a small toad is ambushing ants from under my chair. The day is trading heat for mosquitoes. Tomorrow we drive (hours and hours) back to Nairobi for debriefing then soon back to home where my family waits.

Thank you Africa - I feel you gave me more than I could ever give to you.

Friday, February 10, 2012

Snake bites and measles and less TV

Rounded at hospital today and checked up on baby- he's stable but really no better. He's receiving appropriate antibiotics however I worry about nutrition. He would benefit from supplementation but apparently if you try to place an NG, the parents pull it and disappear with the patient. I'm hoping he does ok. Also rounded on two snakebites including a little girl who woke up to a snakebite on her bottom lip. A few measles cases with complications were receiving care. HIV and TB also were doing their deadly slow dance in the hospital. Many MVA victims and a 24 week pregnant patient with severe pre eclampsia. All of the same gendered patients share rooms. Again I found the staff attentive and caring and doing miracle work considering the tests they had in hospital were malaria and pregnancy. 'Exotic' tests such as urinalysis and hemoglobin were send outs and not immediately available.

Today I gave an impromptu lecture on the relationship of brain development and media to our staff. It was well received and it sounds like several households will be adjusting viewing habits. Happy day for this!

Tomorrow we are heading back to Somalia if no new developments overnight. It is difficult to contemplate tomorrow is our last day in the field and soon I will be back on the other side of the equator, the other side of the world and back home again.

Thursday, February 9, 2012

Days are an amalgam of good, sad, curious and hard

She came with me behind the tent so she could be examined away from the eyes of her village. This would be her seventh child but it stopped moving several days ago. We were both squatted, my hands on her gravid belly, trying to encourage the fetus to move. The fetal head was under my fingers like a floating rock, the back and jutting angles of limbs also palpable. There was no movement. I was looking down at the grass between my feet watching an ant-size ebony black praying mantis hop from dry grass blade to a small brown vine. As I watched his antics, I wished for the reassurance of quickening, or the technology of a fetal doppler to listen for the rapid baby heartbeat I wanted to hear. Neither were to be found. After several minutes in the sun, I began to feel that empty feeling heat gives and slightly dizzy. Distant sounds of children and the march of camels behind me walking single file behind their lead camel,  his wooden bell quietly and rhythmically clacking.  There was still no baby movement and the little happy hopping mantis had long ago disappeared. 

The rest of the clinic day had been uneventful. There were several cases of measles in the community and a few children with complications- measles can predispose to opportunistic infections. These kids were miserable. Can you imagine suffering days of fever in 100 degree heat with no bed, no cool water, no shower, no bathroom? We gave vitamin A and antipyretics and instruction on hydration. There had been many deaths from measles in he community over the last several weeks. A vaccination campaign was reportedly sputtering along; however none of the children I saw that day reported vaccinations. We are working on coordinating a vaccine campaign.

The clinic in Hamey was almost over when I noticed a young mother holding a dirty blue cloth close to her. She was standing quietly near the door. A very still and very pale and very tiny foot was protruding from the dirty cloth she clutched to her breast. I beckoned her over and motioned for her to unwrap her little package. Inside was a dying 20 day old baby. All his bones were visible with skin stretched over his body. His little belly protruded.  He was breathing over 100 times per minute and using every muscle he had to do so. His lungs were coarse and his extremities were cool. We went quickly to work and were able to place venous access and begin fluids and antibiotics. As we were caring for him, the remainder of the team began grouping since we had to take the baby to where expanded care was available (the hospital in Dadaab). Several times the baby's breathing stopped and his heart rate dropped as well. I was uncertain he would survive the drive. Our Kenyan Police security said they would pray for the baby on the way back; I hoped they would be able to pray and watch for bandits at the same time. The baby did survive the two hours bouncing along a track through the desert with us. We turned him over to the staff at the hospital who were attentive and caring. Thinking of hospitals, please don't imagine any hospital you've been to in the developed world. While the staff is trained and effective, there is no monitoring, isolation, labs, sheets, or windows. Rooms are shared with a dozen patients. Tonight we stopped by the hospital and baby was still alive, but sadly not much improved. His mother had been feeding camel milk in addition to nursing because of trouble breast feeding. In the hospital, she was assisted in breast feeding and the camel milk was stopped. I'm hopeful for the baby but am uncertain about his chances.

Adults, however, are ok to drink camel milk and today we had another wonderful cup of camel milk chai after clinic in Kokar today. Sweet, salty, earthy, smokey, spicy and creamy. The community of Kokar gives our team amazing gratitude- both with food and kind words. The prior team finally had to ask them to stop cooking a goat every time they held clinic. I'm not sure I'm glad they did that, I'm starting to enjoy goat even though I eat it every day and would love to try a new recipe- roast goat Kokar style.

Days here are rich and I feel blessed to be of service.

Monday, February 6, 2012

Absolutely amazing Somalian clinic

The warthog proudly curls his ugly tail over its nearly hairless back. He holds his head high and trots across the deep orange sand. He disappears into the brush and is followed by another, equally as jaunty in spite of his complete absence of any cuteness. Warthogs make me laugh because the are just so proud and just so ugly.

I look around for other animals and see a little black and red bird picking at the drying red blossoms on a dense brown thorny tree. The Kenyan army security lean on their truck and talk. Our driver's legs stick out from under the rear of the Landcruiser while he struggles to attach the rear drive shaft with the two remaining bolts. We had noticed increasing vibration about 30 minutes from Daadab heading for Dhobley and the problem was quickly identified. Our replacement vehicle would arrive soon; in the meantime I squat on my heels in the shade under the thorny tree with the red flowers. I stand up embarrassed after the hygiene coordinator announces that I look like her educational poster demonstrating how to bury stool.

We get to Dhobley (Somalia) eventually with several small delays along the way. The border is closed both ways so we have to convene with the Kenyan army on the border. There are no specific border formalities such as immigrations or customs. Our Kenyan transport and security remain on the Kenyan side. We transfer our meds and selves to some beat up station wagons and a pick up under the protection of the TFG. The transitional federal government forces are essentially local militia. While their Kalashnikov rifles were clearly worn and used and their uniforms generally oversized and mismatched, their alert eyes, active postures and unspoken attention to position and duty told me these were more than soldiers, they were experienced fighters. Al Shabaab had been cleared from town recently and a Kenyan air strike had killed, by report, around a hundred Al Shabaab attending a meeting a few days ago. Speaking to people in Dhobley, they were very hopeful for increased peace and stability with a decreased presence of the Al Shabaab. We visited the AFREC clinic and all I can say is I have an incredible admiration for these healthcare workers. They have accomplished building a women and children's center and staffing it. The hospital was being repaired after being used as a base for Al Shabaab when they held the town. It was shelled heavily when they were ousted several weeks ago. At the clinic,  dozens of women and children were there for care. The clinic building was clean, well cared for and the staff very professional. Four days ago these staff were in hiding in as the police station next door was under attack by RPGs; today they were back caring for their patients. Absolutely amazing dedication. I felt honored to meet them. Such unspeakable dedication to their patients and community. On the way out, one stuck his head in the window and asked "Pray for us." Please do.

Sunday, February 5, 2012

Toads in the shower

Four of them tonight.

Dawa ya moto ni moto

'Dawa ya moto ni moto' is Swahili for 'the medicine for heat is heat.' That must explain why I am drinking a cup of hot tea at 4:30 in the afternoon on a day when crossing the twelve feet of sunny courtyard seems like it would b crossing the entire arid expanse of the Sahara.

It's even hotter today. Stunned from the heat. I feel like a wilted piece of kale ready to be thrown in the compost. Hope it's not hotter again tomorrow.

Went to church this morning. It was fun and memorable, especially for me to sing in Swahili. Fortunately reading the hymns is phonetic so singing along was possible as long as I did not lose my place. (Somalian is a bit more difficult for me since the words are not pronounced as spelled). The sermon kept giving thanks for security at church and stating if this was the last Sunday for them, they would be ok with whatever happens becauses it would be in worship. I'm not sure my devotion is at the same level and may or may not go to church next week since I also agree the church could be a target and sadly I did feel nervous. Church is next to the police station and well patrolled however. The singing and warmth of the congregation was very special and being the only five white people, we were welcomed kindly. There was much song, hand holding, clapping and fellowship. During church they gave me a bookmark to remember the Daadab International Worship Centre by. It was a beautiful gathering and, even without the bookmark, these loving and devout people will remain in my heart forever.

Friday, February 3, 2012

Cold cokes, the apacolypse and still no camel bells

This afternoon went to the UN compound to pick up the replacement clutch. While we were waiting, we found a cold drink. I'm not sure why coke tastes so good in a hot third world country but it has to be more than the lack of high fructose corn syrup. Anyhow, it was the first cold drink in several days and was refreshing. Very refreshing. It felt fancy in the shade of a tree in a worn white plastc chair watching water leak slowly from the enormous water tank above. Drip drip sip sip.

When the world ends, I'll miss cold drinks and caffeine more than the cars and certainly more than the iPads (I detest typing on this thing- using the screen keyboard is like picking marbles from a bowl of jello). Speaking of a post apocalyptic world, I don't think the nomads with their camels would even blink while the rest of us would wither. I'm awestruck at how families live with these animals amidst the hot sand and shrubs. No washing machines, air conditioning or hot showers. a Jerry can to store camels milk in and to use as a pillow. A shirt to hold up over your head during a downpour when it is the rainy season.

On our drives, we rocket past these still families barely visible in the shade of the brush and eight foot tall animals and I think about our time passing quickly while theirs remains stationary. I believe sometime in our future these families will be tending their camels and walking past grown over roads and rusted automobiles casting cool shadows on the sand. While our technological society blooms and flourishes and finally exhausts our resources and then wilts, these people living so close to the earth will be hardy seeds of our humanity.

I hope that one of these hardy families will agree to part with a camel bell soon, but it did not happen today either. I was offered to trade an entire camel (bell included I assume) for four head of cattle. Further negotiation resulted in the offer expanded to include goats in case I did not have enough cattle. This would be at the rate of fifteen goats to one cow. Alas, another camel bell deal falls through.