Tuesday, February 17, 2009

unfortunately, no medical excuse for gin and tonics

When I woke up last Thursday, I knew something was off. My neck was stiff and my body ached. Helen calls this a cellular ache. Everything hurt—my eyeballs, my liver, my back, my hair. But that was all that seemed wrong. I figured I’d go to work and come home if things got worse. I lurched out of the car and sat down in the office, assessing within the first five minutes that I needed to go back to the house. Once I got home, the chills set in—it was at least eighty degrees outside, and my nose was cold. Anything touching me was painful, but it worse to be out of the sheets. I tried to imagine being suspended in warm air. The door to my room seemed to zoom in and out, and time slowed to crawl. I tossed and turned, sleeping on and off in the morning and awaking once the chills diminished and my temperature went over a hundred and two in a frighteningly short amount of time. At this point, I took some Tylenol, which dropped me down to a comfortable 99.9, lessened the aches, and brought back a bit of an appetite. It also makes you sweat like crazy, so I spent the afternoon drenched and stinky. WALL-E restored some comfort as well, until my computer battery crapped out. I made the mistake of picking up a book we have at the house that talks about all the various diseases that you can catch in Africa, which gave me several hemorrhagic fevers, infections, parasites, and typhoid as possibilities, though I was pretty sure this was malaria. I’d stopped my anti-malarials, figuring that nine months on antibiotics that make you photosensitive would be a bad idea. I had a treated mosquito net and tried to wear bug spray, but that wasn’t enough, even in the dry season. My dad later called me an idiot, which I guess I had coming.

The volunteers came back, and Helen and I decided it would be wise to get a malaria test the next day. I spent the night mostly awake, running to and from the bathroom, which was neither pleasant for me or for Helen, who woke up every time I got out of bed due to the loud creaks the slats make. She was a wonderful nurse, advising me on what to take, giving me the oral rehydrating salts and Tylenol that I of course did not bring myself, making me drink fluids, flipping my mattress, and even offering to give me a sponge bath (I declined). After spending the morning completely limp and wiped out, I somehow climbed into the Land Cruiser, dizzy from being emptied out, and went to the hospital, where our office neighbor told me that she would “pray for my life” so that I could return to my family in the US alive. This was not reassuring.

Helen I went to the Rayan Laboratory with an order from our Medical Director for blood tests for typhoid and malaria. The building was run down, with peeling paint and the black patches of mildew that gather on all walls in tropical climes. There were horrific posters of the oral sores that most often manifest in HIV-positive patients on the wall. I was a bit nervous, given the infection control methods and bedside manner I’d witnessed in various healthcare situations I’ve experienced here, but the receptionist was fast and efficient. I didn’t even wait five minutes before I was sitting in a high chair (I felt like a small child at the dinner table again) watching the lab tech pull out a fresh pair of gloves and a syringe in a sterile package. Helen looked on with hawk’s eyes, which was reassuring. He pulled the tiniest piece off a cotton ball and swabbed my arm. When he put the strap around my upper arm, he apologized. Please excuse, he said. He found my vein faster than any other nurse, doctor, or blood mobile technician I’ve ever had take my blood, apologizing again—excuse—before sticking me. I was struck by how polite this was—so much better than having someone say Ok, you’re going to feel a slight pinch. He then pulled off another tiny piece of cotton and a tiny piece of cloth tape and bandaged what would become a very nice track mark. Despite the fact that there was no sharps container, everything was done very nicely—labels on the vials, new gloves, needle opened in front of the patient, irreproachable bedside manner. The only scary part came when Helen said, just before he stuck me Are you OK getting blood drawn? I thought this was a polite way of saying This guy did something wrong, which was not exactly soothing as the needle was coming closer, but it turns out she meant Are you going to pass out? Which I did not. The results came back a few hours later—right on time, shockingly—as P. falciparum, the most common, most dangerous, and most responsive to treatment of the four strains of malaria. Falciparum can cause brain hemorrhaging if left untreated but is not recurrent.

Contracting malaria made me think about several things. First off, malaria is strange as a concept because it can be taken so seriously and so lightly. At home, malaria is thought of as some terrible, debilitating illness that leaves the victim in a hallucinatory, feverish nightmare. In Sierra Leone and probably most malarial zones in sub-Saharan Africa, malaria is commonplace, something that makes you feel bad for a bit, but not a big deal—people here will often come in to work, and many won’t use bed nets because they are too hot (true) and claustrophobic.

What malaria should be seen as, for both the US and Sierra Leone, for the Global North and the Global South (or developed and developing countries—there is no good term for this), is as the great killer in Africa and in tropical zones around the globe. Malaria kills more frequently in places like Sierra Leone because health and nutrition are already poor and because people who contract it cannot get to health centers or buy treatment, either because they’re too remote or too poor or both. Malaria is not as much of a problem for me, for example, because I have easy access to transportation, several nurses and doctors, and medicine. I’m well fed and in good health. I could probably buy most medicines without a prescription here because of my skin color, for that matter. Malaria does not need to be thought of with panic (I’m afraid my dad was not so happy when I told him I had it), but it does need to be taken seriously. Malaria kills, but it would kill less frequently if there were more health clinics, or if the roads were better, or if hospital visits were cheaper. Or if children could get enough to eat or weren’t sick most of the time with other things—worms, chronic coughs, malnutrition, diarrhea, etc, etc, etc. Malaria can still kill a well-fed, healthy individual; don’t get me wrong. It’s just that everything becomes so much worse once you add in the factors that put Sierra Leone at the bottom of the Human Development Index this year.

After my results came in, the Medical Director told me what to buy (no prescription needed) at the pharmacy. The man at the pharmacy started when I asked him how to take the Artesunate tablets. He laughed, explaining that he thought I was a doctor, and then advised, once he realized I was the patient, that I should be on anti-malarials and sleep under a bed net. Thank you. Even one pill later, I felt better. I’m still not one hundred and ten percent yet, but I’m getting there. The child of one of our patients came down with an undiagnosed fever yesterday, almost burning to the touch and crying out of discomfort. Her mother sharply told her to quiet down.

Monday, February 9, 2009

Why Poda Podas are Trouble and Other Stories

After leaving Banana Island back in November, we dozen or so pumoi on the trip had a bit of an adventure. The poda-poda (a minibus/large van vehicle that can seat anywhere from 10-20 plus livestock depending on your comfort level) named “Make It Rain” that we had hired out for the weekend did not meet us on the mainland at the scheduled pick up time. A call revealed that the poda-poda had not even left Kissy yet, at least 2 hours away with the evening Freetown traffic. After waiting several hours, as the night grew darker and the block party that spilled off the beach and onto the streets grew rowdier, we got a call. The poda-poda was stuck at a police checkpoint due to some paperwork that was out of order. Numerous pleas over the phone to the officer were unsuccessful, so we decided to walk through the party and meet the vehicle at the checkpoint. We were more than a little conspicuous, and though I felt nervous as we walked by, I made an effort to make eye contact, to walk with squared shoulders. Men grabbed at my arms; I yanked them away. After we’d made it through, a small group of young (and inebriated) men followed us, heckling and asking for money. The road grew less lively, the lights disappeared, the houses looked closed and empty. At the bleakest point on the road, the men suddenly surged forward to grab at stragglers’ packs, back pockets, anything, even targeting the larger men in our group. We tried to chase them, yelling for help, but they kept coming back, and in greater numbers. That was the scariest part—their brazenness. I moved ahead, looking for shelter. Cold Drinks, the sign said. There was light. Thinking it was a bar, I yelled for everyone to get inside, but as we entered the compound, a startled family tried to shoo us out. After begging for help, they ushered us into their living room, an unbearably hot, ramshackle space with dirty lace antimacassars on the shabby chairs and phones plugged into every outlet in the wall—a standard business for any house lucky enough to afford a generator. They asked us to stay inside, locking the door behind us. But the windows were wide open. We could hear yelling and scuffling outside. All of us were unharmed, none of us had been robbed, and everyone was calm.

A check of our cell phones revealed that none of us had service in the house, so a few of the better connected among us (not me) went out to make calls to security buddies at the US Embassy, to bosses at the UN Special Court, to the British High Commission, the Ministry of Foreign Affairs, landlords, powerful friends, roommates. Discussions with the household revealed that the men had called professional thieves and that they had set up a roadblock to catch us if we tried to leave. A few rocks thumped against the side of the house and the women and children of the house were rushed inside with us, huddling in the corner as I moved an electric fan, supplied by our gracious hosts, over the room, trying to keep people from passing out (it was that hot). That was when I got scared—what dangers had we brought on this family? Rumors reached us of a woman unconscious outside, possibly injured by a rock thrown by one of the thieves. A trained medic among us offered help, but the family told us to stay inside, explaining that the thieves may have sent her as a decoy to lure us out on the road, since they assumed that we were all doctors (sidenote: once at the hospital in Bo, a sizeable group of angry friends and relatives of a man critically injured in a car accident gathered around the office and vehicles and it was suggested that I leave, since they thought I was a doctor and were beginning to angrily wonder why I hadn’t come out to help yet).

The entire neighborhood heard and began gathering at the house. Eventually, enough people showed up, including the incredibly kind staff at Banana Island, who boated over to help us, to chase the thieves further down the road. The poda poda arrived, and the driver and apprentices tried to nonchalantly high five a few of us, offering zero apologies and even less remorse. After two hours or so, a large truck full of local police arrived, and an hour later, a UN escort of two vehicles. We thanked the family, the neighbors, the well wishers, the children. They seemed ready to see us off but not in any way upset that we had invaded their house. Many of them had turned the situation into a social event, sipping soft drinks, catching up with neighbors, and boasting about their exploits in the “battle” with the thieves. Making do with soda soap, so to speak. This was the lesson learned: despite the poverty that causes criminal behavior in a few in Sierra Leone, the vast majority of the people will protect you, offer you shelter, and go above and beyond as hosts. I tried to imagine what would have happened if I’d been threatened in New York in a similar way, and I can only think that it would have ended a lot worse. Sierra Leoneans don’t stand by idly when someone is in trouble.

The four who were employees of the Special Court rode in UN vehicles; the rest of us crammed back in to the poda poda, which spun out on the gravel in front of the house and almost crashed when we tried to depart. Needless to say, most of us were ready to kill the driver, especially because he acted as if nothing had happened and that none of it was his fault. We pulled out, the UN vehicles in front, then “Make It Rain,” then the truck full of police. We made it back to Freetown safely, having learned that poda poda drivers are always not trustworthy, that block parties should be avoided, but most importantly, that the people of Sierra Leone are good, generous, gracious people, who will offer the best that they have to guests, even ones that force their way in with danger on their heels.