A conversation with Katie.
Katie and I talked about my blog post from yesterday about health education in Yomandu. She said that it was interesting that I thought my advice was more practical and direct, because she thought that hers was too! And then I explained how I thought her advice was really valid, but that when someone asks a question, I want us to present some options that they haven’t already pursued. Katie said again, that she thought she was doing that. So we talked about it for a while.
By the end of the discussion, a few things were clear. First of all, we don’t understand the Sierra Leonean culture very well, and so it’s difficult to determine which if any of our advices are effective.
Second, Katie’s repeated advice to redouble efforts to communicate comes from her much deeper experience helping people resolve similar personal problems. For instance, her response to the first young man was an exhortation to try and communicate more with the girl about the consequences of not using contraception. In Katie’s experience, people often haven’t tried very effectively to communicate with the other person, and doing so is the best way to solve these problems. To me, that sounds like the best first course of action, and perhaps the best second, third and fourth one as well.
Third, we both agree that my recommended action of recruiting help from others can be dangerous. If a person feels like they are being betrayed or ganged up on, then they are liable to close down and ignore otherwise good ideas and advice. However, the society here is very hierarchical. That advice is an attempt to work around and capitalize on that hierarchy for a positive benefit.
We decided that it’s still good to give many perspectives, because we don’t really know how rural Sierra Leoneans will implement either, and we figure that whichever works will be the one that catches on.
In any case, I decided to share the discussion we had with you readers because, at least for me, it’s very difficult and scary to think that Katie and I are giving such personal advice to people in such a different culture. The problems that people ask about are difficult, and there aren’t any easy answers; the best answers would be tailored to each situation, and what we really want to be teaching is how to understand the problems so that people know which strategies to use for which problems. Unfortunately, it’s not that easy. So we go, ‘small small’ like they say in Krio, and try and figure it out. Hopefully I haven't dramatically misrepresented Katie's perspective! Cheers, Chris.
Friday, July 10, 2009
Thursday, July 9, 2009
Diagnoses, Education, and Update
Lois Park posted an incredible entry on her blog, loispark.blogspot.com. She’s the third intern working for GAF and NOW this summer, and she has designed, implemented, and is now running a feeding project for malnourished children in Masiaka, near Freetown. She’s living in much more hardcore conditions than Katie and me, and is always upbeat and positive.
Katie blogged a bit about the appalling maternal mortality and female genital mutilation practices of this country. Together with domestic abuse and an overtly patriarchal society, it’s a perfect storm for women. We know hardly any women, and most women we have seen are laden with babies and work. We walked back to the clinic with Siah Sumana, Sasseko’s wife. She had walked the two kilometers to and from the market with her eight-months-pregnant belly, and on the way back she was carrying a bundle of sticks on her head and a bag of food in her hand. We carried the sticks for her, but while she walked she placed her free hand under her belly for support.
There is hope. Many of the young Sierra Leonean men and women we speak with are very concerned about making sure and allowing “the girl child” to go to school. Education is essential to help the women of Sierra Leone. If the local economic climate can improve through agriculture – perhaps palm oil? – then there will be more money, more jobs, and more incentive to allow women to pursue careers of their own.
Currently we are working on finishing up the community health education for the survey we are conducting, then we are going to complete a draft of a business plan for the palm oil farm that will fund the clinic operating expenses, and then we are going to write out a framework for a peer education program that NOW will put into action in the fall. The focus of the peer education program, to start, is teenage pregnancy, and both Katie and I are very excited by its potential. Everywhere we go, the people ask us to speak directly with their children about this issue, and the recognition of the importance of education is almost unanimous. One of my new posts is an account of our recent health education in Yomandu, and it gives some insight to the type and nature of questions we field.
We’ve also been spending some more time in the clinic, and I love it. I’ve posted a couple of stories of diagnoses, because I think the progression of learning about a patient and what is troubling them and then trying to formulate both a diagnosis and a treatment is very interesting.
Comment freely! Cheers, Chris
Katie blogged a bit about the appalling maternal mortality and female genital mutilation practices of this country. Together with domestic abuse and an overtly patriarchal society, it’s a perfect storm for women. We know hardly any women, and most women we have seen are laden with babies and work. We walked back to the clinic with Siah Sumana, Sasseko’s wife. She had walked the two kilometers to and from the market with her eight-months-pregnant belly, and on the way back she was carrying a bundle of sticks on her head and a bag of food in her hand. We carried the sticks for her, but while she walked she placed her free hand under her belly for support.
There is hope. Many of the young Sierra Leonean men and women we speak with are very concerned about making sure and allowing “the girl child” to go to school. Education is essential to help the women of Sierra Leone. If the local economic climate can improve through agriculture – perhaps palm oil? – then there will be more money, more jobs, and more incentive to allow women to pursue careers of their own.
Currently we are working on finishing up the community health education for the survey we are conducting, then we are going to complete a draft of a business plan for the palm oil farm that will fund the clinic operating expenses, and then we are going to write out a framework for a peer education program that NOW will put into action in the fall. The focus of the peer education program, to start, is teenage pregnancy, and both Katie and I are very excited by its potential. Everywhere we go, the people ask us to speak directly with their children about this issue, and the recognition of the importance of education is almost unanimous. One of my new posts is an account of our recent health education in Yomandu, and it gives some insight to the type and nature of questions we field.
We’ve also been spending some more time in the clinic, and I love it. I’ve posted a couple of stories of diagnoses, because I think the progression of learning about a patient and what is troubling them and then trying to formulate both a diagnosis and a treatment is very interesting.
Comment freely! Cheers, Chris
Tough Questions: Health Education at Yomandu
“Hey guys.” Jalloh and Bori pulled up the path on a motorbike. The saddlebags were full of drugs and files – today we were educating in the same place as the outreach clinic.
“Hey Jalloh. How you sleep?” We clasped hands in the enthusiastic Sierra Leonean way. Katie did the same.
“Fine. But you know, we are going to Yomandu.” Oh. We were in Kania.
“Did plans change?”
“Yes. Because Sahr Bindi, he told both people the same time. And Ahmidu had to go with the tractor,”
“Oh. Sahr Bindi told both camps the same time.” We had specifically told him to arrange for us to meet the Kania community at 9am, and the Yomandu community at 2pm. But as long as we did the health education for both groups of people, it was fine.
“Yes, he did.” Jalloh was wearing a baggy, nylon Chicago Bears jacket and artistically pressed jeans. I was wearing shorts and a running shirt. “How will you go to Yomandu? Will you walk?”
“Well, we don’t know where it is.” I tried to be diplomatic.
“Mmm, I have to go back for Sasseko, and then I will come. It is just there, by the road.” There were only two roads, none particularly close, but Jalloh’s nonspecific hand motion was unhelpful.
“A will show you.” A small boy skipped ahead of Katie and me with a big grin on his face. Katie shrugged, and we followed him.
“See you, Jalloh!” Katie called, I waved. Then we followed our guide. He wasn’t gangly, but his head was all a little too big for his torso.
“Wetin na you nem?” I asked, walking behind him.
“Aboi,” he said, softly. I leaned closer. “Aboi!”
“Aboi. Me nem na Christopher. Glad to meet you.”
The path wound between small, square houses. Each one had a porch, and each porch was wrapped with a waist-high wall. The wall was always cement, but there was also always a lattice of holes in the wall to let air through. There were people around on most of the porches, and I murmured hello to most of them. Some of them were quite happy to ignore us, and that was a welcome change.
There was thick, light green grass on either side of the path. It grows tall, almost as tall as me, and the blades are wide, maybe three quarters of an inch. They’re not sharp, but they are fibrous. The path itself was tamped down red earth, smooth and well-worn. We passed a grayish-brown water hole that made me think of parasites. We also passed a meeting of people out front of a patent medicine store. “Aboi – why dey de have meeting?”
“Dey talk about nourish.”
“Oh, about nutrition, and malnourished children?”
“Yeah.”
“Okay...”
At this point we were walking on red-dirt road. Apparently there are red-dirt roads throughout Africa, and I think they are often lined with green, bushy grass. It’s a nice scenery that’s growing on me. Aboi and I walked in silence, but Katie was chatting up a couple of little girls that had started trailing her. Their names were Matellani and Marie F. Jimusa, I later learned. We also picked up a lady who thought that Aboi didn’t know where he was going. He did, but that was okay. At one point when we were walking down a very nondescript path between bushy grass, Katie said to me, “We totally would have been able to find our way...”
After a while we were walking through a big market area. There were lots of small tin sheets propped up with sticks serving as stands and booths, and lots of different vegetables laid out on blankets and platters. I could see green bananas, peppers of many different colours, yams, cassava, roasting corn, peanuts, cloth, fuel – standard Sierra Leone market fare. The bustle was a bit more subdued, and we got a lot more attention than usual. I guess white people are much rarer twenty minutes outside Koidu.
On the other side of the market was where we were scheduled to do our education. The village was called “Yomandu.” We were in a small flat area in front of one of the amputee camp houses, and some people brought out benches and plastic lawn chairs. Katie and I waited around, smiling at the growing crowd of children. Eventually Jalloh and Sasseko pulled up on the clinic motorbike. We said our hellos, and Jalloh sat down. Sasseko drove off to Kaniya to join the outreach clinic.
“Sit down, yeah?” Jalloh told me to sit down. Only Katie and him were sitting down, but there was a large crowd gathered.
“They won’t sit down until I do?” I asked, but I already knew the answer.
“No,” Jalloh switched into a lecturing tone, as he often does, “you see, they have habits, of respecting their elders, and they don’t sit down until...” I zoned out.
“I’ve never been respected as an elder before,” I smiled.
Some more community members arrived, including some we remembered from our previous visit to Yomandu. By the time Sahr Bindi arrived and told us we could start, there was a crowd of about fifty gathered around. And by around, I mean that we were in the center of the group. We’d tried to direct it so that we would be at one end of the crowd, but then more people gathered behind us. It wasn’t a big problem. Also, the benches had initially been placed in front of a small flowerbed, but the edge of the flowerbed could be a seat. So we moved the benches. It’s important to make sure there are both desirable and undesirable seats around, because the children will take the undesirable seats. If there are only good seats, the adults tell the children to leave. But the children have the best understanding of English, and the children are the ones with the most potential to put our education into action.
Jalloh began by introducing us and himself. “Okay. Na morning,” the crowd murmured good morning, “Me na student, me comot na Fourah Bay College na Freetown for de do internship na Dorma Amputee Clinic.” A tip for reading Krio: to conjugate a verb, you just put “de” in front of it. If you can’t tell what something means, say it aloud, and listen closely. For example, “comot” is “come out,” so it means “come from.” Jalloh looked at Katie expectantly.
“Me nem de Katie,” Katie always says “nem de” but I’m not sure why, “me na student, a comot na America.”
Sahr Bindi piped up, “Kumba Katie!” Every second daughter in Kono district is named Kumba. Everyone laughed; our Kono names are very popular.
“Me nem na Christopher, an me na student, a de study na America, but a comot na Canada. We comot na Amputee Clinic for de teach una (you) about health education.” Jalloh nodded, and then explained why we’d come in Krio. Then Katie gave the malaria module.
“Okay. So una de get malaria wey de mosquita, dey bet. So if me na mosquita...”
I looked around the crowd, caught the eye of as many people as I could, and returned their smiles. After giving these health education modules a few times, it seems like the best way to retain interest is to let the audience members know that you are paying attention and interested in them, and so I decided to try eye contact for this, even while Katie was speaking and not me. Aboi and Marie (his sister) were sitting across from us on the edge of the flower bed, along with fourteen or fifteen other children.
The health education went off without event until the family planning section. In the family planning section we talk about how smaller families (having fewer children) is better because it allows the family to focus more resources in terms of money for nutrition and school and time for attention on each child.
“I wan for ask, if dem small small girls, dem pikin, can use injection.”
The woman asking the question was middle aged and dressed in bright blue African garb. She held herself with confidence, and asked her question with a gregarious smile to the crowd. Jalloh translated, but I had understood the Krio. Katie and I conferred briefly, and the woman added some detail. Jalloh translated the detail, “She says, many women think that it is not safe to have the injection until they have two-three children. That if they have it before having two-three children, they will be infertile.”
“The injection, the condom, these methods are safe. It’s not true that you need to have two or three children before it will work. If it doesn’t work before two or three children, it won’t work after. You should consult your doctor, because every woman is different.” Katie gave her answer with a very concerned look on her face. Jalloh translated it. The woman nodded. I added something.
“It’s better to use condoms for the young girl because there are no chemicals. But using the injection is much better than getting belle (getting pregnant). Wey you done get belle, you could die.” The woman nodded again.
Katie kept forging ahead until the end of the family planning module.
“So, una de got any question?” Katie asked if anyone had questions. Jalloh repeated her, and added some Krio to explain.
“Me de got question.” A young man behind our right shoulder spoke. We turned. He told a long story about a girl and a guy, involving various attempts by the guy to get the girl to use contraception. First he tried condoms, and she refused, and then she agreed to use injections, but then when the boy took her for injections she again refused, and told him she had too negative a perception of these contraceptives to use them. Jalloh said,
“Okay, so he is asking about what to do when the girl won’t listen, won’t use contraception.”
“Jalloh, he told an entire story, and I didn’t understand all of it. What did he say?” I had understood enough to recognize that it wasn’t so simple.
“No, it’s just that, he wants to know how to convince her.”
“Jalloh, I want to know the entire story. He talked about trying different methods, and negative perceptions... Can you just translate what he said?” Katie nodded. We both understand Krio to a certain extent, but I’m much more willing to guess at what was intended.
“Okay, he just said, that the boy tried to get the girl to use condoms, and she refuse, and then he try to get her to use injections, and still she refuse, and what does he do?”
Katie responded. “So it’s very important that he talk to her, and that she understands that he is worried not just for her health but also for his, and it’s really best to use condoms. He needs to be very clear with her why it’s so important to prevent pregnancy, and really make it clear that he is concerned, and that it’s very important.”
Jalloh translated this. Then I added something. Usually Katie answers first, because she is very good at emphasizing communication and its role in resolving many of the questions that arise. My answers tend to be more direct and practical, and I try and say them in simple Krio/English mix that doesn’t require translation to be understood. Jalloh translates them anyway, but sometimes he adds a lot of words that disguises the crux of the message.
“If de woman, she no de listen to you, den you faut go talk na someone she does listen to, some elder. Or, you de go talk wit’ her friends, and tell dem why you worried, and ask dem to talk to her. You need to recruit allies, make sure she is hearing about why contraception is important from many different sources.”
When Jalloh translated, he added a line about taking the girl to the clinic or the doctor. The young man nodded and listened carefully with a concerned look on his face. Some of the best and most difficult questions at these health educations are asked by young men. They seem genuinely and passionately invested in helping their friends and family, and they give me hope for the future of Sierra Leone.
“A de got question.” While Katie was speaking, I had been watching all the people around me, counting heads and taking note of who was listening. A tall woman in an iridiscent solid blue dress had been standing directly behind us, but she had orbited around the group to the front, and was now asking a question. “You de work for send you pikin na school...” [Krio I didn’t understand] “but you no can walk wit you pikin na school, and dey go get belle, and den...” [Krio I didn’t understand] “but de man, e’ say why you no tell ‘im, why you hide de pikin belle?”
“Okay. So the woman,” Jalloh paused, “she says, what do you do when your husband accuses you, of hiding the girl’s pregnancy, but you didn’t know? He says, that you, the wife, you should know what your daughter is doing, and he gets angry, because you don’t know.”
My mind flashed, and I got distracted by what “gets angry” meant in this small village outside Koidu. Until two years ago, beating your wife was legal in Sierra Leone.
Then, my mind switched to a question we had fielded yesterday, from a local chief. He was tall, and dressed in a grey pea coat (let me remind you that this is Africa). He owned a motorcycle, and demanded that the meeting proceedings follow a certain protocol. And, he had set up the seating so that the women were out in the rain and the men were under the porch. This was his question:
“What do you do, when you know the daughter is pregnant, and you want to find the father, but that woman, the mother, she knows too, and they conspire against you! What do you do when she no de tell you who de papa? Wey you wife no de help you? Wetin you faut do?” He said the question with force, vehemence. It was backed up by the stern nodding of other men. Indeed, what do you do when women are constantly conspiring against you? I had let Katie answer that question. I didn’t know where to begin.
Now, we were facing the opposite question, the other perspective.
“It’s not only important to have a trusting relationship with your children,” in my mind’s eye, I blinked in disbelief at where it looked like Katie was heading with this. It’s difficult to tell a woman in a society with endemic domestic abuse that she needs to have a more understanding relationship with her husband. But at the same time, what else can we say or do? “It’s also important to have a trusting relationship with your husband. He needs to know that you care about the daughter, just like him, and you need to say ‘Why would I hide it? I am concerned above all for her health, it is most important, and we need to help her stay healthy and well.’ He has to know that driving the daughter and the mother from the house is not going to help the health of anyone.” Jalloh translated. Sometimes I worry that the feminist nuance in our answers is lost through his translations. On the other hand, sometimes he does a good job of making our answer culturally relevant. There’s no perfect system.
The woman nodded. Her eyes were deeply set, and her cheeks were drawn down such that her mouth’s neutral position was a frown. But when she had spoken, her features had animated significantly, and she had looked like a different woman. I wondered how she interpreted the answer, and whether it was useful to her.
There was a moment of general talking, and Katie and I glanced at each other to check if we should proceed. But Jalloh said, “She has another question.” The woman in iridiscent blue spoke again. I didn’t understand her question, but she was gesturing wildly. At one point she reached out and grabbed an eight year old boy on the head, and he looked sheepish. Everyone laughed. I think she said, “and dis de papa...” Jalloh translated the question, smiling.
“Okay, so she asks, she says that herself, she is a widow. Her husband is dead. And she has many children to take care of, but she can’t stay home and watch them. So when her daughter goes and gets pregnant, and the father is a little boy like him,” Jalloh pointed to the sheepish eight-year old. I laughed, but was not totally willing to think there was no kernel of truth to the question. “Then, what can she do? She has no money for the child.” I raised my eyebrows. Again, I had no idea. What do you do? It’s a tough question for a North American family, for a North American single mother. It’s perhaps a tougher question for a widow in a relentlessly patriarchal and poverty-stricken society.
“I don’t know, that’s a really tough question.” Katie nodded at me, concerned. She had a better answer than ‘I don’t know.’
“She needs to make her daughter understand that the family can’t afford to have that happen. She can’t say ‘don’t get pregnant,’ she needs to be honest with her daughter and say ‘we can’t afford it if you get pregnant, so you need to use proper contraception,’ and she needs to make that contraception available.”
Jalloh translated. Again, I think some of the nuance was lost. Sierra Leoneans often ask about how they are to discipline and control their children, and Katie’s answers all focus on imparting an understanding of the bigger picture to the children. They are idealistic responses, but from the perspective of changing behavior here in Sierra Leone, I think they are very appropriate. It’s true that not all children are able to understand what is important for their family, and sometimes even when they do, they don’t do it. But teaching children how to consider the bigger picture of what a family needs as opposed to what an individual wants is one way of helping the much-needed societal shift from considering very narrow, small short-term views to considering how one’s actions fit into the society as a whole.
Then, Katie proceeded with the teenage pregnancy section of the health education. By now there were around eighty men, women and children in the crowd. I was especially happy that Aboi and other children around his age (twelve) were in the audience, because teenage pregnancy was lurking dangerously near in their future, but they were still young enough to be both impressionable and ignorant. At the end of this section, there were a few more questions, although many of them had already been asked. It’s both troubling and reassuring that questions related to teenage pregnancy arise so spontaneously out of discussions of family planning.
“A de got question. Now, we de got dis human rights, wey you discipline you pikin, dey turn an go na police. Eh, eh?” It was the first woman again, the gregarious one. She asked the crowd for confirmation and got it.
In fact, this was almost identical to a question the motorcycle-riding, peacoat-sporting chief had asked yesterday. Apparently in Sierra Leone, many parents are worried that the increasing prevalence of human rights is being taken advantage of by their children, and that if they try to control their children in any way the children will go to the police. I have no idea whether this actually happens. Katie thinks that the kids probably just threaten, she doesn’t think they actually do. The police are not exactly a powerful or respected institution in Sierra Leone.
“Jalloh, tell them that we struggle with problems of how to control children like this, even in North America. Tell them we understand that it’s very hard, but that change needs to happen gradually. In the past, corporal punishment was acceptable, and was used, but now times are changing, and it is not always easy.” I tried for a bit of crowd appeasement. It seems to work well – if you throw in a “Jalloh, thank her for asking such a smart question,” or something similar, the audience laps it up. After Jalloh translated that, the woman nodded emphatically, and everyone else seemed to agree. Then Katie added something more substantive.
“It’s very important to have an understanding relationship with your children. Jalloh, can you tell them the story about the water, from yesterday?”
“Yes, yes, I know it.” The story about the water was how Katie answered the chief’s question yesterday. She created a hypothetical situation where a child refuses to get water, and the parent needs the child to do so. She said that instead of hitting the child, yelling at the child, or forcing the child, the parent should explain and educate the child from a young age that fetching water is important for the family.
Katie also said something very interesting to the chief that she didn’t say to the crowd at Yomandu. “I am from America, but my parents are Chinese. In China, corporal punishment was common. But in America, it is not allowed. So in America, if they see a Chinese child with bruises, then they think they are beating the child. So I have some Chinese friends where the parents beat their children, and some Chinese friends where their parents did not beat them. And from my experience it was much more efficient and better for the child as they grow up to not beat them.”
After this woman’s question, another woman, and then a man, confirmed the community’s desire for us to speak directly with the children. They seemed at a loss for how to stop teenage pregnancy amongst their children, and for how to get their children to listen to them. Katie and I mentioned that we are designing a peer education program to be implemented after we leave, but more importantly, we emphasized that change requires that teens hear the message of communication, contraception, and responsibility from many different sources. From parents, from teachers, from friends, from people like Katie and me. They seemed to understand.
Throughout the presentation, I kept turning around. During the health modules, Aboi and the other children had migrated behind me. There were about twenty of them. Every time I looked back, they would stare at me, faces expressionless. But if I gave them even a millimeter of smile, their eyes would open wide and their faces would dance with big grins. All these questions and all this education was for them.
“Hey Jalloh. How you sleep?” We clasped hands in the enthusiastic Sierra Leonean way. Katie did the same.
“Fine. But you know, we are going to Yomandu.” Oh. We were in Kania.
“Did plans change?”
“Yes. Because Sahr Bindi, he told both people the same time. And Ahmidu had to go with the tractor,”
“Oh. Sahr Bindi told both camps the same time.” We had specifically told him to arrange for us to meet the Kania community at 9am, and the Yomandu community at 2pm. But as long as we did the health education for both groups of people, it was fine.
“Yes, he did.” Jalloh was wearing a baggy, nylon Chicago Bears jacket and artistically pressed jeans. I was wearing shorts and a running shirt. “How will you go to Yomandu? Will you walk?”
“Well, we don’t know where it is.” I tried to be diplomatic.
“Mmm, I have to go back for Sasseko, and then I will come. It is just there, by the road.” There were only two roads, none particularly close, but Jalloh’s nonspecific hand motion was unhelpful.
“A will show you.” A small boy skipped ahead of Katie and me with a big grin on his face. Katie shrugged, and we followed him.
“See you, Jalloh!” Katie called, I waved. Then we followed our guide. He wasn’t gangly, but his head was all a little too big for his torso.
“Wetin na you nem?” I asked, walking behind him.
“Aboi,” he said, softly. I leaned closer. “Aboi!”
“Aboi. Me nem na Christopher. Glad to meet you.”
The path wound between small, square houses. Each one had a porch, and each porch was wrapped with a waist-high wall. The wall was always cement, but there was also always a lattice of holes in the wall to let air through. There were people around on most of the porches, and I murmured hello to most of them. Some of them were quite happy to ignore us, and that was a welcome change.
There was thick, light green grass on either side of the path. It grows tall, almost as tall as me, and the blades are wide, maybe three quarters of an inch. They’re not sharp, but they are fibrous. The path itself was tamped down red earth, smooth and well-worn. We passed a grayish-brown water hole that made me think of parasites. We also passed a meeting of people out front of a patent medicine store. “Aboi – why dey de have meeting?”
“Dey talk about nourish.”
“Oh, about nutrition, and malnourished children?”
“Yeah.”
“Okay...”
At this point we were walking on red-dirt road. Apparently there are red-dirt roads throughout Africa, and I think they are often lined with green, bushy grass. It’s a nice scenery that’s growing on me. Aboi and I walked in silence, but Katie was chatting up a couple of little girls that had started trailing her. Their names were Matellani and Marie F. Jimusa, I later learned. We also picked up a lady who thought that Aboi didn’t know where he was going. He did, but that was okay. At one point when we were walking down a very nondescript path between bushy grass, Katie said to me, “We totally would have been able to find our way...”
After a while we were walking through a big market area. There were lots of small tin sheets propped up with sticks serving as stands and booths, and lots of different vegetables laid out on blankets and platters. I could see green bananas, peppers of many different colours, yams, cassava, roasting corn, peanuts, cloth, fuel – standard Sierra Leone market fare. The bustle was a bit more subdued, and we got a lot more attention than usual. I guess white people are much rarer twenty minutes outside Koidu.
On the other side of the market was where we were scheduled to do our education. The village was called “Yomandu.” We were in a small flat area in front of one of the amputee camp houses, and some people brought out benches and plastic lawn chairs. Katie and I waited around, smiling at the growing crowd of children. Eventually Jalloh and Sasseko pulled up on the clinic motorbike. We said our hellos, and Jalloh sat down. Sasseko drove off to Kaniya to join the outreach clinic.
“Sit down, yeah?” Jalloh told me to sit down. Only Katie and him were sitting down, but there was a large crowd gathered.
“They won’t sit down until I do?” I asked, but I already knew the answer.
“No,” Jalloh switched into a lecturing tone, as he often does, “you see, they have habits, of respecting their elders, and they don’t sit down until...” I zoned out.
“I’ve never been respected as an elder before,” I smiled.
Some more community members arrived, including some we remembered from our previous visit to Yomandu. By the time Sahr Bindi arrived and told us we could start, there was a crowd of about fifty gathered around. And by around, I mean that we were in the center of the group. We’d tried to direct it so that we would be at one end of the crowd, but then more people gathered behind us. It wasn’t a big problem. Also, the benches had initially been placed in front of a small flowerbed, but the edge of the flowerbed could be a seat. So we moved the benches. It’s important to make sure there are both desirable and undesirable seats around, because the children will take the undesirable seats. If there are only good seats, the adults tell the children to leave. But the children have the best understanding of English, and the children are the ones with the most potential to put our education into action.
Jalloh began by introducing us and himself. “Okay. Na morning,” the crowd murmured good morning, “Me na student, me comot na Fourah Bay College na Freetown for de do internship na Dorma Amputee Clinic.” A tip for reading Krio: to conjugate a verb, you just put “de” in front of it. If you can’t tell what something means, say it aloud, and listen closely. For example, “comot” is “come out,” so it means “come from.” Jalloh looked at Katie expectantly.
“Me nem de Katie,” Katie always says “nem de” but I’m not sure why, “me na student, a comot na America.”
Sahr Bindi piped up, “Kumba Katie!” Every second daughter in Kono district is named Kumba. Everyone laughed; our Kono names are very popular.
“Me nem na Christopher, an me na student, a de study na America, but a comot na Canada. We comot na Amputee Clinic for de teach una (you) about health education.” Jalloh nodded, and then explained why we’d come in Krio. Then Katie gave the malaria module.
“Okay. So una de get malaria wey de mosquita, dey bet. So if me na mosquita...”
I looked around the crowd, caught the eye of as many people as I could, and returned their smiles. After giving these health education modules a few times, it seems like the best way to retain interest is to let the audience members know that you are paying attention and interested in them, and so I decided to try eye contact for this, even while Katie was speaking and not me. Aboi and Marie (his sister) were sitting across from us on the edge of the flower bed, along with fourteen or fifteen other children.
The health education went off without event until the family planning section. In the family planning section we talk about how smaller families (having fewer children) is better because it allows the family to focus more resources in terms of money for nutrition and school and time for attention on each child.
“I wan for ask, if dem small small girls, dem pikin, can use injection.”
The woman asking the question was middle aged and dressed in bright blue African garb. She held herself with confidence, and asked her question with a gregarious smile to the crowd. Jalloh translated, but I had understood the Krio. Katie and I conferred briefly, and the woman added some detail. Jalloh translated the detail, “She says, many women think that it is not safe to have the injection until they have two-three children. That if they have it before having two-three children, they will be infertile.”
“The injection, the condom, these methods are safe. It’s not true that you need to have two or three children before it will work. If it doesn’t work before two or three children, it won’t work after. You should consult your doctor, because every woman is different.” Katie gave her answer with a very concerned look on her face. Jalloh translated it. The woman nodded. I added something.
“It’s better to use condoms for the young girl because there are no chemicals. But using the injection is much better than getting belle (getting pregnant). Wey you done get belle, you could die.” The woman nodded again.
Katie kept forging ahead until the end of the family planning module.
“So, una de got any question?” Katie asked if anyone had questions. Jalloh repeated her, and added some Krio to explain.
“Me de got question.” A young man behind our right shoulder spoke. We turned. He told a long story about a girl and a guy, involving various attempts by the guy to get the girl to use contraception. First he tried condoms, and she refused, and then she agreed to use injections, but then when the boy took her for injections she again refused, and told him she had too negative a perception of these contraceptives to use them. Jalloh said,
“Okay, so he is asking about what to do when the girl won’t listen, won’t use contraception.”
“Jalloh, he told an entire story, and I didn’t understand all of it. What did he say?” I had understood enough to recognize that it wasn’t so simple.
“No, it’s just that, he wants to know how to convince her.”
“Jalloh, I want to know the entire story. He talked about trying different methods, and negative perceptions... Can you just translate what he said?” Katie nodded. We both understand Krio to a certain extent, but I’m much more willing to guess at what was intended.
“Okay, he just said, that the boy tried to get the girl to use condoms, and she refuse, and then he try to get her to use injections, and still she refuse, and what does he do?”
Katie responded. “So it’s very important that he talk to her, and that she understands that he is worried not just for her health but also for his, and it’s really best to use condoms. He needs to be very clear with her why it’s so important to prevent pregnancy, and really make it clear that he is concerned, and that it’s very important.”
Jalloh translated this. Then I added something. Usually Katie answers first, because she is very good at emphasizing communication and its role in resolving many of the questions that arise. My answers tend to be more direct and practical, and I try and say them in simple Krio/English mix that doesn’t require translation to be understood. Jalloh translates them anyway, but sometimes he adds a lot of words that disguises the crux of the message.
“If de woman, she no de listen to you, den you faut go talk na someone she does listen to, some elder. Or, you de go talk wit’ her friends, and tell dem why you worried, and ask dem to talk to her. You need to recruit allies, make sure she is hearing about why contraception is important from many different sources.”
When Jalloh translated, he added a line about taking the girl to the clinic or the doctor. The young man nodded and listened carefully with a concerned look on his face. Some of the best and most difficult questions at these health educations are asked by young men. They seem genuinely and passionately invested in helping their friends and family, and they give me hope for the future of Sierra Leone.
“A de got question.” While Katie was speaking, I had been watching all the people around me, counting heads and taking note of who was listening. A tall woman in an iridiscent solid blue dress had been standing directly behind us, but she had orbited around the group to the front, and was now asking a question. “You de work for send you pikin na school...” [Krio I didn’t understand] “but you no can walk wit you pikin na school, and dey go get belle, and den...” [Krio I didn’t understand] “but de man, e’ say why you no tell ‘im, why you hide de pikin belle?”
“Okay. So the woman,” Jalloh paused, “she says, what do you do when your husband accuses you, of hiding the girl’s pregnancy, but you didn’t know? He says, that you, the wife, you should know what your daughter is doing, and he gets angry, because you don’t know.”
My mind flashed, and I got distracted by what “gets angry” meant in this small village outside Koidu. Until two years ago, beating your wife was legal in Sierra Leone.
Then, my mind switched to a question we had fielded yesterday, from a local chief. He was tall, and dressed in a grey pea coat (let me remind you that this is Africa). He owned a motorcycle, and demanded that the meeting proceedings follow a certain protocol. And, he had set up the seating so that the women were out in the rain and the men were under the porch. This was his question:
“What do you do, when you know the daughter is pregnant, and you want to find the father, but that woman, the mother, she knows too, and they conspire against you! What do you do when she no de tell you who de papa? Wey you wife no de help you? Wetin you faut do?” He said the question with force, vehemence. It was backed up by the stern nodding of other men. Indeed, what do you do when women are constantly conspiring against you? I had let Katie answer that question. I didn’t know where to begin.
Now, we were facing the opposite question, the other perspective.
“It’s not only important to have a trusting relationship with your children,” in my mind’s eye, I blinked in disbelief at where it looked like Katie was heading with this. It’s difficult to tell a woman in a society with endemic domestic abuse that she needs to have a more understanding relationship with her husband. But at the same time, what else can we say or do? “It’s also important to have a trusting relationship with your husband. He needs to know that you care about the daughter, just like him, and you need to say ‘Why would I hide it? I am concerned above all for her health, it is most important, and we need to help her stay healthy and well.’ He has to know that driving the daughter and the mother from the house is not going to help the health of anyone.” Jalloh translated. Sometimes I worry that the feminist nuance in our answers is lost through his translations. On the other hand, sometimes he does a good job of making our answer culturally relevant. There’s no perfect system.
The woman nodded. Her eyes were deeply set, and her cheeks were drawn down such that her mouth’s neutral position was a frown. But when she had spoken, her features had animated significantly, and she had looked like a different woman. I wondered how she interpreted the answer, and whether it was useful to her.
There was a moment of general talking, and Katie and I glanced at each other to check if we should proceed. But Jalloh said, “She has another question.” The woman in iridiscent blue spoke again. I didn’t understand her question, but she was gesturing wildly. At one point she reached out and grabbed an eight year old boy on the head, and he looked sheepish. Everyone laughed. I think she said, “and dis de papa...” Jalloh translated the question, smiling.
“Okay, so she asks, she says that herself, she is a widow. Her husband is dead. And she has many children to take care of, but she can’t stay home and watch them. So when her daughter goes and gets pregnant, and the father is a little boy like him,” Jalloh pointed to the sheepish eight-year old. I laughed, but was not totally willing to think there was no kernel of truth to the question. “Then, what can she do? She has no money for the child.” I raised my eyebrows. Again, I had no idea. What do you do? It’s a tough question for a North American family, for a North American single mother. It’s perhaps a tougher question for a widow in a relentlessly patriarchal and poverty-stricken society.
“I don’t know, that’s a really tough question.” Katie nodded at me, concerned. She had a better answer than ‘I don’t know.’
“She needs to make her daughter understand that the family can’t afford to have that happen. She can’t say ‘don’t get pregnant,’ she needs to be honest with her daughter and say ‘we can’t afford it if you get pregnant, so you need to use proper contraception,’ and she needs to make that contraception available.”
Jalloh translated. Again, I think some of the nuance was lost. Sierra Leoneans often ask about how they are to discipline and control their children, and Katie’s answers all focus on imparting an understanding of the bigger picture to the children. They are idealistic responses, but from the perspective of changing behavior here in Sierra Leone, I think they are very appropriate. It’s true that not all children are able to understand what is important for their family, and sometimes even when they do, they don’t do it. But teaching children how to consider the bigger picture of what a family needs as opposed to what an individual wants is one way of helping the much-needed societal shift from considering very narrow, small short-term views to considering how one’s actions fit into the society as a whole.
Then, Katie proceeded with the teenage pregnancy section of the health education. By now there were around eighty men, women and children in the crowd. I was especially happy that Aboi and other children around his age (twelve) were in the audience, because teenage pregnancy was lurking dangerously near in their future, but they were still young enough to be both impressionable and ignorant. At the end of this section, there were a few more questions, although many of them had already been asked. It’s both troubling and reassuring that questions related to teenage pregnancy arise so spontaneously out of discussions of family planning.
“A de got question. Now, we de got dis human rights, wey you discipline you pikin, dey turn an go na police. Eh, eh?” It was the first woman again, the gregarious one. She asked the crowd for confirmation and got it.
In fact, this was almost identical to a question the motorcycle-riding, peacoat-sporting chief had asked yesterday. Apparently in Sierra Leone, many parents are worried that the increasing prevalence of human rights is being taken advantage of by their children, and that if they try to control their children in any way the children will go to the police. I have no idea whether this actually happens. Katie thinks that the kids probably just threaten, she doesn’t think they actually do. The police are not exactly a powerful or respected institution in Sierra Leone.
“Jalloh, tell them that we struggle with problems of how to control children like this, even in North America. Tell them we understand that it’s very hard, but that change needs to happen gradually. In the past, corporal punishment was acceptable, and was used, but now times are changing, and it is not always easy.” I tried for a bit of crowd appeasement. It seems to work well – if you throw in a “Jalloh, thank her for asking such a smart question,” or something similar, the audience laps it up. After Jalloh translated that, the woman nodded emphatically, and everyone else seemed to agree. Then Katie added something more substantive.
“It’s very important to have an understanding relationship with your children. Jalloh, can you tell them the story about the water, from yesterday?”
“Yes, yes, I know it.” The story about the water was how Katie answered the chief’s question yesterday. She created a hypothetical situation where a child refuses to get water, and the parent needs the child to do so. She said that instead of hitting the child, yelling at the child, or forcing the child, the parent should explain and educate the child from a young age that fetching water is important for the family.
Katie also said something very interesting to the chief that she didn’t say to the crowd at Yomandu. “I am from America, but my parents are Chinese. In China, corporal punishment was common. But in America, it is not allowed. So in America, if they see a Chinese child with bruises, then they think they are beating the child. So I have some Chinese friends where the parents beat their children, and some Chinese friends where their parents did not beat them. And from my experience it was much more efficient and better for the child as they grow up to not beat them.”
After this woman’s question, another woman, and then a man, confirmed the community’s desire for us to speak directly with the children. They seemed at a loss for how to stop teenage pregnancy amongst their children, and for how to get their children to listen to them. Katie and I mentioned that we are designing a peer education program to be implemented after we leave, but more importantly, we emphasized that change requires that teens hear the message of communication, contraception, and responsibility from many different sources. From parents, from teachers, from friends, from people like Katie and me. They seemed to understand.
Throughout the presentation, I kept turning around. During the health modules, Aboi and the other children had migrated behind me. There were about twenty of them. Every time I looked back, they would stare at me, faces expressionless. But if I gave them even a millimeter of smile, their eyes would open wide and their faces would dance with big grins. All these questions and all this education was for them.
Diagnosis II
Where was Katie? I wondered. We needed to work on the database for the survey we were conducting, a survey about health education. There wasn't really a rush, though. I set out through the clinic to find her.
There were many people waiting to be seen, waiting for lab tests, and waiting for medication. They were sitting on benches in the waiting room and in the halls, their clothes blending together in my peripheral vision. Part of me is afraid to be too friendly lest they get the false idea I am going to give them something or pay for their care. Another part of me is annoyed that I don’t spend more time listening to them, learning their syptoms and stories. Deep down, I worry that I am just unwilling to reach across the divide between us. I wish the divide wasn’t there, but between languages and between continents, it is. As Allan said a few times, in this clinic the fifteenth century meets the twenty-first.
I walked past the consulting room, figuring that Katie was probably in there with Bailor, but deciding to look in the other rooms first, to avoid disturbing the consultation unless absolutely necessary. To be honest, hardly anyone else afforded the consulting room so much respect, so it probably didn’t matter. She wasn’t anywhere else, so I knocked on the consultation door and said, “Hello? Is Katie in there?”
“Come in!” was the response. So I did.
Katie, Dr. Lenny, Bailor, Bori, and Yusuf were all already in the tiny room. Seated in the patient chair was a young mother, holding her daughter. Her daughter was nearly naked, and perhaps a year old. I could see her ribs struggling against her skin as she breathed. She looked sick. Bailor welcomed me with a nod.
“Look at this pikin. She so pale, she is anemic. You see?” I didn’t see. I couldn’t tell that she was pale. But she had pale lines and red lines on her neck. Maybe that’s why Bailor could tell? More likely was just that I wasn’t observant or experienced enough. I looked at her palms, because they are usually a tell-tale sign. They did look a little pale.
“An’ you see how she breathes – she uses the intercostal space. Beside her ribs.” I moved around the mother to peer at the side of the baby. She began to cry when Bailor touched her side, and she started flailing her arms. “Well, now you can’t see it, she’s crying. But when she’s still, you watch.” In a moment, she was still. But her eyes were liquid with distress. I could see the intercostal breathing – her ribcage flared out instead of merely up and down. Her body was using different muscles than usual to draw in as much air as possible. “And you see how her nostrils, dey flare? She’s not breathing fast, but she’s breathing hard. I think it’s pneumonia.”
“The most dangerous things for a child are respiratory infections, like this, and dehydration.” Dr. Lenny addressed Katie and I.
I nodded and murmured the word dehydration. The little girl had her hair braided upwards around her head, with all the braids ending in short stubs in a circle on the top of her head. It’s a popular style among little girls in Sierra Leone.
“Why are they dangerous?” Katie asked.
“Because they kill the child quickly.”
Bailor turned to the mother. “Oustem de pikin ‘e ge’ sick like dis?” When did the child get sick like this?
“Saturday. No, Friday.” Bailor made the peculiar high-pitched “eh!” noise that all Sierra Leoneans make when they are suprised, appalled, or angry.
“Why you de wait so long for come de gi’ de pikin care? Dis pikin ve’y sick, ve’y sick. Why you no de come Saturday?”
The woman shrugged. Behind Bailor, Bori was shaking his head and looking concerned. It was serious, but Bailor and Bori’s scolding faces were a little comical.
“Now we faut gi’ de pikin drip. Wey you de come na Saturday, we jus’ de gi’ em amodiaquin, she de go ge’ welbody quick quick. But now, we faut gi ‘em drip, i’ more dear,” Bailor was telling her off for waiting because now it would be more expensive, “and you no de make de pikin suffer so, wey you de come na Saturday,” and because it would have been easier on the child.
I looked at the little girl, shaking in the arms of her mother. I was glad she was at the clinic at all, even though Bailor was right.
There were many people waiting to be seen, waiting for lab tests, and waiting for medication. They were sitting on benches in the waiting room and in the halls, their clothes blending together in my peripheral vision. Part of me is afraid to be too friendly lest they get the false idea I am going to give them something or pay for their care. Another part of me is annoyed that I don’t spend more time listening to them, learning their syptoms and stories. Deep down, I worry that I am just unwilling to reach across the divide between us. I wish the divide wasn’t there, but between languages and between continents, it is. As Allan said a few times, in this clinic the fifteenth century meets the twenty-first.
I walked past the consulting room, figuring that Katie was probably in there with Bailor, but deciding to look in the other rooms first, to avoid disturbing the consultation unless absolutely necessary. To be honest, hardly anyone else afforded the consulting room so much respect, so it probably didn’t matter. She wasn’t anywhere else, so I knocked on the consultation door and said, “Hello? Is Katie in there?”
“Come in!” was the response. So I did.
Katie, Dr. Lenny, Bailor, Bori, and Yusuf were all already in the tiny room. Seated in the patient chair was a young mother, holding her daughter. Her daughter was nearly naked, and perhaps a year old. I could see her ribs struggling against her skin as she breathed. She looked sick. Bailor welcomed me with a nod.
“Look at this pikin. She so pale, she is anemic. You see?” I didn’t see. I couldn’t tell that she was pale. But she had pale lines and red lines on her neck. Maybe that’s why Bailor could tell? More likely was just that I wasn’t observant or experienced enough. I looked at her palms, because they are usually a tell-tale sign. They did look a little pale.
“An’ you see how she breathes – she uses the intercostal space. Beside her ribs.” I moved around the mother to peer at the side of the baby. She began to cry when Bailor touched her side, and she started flailing her arms. “Well, now you can’t see it, she’s crying. But when she’s still, you watch.” In a moment, she was still. But her eyes were liquid with distress. I could see the intercostal breathing – her ribcage flared out instead of merely up and down. Her body was using different muscles than usual to draw in as much air as possible. “And you see how her nostrils, dey flare? She’s not breathing fast, but she’s breathing hard. I think it’s pneumonia.”
“The most dangerous things for a child are respiratory infections, like this, and dehydration.” Dr. Lenny addressed Katie and I.
I nodded and murmured the word dehydration. The little girl had her hair braided upwards around her head, with all the braids ending in short stubs in a circle on the top of her head. It’s a popular style among little girls in Sierra Leone.
“Why are they dangerous?” Katie asked.
“Because they kill the child quickly.”
Bailor turned to the mother. “Oustem de pikin ‘e ge’ sick like dis?” When did the child get sick like this?
“Saturday. No, Friday.” Bailor made the peculiar high-pitched “eh!” noise that all Sierra Leoneans make when they are suprised, appalled, or angry.
“Why you de wait so long for come de gi’ de pikin care? Dis pikin ve’y sick, ve’y sick. Why you no de come Saturday?”
The woman shrugged. Behind Bailor, Bori was shaking his head and looking concerned. It was serious, but Bailor and Bori’s scolding faces were a little comical.
“Now we faut gi’ de pikin drip. Wey you de come na Saturday, we jus’ de gi’ em amodiaquin, she de go ge’ welbody quick quick. But now, we faut gi ‘em drip, i’ more dear,” Bailor was telling her off for waiting because now it would be more expensive, “and you no de make de pikin suffer so, wey you de come na Saturday,” and because it would have been easier on the child.
I looked at the little girl, shaking in the arms of her mother. I was glad she was at the clinic at all, even though Bailor was right.
Diagnosis I
“Oh, this woman, she no look well.” Bailor’s voice was concerned but matter-of-fact. The consulting room was cramped, with Katie, myself, and Dr. Lenny crammed into different corners. Bailor was behind his desk, and Bori was in front of it, waiting to translate.
The woman entered the room. There was a practical desperation in her movement; it clung to her and hid in the way she sat down and settled into a vacant stare. Her eyes were wide but sunken, and hunger had tightened her wrinkles against her bones. She was robed in a magnificent turquoise and lime green diamond patterned dress. As Dr. Lenny would later point out, she did not look like she was having a good day.
“Wetin na de problem, mama?” Bailor asked her what was wrong. I fiddled with the “Children’s Hospital Care” book on the corner of the desk. Bailor later called it his bible. “Why you come today?”
She rubbed her stomach and looked plaintive. Bori translated. “E’ belly de hurt, e belle de hurt... she de feel snake insigh, crawling insigh, crawling... e’ de hurt beaucoup...” and after some prompting, “e’ body de wam, de joints dey hurt...” While translating, Bori began gathering vitals. He motioned for her to remove her shirt and then slipped a blood pressure cuff around her arm.
“What did she say?” Katie asked. Bori had translated into Krio, which sometimes needs further translating.
“Her stomach hurts,” I slipped in, rather unhelpfully.
“She say, that she feels a snake inside, that her stomach hurts,” Bailor had the real answer, “you know, these people, they will tell you that there is a snake, and they feel it crawling,” his hand traced snake-crawling around his belly, “and then it will bite them here,” his hand made a biting motion at the center-bottom of his ribcage. I nodded sagely. Gastritis, or ulcers, or heartburn, I thought to myself. “Tha’s why you need to know your patients, you need to know where they are coming from, so you can understand,”
“Well, not to downplay the role of understanding,” Dr. Lenny held his hands up and looked bashful, “but I think any good clinician would think of gastritis when a patient mentioned upper chest pain,”
“Does malaria cause that?” Katie asked, about the gastritis. Asking about malaria is always a good idea here; since the parasite attacks the red blood cells, the disease can manifest in many different ways. Bori had written down the blood pressure cuff results on the back of the patient registration card and then pushed it across the table. I eagerly peered at the numbers. Pulse 87 bpm, blood pressure 100/78.
“No, is probably peptic ulcer disease,”
“Well even giardia can cause gastritis, though,” Dr. Lenny added, with a humble shrug of his shoulders. “And even in the US it’s hard to tell whether or not it’s H. pylori, peptic ulcer disease,” he added, “here I bet it’s just that much harder.”
“Yeah, yeah, you know, that’s why, that’s why, I’m not sure, but I will prescribe her [some antibiotics and an antacid].”
“That’ll take care of the giardia too.” Lenny replied, but I was looking at the patient. She didn’t look healthy, and even though she had come in because of the pain in her stomach, that might be masking a more chronic problem. Hmm. Should I say something? I wondered. I was sure the experienced clinicians have already thought of what I wanted to say.
“But, are we going to test for malaria? Maybe the peptic ulcer disease is masking something else, something more important?”
“Well yeah, yeah,” Bailor motioned for her to lie down on the consulting room mattress. He listened to her pulse, “I know we have the pulse, but I’m just listening for to see if it’s irregular, if there’s a gallop,” and then he palpated her abdomen. Then he listened to her lungs. The woman was now sitting up, hunched over. Her head was wrapped in cloth with a similar but not identical pattern to her dress. To me, it looked like it was randomly tied, but I was pretty sure it was very intentional. I could see her ribs, but she wasn’t emaciated. Along her belly there were folds of skin, empty of fat and water. It looked to me like she had been losing weight.
There were several loud knocks on the door while Bailor was doing his exam. He yelled at the door in Krio. Soon he was done.
“Katie, you want to listen? See if you can hear what is in her lungs.” Bailor’s Krio accent always sounded informal and cool. He dropped all kinds of final consonants, and said “I” with an “ah” sound.
Katie started, surprised at being switched from observer to participant. “Yeah!” Bailor handed her the stethoscope. She held it for a moment, and looked back at him. “Well, I don’t really know what to do.”
“Oh! Sorry Katie, I jus’ think you are medical student, that you already know all these things. The idea is to listen symmetrically, okay? Here, here, then here, here, then here, here...” Bailor placed the stethoscope in four spots on each side of the patient’s chest, starting near the armpits and moving down around the ribcage in a J shape. Then he switched to the back and pointed out four spots on either side of her back, the first three moving down the spine and the last one out to the side.
There was more loud knocking. They needed the calculator out at the reception desk. The calculator was sitting on the desk in front of me. Bailor sounded a bit annoyed when he said “Le ‘im come, gi’ ‘em calculatah.” Bori passed the calculator to Dr. Lenny, the door opened a crack, and the calculator disappeared out of his hand. It was more respect for the door than usual – a week ago when Katie had been sick, the clerk had walked right in during her exam, after Yusuf had asked her to remove her shirt so he could listen to her heart.
After he gave up the calculator, Dr. Lenny said, “So, this lady, this woman, one of the ways you know she’s not well is that she is breathing very quickly, and she really doesn’t look like she’s having a good day.” In my mind’s eye I saw her sitting down in the chair at the beginning, her shoulders heaving weakly. Dr. Lenny was right, she had been breathing fast. Katie had put down the stethoscope, and Dr. Lenny picked it up. “Do you mind if I listen?” He asked Bailor.
“No, no, go ahead,” Dr. Lenny went through the same steps. But when he reached the outside of the ribcage, on the woman’s back, he asked Bori to get her to make an “eeee” sound, and then an “aaaa” sound.
“I think there is something wrong with the air intake,” said Bailor, “something wrong. When you listen, you are trying to compare both lungs, to see if there is some problem. But her right lung, it’s not well. I think maybe she has tuberculosis, even though she’s not coughing.” Bailor looked back at Dr. Lenny. “So what you listen for, is some kind of crepits, some weird sounds, like a whistle,” he whistled, “or sounds like hair moving, or,” he gurgled. I was a bit impressed he could make those noises. It was actually pretty helpful.
Dr. Lenny finished, and the woman turned and sat with her legs dangling over the bed, shirtless. I wished I could speak Kono, to find out how she was doing, and what she thought of this mess of doctors and students and nurse inside the tiny consulting room. Dr. Lenny told us what he thought.
“I think there is some blockage in her right lung, at the bottom,”
“Yeah, that’s what, that’s what I heard, and so I think maybe tuberculosis.” Bailor agreed. “But the next thing, is an x-ray, and you know...” He trailed off. During the previous patient consultation we had met a sixty year old woman who had a bullet in her foot. The wound had healed, but her foot always hurt, and was often swollen. Then Bailor told us that there was no x-ray machine in the Kono District; the closest was three and a half hours by driving, or 30 000 Le round-trip by public transit. The x-ray itself was also 30 000 Le. The sum is enough to feed a poor family of six for ten days. At the end of her visit, I asked when she had been shot. After a brief debate about the year of a particular event in the war, I got my answer: 1998.
Dr. Lenny continued. “But you know, the left lung is not so good either. I here a whistle, some kind of a wheeze.”
Then Bailor held up the woman’s hand. “And look, here, you see this, this clubbing.” Dr. Lenny nodded. I remembered that Bailor had told me about clubbing a couple days ago. Katie asked him about it, and he answered, “It’s when there is not enough oxygen in the blood, and the fingers straighten out. This one is not so bad, sometimes they are like drumsticks.” Bailor straightened his fingers for dramatic effect. The woman’s fingers looked a bit swollen, too.
“Why does that happen?” I asked.
“Well, it’s when the blood oxygen is not high enough for a long time. It’s a sign of chronic illness, maybe tuberculosis.” Dr. Lenny’s answer was interesting, but not an explanation of why.
“You know, I was reading in some papers, some scientific papers, that they don’ know,” said Bailor. Okay, I nodded. There you go – a basic clinical exam finding, largely inexplicable.
Katie and I took turns listening to the woman’s lungs. I fitted the stethoscope into my ears, but it was kind of uncomfortable. The woman was impassive and her stare was vacant. But the moment I touched the stethoscope to her back, my ears were filled with a soft, low hum. It was full of life. I could hear the soft roar of air intake, with a small bump at the beginning, and I could hear what sounded like a wheeze. I couldn’t tell that there was something in her lower right lung, and it was hard for me to tell what was general background noise and what was something going on in the lungs. But it sounded like millions of tiny processes, millions of tiny cells transporting proteins and energy in and out, fluids flowing around and through, splitting from arteries to arterioles, perfusing out of capillaries. My head was alive with the cartoons of biology textbooks, but my ears were alive with the sound of life.
“I couldn’t really hear all the things you mentioned,” I told Bailor, a bit sheepish.
“That’s okay, you don’t even know what normal sounds like yet.” True.
Dr. Lenny gestured to the woman that she could put on her shirt again. She took her shirt and bra from him, but didn’t look at them. She looked at him the whole time. Then she sat down in the chair again.
“Bori, thank her for being so patient while we all examined her,” I had no idea if this thank you would be understood, even if every word was translated. Bori told her, and she made a small nod. Then Bailor spoke rapidly in Krio to her, and I didn’t catch it. But Bori translated the answer.
“No, she done sick li’ dis na ten years now. Ten years, she say,” Bori’s eyes were wide. Ten years sick, losing weight, tuberculosis... it sounded like it could be HIV.
Bori said more Krio, that I didn’t understand. Bailor translated. “She say, that you know why she is coming today? Only because her brother came and got her. She lives in the village, and it’s only because her brother came and got her and she is staying with him, and he is paying. That’s why she is here today.”
“Ask her if her husband is sick.” Dr. Lenny had a good idea. Bori asked her.
“She de say yes, ‘e sick, an he done ge’ sick befo her, but ‘e body no done done like ‘e,” Yes, he was sick, and he was sick before her, but he wasn’t losing weight like her.
“Does she have children – are they alive?” Dr. Lenny asked again. Bori asked her, and then translated.
“Ten, six alive, four dead.” Her face was still quite impassive. I didn’t understand. How did this look, from her perspective? She had been sick for ten years. And had not gotten better, had not been healed by traditional medicine. And now she was here, in Koidu, brought by her brother, to this strange clinic, staffed with strange doctors, and even white people. She’d been poked, prodded with strange devices, made to take off her shirt, and questioned. What was she thinking?
Bailor explained to her that he was ordering a bunch of tests. Urinalysis, malaria, typhoid (two types), white blood cell count and differentials, hemoglobin concentration, and a tuberculosis test that the clinic was not certified to administer because it did not have the treatment drugs on hand. It was almost every test the lab can do. Then he explained to her that he wanted her to go to the goverment hospital for HIV testing.
“Mama, okay. So you faut de go na government hospital for testing, okay? You no de go’ pay 100 Leones, test na free. But you faut de go na dere.” She nodded, and asked a question – today? “Yeah, if you go able for go today, i’ betteh. Den, you faut come back na ya, you faut come back ya.” You must go to the government hospital, today if you can, and then you come back here. Bailor slid the form back into her folder, gathered up her registration card, and handed them back to her. She stood up to leave, and her dress unfurled around her. The diamond patterns were edged with gold thread.
“Bori, can you ask her if I can take her picture?” Dr. Lenny had his camera out. Bori told her. She shrugged. “And can you tell her it’s not because she’s sick, but because her clothes are so beautiful. She looks beautiful in this dress, it is one of the most beautiful dresses I have ever seen.” Bori looked bewildered, but translated, and she hardly reacted. Languages can be translated much more easily than cultures, I think. She stood stoically and awkwardly for Dr. Lenny’s photo, in the particular way of someone who has never had their picture taken. Then her dress followed her out the door in a flash of color.
The woman entered the room. There was a practical desperation in her movement; it clung to her and hid in the way she sat down and settled into a vacant stare. Her eyes were wide but sunken, and hunger had tightened her wrinkles against her bones. She was robed in a magnificent turquoise and lime green diamond patterned dress. As Dr. Lenny would later point out, she did not look like she was having a good day.
“Wetin na de problem, mama?” Bailor asked her what was wrong. I fiddled with the “Children’s Hospital Care” book on the corner of the desk. Bailor later called it his bible. “Why you come today?”
She rubbed her stomach and looked plaintive. Bori translated. “E’ belly de hurt, e belle de hurt... she de feel snake insigh, crawling insigh, crawling... e’ de hurt beaucoup...” and after some prompting, “e’ body de wam, de joints dey hurt...” While translating, Bori began gathering vitals. He motioned for her to remove her shirt and then slipped a blood pressure cuff around her arm.
“What did she say?” Katie asked. Bori had translated into Krio, which sometimes needs further translating.
“Her stomach hurts,” I slipped in, rather unhelpfully.
“She say, that she feels a snake inside, that her stomach hurts,” Bailor had the real answer, “you know, these people, they will tell you that there is a snake, and they feel it crawling,” his hand traced snake-crawling around his belly, “and then it will bite them here,” his hand made a biting motion at the center-bottom of his ribcage. I nodded sagely. Gastritis, or ulcers, or heartburn, I thought to myself. “Tha’s why you need to know your patients, you need to know where they are coming from, so you can understand,”
“Well, not to downplay the role of understanding,” Dr. Lenny held his hands up and looked bashful, “but I think any good clinician would think of gastritis when a patient mentioned upper chest pain,”
“Does malaria cause that?” Katie asked, about the gastritis. Asking about malaria is always a good idea here; since the parasite attacks the red blood cells, the disease can manifest in many different ways. Bori had written down the blood pressure cuff results on the back of the patient registration card and then pushed it across the table. I eagerly peered at the numbers. Pulse 87 bpm, blood pressure 100/78.
“No, is probably peptic ulcer disease,”
“Well even giardia can cause gastritis, though,” Dr. Lenny added, with a humble shrug of his shoulders. “And even in the US it’s hard to tell whether or not it’s H. pylori, peptic ulcer disease,” he added, “here I bet it’s just that much harder.”
“Yeah, yeah, you know, that’s why, that’s why, I’m not sure, but I will prescribe her [some antibiotics and an antacid].”
“That’ll take care of the giardia too.” Lenny replied, but I was looking at the patient. She didn’t look healthy, and even though she had come in because of the pain in her stomach, that might be masking a more chronic problem. Hmm. Should I say something? I wondered. I was sure the experienced clinicians have already thought of what I wanted to say.
“But, are we going to test for malaria? Maybe the peptic ulcer disease is masking something else, something more important?”
“Well yeah, yeah,” Bailor motioned for her to lie down on the consulting room mattress. He listened to her pulse, “I know we have the pulse, but I’m just listening for to see if it’s irregular, if there’s a gallop,” and then he palpated her abdomen. Then he listened to her lungs. The woman was now sitting up, hunched over. Her head was wrapped in cloth with a similar but not identical pattern to her dress. To me, it looked like it was randomly tied, but I was pretty sure it was very intentional. I could see her ribs, but she wasn’t emaciated. Along her belly there were folds of skin, empty of fat and water. It looked to me like she had been losing weight.
There were several loud knocks on the door while Bailor was doing his exam. He yelled at the door in Krio. Soon he was done.
“Katie, you want to listen? See if you can hear what is in her lungs.” Bailor’s Krio accent always sounded informal and cool. He dropped all kinds of final consonants, and said “I” with an “ah” sound.
Katie started, surprised at being switched from observer to participant. “Yeah!” Bailor handed her the stethoscope. She held it for a moment, and looked back at him. “Well, I don’t really know what to do.”
“Oh! Sorry Katie, I jus’ think you are medical student, that you already know all these things. The idea is to listen symmetrically, okay? Here, here, then here, here, then here, here...” Bailor placed the stethoscope in four spots on each side of the patient’s chest, starting near the armpits and moving down around the ribcage in a J shape. Then he switched to the back and pointed out four spots on either side of her back, the first three moving down the spine and the last one out to the side.
There was more loud knocking. They needed the calculator out at the reception desk. The calculator was sitting on the desk in front of me. Bailor sounded a bit annoyed when he said “Le ‘im come, gi’ ‘em calculatah.” Bori passed the calculator to Dr. Lenny, the door opened a crack, and the calculator disappeared out of his hand. It was more respect for the door than usual – a week ago when Katie had been sick, the clerk had walked right in during her exam, after Yusuf had asked her to remove her shirt so he could listen to her heart.
After he gave up the calculator, Dr. Lenny said, “So, this lady, this woman, one of the ways you know she’s not well is that she is breathing very quickly, and she really doesn’t look like she’s having a good day.” In my mind’s eye I saw her sitting down in the chair at the beginning, her shoulders heaving weakly. Dr. Lenny was right, she had been breathing fast. Katie had put down the stethoscope, and Dr. Lenny picked it up. “Do you mind if I listen?” He asked Bailor.
“No, no, go ahead,” Dr. Lenny went through the same steps. But when he reached the outside of the ribcage, on the woman’s back, he asked Bori to get her to make an “eeee” sound, and then an “aaaa” sound.
“I think there is something wrong with the air intake,” said Bailor, “something wrong. When you listen, you are trying to compare both lungs, to see if there is some problem. But her right lung, it’s not well. I think maybe she has tuberculosis, even though she’s not coughing.” Bailor looked back at Dr. Lenny. “So what you listen for, is some kind of crepits, some weird sounds, like a whistle,” he whistled, “or sounds like hair moving, or,” he gurgled. I was a bit impressed he could make those noises. It was actually pretty helpful.
Dr. Lenny finished, and the woman turned and sat with her legs dangling over the bed, shirtless. I wished I could speak Kono, to find out how she was doing, and what she thought of this mess of doctors and students and nurse inside the tiny consulting room. Dr. Lenny told us what he thought.
“I think there is some blockage in her right lung, at the bottom,”
“Yeah, that’s what, that’s what I heard, and so I think maybe tuberculosis.” Bailor agreed. “But the next thing, is an x-ray, and you know...” He trailed off. During the previous patient consultation we had met a sixty year old woman who had a bullet in her foot. The wound had healed, but her foot always hurt, and was often swollen. Then Bailor told us that there was no x-ray machine in the Kono District; the closest was three and a half hours by driving, or 30 000 Le round-trip by public transit. The x-ray itself was also 30 000 Le. The sum is enough to feed a poor family of six for ten days. At the end of her visit, I asked when she had been shot. After a brief debate about the year of a particular event in the war, I got my answer: 1998.
Dr. Lenny continued. “But you know, the left lung is not so good either. I here a whistle, some kind of a wheeze.”
Then Bailor held up the woman’s hand. “And look, here, you see this, this clubbing.” Dr. Lenny nodded. I remembered that Bailor had told me about clubbing a couple days ago. Katie asked him about it, and he answered, “It’s when there is not enough oxygen in the blood, and the fingers straighten out. This one is not so bad, sometimes they are like drumsticks.” Bailor straightened his fingers for dramatic effect. The woman’s fingers looked a bit swollen, too.
“Why does that happen?” I asked.
“Well, it’s when the blood oxygen is not high enough for a long time. It’s a sign of chronic illness, maybe tuberculosis.” Dr. Lenny’s answer was interesting, but not an explanation of why.
“You know, I was reading in some papers, some scientific papers, that they don’ know,” said Bailor. Okay, I nodded. There you go – a basic clinical exam finding, largely inexplicable.
Katie and I took turns listening to the woman’s lungs. I fitted the stethoscope into my ears, but it was kind of uncomfortable. The woman was impassive and her stare was vacant. But the moment I touched the stethoscope to her back, my ears were filled with a soft, low hum. It was full of life. I could hear the soft roar of air intake, with a small bump at the beginning, and I could hear what sounded like a wheeze. I couldn’t tell that there was something in her lower right lung, and it was hard for me to tell what was general background noise and what was something going on in the lungs. But it sounded like millions of tiny processes, millions of tiny cells transporting proteins and energy in and out, fluids flowing around and through, splitting from arteries to arterioles, perfusing out of capillaries. My head was alive with the cartoons of biology textbooks, but my ears were alive with the sound of life.
“I couldn’t really hear all the things you mentioned,” I told Bailor, a bit sheepish.
“That’s okay, you don’t even know what normal sounds like yet.” True.
Dr. Lenny gestured to the woman that she could put on her shirt again. She took her shirt and bra from him, but didn’t look at them. She looked at him the whole time. Then she sat down in the chair again.
“Bori, thank her for being so patient while we all examined her,” I had no idea if this thank you would be understood, even if every word was translated. Bori told her, and she made a small nod. Then Bailor spoke rapidly in Krio to her, and I didn’t catch it. But Bori translated the answer.
“No, she done sick li’ dis na ten years now. Ten years, she say,” Bori’s eyes were wide. Ten years sick, losing weight, tuberculosis... it sounded like it could be HIV.
Bori said more Krio, that I didn’t understand. Bailor translated. “She say, that you know why she is coming today? Only because her brother came and got her. She lives in the village, and it’s only because her brother came and got her and she is staying with him, and he is paying. That’s why she is here today.”
“Ask her if her husband is sick.” Dr. Lenny had a good idea. Bori asked her.
“She de say yes, ‘e sick, an he done ge’ sick befo her, but ‘e body no done done like ‘e,” Yes, he was sick, and he was sick before her, but he wasn’t losing weight like her.
“Does she have children – are they alive?” Dr. Lenny asked again. Bori asked her, and then translated.
“Ten, six alive, four dead.” Her face was still quite impassive. I didn’t understand. How did this look, from her perspective? She had been sick for ten years. And had not gotten better, had not been healed by traditional medicine. And now she was here, in Koidu, brought by her brother, to this strange clinic, staffed with strange doctors, and even white people. She’d been poked, prodded with strange devices, made to take off her shirt, and questioned. What was she thinking?
Bailor explained to her that he was ordering a bunch of tests. Urinalysis, malaria, typhoid (two types), white blood cell count and differentials, hemoglobin concentration, and a tuberculosis test that the clinic was not certified to administer because it did not have the treatment drugs on hand. It was almost every test the lab can do. Then he explained to her that he wanted her to go to the goverment hospital for HIV testing.
“Mama, okay. So you faut de go na government hospital for testing, okay? You no de go’ pay 100 Leones, test na free. But you faut de go na dere.” She nodded, and asked a question – today? “Yeah, if you go able for go today, i’ betteh. Den, you faut come back na ya, you faut come back ya.” You must go to the government hospital, today if you can, and then you come back here. Bailor slid the form back into her folder, gathered up her registration card, and handed them back to her. She stood up to leave, and her dress unfurled around her. The diamond patterns were edged with gold thread.
“Bori, can you ask her if I can take her picture?” Dr. Lenny had his camera out. Bori told her. She shrugged. “And can you tell her it’s not because she’s sick, but because her clothes are so beautiful. She looks beautiful in this dress, it is one of the most beautiful dresses I have ever seen.” Bori looked bewildered, but translated, and she hardly reacted. Languages can be translated much more easily than cultures, I think. She stood stoically and awkwardly for Dr. Lenny’s photo, in the particular way of someone who has never had their picture taken. Then her dress followed her out the door in a flash of color.
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