Lost at sea

This post has nothing to do with Africa but with another life I once had, that of an offshore sailor - so long ago I sometimes wonder if it really happened.

I'm not sure if you've seen the news, but a 25 year old Canadian woman (named Laura, who'd lost her mom to cancer when she was younger) went overboard off a tall ship on Friday night. They can't find her.

Its amazing how much this single person - who I've never met, had never heard of before Friday - has brought back my experience of falling overboard, in the middle of the South Pacific Ocea, over 1500nm from anywhere (back when I was about 25). Last night I laid awake thinking about how I could have been just like her, disappeared without a trace.

The Picton Castle was in 7m swells, and it was night time (9:30pm) when a wave washed over the boat and swept Laura into the water. The crew threw life rings & life jackets into the water to mark the spot & give her something to hang on to, they sent out a mayday and the search started. That was more than 48 hours ago, and they haven't found her despite the ongoing search by a tanker, the Picton Castle and US Search & Rescue.

When I went overboard, it was day time. That was the biggest thing that saved my life that day. I also managed to grab the side of the boat and then onto the fishing line and hold on for a little while - long enough to know they'd seen me go. Even then, the stuff that they threw was a ways away from me. When I was at the top of the swells (they were around 5-6m), I could see the man overboard pole (which is about 8ft high, with a bright yellow flag to mark the person in the water), and the white ring and was able to swim to them. By the time the boat came to a stop and a dory launched, they were a long way away from me; only the pole marked my position. The open ocean is so featureless, so changing, and the boat is floating on the top, turning with the wind and waves... its nearly impossible to find an object that isn't well marked.

When I was in the water, I knew the Swift would find me. I knew they'd seen me go, and I was hanging out next to the pole; I wasn't even frightened at the time (just felt really foolish). I can't get out of my mind what it would have been like for that other Laura, in the pitch black. Maybe able to see the boat but knowing that they wouldn't find her.

My thoughts and prayers are with that woman and her family.

Ouagadougou and back again

With the slow progress and the fact things seem are more mundane, there doesn't seem to be as much to write about lately. We spent last week at the First Annual Mother-Infant Congress in Ouagadougou - basically, a joint meeting of the Burkinabe Pediatrics & Gynecological societies. It was good to be there, and make some more connections. I've never seen so many retrospective chart reviews in my life (without understanding of their limitations)! There were some useful studies though.

We visited the main hospital in Ouaga and were impressed by their malnutrition service; they have dedicated nurses, WHO-based protocols and the hospital provides the ingredients for the therapeutic milk. Each meeting and site visit gives us more of an understanding of how things work (or not) here. I think we are slowly convincing people that we are interested in integrating into the existing system. All 4 of us are anxious to start doing more HIV related clinical work. The 3 pediatricians will continue to look after the Over 3 Ward in 2 week blocks. After Christmas in addition to taking my turn on the ward, I will spend a couple weeks at the TB clinic that currently sees the few identified HIV/TB infected kids - will work on developing those partnerships.

Our major focus over the next while will be to work on getting kids tested for HIV. There are around 1500 "Orphans and Vulnerable Children" (that is, children of parents with HIV)registered with the various agencies and only about 20% have been tested. Plus, few of the kids in hospital are tested even though in our hospital about 10% of the inpatients are HIV+. And we are also working on linking with programs that work to prevent mother to child transmission of HIV - those kids are nearly all lost to follow up.

For a variety of complex reasons, I have decided to go home for Christmas - will be swinging through Baltimore, Calgary and Victoria. I am worried about the cold, and the culture shock. So many things took some getting used to all seems quite normal to me...
... most consumer goods are sold from roadside stands, from the clothes from bales of used clothes sent from North America, to hardware (hammers & nails), to artisanat, to fruit from the roadside table that I pass each afternoon on my way home...
... everytime I am in town men wave cell phone recharge cards in my face (OK, I still don't like that)...
... people (away from the sellars of artisanat and the market vendors) are so polite, and kind even to strangers...
... most school age kids I pass stare and call "toubabou, toubabou" and smile their beautiful smiles...
... the roads are all unpaved, rutted red dirt roads that require one to pick their route carefully through on any kind of vehicle...
... kids in the hospital arrive far to late because their parents have no money, and even then sometimes can't buy the medicines they need....
... the taxis are dilapitated vehicles that you would wonder that they are still on the road, no mirrors, door handles usually broken off...
... in the mornings people are people are dressed in toques and heavy coats to ward off the cold - and its rarely colder than 18C (and worse yet, I need to wear a coat to ward off the cold)...

It should be interesting, at any rate. I am really looking forward to spending some time with my friends & family and putting some perspective on these last few months.
Take care!
Laura

winter time

Well, its officially winter now. When Bertand, our taxi driver, picked us up for a meeting this morning he was dressed in toque (thats a woolen cap for the Americans) and down jacket. My guards are similarly dressed, bundling to keep the cold away. The daily high temp is 34C (or 92F)! I can't imagine how people tolerate being bundled up like that. Though it is cold at night right now... well, cold is relative.... its getting down to 15C.

This week we have been visiting the various "associations" - local non-profit groups that work for people living with HIV / AIDS. I have been really impressed by their motivation and hard work. There are many of these groups in Bobo, and they have a variety of activites, including voluntary counselling and testing (mostly of adults), treatment (of adults - the kids are refered to Dr. Nacro, with whom we work at the hospital), nutritional support (through donations from the World Food Programme), and various psychosocial activities. They provide much of the psychosocial and drug adherence support as well.

I'm also spending some time in the microbiology lab at the hospital, and one interesting lesson is that the way things are perceived on the wards is not necessarily the way things really are - thats very true in Canadian hospitals too by the way. I was struck though by the disconnect between what the lab director says is available, and how long things take, from what we were told on the pediatrics ward. It will be important for us to build this relationship I think. And work on the systems problems within the ward that are keeping us from getting the tests we do think are important.

Take care - and be careful in the slippery roads & real winter weather that I know many of you are facing.
Love
Laura

Happy American Thanksgiving!

I haven't been writing that often lately as there isn’t much exciting that’s been going on. For American Thanksgiving on Thursday we were invited a fellow American’s house for dinner, which was really lovely.

I had a lovely but quiet weekend – mostly took it easy and worked on our day hospital proposal. After traveling for so many weeks, I was really glad to stay at home, putter in the garden, and start reading my stack of new novels – I bought some in Kenya, and Claire sent me some. I started my Christmas shopping at Adama’s little artisanat stand; Adama helped me get me telephone hooked up (he’s a friend of the house owner’s nephew who manages the house). Despite being in the artisanat business, he is like a typical Burkinabé person; really friendly & open (and chased away an annoying batique seller who came running up when he saw a toubabu at an artisanat stand); we sat and drank tea, and he taught me anwali, which is an African board game (I think there are versions in most countries). I’m glad to buy things from people who are honest salesmen like that!

Work has mostly been focused on writing our proposal for our clinic; once we have completed it, we hope that BIPAI will help us identify and find the resources we need to provide the level of care we want to provide. We’ve divided up the tasks (both of the proposal and our other work) and one thing I’ve been working on is forecasting numbers of patients & necessary medications and supplies…. I just wish I knew what I was doing! Its interesting trying to put on paper what we’ve learned about the health care system and HIV care here.

The Clinton Foundation has arranged a large donation of all 1st and 2nd line antiretrovirals, cotrimoxazole prophylaxis (to prevent infections in HIV exposed children), testing reagents to provide free HIV testing for kids and a nutritional supplement. That should arrive in January and will be a huge help to our work here. The more challenging problem will be finding funding for some of the other medications for treating opportunistic infections (not to mention the regular problems of childhood) and supplies for treating children with severe malnutrition. We are trying to sneak malnutrition into our HIV clinic because, well…. how to put it diplomatically… that is the biggest weakness we’ve recognized in the general pediatrics care of children here.

By the way, the American issue of Time that has just come out (see http://www.time.com/time/magazine/current) will have two articles about BIPAI and the pediatric AIDS corps. Nothing about Burkina of course, but it does talk about the program in general.

Ouagadougou again

I had brief weekend at home to check out the garden and eat very many cucumbers... the photo is my gardener, Moussa - who has provided all the labour for this gardening project - in between the cucumbers and the basil. Against the wall are the tomatoes, and in the foreground the zucchini. I'm really pleased and I think Moussa and I get along well. I'm looking forward to being at home for a while after this current trip!

Then, it was back to Ouaga... I tried to fly but the flight was cancelled (another mechanical problem) so ended up taking the bus. Its not as fun to be in Ouaga on my own, though I've still had a few really good meals and I've enjoyed the internet access. I head back to Bobo Wednesday.

I've had productive meetings with UNICEF, and some Ministry of Health people about training sessions. We are hoping to fairly rapidly train the physicians who do primary care at regional hospitals to look after kids on ARVs. Right now, they're pretty uncomfortable starting kids on treatment so no kids get started.

At home, my colleagues have been working hard on putting together a proposal for our transitional clinic; BIPAI will help us find the resources we need to get things going. We've divided the tasks to try to be more efficient.

The weather seems cooler now, especially the early mornings - though part of that is just that it is much less humid. And our perspective on what is "hot" is changing... getting off the plane in Bobo the other day, it seemed refreshingly cool... so it was a surprise to hear the pilot say that it was 26C. The rainy season has ended, so we won't expect any more rain until June.

Take care, Laura.

If its not a good time, its a good story... part II

Well, we made it back to Ouaga but our 3 day journey home has turned into nearly a week. We spent Sunday going from Lusaka to Nairobi (normally a 2 hour flight, but from hotel room to hotel room it took us 16 hours...)... then we had a day in Nairobi, Kenya, where I did some shopping and got things that aren't available in Bobo and had a wonderful afternoon with my friend from fellowship, Maryanne. Nairobi has nearly everything a person could want... the grocery store was overwhelming it was so enormous. We spent Tuesday flying from Nairobi-Bamako, Mali-Burkina. Were we ever glad to get off the plane and into the familiar streets of Ouaga.

Now we're in the middle of a couple days of meetings etc here in Ouaga before we head back to Bobo on Friday. We met with the American embassador today; strange to go in through all those layers of security... even stranger that the American embassador really wanted to meet us! But besides the work, we heard all about what things go on in the American community here.

We are all really looking forward to getting home to Bobo - despite the lack of material goods, and fancy malls and restaurants, its got a certain charm... and its home for now.

A plane with a flat tire !?!

Our week in Malawi has drawn to a close. Its been very interesting to spend some time in an existing center, and see what is possible. We spent a fair amount of time meeting with various staff and learning about their perspectives and advice on starting a new program.

The Malawi clinic is much like a clinic in North America; clean, new exam rooms with sinks, computers, examining tables and otoscopes. They even have tongue depressors. The cleaning staff wash the floors about three times a day (though ironically, it is a little hard to get the soap dispensers filled). Upstairs is a room of 4 desks & computers for the 13 PAC docs to share. They have a reasonably fast internet connection, which we definitely took advantage of.

We spent some time sitting with the PAC docs while they saw patients; it was neat to see some actual HIV patients. They have clinical officer students (they are the first line caregivers in Malawi; they have 4 years post high school training) who help with translation, and in return they get some teaching. The clinical director is a world expert in malaria, but also has an enormous font of HIV knowledge and experience, as does the other Malawian staff physician.

I actually had quite mixed feelings about being there, because is sure highlights everything that we don’t have…. materials & supplies. free medications for the kids. administrative staff. clinical support. help to figure out how to navigate the HIV treatment world of Burkina and get what we need. What we do have (which the other PAC docs don’t) is the freedom – to hopefully set things up the way we think they should be, to set our own priorities, to set our own hours (which end up being longer than that of the folks in Malawi – but we choose which hours they are). I wish we could have some level of support but still be able to play a crucial role in the design and running of this clinic. As always, David is the most helpful of anyone, and clearly knows how to get things done, where to get resources. His long experience makes him an invaluable resource.

For us, Malawi seems so Westernized… there are so many NGOs, so many foreigners – hundreds of project vehicles. Its interesting, because with this has come a huge industry of Western-style coffee shops, restaurants and stores that to us seems incredible. Although, as in Burkina, many Western luxury items are really expensive for dubious quality.

I’m actually writing this from the departure lounge in Lusaka, Zambia – when we landed on our stopover, the runway was so hot that it blew out 2 of the tires. So, we’re waiting while they try to replace the tires & repair the mechanism – or failing that, send a new plane from Kenya (a 3 hour flight from here). I am dreaming of the dinner I am supposed to have with my friends Maryanne & Doug, a home cooked dinner that I have been looking forward to for weeks…. that sadly, may not happen. Ah well, the perils of international travel.

…. An update ….

So, my lovely dinner with Maryanne is on hold indefinitely as the flight was cancelled. We’re holed up in the Intercontinental. As always when flights are cancelled, a chaotic scene at the airport, with uptight passengers, a lack of information and general chaos. Those who know me well may be surprised (or doubtful to hear) that traveling along I don’t get too uptight… but in a group of 4, I do absorb some of the anxiety of my traveling partners, despite myself.

Malawi - the BIPAI Network Meeting

Well, we've had a productive several days in Malawi at the network meetings. Great to see all the PAC docs and BIPAI staff from all over. The people in the other countries are doing some really neat projects and some great work in all sorts of areas of HIV care of children. We're all learning lots, and the staff of BIPAI are very creative at finding solutions to lots of different problems regarding the care of kids with HIV.

Unfortunately, we didn't get to present as we weren't informed of the potential to do so until after the schedule was full.

The downside of seeing everyone is that we realize how much support etc the others have. Though its a trade off; with support also comes less freedom. We are thankful for the freedom we have, and to be starting a program from scratch is an amazing opportunity - just the kind of thing I want to know how to do. We just often wish we got some feedback / support to know if we're on the right track, or to let us know if there are avenues we should be exploring etc. So, we're going to try harder to ask more for things that we need / want, and for feedback etc. And we're sticking around here next week to see more about how they do things in Malawi.

One person suggested we should bail and let someone more experienced do this; and I have to say that I don't like that idea one bit. I really, really want to develop this program. I would just like a little advice now and then to help guide us, or even encourage us.

A real highlight was our visit today to Chiwere, David Jones' village - well, not exactly his, but his adopted village. On a hiking trip he met some motivated villagers and then helped them create a community-based orphan / vulnerable children (OVCs) support program. Now the 277 AIDS orphans in the village have been tested, those that need are on therapy, and they have food and other support through a variety of activities. They have a singing and drama group as well. We had a wonderfully warm welcome from the children and the NGO volunteers, with singing, dancing, poetry and a drama. It is just so neat to see how pround they are of their activities. David has said (and I think he's got a good point) that the real battle against HIV in much of Africa won't be fought in the fancy COEs in the capital cities... it will be these small scale, grassroots responses that will be the key to surviving this pandemic.

I don't know how much I've mentioned David; he's one of the Vice Presidents of BIPAI, and I have a world of respect for him. At first glance, you might think him an average administrator, but he is anything but. As far as I'm concerned, he is the key to the success of the AIDS Corps, though he doesn't get much credit. He works quietly in the background, but after 5 years of living in Malawi, and being really touched by Malawi and its people, he really understands things here, and how to get things done. And he keeps us sane, especially us in Burkina Faso who have no other administrative support from BIPAI.

PHOTOS: The first photo is David, and the orphans & vulnerable children. The second one is two orphans, and the final one is 5 of the orphans singing us a welcome song, with the other kids in the background. I can't begin to describe how touching the whole day was.

A weekend off: Lake Malawi

We’ve just returned from a really, really wonderful weekend away at Mumbo Island, on Lake Malawi. “We” is Dana, Allison, Leah and myself. It was a 4 hour drive down to the resort at Cape MacLear on the southern end of the long, thin lake. The water was incredibly blue, with lots of jacaranda in bloom and bougainvilleas everywhere, bright with red, orange and pink flowers. Despite being the hottest time of year here in Malawi, its cooler than at home in Burkina, so we are enjoying the relatively temperate weather (30C during the day).

The 10-km boat ride took about an hour, and as we approached, we could scarcely believe our eyes, a small islet with 5 permanent tents (tents with a thatched roof over top for shade and rain protection, and on the main island hiking trails and a white sand beach with kayaks, snorkel gear, and the main lodge.

We spent the last few days languidly moving from snorkeling to kayak trips around the island, to sunset cruises (well, cruise may be an exaggeration – 10 people in a 15 foot wooden boat with an outboard motor). The snorkeling was better than I expected for a freshwater lake – lots of brightly coloured chiclids (a type of freshwater fish), and the chance to watch cormorants swimming underwater. Leah and I kayaked around the island in about 45 minutes. The meals were lovely.

All in all, it was a wonderful break – good to get some space from the annoyances of work, to help work on keeping some perspective. I feel totally rejuvenated (though I got a terrible cold yesterday). Made me remember how important it is to keep some fun in my life. Since moving to Burkina Faso, I have done very few fun things, besides a little reading, knitting, a concert and designing my garden. Not enough activities that totally separate me from the work. I will work on doing that more!

Anyhow, please do keep in touch – the emails / comments from folks really are important to me, they encourage and sustain me during the lonely times, of which there are quite a few.

Take care
With love
Laura

Dakar – its all about the work

Its been hard to find time to write lately. We spent 3 days in Dakar; hardly left the hotel so I’m not in any position to comment on Dakar, other than to say it is MUCH more cosmopolitan than anything in Burkina – high rise buildings, traffic jams, smog – the whole 9 yards. The food was really good, and women dress very well. The hotel had a beautiful, large pool overlooking the ocean.

But, as geeky as it is… the highlight of the time in Dakar was the work. We made lots of great contacts with people working on various HIV projects across West Africa; some really innovative, others very much needed. The participants were all passionate about decreasing the burden of HIV on the population, whether their role was community mobilization or scientific studies. We made lots of great contacts. Really inspiring people working amazingly hard to lessen the effects of the disease on their community.

In the interest of disclosure… the meeting was a Bristol Myers Squibb sponsored one, and we spent much of the time with the president of the BMS foundation – a guy with control of more money than I will be able to even imagine (the Secure the Future grants, just one small part of his money to give away, was $115 million). Its weird, and not always completely comfortable to think about that my salary and much of my budget comes from “big pharma” (it goes against my social justice bent)… but, to be honest, I am really grateful for how strongly they feel about AIDS in Africa, and how much they believe in us and our program.

A highlight was Île Gorée, which was one of the slave trading outposts… a world of contrasts, of physical beauty with palm trees and white sand beaches with the terrible history of people’s inordinate cruelty against one another. The poverty of the islanders with the tourists who walk through every day.

Garden update

I forgot to add... My garden (after 6 weeks) is coming along nicely – there are lots of baby tomatoes, all still very small & green, and cucumber & zucchini flowers. I’ve been eating basil, spinach, green onions and lettuce too. There are 3 huge and one smaller basil plant, two of which were from seeds; enough for a very large supply of pesto. It will be interesting to see the change after 3 weeks of traveling! I am hoping the veggies hold off until my return. Here is the back garden again (in the photo, the front garden doesn’t look much different although it has filled in quite a bit).

heading out

Well, last weekend was the end of Ramadan, the biggest holiday of the year in this primarily Muslim country. I had a mostly quiet weekend, with some fun things thrown in. Good distractions from work, like a concert, a swim at my friends Dana & Allison’s house, and an Eid luncheon, where we ate a lovely meal and had some music – the kids just LOVED the digital camera, and laughed and laughed at their photos. (The musician hasn't been to Toronto - our host of the event brought the t-shirt back from the AIDS Conference in August).

Tuesday we headed to Ouaga where we’ve discovered a few more good places to eat – very exciting! And also had some productive meetings. Tomorrow I head to Dakar, Senegal – which is supposed to be fascinating, but very dangerous – for a couple days, then on to Malawi. In Malawi we will be having the BIPAI Network meeting, and it will be great to hear what the other sites are doing. Hard not to feel frustrated about our slow progress, but we are making progress nonetheless.

Anyhow, have a lovely week.
Laura

Thoughts on a stressful week

As an ID fellow, we tend to have a lot of time for each patient; we carefully think through each potential diagnosis, how to test for it, the possible treatments. That pace actually suits me quite well; I really like having the time to think carefully through a decision or a patient. I like having as much information as possible. I'm not one for snap decisions...

The style of medicine here is anything but that. Instead, its rushing through the patients, rapid fire. Trying to get through them all before I’m abandoned by nurse and/or intern because I’m taking too long (we round from 8:30 – 12:00; any later and the nurse & intern become mutinous). Struggling with the medical jargon in French, and unable to speak with most of the parents directly. Knowing what the recommendations are, but unable to do them because of “lack of resources” – or lack of will on the part of the hospital. Not knowing the system well enough to get things done. If investigations are done at all – and often the orders are just ignored – they happen the next day.

Some of the kids, so sick when they come in, get better quickly and go home. Actually, that’s most of the kids – its malaria season, so there are at least 10 admissions / night of various forms of severe malaria. Most of them get better quickly with IV quinine. That is so nice to see! But then other kids don’t have malaria… its hard to get other investigations done to sort out what they have. Those kids, I would love to have the time to work through carefully; but there is so little time and so many kids. And sometimes the parents have no money to buy the needed medicines (usually antibiotics).

I know that I will get used to it, and the language get easier, and I will get to know the hospital. Its hard to be patient for those things to happen though! There was nothing else this week besides work, Jula lessons and sleep. No energy for anything else!

However, we did go to a concert at the French Cultural Center Friday night, which was fun – it was really good to get out and do something social.

This weekend is a long weekend here, the end of Ramadan. And then, on Tuesday we head to Ouaga – by plane this time!! Hopefully no misadventures like our last trip. And then on to Dakar for a couple days and Malawi for 2 weeks. We’ll have a long weekend in the middle to do some exploring in Malawi. By the time we come back, my garden will be full of tomatoes, cucumbers, and zucchini as they are all flowering now.

the Pediatrics Ward

OK, so now I am really working. I'm exhausted, and very stressed. (warning... much jargon ahead... I apologize for the medical entry... )

The peds department is organized into 4 wards - Urgences (emergency / "intensive care"), over 3, under 3 and neonates. The doctor who is supposed to be on Over 3 is on Mat leave - so there is no doctor (that's where we come in). And the intern is sick - though yesterday & the day before I shanghaiied another intern into working with me. Today I was on my own. I have never seen so many patients in one day in my life... and in a foreign language (as it turns out, there are VERY many french medical words that I don't know... words that are part of my every day vocab in English....), and the parents rarely speak French, and the nurse doesn't seem to like being a translator.... I think I saw about 45 inpatients.

It is a frusterating ordeal mostly... hard to get the tests done that I think are absolultely essential ... things like malaria smears, blood counts, etc. So, I'm making decisions based on a partial history, physical exam (but no otoscope) and usually no investigations. Sometimes you prescribe antibiotics and the parents don't buy them - so the kid goes without. Other times, they buy them but for unclear reasons, they aren't administered - or they're administered but not recorded. Sometimes the pharmacy dispenses a different medication than is ordered. It is so exhausting that I have more sympathy for the MDs that never work on changing anything.

Some of the things that I want to do - based on WHO recommendations - are not whats done here, so the nurse doesn't like them. Things like, giving de-worming meds to anemic kids and giving a second drug with the artemesinin compounds. Some recommendations that are proven to improve child survival are not available - like zinc tablets for kids with diarrhea. (And I haven't even seen any kids with severe malnutrition on the over 3 ward, so haven't tackled that yet).

The doctor who works in "Urgences" said to Dana & Suzanne - thank God the kids mostly look after themselves, because we sure can't look after them. Its sadly true. There is such a shortage of personel, tests, drugs, and willingness to get things done. Its really hard.

Anyhow, its sure to get easier with time.

Week 2 in the periphery

This week was another informative week. I spent the first 3 days at CSPS Farakan, a clinic where women are actually offered prenatal HIV testing – and if they are positive, they are referred into a study that provides free treatment, including all medications necessary, and if wanted, formula to help prevent mother-to-child transmission of HIV. (Its such a good deal that the consent process is almost coercive – no woman could turn down free care for herself & her baby, plus free ARVs, plus maybe free formula!)

Testing of people over the age of 18 months costs 500-1000CFA though it is supposed to be offered free to pregnant women as part of the free prenatal care. PCR testing (the test you do on children under 18 months) costs 10,000CFA – not affordable to anyone here (remember than most people live on less than 500CFA / day). So in effect, they only diagnose HIV in kids over 18 months.

I watched a “sensibilisation” session – the assembled pregnant women sat on a bench and looked at their toes uncomfortably, while the midwife appeared to be haranguing them… it was in Jula, so all I could understand was the word “SIDA” which appeared in almost every sentence. I wondered what she was saying – although no one filled me in.

The moto riding is going pretty well – though still a bit frightening. I rode to work every day this week, a 20-minute drive through parts of town that were new to me. It was neat – although sometimes I was so interested in what was going on around me it was hard to focus on the road.

I stopped one afternoon to buy a pottery plant pot. Everyone tells me that people here are reluctant to get their photos taken and so I’ve really taken very few photos. But on a whim, I asked the pot seller if I could take a photo of her - much discussion ensued and the end result was that I could take a photo of her – if I also took a photo of another woman too and then brought back a copy of the photo. Then, there was a long discussion of where I should take these two photos… and then they announced that I should come back another day and take photos of them making the pottery. It was a funny experience. But the photo you see here is pretty typical of the roadside vendors, with the wares on the ground beside the road, and more stalls in the background – most of the shops are of the plywood stall-type.

Have a safe week.
Laura

Thanksgiving.

You may have noticed a gap in entries. In a way its been because I’ve been busy – but also because its been hard to know what to write as well.

Its funny, I have so much training and so many degrees & diplomas now… but even though I can easily talk theoretically about many of these problems that we are seeing – for example, the various causes and contributors to child malnutrition, how it should be managed in theory, etc – I feel somewhat overwhelmed when thinking about what to do practically to help ameliorate this system that often just doesn’t work. Part of why I have so much education is that I always think I don’t know enough to actually start… yet, here we are. So, where do you start? What can you do that is going to have a lasting impact? How do you make changes & suggestions without sounding imperialistic? Where do you find sustainable funds to pay for necessary medicines and treatments? These are the questions I’ve been wrestling with, how to take all this theory I now know so well and transfer it to action.

We are starting with an 8 week orientation of sorts. A series of rotations through the peripheral clinics, the pediatric service and the adult (maternity & internal medicine) services so that we can get a handle on the way the health system functions. Or doesn’t.

I’ve been in the peripheral clinics and Thursday and Friday I spent visiting the CSPS Accart-Ville, where I got to see nutrition interventions – the monthly weighing of well kids (with checks of their vaccine records) and the CREN (Centre de Rehabilitation et Education Nutritionnel) where they provide food supplements and education to mothers of kids who are malnourished. Severely malnourished kids are referred to the main hospital, but mild-moderate ones are treated locally. The kids receive vitamin A on admission to the program, and their mothers come every day and are taught how to make a number of different “bouilles” or gruels, with rice or milk or eggs. The mothers are responsible for cooking the bouille, with supervision of the nurse / nutritionist. In the process, they learn about different public health interventions, like hand washing & hygiene, vaccinations, home management of diarrhea, signs of severe malnutrition and other topics chosen by the mothers. At this CREN, it costs the families 25 CFA / day; nearly everyone can scrape together that much and it would cost more to buy the nutritious food that is provided. The kids are weighed once weekly, and referred to see the nurse if they aren’t gaining weight appropriately.

Friday I did consultations with two of the nurses – there are not enough doctors, so nurses provide the primary care. At first they seemed displeased that I was there, but over the course of the morning they warmed to me, and I did a few teaching things. (Like, recommended that they use Tylenol instead of aspirin for kids who may have viral infections because of the risk of Reye’s syndrome, which they’d never heard of). Most of the kids had fever, and they were all given a diagnosis of malaria and prescribed oral quinine. No smears are done at the CSPS level (or in the hospital for that matter but that’s for another day). It was interesting to see how things work. I asked about their PMTCT (Prevention of Mother to Child Transmission of HIV) program – the person who was trained in that left, so they don’t do it any more. They do recommend HIV testing and if the mothers accept testing, and are positive, they are referred on to a center that can follow them.

This coming week, I’ll be spending time at another CSPS that does lots of maternity and even PMTCT. It will be interesting to learn more about the barriers to care, and the strengths too of the decentralized system.

The other big news was my moto. I’ve been thinking about purchasing it since shortly after arrival and the only reason it took this long was procrastination. Bobo has more motorcycles / mopeds / scooters per capita than any other city I’ve ever seen. Even the hospital parking lot is mostly for motos. There are relatively few cars on the road here (1 car for every 5-10 motos!) and many of the streets are wide although rutted & potholed. However, until a few weeks ago, I had never driven any two wheeled motorized vehicle… so its still a little terrifying. But I have to say that it is SO much nicer to have my own transport and not have to depend on finding a taxi willing to take me to my house. All 4 of us now have motos – Dana bought hers yesterday, the last to go. Sunday, I was able to go visit Dana for a while, a feat nearly impossible without wheels as no taxis go from my house to hers.

Anyhow, I hope everyone at home had a lovely Thanksgiving. (OK, well, all those Canadians for whom it was Thanksgiving this weekend). Its odd to think of you at home, the leaves turning, the weather cold, tucked inside and having turkey feasts… while I am sitting here sweating in a tank top & shorts, and struggling to think of where we’re going to find refeeding formula to give to the malnourished kids in the hospital.

What is it like there?

I was thinking about that question as I took a taxi home from our meeting this afternoon. Let me try to describe a typical taxi ride.

At the corner of the market, next to the lady where I often buy my fruit (right now, papayas, grapefruit, avocado, pineapple) I can often find a taxi. The corner has lots of people around, and across the street is a moto parkade – more motos than I’d ever seen in one place, neatly placed one against the next. It costs 50CFA (10 cents) to park your moto in the lots. Also in front of the market is one of very many plastic bucket sellers. I’m not sure why, but many corners have a woman with a large array of brightly coloured plastic buckets, and occasionally other things like jugs, baskets and garbage cans. The taxis are all painted green, and almost all are in dreadful condition… often, you can either open the door from the outside or the inside – but rarely both. And the inside handle is often a twisted piece of wire. The windows are stuck where they are (so if it rains, you get wet). The upholstery has a general red tinge from the dust. The car often sounds and looks as if its on its last legs (they all do). I pile in, with a number of other people and head off. Sometimes, there’s two people in the front bucket seat, and up to 4 in the back. (These are small cars!)

The main roads downtown are paved, but on the edges the pavement breaks. There’s no sidewalks, just red dust. Even downtown the smaller roads are unpaved. As we head for the first rond-point (traffic circle), we pass many men with sticks displaying cell phone recharge cards, 2 or 3 on every block. We may pass the pillow salesman, walking down the road with a stack of 4 pillows on his head, and two hanging from each arm. Or the bag salesmen, with 10 different backpacks or sports bags hanging from them. Or one of the dozens of women with a large tin bowl or platter balanced on her head, containing bananas or papayas or something else. We also will pass the beggars, there’s a family on each of several corners; the kids dressed in fancy dresses (that surely came from the clothing donations that are packaged and sent to Africa in 1-ton cubes) with small plastic bowls and sad eyes. We will also see a number of 10-12 year old boys with boxes balanced on their heads, containing travel-sized packages of Kleenex, or toothbrushes, or some other random thing. We will pass several “telecentres” which are Burkina’s answer to public phones – they’re private businesses that let you make a phone call for a fee. There are always a group of 6 or 7 men hanging around the foosball table that’s on one corner.

Past the rond-point, we’ve now left the “urban” area and get to the “suburbs”. Now we pass more women carrying loads of fruit or wood, or other packages on their head. At least 2/3 of them have a baby strapped to their back, almost always sleeping or quietly looking around (never crying or fussing). We will pass on each corner a woman sitting on a stool in front of a little charcoal burner that has ears of corn being roasted, or sometimes plantains. There is a plethora of plywood stalls, sometimes just a bench with a sunshade, sometimes a small building; they sell fruit or eggs or sometimes drinks.

The taxi turns to the right, off the paved road and into the “quartier populaire,” either Balomakote or Sarfalo – the first time this happened, I just about had a heart attack. Now I know that 80% of the taxi’s I take will swing through one of the neighbourhoods bordering my own. The pavement ends, 5 meters from the main road, and the road becomes a rutted obstacle course, with huge grooves carved by the rainfall, and goats (many goats), and occasionally donkeys, cows and rarely pigs. There are small children everywhere, often wearing a t-shirt & underwear and nothing else. The houses are all made of red mud brick and some look quite tidy but many appear as if they are about to fall down. There are markets out there too, but rather than the stalls of the Grand Marché, there are plywood benches with a roof, each with a scanty pile of tomatoes, or peanuts, or peppers. We pass people collecting water from a communal tap, some with oil drums on wheels (I think those are small businesses that then deliver water to homes & businesses), some by girls and sometimes boys with buckets or large bowls that then get hoisted onto the head and gingerly walked home. On several corners we pass what are effectively garbage dumps, in the middle of the road; there is often someone picking through to find any recyclable, and often an animal or two rooting around in there as well. Sometimes we’ll pass some bigger girls carrying firewood on their heads, and a smaller sibling walks behind with one small thing, learning to balance it on his or her head. The kids stare at me peering out of the taxi and yell “toubabu, toubabu” and I smile & wave and they get a huge kick out of that. Eventually, we drop off the other passengers and continue back on the paved road towards my house.

At my corner, we turn to the left, down a street that almost never sees taxis (people who live on this street own cars, except me!)… despite the fact that its one of the fancier neighbourhoods, the roads are just as rutted but there’s little garbage around. And instead of mud brick houses, the streets are lined with the walls of the homes, each with a metal gate and a driveway for the car. There are trees & shrubs along the sides, and it is green, much greener than the neighborhood we’ve just left. And in comparison, there is hardly anyone about, just a guard sitting board in front of each door, and a couple kids running around. And then, I walk into my house (which is as big as 6 houses in Sarfalo), with the refrigerator running, and turn on my fan and lights, pull out my computer or my books, and look at my garden. My home existence is so very privileged. Even though I have few “toys”, no TV, or stereo, and only a few books, and my house is sparsely furnished, its hot running water, fridge, stove and air conditioners are still unimaginable luxury compared to how the vast majority of Burkinabé live.

starting in the clinic Monday!

Just a brief entry. We met with Dr. Nacro this morning, and we're all set to start at 7:30 am Monday. We'll begin as observers, but hopefully this will help things progress a bit further. And we will all be happy to start seeing patients. I will be starting in a regional medical center - a CMA, in the northern part of the city. Dana & Leah will start in pediatrics, and Suzanne will start in Maternity. I'm nervous but looking forward to starting the clinical work at long last.

A couple photos here - the first is an example of the scenery here - its about the same, all the way from Bobo to Ouaga - in the wet season, that is.

The second is my nascent vegetable garden - doesn't look like much, but considering this was a patch of red dirt 2 weeks ago, I'm pretty impressed. The tall things along the back are the tomato plants, with lettuce in the foreground and onions off to the right.

Hope you all have a peaceful & restful weekend.

Doni doni kono nita niama

That is Jula for “slowly, slowly, the bird builds its nest”… little by little things come together. Very, very slowly.

On Wednesday we visited the CREN, or outpatient malnutrition ward. This is also where the kids above age 18 months who have HIV come to be checked in and have weight and temperature checked. Its all open air, with a tin roof and is made up of a cooking area, where they make breakfast & lunch for the kids every day over an open fire (with smoke filling the rest of the area), a weight / visit / education area and a paillote or palapa for eating in (funny that I know French & Spanish words but not an English word for that – it’s a conical roof structure, with low walls so its open to the breeze but the roof shape is cooler than a flat roof).

The kids are weighed every Wednesday, and their weights carefully written in their carnet de santé and their CREN chart. They come each morning for their breakfast & lunch, and the parents theoretically find dinner for them somewhere else. They have education sessions once every 2-4 weeks, things like how to prepare nutrition meals with local ingredients, etc. Some of the kids are losing weight even while being followed in the CREN… its not clear if anything different is done for those kids.

It was upsetting to see kids that are losing weight even there; two kids stand out. One had puffiness around his eyes and feet that suggested kwashiorkor; he was listless and a bit fussy. The nutritionist dutifully wrote down the weight, no plan to do anything else. The second was a 2 year old who weighed 4.9kg, and who’s weight has been decreasing steadily for 2 months of weekly weigh-ins in the CREN. When his mom put him on the scale to be weighed, he puckered his face as if to cry, but there was no energy to actually cry. He tried to raise his arm to his mother, but the tiny arm of skin & bones, only made it half way up before he couldn’t raise it any further. His skin hung off him in folds. His mother was cachectic (looked like she was starving herself). The morning brought home to me in a very painful way that we have been here 2 months and are not yet seeing patients… while we could ask about the kids, suggest they be referred, there was nothing we could actually do. When I got home, I cried.

On the optimistic side, we should be starting work in the hospital on Monday, so we will be spending 7-2 every day there, and then in the afternoons work on the meetings and relationship building that we need to do to get to know the players and the system and to integrate our project well. (And if you’re wondering why we’re not being pushier at this time, its because if we did that we could be creating bigger problems and roadblocks for ourselves, so we’re trying to do things the ‘right’ way).

On a totally unrelated, frivolous note…

I got a package from home! What a treat to get some mail. My dad sent me the DVD Capote, and my East Africa handbook. It took only 2 weeks, which was much faster than expected. And it cost 150CFA to liberate it from the post office… I think if it’s a high value package there may be taxes to pay as well, but there wasn’t on this package.

My garden is coming along, the zucchini & cucumber from seeds are coming up, there is are several tomato flowers and a small tomato on one of the plants, and I got some flowering bushes and a frangipani (my favorite flower, native to the Pacific) to put in the front yard yesterday.

It seems that every time I turn around I'm having a plumbing or electrical problem. Monday, blocked sink & 3 running toilets, Tuesday a broken light fixture cover, Wednesday a blown fuse, Thursday the kitchen tap started making bizarre sounds and then this morning after my shower I heard a "drip drip drip" and my hot water tank was leaking... so for the 2nd time this week, I had the plumber here and the hot water tank problem was easily fixed but the strange sounds from the kitchen tap signified a dying kitchen tap and so that I've had to replace for $50. Ugh! Good thing labor is cheap here - the electrician visit for the blown fuse (it’s the kind you need to replace the actual fuse) cost $1.50 for the fuse and $1 for the labor. Not the same as at home!

I hope everyone has a safe & relaxing weekend. Feel free to write comments on the blog!
With love,
Laura

The Burkinabé health care system

Cristina asked in her email about the health care system, and I thought it was a good question, so I’m including my response here.

The health care system is based on a hierarchical, fee-for-service model. The first level of care, present in many villages and communities throughout the country is the “Centre de Santé et Promotion Sanitaire” or “CSPS;” these are health posts or clinics, and have health worker +/- nurse +/- midwife working there. They do IMCI (an algorithm-based strategy for looking after sick kids used by health workers), vaccines, and health teaching, and some supervision of tuberculosis therapy (Directly Observed Therapy, or DOTS). If they can’t handle the problem, the patient is referred to a “CM” or “CMA” (Centre Medical) which is like a small hospital that may have a basic lab, staffed by a physician. They can refer to regional hospitals (which have at least the capability to do blood smears for malaria, sputum smears and a few other labs), and there are 3 reference, “tertiary care” hospitals. In Ouaga, a general hospital and a children’s hospital and here in Bobo a general hospital. The large general hospital has several pediatric subspecialities.

There is little provided for free, although some preventive care and TB care theoretically is. Cost is a huge barrier to seeking care (from what the pediatricians say, and what’s in the literature as well). The pediatricians and GPs at the workshop this weekend were adamant that care of kids & mothers with HIV should be free but the government seems equally adamant that it should not be. Many people have no income; more than half of the people in the country make less than 500CFA (1 USD) per day. An outpatient visit costs 2500CFA. A hospitalization (which includes tests but not medicines) costs at least 2000CFA per day. HIV PCR, a test to diagnose HIV in kids under the age of 18 months, costs 10,000CFA. Almost no parents will pay for that; they can’t afford it, and if there is that much extra money around it rarely goes to that sort of thing. I think that antenatal care, including theoretically available PMTCT (Prevention of Mother to Child Transmission, which includes HIV testing of the mother and single dose nevirapine for mother and baby) is free though we got conflicting info on that. ARVs cost something like 10,000 / month. A normal delivery costs 4500CFA, and a cesarian section 55,000CFA so very few women go to a health care center for their deliveries – they can’t afford it and also, women’s & children’s health isn’t valued all that much. 1000 in 100,000 women here die in childbirth every year, and a woman has a 1 in 12 chance of dying in childbirth in her life… compare that to Canada, where 6 in 100,000 women die in childbirth per year, with a 1 in 8700 lifetime chance of dying in childbirth (its 17 per 100,000 or 1 in 25000 in the US).

While we’re talking about health statistics, did you know that 20% of kids born in Burkina Faso die by the age of 5? (Under 5 mortality rate of 192 per 1000 live births). In Canada its 0.6%, in the US 0.8%. By every measure, Burkina Faso has poor health status.

We got a tour of the Children’s Hospital in Ouagadougou on Friday, which was really interesting. It is new, built in 2002, and has nice wide paths, nice looking buildings and is likely the best equipped hospital in the country. The rooms are mostly 4 beds (exept the expensive private room, for 10,000CFA / day, for which you get a private, air conditioned room). They have a working XRay machine, but their ultrasound machine that has been broken for 2 years. Their hospital equipment maintenance guy died a year ago, and there’s no one to replace him, so all the equipment is slowly disintegrating… and that’s in the well set up children’s hospital! In the ICU they can provide oxygen and more intensive nursing care (frequent vital signs etc). There is one dialysis machine, for acute renal failure.

We’ll be working most of the time in the general peds ward & clinic at the Bobo hospital; I think it will be really challenging. Just to give you an idea of what’s available here … there is an x-ray machine; but it broke, some months ago. No one knows when it will be fixed. We haven’t had an official tour of the hospital here yet, but saw bits of the general peds ward when we were there for some meetings. Its got that African hospital smell (I don’t know what the smell is, but the Children’s ward in Mbarara, Uganda smelled the same). The rooms have 4 beds each, and the day we were there, there was less than 1 kid per bed. I didn’t see any sinks for handwashing anywhere. We will be spending some time visiting the CSPS, CMA and CHRs to get a better sense of how everything works in real life.

bureacracy & poverty

Sometimes I can forget that I’m living in the 3rd poorest country in the world; my house is quite nice (this is the living room & dining room) and some things things start to seem so normal, like the rutted dirt roads, the mud brick houses in the “district populaire”, the chaos of the market.

And other times its unavoidable; the skinny, stunted kids with clothes that are disintegrating on their backs, the beggars, the desperate merchants.

We had to fire our driver yesterday (the one who went with us to Ouaga), and he was so sad, and so disappointed. And I know he really needed the work. So, it was really hard on me to say, I’m sorry but we gave you many, many chances – but he wasn’t honest towards us; he lied about the condition of the car on Saturday (it had broken down again), and then failed to either pick us up or call us and let us know.

I’m one step closer to having a land line – I actually have a phone number though it won’t be installed until later this week. In theory. So, if anyone has an urge to call me here in Burkina Faso, my land line number will be +226-20-98-52-83 (226 is the country code). (And for those who’ve forgotten – my snail mail address is 01 BP 1243, Bobo Dioulasso, Burkina Faso). Internet at home will hopefully be in the next 2-3 weeks (so then I can make / receive calls on Skype)... however, despite people telling us it is easy, our chart has to be transferred from one department to another, then we have to pay a deposit, then they will do the next step, whatever that is. In the meantime, there are not enough "cartes" (some crucial piece of equipment for us to get DSL at home) in the country, they are sitting in Customs in Ouaga. They should be arriving next week. Inshallah.

If its not a good time, it’s a good story…

Our trip to Ouaga was very successful (although the transportation was a disaster). We met with a bunch of different departments of the Ministry of Health to discuss our project, and learn about how the Burkinabé health care system works. We also took part in a workshop that looked at the organization of the scale up of management of pediatric HIV in Burkina Faso; that was useful because of the presentations on the first day, and the chance to make lots of good contacts. We also got to tour the children’s hospital and talk with the physician who looks after the HIV patients in Ouaga who is really dynamic and knowledgeable.

We sampled a few of the restaurants of Ouaga, which offer considerably more variety than Bobo… Chinese food, amazing lasagna (would you believe I had the same thing for 2 dinners & a lunch), great pizza, all within walking distance of our new hotel. And there’s a home décor store with stuff that “appeals to western tastes” as the guidebook puts it (Dana & I were like kids in a candy shop).

From the get go, our rental car was a disaster; I already described the trip to Ouaga. Monday, Soliman drove us to our meeting, then failed to show up at the end of the day. Tuesday & Wednesday he spent the day getting the car fixed, so wasn’t available to us. We debated firing them, but I argued with the group that it wasn’t his fault that his car broke down, and that he was trying hard, (and his stereo was stolen) so we should give him the benefit of the doubt. Thursday & Friday he was able to drive us around again, although he failed to show up to pick Dustin up from the airport on Friday afternoon. (He came an hour late, saying he was getting more repairs done and it took longer than he thought). He was to pick us up for the trip home at 8am the next morning.

Soliman came at 7:20 with a story about his papers being taken by the police and he had to retrieve them, but he would pick us up at 10am. At 10:45, he phoned and said that he hadn't got them yet, but would have them for sure by 2pm. We threatened to take the bus but he said no, no, no, he would be there. For sure. So we agreed that if he didn't turn up at 2pm, we would find our own way home, and not pay him for the last 3 days. Leah & Dustin took the bus, but Dana & I agreed to give him one more chance. At 1:45 he called and said he was on his way. At 3pm, no sign of Soliman. We decided to stay in a hotel, and take the 7am bus on Sunday... but we foolishly let the guard convince us that his buddy could drive us, and the price was only slightly higher than what we would have paid our driver. So off we headed... 2 hours into the drive, we hit a traffic jam as they retrieved an overturned, squashed bus out of the ditch (the actual accident had been 2 days before), and watched while they righted it, and a group of 15 men started pushing it down the highway; the wheels still turned just fine, even if the top of the bus was squashed. It got dark. We weren't making very good time. And then, about 80km from Bobo (it’s a 400km trip), on a dirt road detour, the lights faded, dimmed, and the car stopped. So, there we were, broken down car, at night, in a tiny village, 80km from home. Long story short, a kind passer by tried to tow us, but the rope kept breaking and eventually we left the car & driver in the village, and the stranger drove us home. We got home at midnight. While we were on the road, Soliman called Suzanne (who'd returned home the previous day) and said that he was ashamed to call me, since his car had broken down again. She got the update from me, and he later called her back and was surprised and dismayed to hear that we'd left without him, as if we hadn't already given him the benefit of the doubt, only to have him not come through, at least 4 times in the previous days. What did he expect!!!

Transport back and forth to Ouaga is a huge problem. The bus is cheap, but very uncomfortable… and we would be the only NGO other than Peace Corps to be using the bus as our method of transport. Flights are available only 3 days / week and of course are really expensive. And our attempt at a rental car was a huge disaster. I was the one who found the contact, so I feel somewhat responsible for that. There are rental agencies that will rent a 4x4 & driver for >$150 / day plus gas but that is too exhorbitant. But we don’t have the contacts here to get something reasonably priced and reliable.

back to Ouagadougou - again.

It’s been an eventful few days. The totally frivolous, eventful thing was that my garden is all done; well, everything is planted. From pile of mud (first photo) to a donkey cart with topsoil (second photo) to yard filled with baby plants in 3 days (third photo). The gardener comes 1-2 times a day to check on everything because it’s so new. By the time we arrive back from Ouaga, the sparse ground cover should start filling in a bit. I may need to get another few bushes for the front yard though – it doesn’t look as filled in as I was thinking it would. I have 4 papaya trees, 2 banana plants and a plantain, a cherimoya, a pomegranate and 3 pre-existing mango trees. And a large vegetable garden – too large for a single person. I suspect I will be feeding Maimone’s family with all that!

We had another meeting with the Director of Pediatrics, Dr. Nacro on Saturday; he seems like he is very passionate about working for the kids of Bobo Dioulasso – and passionate about his frustrations about some of the problems in the system here. In fact, much of what we talked about was that; we hardly had a word in edgewise to present our ideas about our work. He made a comment that I think will make him good to work with from a North American’s point of view – basically, he said “People say I’m impossible to work with, but I tell it like it is – even though that’s not what’s done here in Burkina” – but I’m glad to have a colleague in a key area that will openly communicate with us. Often what happens if you annoy people is that they won’t tell you that you’ve done something wrong; but you just find that it gets harder and harder to do anything. Dr. Nacro wants to keep that from happening to us, which is nice.

I stopped at the internet quickly just before heading home and discovered an email from Dr. Sanou, the Director of Hospital Services, who is turning out to be another of our key contacts and allies. She was going to organize some meetings in Ouaga for us, but we hadn’t heard when yet. We discovered Saturday afternoon that they’ve been organized for this coming week!! So we had a bit of a scramble to arrange transport (we’re trying a private car / driver hire this time), accommodation and things like canceling Dioula class and finding someone to feed Leah’s cat. But despite the last minute scramble, we’re glad we’re heading back there this week – the sooner we have those meetings, the sooner we’ll be doing clinical work.

So, at 7am Monday morning, our driver, Soliman, picked us up, and we ran errands and by 9:30 were on the road, in plenty of time for our 3:30pm meeting (after all, it’s a 4 hour drive in a private car). Or so we thought. The first sign of difficulties was at Boromo, about half way to Ouaga… we pulled off to a gas station, and Soliman did something under the hood, and within 5 minutes, we were off… stopped again at a toll booth just outside Boromo, and it was clear that the car was overheating. We stood in the shade and made small talk with the toll booth guys (one of whom is a huge Fifty Cent & Tupac fan), and 20 minutes later got on the road again… 20 minutes after that were pulled over to the side of the road overheated. So, back to Boromo where they fixed the fan but were unable to fix something else… so for the next 4 hours, we drove about 45 minutes at a time, no faster than 50km/h, with frequent overheating stops. At one stop, some village boys brought us water for the radiator… they didn’t speak Jula or any French, really. One little boy (about 6yrs) was attired in a pair of shorts, so worn that there was literally no bum in them… he always stayed so he was facing us, not wanting us to see the gaping hole in the read. It was a relief to finally get to Ouaga and get to our hotel rooms. Somehow, though, the hotel rooms at our new hotel are not all equal – I have a deluxe room complete with bathtub… Dana’s room the hot water didn’t work and is half the size, Suzanne had to change rooms because her cold water didn’t work, and Leah’s air conditioner was marginal… I feel a little guilty about that! But last night we had one of the best meals since arriving in Burkina Faso. I had lasagna that was truly wonderful, in a lovely courtyard setting.

Today’s meetings were really interesting. It was day 1 of a 3 day workshop on the development of a plan of pediatric HIV treatment for Burkina Faso; until now, kids have largely been ignored from the HIV planning. So we are really excited to be part of this forum even though we are totally new here. There are no other NGOs present at the meeting, even though there are several providing HIV care in Burkina. Today was a series of presentations on the status of pediatric HIV treatment here. In fact, they have a clinic in Ouaga that follows a very similar model to the COE clinics, which is interesting. We are going to try to spend more time with them to see what they are doing.

Anyhow, I have work to do yet, so I’ll sign off here.
More later!
Laura

movement on home & work fronts

Thursday I met with the gardener, Moussa & his brother. They came at 9am, and we chatted for an hour about what I wanted in my garden, we came up with an estimate, I paid my deposit – and within 10 minutes the weed clearing started, by noon, the topsoil & compost were delivered by donkey (!) and so the work continues – they thought they’d have most of it in today! And in fact, by the time I left the house at 9:30, a good part of the garden was planted. Its amazing how some things can be done so very quickly (one wonders if they had the team of people and the donkey cart waiting just outside the gate while we talked…) and yet trying to work in the hospital takes weeks!

The cost of my garden, which includes 2 months of labor plus topsoil & compost, and the plants - papaya, cherimoya, pomegranate trees, ground cover, bougainvillea, and a vegetable garden (tomatoes, lettuce, cucumber, chili, green pepper, zucchini, basil, onion), and a compost pile for me – will be about $140.

Friday morning, we finally met with the director of pediatrics – yay! And we will propose a work plan to him tomorrow morning, with us at first rotating through the pediatrics (1/2 time), maternity & internal medicine (1/4) and peripheral centers (1/4). Plus, meetings etc with lab, pharmacy, etc. And my plan is that within that, we will start identifying new patients and hopefully start with a one day a week transitional clinic for new HIV patients (without a pediatrician) too. I am glad to finally have some movement. He warned us in strident terms that there are very many problems, at all levels from both lack of funds, and to a certain extent poor use of the funds that are available. And that children are generally excluded from HIV planning in this country. Not to mention health planning in general – despite the fact that 48% of the population is under the age of 18!

My first impressions of the hospital… well, the grounds are really nice, wide covered pathways, with several 3 story buildings, some flowers etc. on the grounds. The inside of the children’s ward had that particular African hospital smell that reminded me of the Mbarara hospital, and there were patients waiting everywhere to be seen. The patient rooms (which we looked at as we went by) have rows of 6 beds, and at least this morning seemed to only have 1 patient per bed. This will be really tough. But I’m excited to get started. More later!

By the way – in response to a comment – “ARVs” are anti-retrovirals, or HIV drugs for the non-physicians in the bunch (I try to use normal English but it doesn’t always work out! If I’m not making sense, let me know.)

Another attempt at photos from the trip… its been a bad few internet days Along the highway we passed a dozen of these “bush taxis” – impossibly overloaded, with 4 rows of seats, 4-5 people in each and often 2 in the front. And an incredible array of stuff piled on the roof. Like this bush taxi, its common to see one or more motos, some bikes, wheelbarrows, and assorted furniture piled precariously on the roof.

The second photo is another classic Burkina shot… I was trying to take a picture of the gas station with its gas in used pop bottles (on the left hand edge) but also caught this van – notice the upside down chickens (they're the feathery things at the front & in the middle)?! Apparently, hanging upside down is the preferred way to transport one’s chickens, as it stuns them and they hang quietly there for the duration of the voyage, in this case flanked by sacks of potatoes, bicycles and goodness knows what else.

images of Burkina

This is the first of the photos I wanted to include last time… today is still slow, so I'll insert just the first one.
Driving through Ouagadougou is fascinating because it gives a glimpse of everyday Burkinabé life… from the fancy looking billboards, to the ubiquitos green taxis, bikes and motos, to the water delivery wagons (bottom left hand corner), this photo is a snapshot of a normal streetcorner, like a thousand others. The red dirt is ubiquitous and penetrating.

I got more food & necessities of life today... its such a pain not having transportation here! But I'm slowly collecting the things that I need for life here. Each time I go to town, I return with an armload of stuff. The four of us are the only foreigners in town (besides the Peace Corps volunteers) who don’t have cars or motos. In fact, everyone asks us if we’re with Peace Corps, as they assume that anyone foreigner who gets around on foot / taxi must be with them.

Our "fixer", M. Cobre was meeting with Onatel (the phone company) today to see what needed to be done to "help" our phones get connected - we will give him a little money "for gas for his moto". As an aside, M. Cobre is a fascinating older man maybe in his 60s or thereabouts) - clearly not wealthy but always elegantly dressed, and totally on top of getting things done - he found 2 of our 4 houses for us, and will be working for Leah & Dustin, while his daughter will work for Suzanne. His French is really hard to understand (between the 4 of us, we often only get 2/3 of what he says), and I think he sees us as as a bit helpless. His services have been invaluable.

Anyhow, I'd better get back to work - I have a fair amount to do today for a change! Its good to be busier again, though I also want to make sure I keep some balance. Its harder to keep balance here with not as many distractions, no movies, few friends, rarely go out at night…. that makes it easier, since if to work all the time I don't feel like I’m missing out on things as much.

The bus ride home

Well, after a whirlwind few days, we’re back home again. Despite being in the big city, the only place we ate in Ouaga was the hotel restaurant & room service – the food was better this time than before, but still totally overpriced. But every night we were just too wiped out to want to go out. And also, no one wanted to leave the in-room internet access – its such as switch from our daily trek to the internet café!

After a disrupted sleep (don’t ask), I dragged myself out of bed and to the breakfast buffet… to enjoy one last pain chocolat before returning to Bobo. We checked out, which takes a surprisingly long time, and flagged the taxi. He was surprised we were going from the Sofitel to the bus station. No one goes between the Sofitel and the bus station. So, the 5 of us (minus Dustin, who is away on a business trip) crammed into a taxi for 4 and off we went, our driver trying to convince us that next time we go to Bobo we should rent his SUV, for 40,000CFA each way. The bus cost us 11,000CFA each, so 55,000 for the round trip in total. But in retrospect – the rental SUV would be worth it! Next time, we’re doing what the other NGO’s do: rent a car or fly.

We pulled up to the bus terminal, and the car was surrounded by people trying to “help” us – for a fee, of course. We scuttled around to the back of the car and grabbed our bags without letting anyone touch them… the “helpers” will sometimes try to take you bags right out of your hands if you’re not aggressive enough and then of course feel they deserved to be paid regardless of whether you wanted or needed their help. Although I am sure there are some pickpockets and petty criminals, I once felt grateful that Burkina is generally so safe, while we were in the crowd of people. We made our way into the terminal and there are no signs, no waiting areas, no one to ask for directions… but we asked a few people and stood with the other more nicely dressed people and eventually the air conditioned bus pulled in. At least, we paid an extra 1000CFA for an air conditioned bus. After we got on, it became clear that while it was certainly a bus with an airconditioner, this feature wasn’t actually working. So, bus loaded, we drove to the bus yard to sit for 45 minutes while they fixed the air conditioning. We finally left Bobo and shortly thereafter were stopped at a checkpoint, and the police started going through the luggage compartments… again, yay Burkina – in most places in West Africa, this process is one in which the police always find a few people who’s documents (or something) are not in order, and for the bus to continue, a fee must be paid. But here in Burkina, the police inspected the bus, and we were on our way.

Along the highway we passed a dozen of these “bush taxis” – impossibly overloaded, with 4 rows of seats, 4-5 people in each and often 2 in the front. And an incredible array of stuff piled on the roof. Its common to see one or more motos, some bikes, wheelbarrows, and assorted furniture piled precariously on the roof.

Despite the occasional interesting vehicle or village, the scenery is fairly monotonous and absolutely flat for most of the 5 hour drive… red dirt, trees, puddles and the occasional pond, with cows and goats here and there. We stopped in Boromo at the big bus station; the specialties of the bus station in Boromo are sesame snacks, bagnés, eggs (either hard boiled or an omelet sandwhich), bright orange drink that looked like fanta in coke bottles, baggies of water and ginger juice and onions. Piles and piles of onions. More onions than all the rest put together, its really odd. It was pouring rain, so as the vendors approached the windows and leaned in the door and shouted “madame, madame, cent francs cent francs” which is the price of several of the items. It doesn’t matter who you buy from, there’s always another girl suggesting you need to buy some from her too…

It was nice to be home, make a big bowl of soup and fall into my bed… I slept for 13 hours! And finally was able to put away my clothes with the hangers purchased the day before we left. And joy of joys, I finally unpacked, washed and used my espresso machine today. It was such a treat to have good, dark roast coffee this morning. Yum.

We’re hoping to have internet connected at home before to long – which will be good, as this daily trip to the internet café is getting old. Today is a slow day, and I have lots to upload & download so the photos I was going to include have been canceled. Next time, in shallah. Speaking of home, I’ll attach photos of my house on the next entry. (too many photos at a time makes it impossibly slow).

the end of leisure

After some very laid back weeks, suddenly I feel like I've returned (somewhat unwillingly) to my previous pace of life... the last 5 days have been really busy!

Monday night I moved, at 9pm, after hourly calls to the guy who was supposed to bring my keys, from 5pm onwords... its great to be partially unpacked, and to be settling into a home again after 3 months of living in suitcases.

Wednesday we took the bus back up to Ouaga (pictured in the photo), a 5 hour ride that even in the air conditioned bus wasn't, well, cool... I've realized that Bobo is really much nicer than Ouaga!!

Thursday & Friday we met with the Ministry of Health, and much to the frusteration of the BIPAI staff who have had many meetings with the Burkinabe ministry of health before found themselves having to re-explain everything about the project as if it were new information. However, after a shaky start, people seemed to become more enthusiastic. We put together a list of our learning and work objectives for the next few months (focusing on what we need to learn to truely integrate into the Burkinabe health care system - and ensuring that we send the message that we do respect their expertise and programs) and I spend several hours translating into French... then had to give a 15 minute presentation on it. In French. Did I mention that the last time I did any public speaking in French was in 1989!?! Talk about nerve wracking... I'm sure I sounded a bit like a dull teenager in my language choice... but despite that, they clearly appreciated the effort for me to present in French (the chair even joked that since I presented in French, then all the questions therefore should be in English!) and we had some good and, I hope, fruitful discussion about next steps.

Hopefully next week we'll be meeting with the hospital director, pediatrics director and a number of other relevant players to sort out our work for the next while. Likely to be a combination of some general peds, with identification of HIV+ kids and starting to recruit for our transitional clinic (which will be at the very least HIV & TB). We will also be working on getting to know the various NGOs and other stakeholders (did I really just use "stakeholders" in a sentance... clearly the JHSPH brainwashing worked...).

Anyhow, overall some positive movement. And we also met with the UNICEF Country Director for Burkina, who has as one of her main goals to support the rollout of pediatric ARVs, including training etc. So that should be a great partnership!

We've been really enjoying having good internet access for a few days here at the sofitel... tomorrow its back to the internet cafe again sadly. One of the tasks for next week is to see what needs to be done to "help" get our phone lines going.

Anyhow, more later. Take care! L.

Moving day (?)

Well, I think today is moving day, as long as the hot water heater is replaced, the blown fuse repaired and the broken light fixtures replaced. Guingane, who is the "fixer," went through everything with me this morning and when we left the house the plumbers were there installing the new water heater. Now I have to face the task of squashing everything back into my suitcases again. ugh. But I am really looking forward to unpacking and having a place for everything.

This photo is one I tried to post earlier when the blog wasn't working well. It is the 6 of us in our shared temporary house, at our first meal together. We've been taking turns cooking dinner most days. I am the first one to move out of the shared house. Tomorrow, I think work will begin on my room to install air conditioners for Suzanne who will be staying there.

I have found a new internet cafe, that has a faster connection - and wireless yet! - and so uploading photos may become more doable.... now i just have to take some photos! Anyhow, I'll let you know if I'm actually able to move.
L.

moving preparations

Well, my lease is signed, my deposit has been given, and the house is almost ready to go… except the electricity.  I made the application to have the electricity turned on, but if you don’t do something to “help the process along” then you will be without electricity a very long time.  So, Guingane, the helper of my landlord, has been doing what needs to be done to turn on the electricity as that is all that is standing between me and my new home.  I fear we may have to embark on the same process to get the phone hooked up.  I may be meeting with someone today to interview her for the job of helping me with laundry, cleaning, cooking – but above all laundry.  Hand washing my clothes is another non-strength of mine!  Families often have a couple people to help with those things (one cook, one cleaner, one laundry person) but as I am one person living alone, I certainly don’t need all that!  If someone would just go to the market for me, I’d be all set…

Dana & I went shopping Saturday, to get some of the necessities of life… cutlery, bowls, a water filter, buckets.  Most of it we bought in a fixed price store, but the buckets I had to bargain for in the market.  So far, bargaining is not my strength.  My friends tell me you just have to know how much you’re willing to pay… but how on earth do you know what a fair price for things are? That’s what I can never sort out.  I do know that the price is always inflated for us, “les blancs”.  We certainly attract more attention in groups than singly.

The internet café is becoming our home away from home.  The staff all know us, and are becoming sources of advice for whats going on around town.  We each spend an hour or more most days there… its become a big part of our daily routine, the trek into town with our computers to connect to the outside world.  We are all really looking forward to being able to check email from home.  That may be a month away though!

I’m learning that although I generally avoided bringing white clothes here, beige pants & skirts aren’t a good idea here.  Many days we get caught out in the rain, and with the rain comes this pervasive red mud that is really tough to wash out of beige or light coloured clothes.  So for those coming to visit, bring darker coloured or patterned clothes that won’t show red mud. 

Well, I think I’ll sign off there – not much interesting to say, as things are pretty routine right now.  But next week we’ll be going to Ouaga and hopefully after that we’ll get to start work.  Take care & keep in touch.

 

And then it rained.

So, you know how I wrote that the farmers were in distress because it wasn’t raining?  Well, the last 4 days have made up for it.  Life here just stops when it rains for most people.  On Monday afternoon, I headed out on foot for the 20 minute walk to my house… not even 5 minutes into the walk, the heavens opened up.  Horizontal rain, coming down so hard, I could hardly walk… by the time I arrived at the meeting I looked rather like a bedraggled wet rat, soaked and splattered with red mud.  It rained for an hour.  Then, yesterday morning I had every intention of leaving for the internet at 8am, to get on with my day… but the torrential downpour started at 0400 and continued through ‘til noon.  And now, as I write, the rain is coming down, and the sun is setting so the light is that beautiful twilight that is very soft, but at the same time strangely distinct.

Today, I finally gave my deposit on my house.  I am trying desperately to extract my rent from Bank of America (its my money!) and have it sent here… Joanna is helping me out, thank goodness.  Otherwise I may be homeless!  But its been another exercise in frustration and the American system….

Tuesday Dana, Allison & I decided to take advantage of our leisure time and explore a bit more of Bobo Dioulasso.  We walked for about 2 hours, and made some great discoveries like the teak furniture store, a seed shop for veggies, and the pottery neighbourhood.  But really, what was really enjoyable was just seeing more of daily life of Bobo, away from the touts downtown who harass us all the time (though already that is getting less).  Women walking with incredible loads of vegetables on their heads, girls of 7 or 8 helping their mother sell corn with a baby strapped to their back, bicycles passing by with impossible loads (like the guy who was carrying a 15 foot length of pipe).  A crowd of little kids running up to us yelling “Toubabu! Toubabu!” and wanting to shake our hands.  There are an incredible number of small merchants here, small stalls stuffed with all sorts of crazy things.  We wonder sometimes who actually buys anything when most people have so little formal employment… but there are literally hundreds of sellers of cell phone recharge cards – one every 50m or sometimes more!

Some of the things I’d hoped to get here may prove to be tough to find, but other things that we thought would be a problem are plentiful.  So I lugged my good frying pan all the way from Baltimore only to find a whole t-fal section of the grocery store here!  And yet a ceramic candle water filter has proven much more elusive. 

Thanks to all those who have been writing & leaving comments! I love getting emails & comments from people, it makes me feel much more connected.

A couple photos

The blogging program hasn't been working very well... but I am going to attempt to add a couple photos - I really am here in Africa!

Here I am in the van on the way to Bobo with all of our stuff – we had 2 vans piled high with suitcases and boxes (photo taken by David Jones).





The next photo is Dana, Suzanne and myself at the COE site – we will have the groundbreaking next week.

Today, I am going to give my deposit on my house. I am trying desperately to extract my rent from Bank of America (its my money!) and have it sent here… Joanna is helping me out, thank goodness. Otherwise I may be homeless! But its been another exercise in frustration and the American system….

Anyhow, more later. Thanks to all those who have been writing! I love getting emails & comments from people.

So, are you there to work, or what?...

A number of people have asked me about work, and when we are starting.  Inshallah, we will start after our meetings with the Ministry of Health on Sept 7-8 and the official groundbreaking for the COE building on Sept 9^th… that’s the plan, any how.  We can’t start to work until our Memorandum of Agreement is modified to include what exactly us 4 physicians are doing (and to specify in part that we’re not just here to increase the numbers of pediatricians doing general peds care, but that we’re here specifically to look after kids with HIV and TB.

 

As far as BIPAI is concerned, after Sept 9^th, the plan is for us to start working in the general pediatric clinic, identify the first HIV infected kids and get to know the hospital.  While we do that, we’ll hopefully find a space in the hospital that we can use (+/- renovations) for our “transitional clinic”.  Once the transitional clinic is up and running, we will restrict ourselves to looking after HIV patients, +/- pediatric TB patients, as this is supposed to be a Center of Excellence for Pediatric HIV, TB and malaria… how we’re supposed to work the latter into an outpatient clinic I’m not totally sure.

 

Part of our role at first will be in building relationships with the local physicians, clinic staff, NGOs etc.  One of the important premises of BIPAI is that we are not there to steal staff away from government jobs (contributing in a way to brain drain). So each country has a policy that people already working for the government are ineligible to work for us.  And the staff get paid about the same that they would be making working for a government hospital. (in the spirit of full disclosure, that rule doesn’t apply to us… we will be getting paid much more than the local physicians although at a rate much lower than we would expect to make at home).

 

Another important part of our job is to provide continuing education for local health care workers, to improve their skills in managing kids with HIV.

 

Of course, this is all pretty theoretical… it will be interesting to see how we can make this come to life.  It’s a huge responsibility to be starting this from scratch, without even a local country director or anything. Just us. Its exciting but… what a challenge it will be.  And that’s without taking into account that we’re working in one of the most resource poor settings, in a health care system that is seriously underfunded with nowhere near the numbers of health care workers that are needed.  And not even mentioning the clinical challenges of being a brand new attending!

 

So, now that the housing is more or less settled, I’ll be spending part of every day learning Djoula so I can talk with some of the patients (and go to the market!), and part of the day reading and studying to prepare.  And then continue the emailing, and other settling in things we need to do.

 

Once we start working, I will talk more about it… but for now, it’s a matter of getting to know the place, and getting settled.