Traveling and home again

It has been about three weeks since I got back to the United States and I wanted to write a final entry to tie everything up in a neat bow. If only it were that simple. First there were three weeks of pure joy as my husband and I traveled around the country. We did a complete circuit of Gabon, starting in the NW corner at the capitol, riding the train all the way east to near the border with Congo and then working our way back west and south. We saw national parks, elephants, train life, distinct ecosystems, all in one relatively wealthy African country. The story that sticks out in my mind of traveling with Owen happened near the end of our journey. I think it vividly illustrates what kind of country Gabon is, as well as the haphazard way in which we tend to travel.

We were in Port Gentil, an oil man's center of commerce on the Atlantic coast, about in the middle of the Gabonese coastline. Did I mention that we took a decomissioned Russian freighter ship stuffed with goats for a Muslim festival overnight to get there? Because we did. Our goal for one day was to walk to a local beach area, lie in the sand, and maybe eat some fresh-caught fish. According to our faulty guidebook map, it was only 4km to the beach so being the intrepid, and somewhat homeless, travelers that we are, we decided to walk. After about an hour and a half, the beach did not seem any closer and there was only one main road in the countryside so it was not as though we could be lost. Finally I approached two middle age men and asked for directions. They laughed uproariously when I told them we were trying to walk to the beach, as it was actually 18km from the center of town, not 4km. After talking a bit, they offered to have us jump in the back of their pick-up truck because they were on their way to the beach town as well. We drove all the way with them, stopping for a roadside beer and talking about all aspects of Gabonese culture and landscape. It turned out that they were friends with the village chief of the beach town, so we had to meet with him, give him some wine (you always have to give the chief some alcohol), and take pictures. Then they directed us to a restaurant with just caught grilled fish. SO good. Then we had to drink some local spirits with them and the chief, go for a walk on the beach where the village was bringing in the tuna catch for the day, and try to find vin de palme.

When we got back to Port Gentil, one of the men insisted on drinking more beers with us and eating brochettes of grilled meat for several more hours. He was extremely affronted when we tried to pay for the meal and instead urged us to buy more beers on his tab. It was a totally beautiful, funny, local, delicious, warm day and illustrative of how kind and protective and proud the Gabonese people tend to be.

Unfortunately, we had to leave our equitorial paradise for full-on Chicago winter. It has been a difficult transition back in many ways. I liked my work a great deal at Hopital Albert Schweitzer and felt useful and appreciated. Now, I am back to the lowest position on the totem pole of medical student where I get to do fairly little. And it is so cold! I am trying to be positive about the last six months of medical school and make the most of my time here in Chicago, but it is hard. Lambarene and Gabon in general, have taken a piece of my heart and I am already plotting my return for the earliest possible moment.

Leaving something lasting

As I leave for Libreville today to pick up my husband (finally!) and go traveling, I have been thinking about the traces that we leave behind. I went to talk with the directrice of care at the hospital to prepare for my departure and she asked me to sign in a book of students that have passed through Schweitzer over the past years. In the comments section, everyone always writes super cheery things “thank you for the best experience I can imagine,” or “the spirit of Schweitzer is embodied by everyone works at this hospital,” things that I consider might be true only the best of conditions here. Everyone likes to remember experiences and themselves as better than they really were. But when I look back honestly at my time at Schweitzer, I view it as a microcosm for my professional career as a whole: I hope that a few people were very positively impacted by my care and that the rest were well cared for to neutral. As if you gave all of my patients and contacts here a “sophie satisfaction scale of 1-10” and everyone rated me 5 and above. Maybe my motto can be: touch a few, and leave the rest neutral. Not wildly inspiring, but realistic?

Leaving emotional traces behind, let us think about the physical aspects of myself that I want to leave and will leave. Already I have worked on the guide to Pediatrie that another doctor started and I will continue to add to that. I will be sure to distribute that to future stagieres and to the American Schweitzer Foundation. I aim to make a little handout on diarrhea. I gave a kick bootie presentation on Pediatric asthma management, replete with posters. And I will create a mini one-page guide to Maternite for future students here as well. Will anything of these things last? How do any of us leave enduring traces of ourselves? If even, I would contend, the spirit of Schweitzer corrodes, what can a mere mortal leave?

Bliss

After a funny night out on the town, eating grilled carp from the Ogooue, Castel beer, and Biskrem (nature's perfect food, a shortbread like cookie with a cocoa filled interior found only in Western/Central Africa apparently), I awoke to a gentle foggy morning in Lambarene. Whereupon I made myself some lentil soup for breakfast and ate it while reading the New Yorker (thank you! roommate who just arrived from the US and brought my dose of middle-brow culture so sorely lacking here). I am in seventh heaven.

Second Monthly report

Spoiler alert: This post is LONG--and even abridged from my actual report-- and intended mostly for people who are thinking about applying to the fellowship and/or my family. It serves an example of what you are expected to do in terms of reflection during the fellowship. It is also a status update on my heart.

This report encompasses the time roughly from September 10, 2010 to October 22, 2010, or about six weeks of my time here. During this time I switched from working in Pediatrie to working in Maternite (a move I will talk about more later) and will thus focus first on Peds before switching over to describe my time in Maternite.

My heartfelt impression of pediatrics, when the place floats into my head, is that I love it there. I adored most of my patients and parents, as well as valued the experience of doing so many history and physicals, exam maneuvers, and clinical decision making. I noticed that I tend towards tough love and need to work on my judgment as far as when to take a complaint seriously (ie my baby breathes funny, has diarrhea all day, has a red anus) and when to offer reassurance. Overall I had moments, even whole afternoons when I experienced what Mihal Csikszentmihalyi's concept of “Flow” as part of good work, the notion that you are so present in what you are doing you don't even notice the passage of time. I also felt impossibly lucky at times when I realized that this is going to be my life-- I really get to take care of babies, kids, families for the rest of my life. How could I have possibly gotten so fortunate as to stumble into this job?

In terms of my actual medical work in Peds, I feel good about what I was able to do in regards to seeing a good daily load of patients and in individual cases where I felt that I made a difference. Here are some of the stories of my patients whose care and lives I became more involved with:

1. EB, a 4 year old asthmatic that I saw during three separate hospitalizations for crises in August/early September. I read about what medications were available in Gabon, measured her peak flow, tried out different doses until we seem to have found the combination that is working for her right now. It is so nice to listen to her lungs now as opposed to the first time I heard them wheezing and crackling three months ago.

2.CE, a malnourished, HIV positive baby that was with us for three weeks trying to get her nutritional status corrected. I ended up getting the family food and other resources as well as getting to know the entire extended clan well.

3.KM, a sick little 8 year old boy. I did my first LP on a child in him, which turned out to be a champagne tap (!) and we treated him for meningitis. He got so much better after the tap we joked either that it was therapeutic or that he suffered from Stockholm syndrome and fell in love with me because I was his tormentor.

4.Baby B, a premie baby that Dr. Florian and I performed CPR on my very first 15 minutes in Pediatrie (literally on the very first day of my time at HAS!), who ended up surviving that arrest episode, as well as two others, gaining 700g in the hospital and being discharged right as I switched to Maternite. We, me and Florian, tried in vain to get the mother to name the baby after me, or even him, but to no avail.

5.Drepa Mom, a kid whose electrophoresis showed homozygous SS, and when I offered to do a teaching session on sickle cell with her and the child came back the next day at 8am with tons of questions, eagerly accepted all my handmade handouts, and generally seemed like a superstar involved parent.

There are two cases that linger with me as mistakes that I made that may have negatively impacted the outcome for the patient. Not that I want to dwell on these cases, but they both gnaw at me for different reasons. The first case was a child with diarrhea and vomiting that I saw in consultation who came back to the hospital over the weekend (4-5 days later) severely dehydrated and ended up dying one day after being admitted. This bothers me because I did not have a high enough index of suspicion for a severe illness, apparently, and must not have given good instructions about warning signs that necessitate coming back to the hospital. In the second case, I gave a mother positive HIV results for her and her baby and she fled the hospital in the middle of the night because she did not believe me/HAS. In this case, I should have approached the counseling scene differently, maybe waited until Monday to give the results rather than doing it on a weekend, maybe brought a nurse or HIV counselor with me to avoid/buffer the mother's denial response. As a final set of comments on the Pediatrie:

1. I love the nurses there and think that they do a great job and deserve recognition for that fact.

2. There should be continued focus and development on neo-natal care at HAS, both nursing/medical care as well as the hospital's technical capacity to care for premature infants. Neo-natal death is a huge cause of mortality in Peds and could be a shining success for the hospital, like the TB project, in the sense that it advances our goal of creating a culture of results. Maybe we could get a neo-natologist to come consult or dust off some of Dr. Cumming's stuff (Yale peds person that created neo-natal curriculum and monitoring sheets here) that sits on an abandoned shelf in the Pediatrie.

Throughout my three months here I have worked with the PMI every Thursday, which has provided a nice thread of continuity to my fellowship time. An interesting case has emerged from one of our sites, Bellevue, which is accessible only by pirogue. The first time I went to that village, there was a 4 month old baby with recently developed hydrocephaly, I referred the kid to peds, where Dr. Florian saw him and suggested the mom try going to Owendo, the children's hospital in LBV. When we went back as the PMI six weeks later, the kid's head was bigger and I got in touch with Bongolo Hospital, in the south of Gabon, because I had seen a patient with a VP shunt in peds who received the operation at Bongolo. This case, to me, begs the question of medical evacuation from PMI sites/Schweitzer as well as the possibility and desirability of a collaboration with Bongolo Hospital. I am currently trying to get the patient down there for the VP shunt surgery, have already been in touch with the surgery team there, and they have okay-ed him for surgery even if his mother cannot find the 120,000 CFA that they charge. We should also make this resource more widely known to/for our patients, especially in peds as they have a neurosurgeon there doing the hydrocephaly operation. This seems like it would be a great link up, win-win type of deal. I am so glad to have consistently voyaged with the PMI, gotten to know those nurses well, done my first true solo consultations as a physician and gotten a better sense of the geographical and emotional lay of the land in the Moyen-Oogue. It also piqued my interest and ever-running internal debate over free versus low-cost health provision, as people in the villages are much poorer, on average, than the people who can make it to Schweitzer as patients. It puts disparity and questions of value and fairness into my mind. Also every time we got out, I think of the old Quaker proverb that my Busia, Polish grandmother, used to write to me at the end of some of her letters. “I expect to pass through this world but once. Any good, therefore, that I can do or any kindness I can show to any fellow creature, let me do it now. Let me not defer or neglect it for I shall not pass this way again.”

How I learned to love childbirth and stop fearing the human body

Helping out in labor and delivery here in Gabon gives me hope and faith for my own eventual personal childbirth as well as in the capabilities and resilience of the human body. The mothers here arrive at the hospital with their cervices well dilated, often anemic, and give birth with nary a sound. It happens so much more quickly and without trouble than the deliveries that I helped out with back in Chicago. There women were usually some combination of obese, (pre)eclamptic, diabetic, and under epidural anesthesia. Their deliveries went on and on and nearly half of the time ended in C-section. Here, maybe 5 or 10% of the deliveries are C-sections. And that is at a hospital where it is possible; the majority of women still give birth at home. If a woman starts yelling, when the head is crowning, for example, a nurse will slap her abdomen or her cheek and say “tu cri pourquoi” which translates to why are you yelling. The woman will usually quickly get herself under control, stop making noise, and finish delivering the baby in seconds. Amazing. And they are up and walking minutes within delivering the placenta !?! And within a few hours you would never know that they had just recently passed a human being through their vagina. American women are horribly out-of-shape weenies by comparison. I hope to take a page from the African woman playbook and endure my pregnancy and delivery with stoicism and resilience. The one aspect of delivery in America that I would like to keep is that there delivery is a momentous event, whereas here it is viewed as common and no cause for celebration or congratulations. I would like to guard that sense of wonder and grand importance during my children's birth, while keeping it quick and stoic like African women. Are those two extremes unreconcilable?


What do in a polygamous society about HIV tests?
As I have written about dilemmas that I see at the hospital in terms of payment, choices of when to seek care, how to respond when your child dies, and physical abuse, I wanted to add another wrenching thought to our burbling cauldron: as a woman in a polygamous relationship and/or household, how do you stay HIV negative? When I give the results of the mandatory HIV tests to pregnant women (the result of a recent and I think, very beneficial, Gabonese law), I often comment that they should try to get their partners tested too. Often a woman will reply that he refuses, as in his eyes, her negative test means that his must be negative as well, or they sigh that it won't matter if he gets tested as he also sleeps with numerous other women. Can you imagine if you were trying to protect yourself, which is hard in a society that views condoms with suspicion and HIV testing as a sign that you think you might be positive, and your partner were holding you back so significantly? People here have problems that I would have a wretched time dealing with, as I have a hard enough time counseling them about their dilemmas.

Lack of resources dumbfounds medical student

Today I was doing prenatal consultations in the maternite, and as I do with all patients, I closed the interview by asking if she had any questions or concerns. This patient completely dumbfounded me by saying, yes, I do have a concern, my husband's mother beats me. She pulls up her dress to show me all these bruises on her body. She goes on to explain that she moved to Lambarene to be with her husband's family and she has no support here. So she gets beaten and no one stands up for her. Goodness, that is not what I meant by any concerns. I was literally dumbfounded. I had no idea how to counsel her or what resources were available. After asking around, I found that none exist here, of course. I felt so helpless. What on earth could I offer this patient? People don't hug here, so even my human contact with her was limited and constrained by cultural differences. Agh, so frustrating to not have anything at all to tell my patient or offer to her.

Born on arrival

Today we had the third baby I have seen in three weeks nearly born in a taxi. If your amniotic fluid gushed in a taxi, plus or minus some blood and excrement, what do you think would be a fair price to pay the taxi driver for clean-up charges? Also who knew this would be such a common occurrence? The first time it felt like a movie. Now it is starting to feel a little ordinary.

The French and their shorty shorts

This weekend, my roommates and I embarked upon a Libreville expedition of epic proportions. Purportedly, our aim was to drop our French roommate off at the airport for her return trip to Dijon, but there was also big city tomfoolery to be had. I have already written about our French military friend, who is an absolute sweetheart. Well this weekend he introduced us to French military life a la etrangere. First and foremost, when the French military embarks to a hot weather climate, they have tiny shorts that they wear as their uniform. It is too super! We arrived at an after work party on Friday afternoon to find dozens of men in military shorty shorts. I was so taken by the scene and expressed my appreciation for this mass display of sexy shorts that our friend commanded one of his subordinates to strip and give me his shorts. So if back in the US, or elsewhere in the world, you see me wearing a pair of tiny cammos, you know they came directly from the thighs of a young French military man. Too great.

In other news, I bought all the train tickets that I will use for when my husband arrives at the end of the month. We are going to travel this country--I am so excited!

Be careful what you pretend to be

In middle school when everyone was reading Kurt Vonnegut because he was a relatively deep, interesting author that was nonetheless accessible to young minds, I wrote one on his quotes on my wall that stayed there well into college. It read: “Be careful what you pretend to be, because you are what you pretend to be.” Although this is a bit cliche, reflecting on this idea has served me well in the domain of medicine since so often I am just pretending to be a doctor. I have to pay attention because the habits, manerisms, and knowledge that I display now are the kind of doctor that I will be. I have been thinking about this recently in the Maternite because there is not always a lot of supervision of the work there and I get to make decisions somewhat on my own. Thus the habits that I am developing in examining patients, in doing pre-natal consultations, and in doing deliveries are the habits that will shape the kind of doctor that I am. I think about this every time I do something new, like rupture an amniotic sac yesterday afternoon, that the way I do this now may be the way that I do it for the rest of my life. Or at least for some time. It is a wonderful and frightening feeling at the same time.

In other random musings, I think that living in a foreign country for so long has been an impetus for me to reject received notions of my tastes and limitations. In short, Gabon has helped me to work through some of my fears and dislikes. For example, before I came here I would have sworn to you that cheesecake makes me vomit. But at the American house in Libreville, I ate two pieces of cheesecake, and it was delicious. I have been eating mayonaise on fish and omelettes for dinner (when there is not a good vegetarian option) the whole time I have been here. Those three foods are things I would have told you are repulsive to me before Gabon. Interestingly, it turns out that is not the case here.

My greatest triumph over my formed ideas of myself and my limitations occurred today though: I gave blood! Pre-Gabon, I would have told you that I was not someone who could donate, that I would faint, or be anemic, or just not tolerate the procedure. But I was wrong. I guess that my food and blood limitations are the corrollary to the notion that you are what you pretend to be. Even if you pretend to be something, and it starts to become a part of you, it does not mean that you can't pretend to be something else later on.

Be careful what you pretend to be

In middle school when everyone was reading Kurt Vonnegut because he was a relatively deep, interesting author that was nonetheless accessible to young minds, I wrote one on his quotes on my wall that stayed there well into college. It read: “Be careful what you pretend to be, because you are what you pretend to be.” Although this is a bit cliche, reflecting on this idea has served me well in the domain of medicine since so often I am just pretending to be a doctor. I have to pay attention because the habits, manerisms, and knowledge that I display now are the kind of doctor that I will be. I have been thinking about this recently in the Maternite because there is not always a lot of supervision of the work there and I get to make decisions somewhat on my own. Thus the habits that I am developing in examining patients, in doing pre-natal consultations, and in doing deliveries are the habits that will shape the kind of doctor that I am. I think about this every time I do something new, like rupture an amniotic sac yesterday afternoon, that the way I do this now may be the way that I do it for the rest of my life. Or at least for some time. It is a wonderful and frightening feeling at the same time.

In other random musings, I think that living in a foreign country for so long has been an impetus for me to reject received notions of my tastes and limitations. In short, Gabon has helped me to work through some of my fears and dislikes. For example, before I came here I would have sworn to you that cheesecake makes me vomit. But at the American house in Libreville, I ate two pieces of cheesecake, and it was delicious. I have been eating mayonaise on fish and omelettes for dinner (when there is not a good vegetarian option) the whole time I have been here. Those three foods are things I would have told you are repulsive to me before Gabon. Interestingly, it turns out that is not the case here.

My greatest triumph over my formed ideas of myself and my limitations occurred today though: I gave blood! Pre-Gabon, I would have told you that I was not someone who could donate, that I would faint, or be anemic, or just not tolerate the procedure. But I was wrong. I guess that my food and blood limitations are the corrollary to the notion that you are what you pretend to be. Even if you pretend to be something, and it starts to become a part of you, it does not mean that you can't pretend to be something else later on.

Maternite!

I am working in maternite now, seeing lots of babies being born. Yay future career! I am very happy.

Snakes on a Plain!

Yesterday in the pediatrie, we had a kid with a snake bite! He probably wasn't really bitten on a plain, but I wanted to use that phrase so badly because of the movie, so I hope you will permit me the liberty. He was in all likelihood bitten in more a jungle/wooded area. En tout cas, it was the first time in my life that I have seen a snake bite victim. He was walking when he came across a long, black snake that struck him on the foot. The bite was not that big, but pretty deep. We cleaned and debrided the wound a bit, and then loosely wrapped it in gauze. Then, since we only had the word of a 12 year-old describing the snake (no one had been able to capture or kill the snake to aid in identification) we gave him a polyvalent anti-venom serum. Then we observed him for 24 hours for signs of local tissue swelling, trouble breathing, or heart problems. All went well and we were able to discharge him from the hospital. I thought for sure with a snake bite, the kid was going to die, but the doctor that I was working with told me that the huge majority of snake bite victims survive, either because the snake that bit them wasn't really venomous, didn't bite them very hard, or did not inject venom when it bit. The most important thing to do, he explained to me, is to reassure the patient and their family so that they remain calm and don't have tachycardia, which only further distributes the venom. Interesting that human interaction and reassurance is actually the key to successful snake bite management.

Snakes on a Plain!

La fatigue or WWASD?

It is getting HOT here; the saison de pluie has really made its inroads. The afternoons are starting to push into the high 80s with lots of humidity. And it is only going to heat up, according to what locals tell me. Along with a lot of work and the chaud politics at the hospital, I am totally exhausted. I wonder what Albert Schweitzer would do at this point? I think he must have frequently felt at his wits end. I haven't read his autobiography yet, but I am curious what he has to say about sustaining one's commitment to service in the face of physical and emotional overload.

La fatigue

It is getting hot here. The afternoons are starting to push into the high 80s with lots of humidity.

Road Accident

Traveling in a car is one of the most dangerous things you can do in Africa. More people die in road accidents than by any other cause of preventable injury. Usually it is the case of single cars crashing into each other, but every once in awhile very gory large vehicle collisions occur. The gore is compounded by the fact that people here ride in the back of trucks, which are already piled high with baggage, by the dozen. Sunday night and Monday morning we received 66 patients who were the victims of one such mass casualty event, which occurred at 50km from the hospital. Apparently they were riding in the back of a huge trailer truck, celebrating a soccer team's victory, when the truck skidded out and flipped. Four people died at the scene and the rest were transported urgently to Schweitzer. They were triaged, bandaged, and kept in waiting rooms, consultation rooms, and even outside. We did a lot of x-rays and a lot of wound debridement. And two days later, most of them have returned home cut and bruised, with whip lash, but surprisingly lacking major injuries. There was almost no abdominal or thoracic trauma (only one splenectomy!) and relatively few broken bones. All in all, it was a success for the hospital to manage a mass casualty scene like that and lots of luck that it turned out so well.

Another weekend sans arret

This week and weekend went by in an absolute blur. This is partly because I was in Libreville at the beginning of last week, which set off my internal weekday/weekend calibration and partly because the PMI trip on Thursday was brief so we had the afternoon off. My roommate and I used that time to go on a LONG walk and to pick up stuff at the tailor's. I had several things made: skinny jeans from flared jeans I got at the bins, pajama pants from elephant-print cloth, and a purse from fabric I found in the garbage. Even in Africa I like to dumpster dive! The tailor did a really nice job though, unlike the clothes I had made when I lived in India, so I am excited to get a few more things made as well.

Anyway, this weekend was completely fast and furious. Friday night we left the Schweitzer compound right after dinner to go a funeral/wake for one of the nurse's uncle who died earlier in the week. It was interesting to hear about how death is dealt with here: after an adult dies all of the women of the family who are free sit with the body for five days. People drop by all the time to pay their respects and visit with the family. You say “mes condolences”, not I am sorry for your loss, as we say in the US. After five days of sitting with the body, there is a vigil/wake the night before the burial. Everyone sits outside the house, men on one side, women on the other, and talks quietly or just sits. A lot of people spend the night with the family outside that night. Then the next day you wake up and the men start digging the hole for the burial. Burial happens, then lots of drinking and eating. Then one month to one year later there is a deuille, which is a celebration of the dead person's life and is basically just a huge party. After we sat with the family for awhile on Friday night we went to get a few beers with some of the family members.

Saturday morning we woke up early to go on a boat trip on the Oogue to the lakes that are upstream from us. This pirogue trip is kind of a classic Schweitzer experience, everyone has to do it at least once. Also you get to see hippos! I thought of my mother-in-law the whole time because she loves hippos and we were able to see several families of them swimming in quieter parts of the river. They were so funny, they would just surface with their big heads, blow off water and air, and swivel around with their ears. It made quite a racket when they would come up for air like this. Hippos can stay underwater for up to 30min, but they tend to surface every few minutes for air. We also saw monkeys, crocodiles, iguanas, and pelicans on the trip.

On Sunday morning we were again treated to the opportunity to wake up early and do something African. One of the nurses who works with us invited us to go planting in her village. Here it is often referred to as going “en brousse,” which means going into the jungle, even if you are not walking very far away from the road. Planting is traditionally considered women's work and we only saw women and children out in the jungle. The African women we were with carried everything we needed out to the field in giant paniers, which are woven baskets that have straps threaded through them that you can either wear like a backpack or around your forehead. Most women choose the forehead method which I find absolutely stunning. It would put so much pressure on your neck. Anyway, the women loaded up the paniers with machetes, taro bulbs, and small banana tree roots and me and Annie put on our backpacks. And then we headed off down a steep path into the jungle. We walked for about 20 or 30 minutes to a clearing that had been burned the week prior to prepare the soil. Here you always burn before you plant bananas. You don't have to clear the jungle, because the banana trees will grow in between the other vegetation but you do need to prepare the soil with burning. Once we got there, we got to planting. You dig a hole about 6 inches deep—with a machete, mind you-- and plop the banana or the taro into the space. Then you cover and repeat. You try and plant the taro in between the banana plants. After we had planted the first batch we went back to another, older plantation to dig up more banana roots to go back and plant at the first site. You have to do this because banana trees only give one fruiting, they are not annuals, so you have to keep replanting them every 6 months to one year. Once we finished with the third round of planting, we headed back home, in the pouring down rain (saison de pluie!), which I loved because I come from a rainy city and rain makes me happy. When we got back to Schweitzer, I fell asleep almost immediately and complained loudly the next day about how hard the work was. The life of an African woman is so physically demanding, I do not know if I could do it. Maybe if I had been raised like this and was in the habit it would be okay, but after one day of mini learning, I am exhausted and sore!

Best Weekend Ever, Part Deux

Practical life in Libreville and how the people helped us:
One of the tropes of life in Gabon is that Libreville, the big capital city, is not a friendly place. Maybe people say that about any large city or gathering of people, but the intense animosity sometimes expressed about the capital is surprising here. Thus it was with heavy, somewhat anxious hearts that Annie and I set out to accomplish practical life matters Monday morning. We had been appropriately warned about how bad things can be here. But it was nothing like that for us! Annie was welcomed and attended to heartily at the Guinean embassy. And though I was passed from one tourist agency to another, when I finally found out where to buy train tickets, an older woman actually took me in a taxi, paid the taxi for us, and walked me to the street of the train ticket office. I got a little lost on the way back home and a newspaper salesperson walked me to the taxi stand. Our experience of the big city was actually quite welcoming, a pleasant surprise.

Sweethearts:
Along our travels we have managed to make some very kind friends in Gabon. One of them is a young female university student who we met at her parent's hotel at Cap Esterias. We hung out with her during our time in LBV and she was a darling showing us her city and friends. The other is a French military officer, friend of a friend, who also took us under his wing, showed us the city and offered to help with anything that was tough or going wrong here. Total darlings. When you are traveling having kind people as your friends makes a world of difference.

Best Weekend Ever, Part 1

This past weekend and surrounding days have been absolutely delightful. This explains why I haven't had time to blog--life has been too busy and fun. Allow me to tell you about the past five days in easily digestible separate blog entries:

Some interesting patients from clinic and hospital on Friday:
1.Two year old boy who presented two months ago with difficulty breathing, chest x-ray shows cardiomegaly (heart is 75% of the thorax diameter) and probable pneumonia, previous chest x-rays normal. We treated the pneumonia and the wheezing has somewhat ameliorated, but at all the follow-ups the cardiomegaly persists and he has now developed generalized lymphadenopathy including some huge lymph nodes in the armpits. Serology is negative. Next appointment in one week, let me know if you have thoughts or suggestions.
2.Kwashikor (protein deficiency that causes swelling because you don't have enough protein in your blood to keep the water in your vessels) baby!! This baby's feet and abdomen are hugely swollen for lack of protein, even as we try to refeed her protein. Did you know that Kwashikor means second baby because it is often observed in the older child when a new baby arrives because the mom starts nursing the new baby and not feeding the old one? In this patient, it actually happened this way with a new baby arriving in the family and her getting malnourished over the course of several months.

La journee d'acronymes, or I finish ERAS and FAFSA:
The world is really a small place. I can sit in the research lab at Albert Schweitzer hospital and turn in all the required documents for financial aid and residency applications! I turned in the majority of my residency documents two weeks ago, but I just put the finishing touches on programs that I applying to and uploaded a photo Sunday morning. And as I had forgotten to fill out FAFSA for this school year, my school's financial aid office kindly reminded me of this error with multiple emails and I was able to remedy that situation Sunday morning. Now all I have to do is sit back and wait for the residency decisions to roll in. It's amazing to think that I applied to residency, which is this huge process from an African country.

My other in-laws:
After I turned in my remaining official documentation to America on Sunday morning, my roommate Annie and I headed to Libreville, the capital city to take care of business there. A few weeks ago an American medical evacuation pilot/Christian missionary left a message on my blog telling us to come stay with him and his family at their guest house if I were in Libreville again. The combination of America and medical stuff made me jump at the possibility. It was a complete delight staying with them. They had American food like cheesecake (I ate it and liked it Owen!), buttered microwave popcorn, and grape jelly at their house which they generously shared with us creating us a little America in Gabon the likes of which I have never experienced. They also took us to the clinic that their church runs and helped us with a bunch of practical details. So sweet! They remind me of my in-laws who are also really good Christians, though not missionaries, which was extra nice to have that feeling of being around familiar people. And unlike all the old jokes, I love my in-laws greatly, so it was a very positive association. What a provident surprise to find each other in Gabon.

One year of marital bliss sans divorce, yay!
Speaking of in-laws, Sunday was my one year anniversary of marriage. Unfortunately Owen, my husband, is in the US working but I celebrated here in Gabon with my lovely rooommate as a stand-in. We went out to a romantic Italian dinner on the water in Libreville (Dolce Vita at Port Mole) and then watched Princess Bride when we got home. Owen and I got to gchat a little bit about our first year and agree that it has been super fantastic and we want to renew our promises that we made to each other last September 19th. We'll eat our ceremonial frozen piece of wedding cake when we are back in the US together...

Should Poor People Pay for things?

Bonjour equipe-- I have been thinking about something recently due to a spate of really poor mothers that I have met on PMI trips. Should poor people have to pay for medical care at all? It kills me when a mother says that she cannot afford the 2000 CFA (about 4 dollars) for a consultation and medicine on the PMI trips. There have been some extremely sick kids that we have not seen because of the barrier enacted by the consultation fee. It makes me feel like we should see everyone for free. But when I offered this idea to the PMI nurses, they were vehemently against it because they said it would overwhelm the system and it would cause mothers to prioritize/value health less because they would be able to get it for free. Although this idea is a bit unpleasant, there are studies (even put out by the World Health Organization) to support the idea that there should be small fees associated with health care. For the time being, I wish that I could give things for free to all my patients but I recognize that I have to respect the rules of the system that I am working in. Otherwise, if it is only me who gives things away that will only disequilibrate the hospital and community health services of the hospital even more.

Organization of Hopital Schweitzer

As I was walking around the hospital grounds today, I realized that I don't know if I have ever explained to everyone how the hospital is organized. Excuse my error in not laying the groundwork with a good expose. Let me try and paint a picture of how things work here.

The Schweitzer compound is situated on the banks of the Ogooue River, but not right along the river as it originally was. Schweitzer built his house and the first hospital wing literally abording the river (probably to save time and energy from hauling everything to a higher location), but in the 1970s or 80s they moved all the hospital buildings to higher ground. Now everything sits about a quarter mile from the river on a hill overlooking the water. The hospital consists of a cluster of buildings organized into wards. The wings of hospital are internal medicine, surgery, pediatrics, maternity (where childbirth and the first few days of life happen), “cas sociale” (psychiatric cases), and a big classroom. There is also a huge building called, appropriately enough, “la grande salle” where adults are seen as outpatients, the pharmacy, radiology, ER, and laboratory are all found. I spend most of my day in the pediatrics ward, with sproadic trips to maternity, radiology, and the laboratory.

The hospital set up is straight forward enough. The weird thing about the rest of the grounds is all political. There is a giant laboratory run by the University of Tubingen (German) that does research on malaria and TB. They have a lot of money, grants, Gates Foundation backing, so they have a lot of sway. And they bring a lot of Germans to roost here. This sets up the potential and sometimes realized inter-European conflict between the lab Germans and the French who run the hospital, as well as adds to the subtle anti-American spirit that courses throughout Schweitzer. Finally there are other random European-Swiss, Spanish, and Austrian--folks who wander though rounding out our ragtag international ex-patriot community. I have had good relations with just about everyone that I have crossed here, but I had no idea that the scene at the Hospital would be as politically charged as it is. My naivite strikes again.

Life is like this here, or La Vie au Gabon

One thing that people seem to like doing here is to compare various nationalities and their dirty habits. In my eavesdropping on conversations around me, it seems as though every Central African country has a slam for every other Central African country. This funny habit the Gabonese have of trash-talking other countries is also tempered by a heavy dose of self-criticism.

When I go on PMI trips one of the constant topics of conversation is the ways in which Gabon is screwed up. Most of it has to do with the sexual morays here. Men and to some extent women are allowed and expected to have multiple sexual partners. Polygamy is also legally permissible. I have tried to figure out exactly how many wives a man can take, but peoples' responses vary from 4 to 8. En tout cas, people are not expected to be in committed monogamous relationships. When a child is born from one of these multiple unions, quite often it is raised by just one of the parents. Or by the parents alternating who takes care of the kid. Or by the grandparents. This infidelity and instability is much maligned but also much joked about and serves as gossip fodder.

There is a tradition of trash-talking the younger generation in Gabon for having children too young, for not going to school, for turning away from the values of their parents. This type of criticism of the young is a cultural constant in my opinion, but here, people insist, it is really true. Maman Sophie pinpoints the age of adolescent decline in Gabon as 1990. Why, I don't know, but she is sure that something changed after that year and all the babies born then or later are wild children.

Spirituality is also a big topic of conversation and even joking, especially in reference to the above two issues. Everyday discussions are liberally peppered with Jesus and “Dieu merci” interjections. Of course, all of these topics sound so much cuter here because the Gabonese add -o to the end of most sentences or paragraphs. So you might say “bonjour-o” and your conversant partner would say “ca va-o” onwards and upwards to -o infinity.

How fun it is to listen to these discussions as people bemoan the habits and morays of Gabon, while also secretly, I think, being fiercely proud of their country.

La Saison de Pluie Commence

Good news first: my intestines seem to be getting back into some kind of order! Yeah for not having greasy pale stools all day. This is something to be celebrated. Although it would have been fun to see those little smiley faces under the microscope. I can always hope for next time.

Medium news: la saison de pluie seems to have started today. It was hot hot during the day and there was more blue sky to be seen than I have seen in my six weeks here. Then at about 7pm the skies opened up and it began to pour like all craziness for several hours. It just stopped actually. The return of the rains is a good thing because the river level will rise thereby preventing further boat accidents from occuring.

Bad news: There is none! Life in Lambarene is always pretty spectacular for me. We continue the fight here for the health of the region and for inter-national cooperation. Good night mes amis where ever you may be!

Giardia!?

Bonsoir tout le monde. I apologize for the long break over the weekend. There were a bunch of things going on: I took call with the pediatrician on duty on Saturday and Sunday, one of my favorite people here left so we had to fete her, and I feel as though I might have gotten Giardia last weekend in Libreville. Not to be too graphic, but I have all the tell-tale signs. I have yet to look at a stool sample under the microscope but I may just start empiric treatment to get rid of some of the symptoms. Its such a close call as to whether I just have bad traveler's diarrhea and it will go away without a harsh antibiotic or whether I need to jump on the Flagyl bandwagon. As this is my first real gastrointestinal derangement since I have arrived, I will keep everyone updated as conditions progress. For the meantime, wish my intestines luck in battling whatever it is that ails them.

Thankful

Yesterday I went out again with the PMI community health nurses. This time we took a motor boat (although they still the traditional word, pirogue, to describe it so I thought we were going in a dugout boat by paddle, which was really exciting until I saw that it was a regular boat). Traveling by boat was an adventure in itself because we are in the dry season right now and the river is quite low. This makes for lots of sand bars. One of those sand bars caught the boat's motor and we almost flipped over in the river. Mercifully just the boat driver fell in, but judging by the cries of "Jesus sauve nous, dieu sauve nous" emanating from the nurses you would think that we all drowned. We organized ourselves and made it to the village though. Even today at the hospital everyone was gossiping (congossa in the local dialect) about our plunge into the Oogue and how dramatic it all was. That is the culture here though, that information/gossip is very theatrical and communal.

Once we got to the village it was very interesting to see how a village that is only accessible by boat is so much more communal and basic. There were really sick babies (hydrocephaly for two months! malnourished to the point of exhaustion!) there whose parents were taking care of them the best that they could, but were in bad shape because their families were too poor to take them to the hospital. Can you imagine the thoughts and decisions that go through a parent's head as they grapple with the health of their child in a village like that? It's almost unbearably complicated.

As I was sitting on a bench under a mango tree seeing baby patients, eating fried fish a la chocolat, and riding in a crazy motorboat through a gorgeous tropical rainforest, I was struck repeatedly by how lucky I am. Lucky that I live in this beautiful place, that I get to speak French and German everyday, get to take time out of medical school to experience how people live in equitorial Africa, and think about the choices that I face and that my patients face. If I were more religious I would ascribe this all to divine providence, but I will say instead that I have been given a great deal of chance dans ma vie.

PMI en pirogue

Cap Esterias

Now that my excitement over the lumbar puncture has died down a bit, I can write with a clear head about this weekend. It was definitely time to get out of Lambarene. I have been in country for a month with only small weekend day trips and outings with the PMI as my means of escape. The other Americans also needed to move a bit and shake things up. Initially we planned to go to Nyonie, which is a beach resort just south of Libreville. It is run by an expatriate French woman who has set up nice bungalows near the water with day-long safaris organized every day. Did I mention that alcohol is included in the price of the weekend? And there is the possibility of seeing elephants on the beach? All in all it sounded like a sweet set-up. Except we ran into two artists at the hospital who convinced us that the Nyonie experience was too expensive to be worth it. They also connected us with a ride to Libreville and recommendations for other beach resorts to try.

Armed with knowledge and a resolve to have a relaxing weekend we gamely decided to try their suggestions. We arrived in Libreville at 4pm on Friday afternoon, with enough time to enjoy an awesome exhibit about the history of Gabon called “Ma Terre, Ma Future.” It was organized by the Ministry of Tourism for the 50th anniversary of Gabon and was the best thing I have seen put out by this country so far. In giant air-conditioned tents there were six exhibits about the country: geological and archeological history (apparently multi-cellular life began in Gabon!), the different ecosystems, the traditional foods and arts, French colonial presence, independence and the government, and the future plans. Local college students who are studying the different subjects acted as guides. This was in many ways the best part of the exhibit: these people were so enthusiastic and proud of their country. It was very cool to add that interaction to the exhibit. We loved it.

The next morning we woke up with dual goals in mind: find local tissue/panne (fabric) at the big market near our hotel and find a clandestine taxi (unofficial/unlicensed) to take us to Cap Esterias. Done and done. The market was huge and crazy but we managed to get some cool tissue even in the midst of all that turmoil. I'm going to have a dress and pants made by a tailor here. When in Afrique, il faut faire comme les Afriquaines.

We also had pretty great luck getting out to the cape, which turned out to be a gem of a town. Libreville is a big crowded bustling dirty African city and this town just 25km away was completely calm and cute. No one hassled us like they do in the cities. We took long walks, hung out on the beach, drank local beers, ate some good seafood, and swam in the ocean. Then at night, the owner of our hotel's niece invited us to the one local bar in town to drink and dance. So fun. Dancing here is a lot like home, girls on one side, boys on the other, circles of dance-offs, lots of giggling and high fives. I love it-- it's so fun. (As a sidenote for my friends who know how I love a good non-judgemental dance party, I now have to call it a SDSJ, or soiree de dance sans jugement).

The next morning, the nephew of the hotel owner took us on a long walk on the beach and explained about local trees and plants and showed us the site of the first local Catholic mission. Amusingly enough the mission is now a training site for the French military and when we showed up there were about 30 shirtless men in tiny running shorts milling about. The scene was very homoerotic lost boys style. The coastline running north from the cape was so beautiful. I loathe that my internet is not fast enough to load photos because I would love to show it to everyone. When I get back to the states, I will add pictures to the blog which to make it complete and illustrative. For now imagine an unspoilt greenish gray paradise. That was my backdrop this weekend.

Champagne Tap!!!!

Bonjour mes amis!! I miss everyone terribly but I just had the sweetest doctor in training moment-- a champagne tap (for non-medical people this is when you get spinal fluid from the back without introducing blood into the sample) on a screaming, writhing meningitic 5 year old in perhaps less than sterile conditions. It feels good, oh yes it feels good.

I will write about this at another time, but we American ladies also had a great weekend at the beach outside Libreville. So nice to get away to a tiny beach town, not unlike the Oregon coast, unwind, drink some GinTonic (deja pre-mixed!), and get away from the hospital. Love it. Off to celebrate my success, more about the weekend soon.

An unfortunate conclusion

Tomorrow me and my two American roommates are heading out on a baby safari to Nyonie, on the Atlantic coast. It is savannah land and we hope to see elephants. Since we have to up early to pack and head out, I will make tonight's blog quick. Plus, I am still digesting what happened so maybe I will write more once I have thought about it more. Basically the tetanus kid died abruptly and peacefully yesterday evening. He had a cardiac arrest and could not be revived. His mother and father were wailing and the whole pediatric ward emptied to pay their respects to the family and to the body. The mother walked through the whole hospital compound singing/wailing a mourning song. It was incredibly sad and yet weirdly calm inside of me. Some of the other deaths have roiled me, I have felt sweaty, or the urge to vomit, or cry. But this time I felt oddly and perhaps incongruently calm and quiet. Maybe I was kidding myself thinking that he might make it through. Perhaps I had to believe it so that when I would see him and his parents in the morning, I could credibly convey those hopes to them. I asked one of the staff doctors here whether he has seen a child pull through tetanus. One of approximately ten in 2 years he said. Those are bad odds. Online it says that mortality ranges from 25-60% and that is for places with ICU support. Our small hospital in equitorial Africa does not offer anywhere near that level of monitoring, support, or intervention. I could not help but hope for him though.

Tetanus Update

Today was a great day at the hospital, I felt really good in terms of my patient care and my ability to manage multiple cases. It also seems like the number of patients with gastro enteritis are going down leaving room for more interesting cases. There were a lot of new, exciting cases today. I saw a kid with a severe neurologic delay from birth. He was sixteen months old, couldn't sit up, couldn't hold his head still, can't talk, can't really interact with other people. On exam his muscle toner was very flaccid, but his reflexes were all hyper reactive. I spent a while with the mom trying to find a physical therapist and a child development specialist in Libreville, the capitol city. It was interesting to think about all the ancillary services that are available in the US (to varying degrees depending on where you live and how much money you have) that cannot be found here. Or they are extremely difficult to discover. Tomorrow I plan to call the pediatric hospital in Libreville to see if they have any leads.

I managed to convince a mother who was very reluctant to pay for surgery for her child with two broken arms (! fall from a mango tree!) to stay in the hospital overnight so that we could operate first thing in the morning. And, joy of joys, the tetanus child is still alive. We will see how he makes it over the next few days but I am cautiously hoping that he makes it out. We gave immunoglobulin, have valium on board to relax the muscles and calm spasms, are giving metronidazole as the recommended antibiotic, are lining up his tetanus vaccine to give him passive immunity, and are looking for esmolol. I have learned a lot in this case and will anxiously await improvement in his clinical course.

Bad day

Today ranks among my sheistier days here in Lambarene. There were some really sick kids in the hospital today and some terrible outcomes. The first thing that happened was a kid who arrived with tetanus. Straight out tetanic spasms, sardonic smile, lockjaw, arched back, and lack of proper vaccination (only one of three DPT vaccines). It was awful to see. The kid seems super sweet too. He kept telling his mom not to cry, that she shouldn't worry about him. But then when we gave him medicine and he went into deeper spams he started whimpering “je vais mourir, je vais mourir” which means I am going to die. Too freakin depressing. We looked up the dosage for tetanus immunoglobulin and then went to see if the pharmacy had some. They did. So I mixed up a big syringe full of immunoglobulin and adminstered it. Yes, that's right. Today I adminstered tetanus immunoglobulin. Never in my life did I think I would do such a thing. He is hanging in there for now, but we will see how it plays out. I am not too optimistic.

The other maddeningly depressing event today was the arrival of two day old twins in septic shock. We couldn't figure out a source or a causative bacteria so we put them on amp and gent, which is the standard when you don't know the source of infection. Then we waited. Within a few hours one of the twins went into arrest. By the time the mom alerted us, the baby was cool and very dead looking. We did CPR for 10 minutes while the mom and grandma cried beside us. It was so sad to hold a tiny dead baby in my hands and try to pump its heart and lungs back to life with no effect.

The Agony and the Ectasy

This morning two striking events occurred in close proximity to each other that illustrate the polar opposite of pediatrics both in the US and in Gabon. In the first case there was a young girl of five who arrived during the night with a peanut lodged in her windpipe. It was a big peanut that she had choked on and it was blocking most of the air in and out of her lungs. At some point overnight she went into cardiopulmonary shock and had to be resuscitated. This morning she was holding up alright on 5L of oxygen until we were about to start rounds. She went into arrest again and this time none of our efforts worked to revive her. It was crazy sad. Her mom, aunt, and GM all started wailing the child's name and other laments. The whole hospital kind of stopped to watch and listen, Just a very very sad scene all the way around for a child to pass away from such bad luck.

Not five minutes later I had one of my greatest successes yet. It drives me crazy when parents seem not to look after their children's health be it back home in Chicago or here in Lambarene. So when a parent really does take a close interest it makes me incredibly happy and thrilled. I had looked up an electrophoresis result for a recently discharged patient and it had come back positive, meaning that the girl had sickle cell disease. I called the mom's cell and she promised to bring the daughter the next morning (ie this morning). Not only did she show up on time, but she had lots of questions about the diagnosis and treatment of sickle cell. I wrote down a bunch of information for her and arranged our first follow-up appointment in a month to monitor hemoglobin and thick smear status. Satisfaction in the midst of an otherwise dismal morning.

Room for Improvement

(written Thursday August 19th) It's pretty amazing to think that I have been working at Schweitzer for almost three weeks now. Time flies when you are treating gastroenteritis and malaria, eating pseudo-European meals, and fighting off mosquitos after 6pm. Sidenote: even with 95% DEET on I am a freaking mosquito magnet. It's a good thing that there are few malaria carriers around the hospital and that mefloquin is such an effective prophylactic medication because otherwise I would certainly have had malaria 10 times already.

Tomorrow marks my ¼ of the time here and thus I would like to take a moment of reflection and respite. I have come a long way in my tropical medicine and medical French ways. I can take on and entire afternoon's worth of patients on my own. I am learning the names and dosages of European medications. Ca arrive. But I am also at the point where I can think about making improvements in my treatment of patients as well as how the pediatrie handles things. Thus I would like to send a special thought/question out to my medically minded family and friends: if you imagine yourself practicing medicine in a developing country, what kinds of things would you focus on for improvement? Specific knowledge base? Management of certain diseases? Approach/education of patients and their families? Community health mini-initiative? Any thoughts or ideas would be much appreciated. I definitely want to continually improve as a practioner while I am here so I will make a plan of attack based on people's input and my own reflection. Please email or leave comments. Thank you in advance and a toute a l'heure mes amis!

Gabonese independence

Yesterday marked 50 years of Gabonese independence from French rule. There was much drinking and carousing in the streets. Lots of yellow, green, and blue (the national colors of the Gabonese). Dancing. Parades. Fireworks. Surprisingly little political fanfare or discussion. I wonder what people really think of the French or of being a former colony. Whenever I ask people, I feel as though I don't get a straight answer. And I probably do not. For me the best part was that two of the French girls here had organized a soiree of Gabonese foods and one of the nurses at the pediatrie, who lives nearby, taught us how to cook some basic local dishes. It was fun to mash bananas the traditional way and to have everyone laugh at our inept whiteness. Plus some of the things are delightfully yummy like fonlon leaves, which are a creamier spinach.

Lambarene 10K

I have never regretted forgetting my camera more than I did yesterday morning. Today is the celebration of 50 years of independence for Gabon. There already has been drinking and carousing and there will be much more celebrating today. As part of the festivities, the mayor's office organized a 10K (approximately 10K, no one knows the real distance) road race yesterday morning. My roommate found out about it and invited me to come along with her. Oh the scene of it all! We took a taxi out to a police checkpoint outside Lambarene where we found about 40 people milling about with their tiny and brightly colored running ensembles. And oh the footwear! Most people were running in plastic sandals called jellies or barefoot. I could not believe it! As we lined up for the start I wished so badly that I had not left my camera back at the house. It was too incredible of a scene with all the young lithe men in jellies and tiny Gabon emblazoned singlets. There were three women besides me and my roommate to run as well. The first was a young woman who competes in track in Libreville the capital city. She was tiny and fast and beat us all handily. The second was a high school aged girl who ran in, yes, jellies, and had incredible blisters at the end of the race, but still beat me. Elise edged her out for second though. The final woman was about 50 years old and a total ham. I loved her esprit. As we wound through the different neighborhoods of Lambarene people all came out to the road to cheer for us and yell “bon courage”. I laughed with a lot of the people because I get really red when I run, which was a hilarious sight to them. Little kids ran with me, teenage boys ran with me, and at the end this super fast guy doubled back to run with me and coach me to the finish. It was very cool and felt a little like running a marathon in the US except it was tropical weather, there were no water stations, and government officials waited at the finish line here to clap for us. There was a trophy presentation ceremony at the end, and I got the “esprit de competition” trophy, which cracked me up. I think the race officials felt bad because Elise had won a 2nd place trophy and I won nothing. It also reminds me of how I always won spirit awards in high school athletics. At least if I'm not the best, than I have a good time with the competition! Once again, the internet is too slow to load pics, but Elise and I took a bunch of photos with our winnings after the race when we got back home. I'll post when I can. What a hilarious time though. Later today we'll head into town to watch the parade and celebration of Independence. A toute a l'heure mes amis!

Community Health at Schweitzer

This Thursday I went out with the community health nurses to do a PMI visit there. It was pretty fascinating. Allow me to explain. PMI stands for Protection Maternale et Infantile. It is the community health arm of the hospital and has been run for almost 30 years by a nurse named Maman Sophie who is famous throughout the region for her efforts. The nurses have a clinic here on the hospital campus where they do immunizations and weigh children. Vaccination is free up until 1 year of age, provided by the Gabonese government. They actually just got the Penta vaccines here (DPT, Hepatitis B, and HiB make it up, I think). In any case, it's a great early childhood vaccine. They also still use BCG vaccine against TB. The Schweitzer PMI have achieved great vaccination coverage for this region, averaging around 85% of kids vaccinated. For Africa that is an impressive number.

As I was saying they vaccinate kids here at the hospital, but also on community visits every Wednesday and Thursday. They have 16 towns around Lambarene that they visit on a rotating basis. When they arrive, they weigh all the babies. This was quite the scene Thursday as there were about 50 moms and babies waiting for us. They all rushed forward to get a little harness for their kid, then they strip them nude, load them in the harness, and hang the kids up on hanging scales. For some reason all the babies hate this and so there was a crazy ruckus with all these naked kids screaming and hanging on scales.

Once they get weighed, the nurses go through the kids' health booklets to see what vaccines they need. Then they give them out. Another wild round of tears. While the three nurses were doing all the vaccines, Maman Sophie and I did “consulations” together. Basically this means doing a little clinic visit together. We are in the midst of an intense gastroenteritis (vomiting, diarrhea) epidemic, so that was the majority of cases. There was also an impressive case of a little one with months of scabies burrows that the mom had not taken care of. Those things can really get situated in your skin if you let them. After Maman Sophie and I saw the moms, I would take them over to this ancient chest of drawers that contained all the medicines and would try to get out all of the medicines that they needed. At the end, Maman Sophie gave a talk about safe sex, family planning, dehydration, and education. It was community public health at its best. I really enjoyed getting out a bit and seeing how things work outside of the hospital. Its neat to see how this system of vaccination and triage works in Gabon and to note its success.

The local nourishment

A number of people have asked about this and so I figured it was time to discuss both the traditional foods of Gabon as well as the foods that I eat here. Obviously, the two do not overlap perfectly.

Gabon is an equitorial country and as such it is relatively warm here all year long. Also there are a uniform number of hours of sunlight every day. This makes for a strange and poor growing season. Two things grow naturally here. Bananas of a great sort and variety and manioc, which is a tuber similar to a potato. Bananas are eaten raw, but more often cooked like french fries, deep-fried in oil. Delicious and treacherous to the waistline. Manioc can be eaten both as the root itself, in which case you boil it, or you can eat the leaves, which look like spinach, sauteed. On its own manioc smells and tastes like vegetal sweaty gym socks. The leaves are very tasty though. I thought of them as a richer version of sauteed spinach. As far as other things that are grown here—and there aren't many things, Gabon imports almost all of its nourishment—there are mangoes, grapefruits, passion fruits, peanuts, and taro. Basically tropical fruits. Some places are also trying to get cocoa and coffee plantations underway.

As far as what I eat, this is deeply influenced by living at a hospital encampment controlled by a French administration. In short, I eat a nouveau Franco-gabonese style cuisine at the refectectoire, or cafeteria on campus. We have coffee and baguette for breakfast every morning. Always. That is the only thing I have eaten for breakfast here. I may die a carbohydrate induced death. For lunch and dinner, it is always a salad, a main dish, a side vegetable dish, and a desert. The salad is often shredded cabbage, cut tomatoes, or some lettuce. Then we have a meat entree, or grilled fish (which I prefer for obvious vegetarian reasons). The grilled fish is delicious and caught locally (in the Ogooue River). Some people eat the whole thing, head and all, but I have not worked up to that point yet. The side vegetable is usually aubergine, corn, or leek, usually swimming in a sea of delicious palm oil. Desert can either be fruit, or occasionally a small piece of cake or pie. In sum, we eat well. Like when I lived in India, I may very well gain weight in Gabon. At the supermarket, they also have a tremendous array of little cakes and biscuits as well as two fine local beers, Castel and Regab. In sum, Gabon is not my ideal gustatory zone but I am holding up pretty well all things considered.

Adjustements

I am quickly adjusting to life in Gabon and at Hopital Schweitzer especially. I still feel a little tired and stomach achy, but it is going down. To me, this indicates that my immune system is adapting to all of the new antigens that are assaulting it. I have also been washing my hands like a crazy person which I think has avoided any giant gastro-intestinal problems thus far. Interestingly I had a lot of problems sleeping the first few nights because all the noises kept me up. Now I sleep like an old log at night and during my afternoon siesta. The sounds of animals, people, wind, water, insects no longer bother me. Speaking of insects, on Monday we had a migratory ant invasion. Apparently, a huge column of ants arrived at 7pm and invaded the house. According to my roommate (I was out at dinner) they covered the drapes and the floor. She fought valiantly against them with water and bug spray, and was able to get rid of them. By the time I got home they were much less numerous. Still you could sweep up giant piles of dead ants and the kitchen sink was full of drowned ants.

In terms of hospital work, there is a French medical student working with me in pediatrie and we are seeing patients all by ourselves all day long. We do the newborn visits in the morning, help with rounding, see patients in the late morning and develop the treatment plans together. We even admit our patients and follow them in the hospital now. Most of the cases we see are gastroenteritis and malaria, but even with the trickier things we are starting to head out on our own. It's a nice pace of work. Sometimes I worry that we are going to screw something up for a patient, but I remember that you can get antibiotics at the pharmacy here without seeing a doctor and that a lot of people use traditional healers still, so we cannot be doing more harm than those two avenues of health care. I do need to organize what I have learned and my work into more of a guide though. That way I will become more efficient and be able to help out even more. For example, today we saw 11 patients in total. I think within a few weeks I should be able to see even more.

My first real patient

Not Crocodiles, Waterfalls

One instructive part about living in a semi-jungle is that plans change frequently and that you have to be flexible and go with the flow (toaist if you will). My roommate and I had hoped to go out crocodile viewing with a friend of a friend who studies crocodile biodiversity. He was going to take us this weekend, hunt some crocodiles in a nearby lake, catch them, tie their mouths shut and then take samples and pictures. But he ended up leaving at the earliest possible morning light, without us and our eager virgin crocodile eyes. So we had to retool our plans. I ended up going to a goodbye party for a Gabonese/German student who had been here the past months. This was a great success and interesting for its good mix of people from different parts of the world and different parts of the hospital and research center. Then on Sunday my partner in pediatrie who is a super French med student and I headed out to see the chutes de Fugamou, or les chutes de l'Imperatrice, named by a French explorer after Napoleon's wife, the empress Eugenie. It was a good day trip, both for the experience of traveling in Gabon itself, always by taxi and in a big group of people, and for seeing all these small villages along the side of the road. People here are accustomed to white people and unlike in India, no body begs. In fact, the only reason people approach you in general is to try and pick you up. Polygamy is relatively common here and a wedding ring is not even a mild deterrent. Anyway, Eve and I, the French girl, made it to the chutes in fine form. We even navigated the jungle-dense terrain on our own on the way home. A good weekend all in all. Just sans crocodiles unfortunately. A toute a l'heure mes amis.

Drama in Gabon

One thing that has been interesting in my first week is how communal the hospital experience is for patients. (Sorry that I did not write for two days family, I just felt fluish and under the weather and slept a lot, apparently this is a common reaction to arriving in Gabon. It's a full on immune system attack so it takes a bit of time to adjust.) Patients are kept three to a room and everybody knows exactly what is going on with all the different babies in the room, they help each other out, they answer each other's questions from the doctor. There is little concern about health care privacy. Even clinic visits are done two to a room. There was a particularly dramatic example of this communal health care on Thursday when a 14 year old girl who had arrived 3 days earlier from a small village with a premature baby that she had just given birth to that was all floppy and weak asked to leave the hospital. She told us that her father had called from the village and wanted them to come home. The main pediatrician refused saying that the baby is too weak, which he is. He barely breast feeds and only takes 2ccs of breast milk every few hours through a naso-gastric tube. The girl insists. Then the nurse gets the father's phone number and calls. He has not asked for any such thing as the girl returning to her village. Clearly she wanted to get out and this was her ruse. Interestingly, the nurse (and nurses do a lot of public health type stuff her with what they say to patients) announces to everyone in the room what the girl wanted to do. All the moms start in on her about how she has to care for her baby, does she want a dead baby, what will she do when she shows up at the village with a dead baby. The other nurses start nagging her about staying. It was as if the small pseudo-village in the pediatrie waiting room rose up to issue collective advice and pressure. I had never seen anything like it in the US. And what did the young mom do? Of course, after all that, she stayed.

La Palu, or Malaria

Before I came to Lambarene I had never seen a case of malaria. My first day here I saw 15. It is incredible the time and resources at the hospital that are dedicated to malaria, just a huge percentage of what we do. Then when you imagine how much time and energy it takes for the families to come to the hospital, scrape together money to pay, time off work, worry for everyone involved. It is just an enormous amount of stuff in this country decimated by malaria. Even though we try to give out mosquito nets and tell people to have little ones sleep under them, it still dominates the health care scene here (Unicef article on the current state of the fight against malaria). Briefly, malaria is a parasitical infection caused by one of four main parasites (here is Gabon, mostly falciparum). It enters the blood by the bite of a certain kind of mosquito. Then the parasite multiplies within red blood cells until they are so many that their mass causes the cell to lyse and they all rush into the blood stream causing a fever spike. Each parasite has a specific reproduction cycle length, giving a specific every 48hr, 72hr, or 96hr fever. Malaria also gives headaches, vomiting, loss of appetite, and (possibly) severe anemia. It can also cause neural malaria, which is the worst and deadliest manifestation possible. If I get back to the US and there is a malaria case, I am going to manage it like no body's business. As a sidenote to my medical school compatriots- I had somehow remembered that sickle cell disease is protective against malaria. It is not. Sickle cell trait is (and even then they can still have mild cases). Sickle cell disease gives a terrible malaria with worse anemia than otherwise. A toute a l'heure mes amis.

La Pediatrie

As I now have two days of working at the hospital under my belt, I think I can talk a bit more authoritatively about the daily schedule. It is both similar to medical school rotations in the United States and crazily different. First thing we do is gather to hear about the patient's overnight from the nurse who was on call. There is no doctor who takes call normally. The nurses just have everyone's cell phone numbers and they call if something really serious is going on. The report also consists of kids who had fevers, and the rest is "rien a signaler" (nothing to report). Next we round on all the patients, the first day there were 44, this morning there were 40. Patients are 3, to a room, or if they sick/premie babies there are 4 incubators, 2 to a room. We chat with each patient, look at their hemogram if they have one, and then move on. There are no daily notes, certainly no daily labs, and a very difficult to learn formulary list of medications. Rounding takes a couple of hours. Then we go do newborn baby checks, which I loved in Chicago and continue to do so here. Next we start "consultations" which are basically clinic appointments. These run until 1/2pm, we have lunch, come back and finish up with consults who need lab results returned to them and anyone else who may have straggled in. But at any point if there are emergencies or things to talk about then we do those things as well when the moment calls for it.

So far that about makes up my day. I work with an ever changing team of French/German/Gabonese/Togoan/Guinean doctors which also makes things interesting and spicy. I took some pictures today and will post them soon. A toute a l'heure mes amis.

Baby CPR

First day today-- totally exhilirating--I loved the hospital experience. I'll write tons more later, I'm just super tired. Let's just say my first act of the day was to perform infant CPR on a 1-day old baby born premature at 7mos. And it lived! Now that is a crazy way to get started with you big hands holding the delicate chest of a 1,2 kg baby and pressing you two thumbs against its tiny thorax. A toute a l'heure mes amis!

Albert Schweitzer, back story

After writing yesterday about the basics of Gabon, I thought today it might behoove me to write a bit about Albert Schweitzer, the man who started the hospital at Lambarene, where I begin my work tomorrow. Once I start work, I can start explaining the hospital and my patients.

So, notre grand Docteur Schweitzer was German-French, having been born in 1875 in Alsace. He initially was a theologian and distinguished himself by writing a famous treatise on the historical Jesus. Along with his theological doctorate, he was also well-known for his masterful organ recitals and seminal work on Bach. In 1905 he read about the Paris Theological Mission's call for a doctor to come to their mission site in Lambarene, Gabon. Although he had no medical training and disagreed with much of their theology, he embarked upon a 7 year process of obtaining a medical doctorate so that he could serve as their doctor and "make his life argument." Schweitzer also argued that rather than preaching to Africans about Christianity, dedicating his life to service in Africa would allow him to show compassion and humanity directly.

After he obtained his medical degree, he and his wife moved to Lambarene, started building the hospital, and saw patients initially in a converted chicken coop. He worked at the hospital most of the time until his death in 1965. He also spent time abroad, giving speeches and organ recitals to raise money for the hospital. In 1952 he received the Nobel Prize for Peace for his work. Discussion and criticism of Schweitzer linger, and probably always will, as to whether he bore paternalistic attitudes towards local Gabonese staff and patients. Regardless of what you think about that question, and how you judge Schweitzer's attitudes, you cannot dispute that he followed through on commitment to moving to Gabon and serving as a doctor here. That shows incredible strong will, faith, and dedication. Coupled with his diverse intellectual achievements and engagements, I find Schweitzer personally relevant and inspirational in my life.

Gabon, the back story

A few of you may be wondering, as I did when researching the Lambarene fellowship, where is Gabon? And what is the story there? I'll give you a few lines of background so that the rest of my time here will make more sense to you. Thus, as a point of departure, my current location: Gabon is an equitorial country on the West coast of Africa, bordering the Atlantic, often referred to as the Last Eden as over 85% of the countryside is still covered with rainforest. The town of Lambarene is located 200km inland on the Ogooue River, Gabon's largest and longest river. Schweitzer chose this location because the river afforded him the ability to float all of the construction and building supplies to the site. Amusingly enough, Lambarene is south of the equator while Libreville, the capital city, is north of the equator so when we drove in from the capital, I passed from "summer" to "winter" in a few short hours. The notion of seasons doesn't quite work out near the equator, apparently here there is a hot wet season and a hot dry season. We are in the hot dry combination right now, which the locals call the "bon temps". It is surprisingly nice. Cloudy, but high 70s to mid 80s both days that I have been here.

Ok, we've gone through geography and climate, now a tiny bit on history and culture. The area that comprises Gabon has been inhabited for thousands of years, unsurprisingly, since it is Africa. The pygmy tribes were the most numerous for much of that time, only to be pushed out by the Bantu, who remained the dominant tribe until the French arrived. The French officially entered Gabon in 1885, though Europeans such as the Portuguese and Dutch had been there in various capacities since the 1500s. In 1910 Gabon became one of four "French Equitorial Colonies" and remained a territory until 1960. On August 17, 1960 (50 year anniversary this year- it's going to be a big celebration!) Gabon gained independence from France. The first president of Gabon, elected in 1961, was Léon M’ba, with Omar Bongo Ondimba as his vice president. Omar Bongo became president in 1967 and remained so until his death in 2009. His son, Ali, succeeded him with a landslide victory in the polls. Gabon is often touted as one of the richest Africa nations, with a per capita income of $5000 annually, but I think the figure is skewed by the petrol companies operating off shore here. Fundamentally, the country remains an impoverished tropical nation, straddling modernity (cell phones and satellite TV) and poverty (living in huts without electricity or running water and turning to a traditional voodoo sorcery belief system in times of need). It will be interesting to start my time here on Monday and start interacting with locals on more than a bonjour basis. A toute a l'heure mes amis.

PS I wanted to post pictures today of the landscape, but that would have required a functional converter to charge my rechargable batteries. I know where to buy a good converter and I will do so soon so that I can start showing, as well as telling you about the land.

J'arrive, j'arrive!

Just a quick note to report that I have safely arrived at the Albert Schweitzer hospital in Lambarene as of two hours ago! I should win a medal for best arrival at a third world airport ever as well. If you have ever flown into an airport in a third world country, you know it can be a little bit of a circus with crazy crowds, people grabbing at your luggage, long and inexplicable lines at passport control and customs, and missed connections with people who are meeting you. With all of this in mind, I flew into Libreville, the capitol city of Gabon, fully cognizant that I needed a back-up plan and a back-up back-up plan. There were a few things going in my favor for this to be a successful trip. I had flown Lufthansa all the way from Chicago to Libreville and it was comforting to arrive at the unfamiliar in a familiar way (hyper-efficient German sandwich and coca-cola dealing stewardesses with a mixed bag of international travelers). Also I had made good contact with the directrice of the hospital two weeks ago to confirm my arrival and send my picture. And my flight was only delayed by 30 minutes. Still I had some butterflies in my stomach. Imagine my grand surprise when passport control passed mostly uneventfully, my bags were waiting for me circling the carousel, no one looked at me twice through customs, and two people from Albert Schweitzer were waiting for me literally outside the door of customs. Parfait! We went to a nearby hotel to spend the night, took much of the next day (today) buying provisions in town for the hospital, and took to the road at 3pm arriving at the hospital by 7pm. I'll have much to say by way of background on Gabon, Schweitzer, medical practice here, but for now the most important thing is: I'm here. I'm safe. I have the whole weekend to figure out how things work around here, the lay of the land, and where I have to go to work on Monday. A toute a l'heure mes amis.

Background

Hello friends and family and potential internet travelers,

My name is Sophie and I recently finished my third year of medical school at the University if Illinois in Chicago. In a few days, I will be on a plane to Gabon for 3 months of internship in pediatrics at Hopital Albert Schweitzer in Lambarene, Gabon. I plan to write about my time as a way to keep in touch with all the good people in my life, to reflect publicly about medicine as service, and to give people a sense of what practicing medicine in the developing world is like on a day to day basis. I leave on July 28th for Africa, part of a multi-day journey that will land me in Lambarene about 56 hours after I take off from Chicago. Right now, I am excited and apprehensive. Excited because I see this as the capstone of my medical education and because I have never been to Africa before. Apprehensive because I have spent the last months studying for Step 2 and finishing third year of medical school so I do not feel prepared for this. I understand that there is no way to fully prepare, but I have not even cracked my guidebooks. Oh well, that's one of the good things about having flights scheduled, you can't push something back, you just have to get in there and start going. If you are interested in following my time in Africa, please bookmark this page and I will reciprocate by blogging frequently. The next time I write will be next week in transit or when I am actually on the ground! Unbelievable. Until then.