Today we have two visitors in Koidu Town: Lois Park and Mathias Esmann.
Lois is the third GAF intern in Sierra Leone this summer. She was also a GAF intern last summer, and so this summer she came back with funding and a plan for a feeding program to help malnourished children in the Portloko District. She has a blog that describes her experience; it's here.
Mathias is a UCW grad from the Nordic College who also attends Princeton. He is a co-founder of an organization called Gmin and recently returned from distributing 4000 bednets (and education about how to use them) to villagers in southern Sierra Leone.
Both of these two have really impressed me with their combination of independence, capability, and realism about their projects. Each project is specific, with reasonable goals and practical implementation plans, and yet they also address issues at the heart of the low life expectancy and high child mortality rates that haunt Sierra Leone. In both cases they use community involvement and have viable plans to measure and monitor their progress. I hope that the future of the world's public health projects falls into the hands of people like Lois and Mathias.
Friday, July 24, 2009
Wednesday, July 22, 2009
Scars
I didn’t knock. The bedroom in the clinic also functions as a storage room for items that you don’t want to disappear. But when I pushed open the door, I remembered that Sahr J. was sick and recovering inside.
“Hey Sahr J.. How you de feel?” He was sitting on the end of the bed, facing the window. He was wearing his jeans but no shirt, and his eyes were red-lined and yellow.
“Ehh, a de begin for feel betteh, small small,” he sounded sick.
Sahr J. conducted the first round of surveys that Katie and I were using to establish the baseline level of health education in the amputee camps and their surrounding communities. We had since done some health education in each location, and now we were returning with some surveyors to assess the efficacy of the education program. There were many inconsistencies and oddities in the initial surveys, but I hadn’t asked Sahr J. about many of them, because he was not well.
“How the surveys?”
“Fine, dey go fine,” I put my computer back in my bag and then turned to leave once more.
“You de go na Wardu tomarra?”
“Mm,” I made the bouncing humming noise that Sierra Leoneans often use, either to express noncommittal agreement, small surprise, or gentle contradiction, “we done go na Wardu.”
“Why do I hear them going back, then?”
“Dey de go back becos we done miss some people, dey no been dere na ose[house]. Dey done go na farm.” We had missed a few people that had been out farming, so some surveyors were returning at dusk to conduct those surveys after the farmers had returned. “We de do Bumpeh and Motema tomarra.” Instead of leaving, I sat down on the bed behind Sahr J., facing the door.
The day before I had asked Sahr J. if the name written as ‘Household Head’ on all the surveys had actually been the person surveyed; he had said yes. Then later that day we discovered that two of those people initially surveyed had been dead for more than two years. Such is surveying in Sierra Leone. We have to constantly remind our surveyors to take note if they survey a man’s wife instead of the man, or a daughter instead of a father. I don’t think Sahr J. was much better, and had been wanting to question him closely, but it wasn’t clear that would help. Information and clear answers are very hard to come by here.
I looked over at Sahr J.. His back was to me, and he was slouched over looking out the window. Suddenly, I noticed a pattern of scars on his back. There were two lines of small, circular scars alternating just to the right and left of his spine. They started just below the ball at the base of the neck, and alternated about every inch until his lower back. Some were circular, some were more irregular, but none were larger than the end of my pinky finger. They looked like burn scars.
In fact, I had noticed scars like this before, on the back of the necks of some people. K., one of our secondary student surveyors, had particular evident scars like these climbing all the way up to his hairline. I remembered noticing them, and wanting to ask him about them, but I hadn’t.
Curious, I traced the back of my fingers down his back. “Sahr J., why do so many people here have scars like these?”
As soon as I asked the question, I knew the answer.
“You will never know, my brother. Don’t even try. They will give you many answers, but they are all lies, all! You will never know.”
I looked carefully at the scars. They were a bit lighter than the prevailing dark brown of Sahr J.’ back, and slightly raised. K.’s scars were more raised, more pronounced. Maybe they were newer?
“Oustem you done get dese scars?” When did you get these scars?
“When I was very young, just a young boy.”
“How young?”
“Very young. I don’t know.”
Silence fell. The sun was setting outside, casting a yellowish glow onto the cassava leaves just outside the window. The ground was red and brown and dusty. In the distance there were billowing thunderheads. All this was framed by the baby blue walls of the bedroom, and the delicate white curtains tied in a knot off to the side.
“But how is the survey? Are the surveyors, the surveyors they are good?”
“Oh, yeah, they’re great. Fine.”
Before the IMF, before international donor pressure, before AK-47’s and Rambo films, Sierra Leone and Western Africa was home to many different tribes most governed in a similar way – by two secret societies. And we shouldn’t be using past tense, because these societies persist. There is the Bondu society for women, and the Poro society for men. Nobody initiated into a society is permitted to tell an uninitiated person a single word about the society. Secrecy is the core tenet of membership.
“So they [the surveyors] are doing a good job?”
The Bondu society is infamous for its initiation rites. They are better known as female genital mutilation (FGM). This involves cutting of various parts of the vagina, including the clitoris and labia. When I first learned of the Bondu society, I tried to learn all that my plodding internet could tell me about it.
“Yes, yes, a fine job. They are very smart.”
From what I read, it seems that Bondu and Poro societies are similar in some ways. They are both rites of passage for young people, and all mature members of society are initiated into one or the other. Both involve an extended stay in a remote, perhaps sacred, area of the forest, beginning with an initiation ceremony and ending in a triumphant return. Masked dancers that are meant to be gods are important in some way. There are levels and hierarchies within each society, and each progression requires a new form of initiation. At higher levels within the societies, one learns more and more privileged information. Within the society, a person’s acknowledged awareness must keep in step with their status. For example, as far as the new initiates are concerned, the masked dancers are gods. But at higher levels within the society, one learns that the masked dancers are people, not gods. So even if a new initiate knew that the masked dancers were actually people, they are not permitted to admit that they know this, or to act in any way that implies they know this.
“That’s good. You found all the people?”
It’s not clear to what extent the societies collaborate. The initiation rites are certainly separate and mutually secret. Together, however, they set the rules, enforce the rules, and make all important decisions for the tribe.
“Well, most of them.”
The shadows from the cassava leaves flickered across the reddish brown dirt, and the grey of the thunderheads waited quietly. Sahr J. had not succeeded in changing the topic.
“Sahr J., someone told me that the Poro society does not do things like this.” In particular, I had asked Amhidu if the Poro society had an equivalent physical initiation to the FGM of the Bondu. He had said know.
“Well, you will never know.”
I touched one of the scars again with the back of my middle finger, with the top of my fingernail. He continued.
“The reason why, is, look at the Bondu society. They told. They even filmed it. Now everyone knows, and it’s useless. Everybody knows, there is no secret.”
I tried to see if he would reveal something about the Poro society in comparison with the Bondu, something other than that its secrecy is superior. “What do you think of the Bondu society?”
“Well,” he stretched the ‘well’ far into the humid dusk, “it is not right for those small small girls. But the grown women, I think they can decide. But now, it’s no secret, everyone knows. They even filmed it.”
A horrible possibility crossed my mind. What if the Poro society did have equally violent initiation rites, but that they had just succeeded in hiding them from the outside world? When I read about the societies online, one article claimed that the Poro society did not exist in the Kono tribe. Sahr J. is Kono. What if their secrecy is successfully concealing violence on par with FGM?
I decided to try a different tack, to try and gain some insight into the phenomenon of privileged knowledge.
“Sahr J., are there many truths about these scars? Is there more than one truth about where these scars come from?”
“You will never know. There are only many lies. No one can tell.” He paused, and I stared at the buzzed and graying hair on the back of his head, then at the trail of scars on his spine. “But every society needs customs, and a place where people converge and decide. In the past, very important things, very good things happened when they met.”
The core tenet is secrecy.
We were silent again. He seemed smaller than usual, and sagging from sickness, and there were beads of sweat glistening between the short black and gray hairs on his head. I stood up to go.
“I hope you feel better, Sahr J..”
He stretched a bit. “A, no problem. A begin for de feel betteh, more betteh than in Masiaka. But a no can eat.”
I nodded sympathetically. He was in good hands; there was plenty of water, some bananas right in front of him, Bailor was around, and there was a plastic bag of his drugs in the corner. “See you, Sahr J.. Feel better.” I stepped out and eased the door shut behind me.
“So, yeah, Sahr J., the man who is not feeling well at the clinic, the one who works for NOW. You know him?”
A.A. and F., two of the young (around 18 and 16 respectively) surveyors, looked concerned. We were walking, looking for A.J. Arisumana, but it may also have been A.K. Ansumana, or A.J. Ansumana...
“No, I don’t know him. We will wish him well when we return.”
“Oh, yeah, definitely. But yesterday, I saw his back, and he has scars, on his back, down his spine, here,” I pointed on A.A.’s back.
“Oh...” nothing for a moment, then recognition, “Oh! Yes, those are traditional. Custom.”
“Well, I asked him about them, and he told me I would never know.”
They laughed, and A.A. spoke. “That’s right, you will never know. Until you are there, you will never know. Do they have the Poro Society in North America?”
“No, not at all. And hardly anything like it.”
We walked for a moment, turning left onto a path that climbed a short hill.
“As for me,” A.A. continued, “I refuse. I refuse to join.”
What? I processed in silence for a moment.
“...why do you refuse?”
“Because I no want to endanger my life. It’s very dangerous, very dangerous. I don’t need that.”
“Wait, is there something more than the scars that is dangerous?” The specter of my conversation with Sahr J. loomed in my mind.
“No, is tetanus. They cut you with irons, very deep, it’s not clean, you know,”
We stopped by the front door of a house to ask about Mr. A.J./K. Arisumana/Ansumana. After confirming that we were not police, the man directed us further. The clay bricks of his house were crumbling around him.
“But even if you refuse,” A.A. continued, “they will come and take you. Sometimes they just take you to the bush, and initiate you.”
“At what age do you join the Poro society?”
“Any age, any age. Not less than seven.”
We arrived at the house of (we confirmed with his wife) Mr. A.J. Ansumana. He was not there, so we asked his wife if she had done the original survey. She had. So we surveyed her. While surveying I jotted down the essentials of my conversation with A.A. and F. thus far.
Then we left to return to the Motema junction, where we could find motorbikes to the next camp. Katie had already taken the other ten surveyors there; we had finished the surveys in Motema. I gathered my thoughts as we stepped around some tree roots, then broached the topic again.
“How many of your friends are in the Poro society, A.A.?”
“Many, many of them. You know, even my mother, even my father and my fA.S.ly, they all want me to join. They are angry that I will not join. But still, I tell them that I refuse.”
F. pointed us down the correct branch in the path. A.A. continued.
“If you refuse to join, you will not get any position. You will not go to these meetings, you will not go to any meeting where they decide what happens in the community. As soon as they find out you are not yet joined, you will never get any position.”
Then F. spoke. “Even in Makeni, this Poro society is everywhere. They will take you in the street if you refuse, they will take you.” Makeni was a large city between Koidu and Freetown. It’s ostensibly Bailor’s hometown.
“Have you joined, F.?”
“As for me, no, I have not joined. I am scared. But when the time comes, I think I too will refuse.”
A.A. lifted up his shirt. “Look. I refuse. No scars.” He was right. No scars.
“It’ s very brave of both of you. It de take courage for refuse.” I injected a bit of Krio in the hopes that they would understand my admiration. They had guts, to refuse almost every elder and sabotage so many opportunities for themselves.
“Even in Makeni, they will take you to the Poro bush. It’s owned by the Temne,”
“The Temne?” They were an ethnic group.
“No, actually, the Limba,” another ethnic group, “but there are so Temne, they mainly use it.”
We crossed the road to wait for motorbikes. I stopped listening for a moment to make sure we didn’t get run over by a creaking dilapidated van. When I tuned back in, A.A. said, “Even our president has joined.”
“The Poro society?”
“Yes, he has joined. If you have not joined, you will not get a position, never get one,”
“In government?”
“Yes.”
A brief pause, then F. said, “When they come to take you, even if you don’t want to go, you can’t stop them, you can’t resist. They will take you.” He made a fist with his left hand and then grabbed his left forearm and pulled it down, to demonstrate someone being overpowered. I had no reply.
We flagged down a motorbike and haggled over the price. He drove away without us, angry that I actually knew how much it cost. I’d tried to look at the back of his neck, between his helmet and his thick jacket, but I couldn’t see it.
“Ka-tee,” I called her name in the musical way some Sierra Leoneans say it, “how are you?”
“Fine,”
We talked about the surveys for a moment. It turns out that all the Bumpeh surveys were done. More interesting, as we walked Katie updated me on her conversations with A.S.e, a 19 year old female surveyor, about the Bondu and Poro societies. Below I’ve paraphrased and reconstituted that conversation and its continuation later in Koidu Town.
“A.S. said it was pretty much like we read, that after the initiation, they mostly learn about housework, and how to have sexual intercourse, and how to cook, and stuff like that. And she said that the Poro society, all the women lock themselves in their houses and then the men all leave to go to the bush. They all lie down and they give them the scars with hot irons. Then they stay and live in the bush with nothing, not even clothes, for four months. She said that last year, or two years ago, a reporter hid in the bush and took videos and photos of the ceremony, and now they all want to kill him.”
“I bet they do. I hope he left the country.”
“He’s long gone, A.S. said. She was really scared, I think she’s scared they’re going to force here to join the Bondu society.”
I murmured with concern.
“Yeah. She doesn’t want to join. Her father takes the British view, apparently,”
“That sounds promising,”
“Which is to let her choose. But he’s in Freetown,” and A.S. is not. “I think he told the traditional women that if they take A.S., he’ll call the police on them. But when he’s in Freetown, I’m scared they’ll just do it anyway. She said in one or two months,”
“They always do it during the dry season, right?”
“Yeah,”
“That’s in more than one or two months. But scary,” One month, three months, or one year, it would always be too soon for A.S..
“I think they just capture them while they are sleeping, one night, they just come, and take you to the bush. There’s lots of screA.S.ng and crying, but in the end, you go. She also wanted to know whether there was anything like this in North America,”
“No,” I said, shaking my head and staring at my sandals.
“That’s what I told her. One thing I asked them, and that I don’t understand, is why the parents want to force the children to join. The only way to be protected is to have your parents support you in refusing. And I asked U., and K., and A.S.,” U. and K. being other surveyors, both male, “why, if the young people are so against it, do the parents support it so much? U. said that he thought it would never change, that it would always be there.”
“No, it’ll fade gradually,”
“Yeah, I agree. But I asked them why it would continue, if the young people don’t support it now, and then they will grow up to become the adults. It doesn’t make sense.”
I grunted assent and stared gravely at the gravel. “Maybe it’s because the cost is all upfront, and once you are in, it’s not so bad.”
“I just don’t understand how the pain of that can ever go away.”
“The scars for the guys, that pain will go away.”
“Yeah. But for the girls, I just don’t see how it can ever go away. And even if it didn’t hurt all the time, I don’t see how it wouldn’t hurt every time you have sex.”
I kept shuffling my feet through the gravel, and trying to work out the occasional stone that crept under my foot. The sun was really bright. I'm glad North America doesn't have secret societies like the Poro and Bondu.
“Hey Sahr J.. How you de feel?” He was sitting on the end of the bed, facing the window. He was wearing his jeans but no shirt, and his eyes were red-lined and yellow.
“Ehh, a de begin for feel betteh, small small,” he sounded sick.
Sahr J. conducted the first round of surveys that Katie and I were using to establish the baseline level of health education in the amputee camps and their surrounding communities. We had since done some health education in each location, and now we were returning with some surveyors to assess the efficacy of the education program. There were many inconsistencies and oddities in the initial surveys, but I hadn’t asked Sahr J. about many of them, because he was not well.
“How the surveys?”
“Fine, dey go fine,” I put my computer back in my bag and then turned to leave once more.
“You de go na Wardu tomarra?”
“Mm,” I made the bouncing humming noise that Sierra Leoneans often use, either to express noncommittal agreement, small surprise, or gentle contradiction, “we done go na Wardu.”
“Why do I hear them going back, then?”
“Dey de go back becos we done miss some people, dey no been dere na ose[house]. Dey done go na farm.” We had missed a few people that had been out farming, so some surveyors were returning at dusk to conduct those surveys after the farmers had returned. “We de do Bumpeh and Motema tomarra.” Instead of leaving, I sat down on the bed behind Sahr J., facing the door.
The day before I had asked Sahr J. if the name written as ‘Household Head’ on all the surveys had actually been the person surveyed; he had said yes. Then later that day we discovered that two of those people initially surveyed had been dead for more than two years. Such is surveying in Sierra Leone. We have to constantly remind our surveyors to take note if they survey a man’s wife instead of the man, or a daughter instead of a father. I don’t think Sahr J. was much better, and had been wanting to question him closely, but it wasn’t clear that would help. Information and clear answers are very hard to come by here.
I looked over at Sahr J.. His back was to me, and he was slouched over looking out the window. Suddenly, I noticed a pattern of scars on his back. There were two lines of small, circular scars alternating just to the right and left of his spine. They started just below the ball at the base of the neck, and alternated about every inch until his lower back. Some were circular, some were more irregular, but none were larger than the end of my pinky finger. They looked like burn scars.
In fact, I had noticed scars like this before, on the back of the necks of some people. K., one of our secondary student surveyors, had particular evident scars like these climbing all the way up to his hairline. I remembered noticing them, and wanting to ask him about them, but I hadn’t.
Curious, I traced the back of my fingers down his back. “Sahr J., why do so many people here have scars like these?”
As soon as I asked the question, I knew the answer.
“You will never know, my brother. Don’t even try. They will give you many answers, but they are all lies, all! You will never know.”
I looked carefully at the scars. They were a bit lighter than the prevailing dark brown of Sahr J.’ back, and slightly raised. K.’s scars were more raised, more pronounced. Maybe they were newer?
“Oustem you done get dese scars?” When did you get these scars?
“When I was very young, just a young boy.”
“How young?”
“Very young. I don’t know.”
Silence fell. The sun was setting outside, casting a yellowish glow onto the cassava leaves just outside the window. The ground was red and brown and dusty. In the distance there were billowing thunderheads. All this was framed by the baby blue walls of the bedroom, and the delicate white curtains tied in a knot off to the side.
“But how is the survey? Are the surveyors, the surveyors they are good?”
“Oh, yeah, they’re great. Fine.”
Before the IMF, before international donor pressure, before AK-47’s and Rambo films, Sierra Leone and Western Africa was home to many different tribes most governed in a similar way – by two secret societies. And we shouldn’t be using past tense, because these societies persist. There is the Bondu society for women, and the Poro society for men. Nobody initiated into a society is permitted to tell an uninitiated person a single word about the society. Secrecy is the core tenet of membership.
“So they [the surveyors] are doing a good job?”
The Bondu society is infamous for its initiation rites. They are better known as female genital mutilation (FGM). This involves cutting of various parts of the vagina, including the clitoris and labia. When I first learned of the Bondu society, I tried to learn all that my plodding internet could tell me about it.
“Yes, yes, a fine job. They are very smart.”
From what I read, it seems that Bondu and Poro societies are similar in some ways. They are both rites of passage for young people, and all mature members of society are initiated into one or the other. Both involve an extended stay in a remote, perhaps sacred, area of the forest, beginning with an initiation ceremony and ending in a triumphant return. Masked dancers that are meant to be gods are important in some way. There are levels and hierarchies within each society, and each progression requires a new form of initiation. At higher levels within the societies, one learns more and more privileged information. Within the society, a person’s acknowledged awareness must keep in step with their status. For example, as far as the new initiates are concerned, the masked dancers are gods. But at higher levels within the society, one learns that the masked dancers are people, not gods. So even if a new initiate knew that the masked dancers were actually people, they are not permitted to admit that they know this, or to act in any way that implies they know this.
“That’s good. You found all the people?”
It’s not clear to what extent the societies collaborate. The initiation rites are certainly separate and mutually secret. Together, however, they set the rules, enforce the rules, and make all important decisions for the tribe.
“Well, most of them.”
The shadows from the cassava leaves flickered across the reddish brown dirt, and the grey of the thunderheads waited quietly. Sahr J. had not succeeded in changing the topic.
“Sahr J., someone told me that the Poro society does not do things like this.” In particular, I had asked Amhidu if the Poro society had an equivalent physical initiation to the FGM of the Bondu. He had said know.
“Well, you will never know.”
I touched one of the scars again with the back of my middle finger, with the top of my fingernail. He continued.
“The reason why, is, look at the Bondu society. They told. They even filmed it. Now everyone knows, and it’s useless. Everybody knows, there is no secret.”
I tried to see if he would reveal something about the Poro society in comparison with the Bondu, something other than that its secrecy is superior. “What do you think of the Bondu society?”
“Well,” he stretched the ‘well’ far into the humid dusk, “it is not right for those small small girls. But the grown women, I think they can decide. But now, it’s no secret, everyone knows. They even filmed it.”
A horrible possibility crossed my mind. What if the Poro society did have equally violent initiation rites, but that they had just succeeded in hiding them from the outside world? When I read about the societies online, one article claimed that the Poro society did not exist in the Kono tribe. Sahr J. is Kono. What if their secrecy is successfully concealing violence on par with FGM?
I decided to try a different tack, to try and gain some insight into the phenomenon of privileged knowledge.
“Sahr J., are there many truths about these scars? Is there more than one truth about where these scars come from?”
“You will never know. There are only many lies. No one can tell.” He paused, and I stared at the buzzed and graying hair on the back of his head, then at the trail of scars on his spine. “But every society needs customs, and a place where people converge and decide. In the past, very important things, very good things happened when they met.”
The core tenet is secrecy.
We were silent again. He seemed smaller than usual, and sagging from sickness, and there were beads of sweat glistening between the short black and gray hairs on his head. I stood up to go.
“I hope you feel better, Sahr J..”
He stretched a bit. “A, no problem. A begin for de feel betteh, more betteh than in Masiaka. But a no can eat.”
I nodded sympathetically. He was in good hands; there was plenty of water, some bananas right in front of him, Bailor was around, and there was a plastic bag of his drugs in the corner. “See you, Sahr J.. Feel better.” I stepped out and eased the door shut behind me.
“So, yeah, Sahr J., the man who is not feeling well at the clinic, the one who works for NOW. You know him?”
A.A. and F., two of the young (around 18 and 16 respectively) surveyors, looked concerned. We were walking, looking for A.J. Arisumana, but it may also have been A.K. Ansumana, or A.J. Ansumana...
“No, I don’t know him. We will wish him well when we return.”
“Oh, yeah, definitely. But yesterday, I saw his back, and he has scars, on his back, down his spine, here,” I pointed on A.A.’s back.
“Oh...” nothing for a moment, then recognition, “Oh! Yes, those are traditional. Custom.”
“Well, I asked him about them, and he told me I would never know.”
They laughed, and A.A. spoke. “That’s right, you will never know. Until you are there, you will never know. Do they have the Poro Society in North America?”
“No, not at all. And hardly anything like it.”
We walked for a moment, turning left onto a path that climbed a short hill.
“As for me,” A.A. continued, “I refuse. I refuse to join.”
What? I processed in silence for a moment.
“...why do you refuse?”
“Because I no want to endanger my life. It’s very dangerous, very dangerous. I don’t need that.”
“Wait, is there something more than the scars that is dangerous?” The specter of my conversation with Sahr J. loomed in my mind.
“No, is tetanus. They cut you with irons, very deep, it’s not clean, you know,”
We stopped by the front door of a house to ask about Mr. A.J./K. Arisumana/Ansumana. After confirming that we were not police, the man directed us further. The clay bricks of his house were crumbling around him.
“But even if you refuse,” A.A. continued, “they will come and take you. Sometimes they just take you to the bush, and initiate you.”
“At what age do you join the Poro society?”
“Any age, any age. Not less than seven.”
We arrived at the house of (we confirmed with his wife) Mr. A.J. Ansumana. He was not there, so we asked his wife if she had done the original survey. She had. So we surveyed her. While surveying I jotted down the essentials of my conversation with A.A. and F. thus far.
Then we left to return to the Motema junction, where we could find motorbikes to the next camp. Katie had already taken the other ten surveyors there; we had finished the surveys in Motema. I gathered my thoughts as we stepped around some tree roots, then broached the topic again.
“How many of your friends are in the Poro society, A.A.?”
“Many, many of them. You know, even my mother, even my father and my fA.S.ly, they all want me to join. They are angry that I will not join. But still, I tell them that I refuse.”
F. pointed us down the correct branch in the path. A.A. continued.
“If you refuse to join, you will not get any position. You will not go to these meetings, you will not go to any meeting where they decide what happens in the community. As soon as they find out you are not yet joined, you will never get any position.”
Then F. spoke. “Even in Makeni, this Poro society is everywhere. They will take you in the street if you refuse, they will take you.” Makeni was a large city between Koidu and Freetown. It’s ostensibly Bailor’s hometown.
“Have you joined, F.?”
“As for me, no, I have not joined. I am scared. But when the time comes, I think I too will refuse.”
A.A. lifted up his shirt. “Look. I refuse. No scars.” He was right. No scars.
“It’ s very brave of both of you. It de take courage for refuse.” I injected a bit of Krio in the hopes that they would understand my admiration. They had guts, to refuse almost every elder and sabotage so many opportunities for themselves.
“Even in Makeni, they will take you to the Poro bush. It’s owned by the Temne,”
“The Temne?” They were an ethnic group.
“No, actually, the Limba,” another ethnic group, “but there are so Temne, they mainly use it.”
We crossed the road to wait for motorbikes. I stopped listening for a moment to make sure we didn’t get run over by a creaking dilapidated van. When I tuned back in, A.A. said, “Even our president has joined.”
“The Poro society?”
“Yes, he has joined. If you have not joined, you will not get a position, never get one,”
“In government?”
“Yes.”
A brief pause, then F. said, “When they come to take you, even if you don’t want to go, you can’t stop them, you can’t resist. They will take you.” He made a fist with his left hand and then grabbed his left forearm and pulled it down, to demonstrate someone being overpowered. I had no reply.
We flagged down a motorbike and haggled over the price. He drove away without us, angry that I actually knew how much it cost. I’d tried to look at the back of his neck, between his helmet and his thick jacket, but I couldn’t see it.
“Ka-tee,” I called her name in the musical way some Sierra Leoneans say it, “how are you?”
“Fine,”
We talked about the surveys for a moment. It turns out that all the Bumpeh surveys were done. More interesting, as we walked Katie updated me on her conversations with A.S.e, a 19 year old female surveyor, about the Bondu and Poro societies. Below I’ve paraphrased and reconstituted that conversation and its continuation later in Koidu Town.
“A.S. said it was pretty much like we read, that after the initiation, they mostly learn about housework, and how to have sexual intercourse, and how to cook, and stuff like that. And she said that the Poro society, all the women lock themselves in their houses and then the men all leave to go to the bush. They all lie down and they give them the scars with hot irons. Then they stay and live in the bush with nothing, not even clothes, for four months. She said that last year, or two years ago, a reporter hid in the bush and took videos and photos of the ceremony, and now they all want to kill him.”
“I bet they do. I hope he left the country.”
“He’s long gone, A.S. said. She was really scared, I think she’s scared they’re going to force here to join the Bondu society.”
I murmured with concern.
“Yeah. She doesn’t want to join. Her father takes the British view, apparently,”
“That sounds promising,”
“Which is to let her choose. But he’s in Freetown,” and A.S. is not. “I think he told the traditional women that if they take A.S., he’ll call the police on them. But when he’s in Freetown, I’m scared they’ll just do it anyway. She said in one or two months,”
“They always do it during the dry season, right?”
“Yeah,”
“That’s in more than one or two months. But scary,” One month, three months, or one year, it would always be too soon for A.S..
“I think they just capture them while they are sleeping, one night, they just come, and take you to the bush. There’s lots of screA.S.ng and crying, but in the end, you go. She also wanted to know whether there was anything like this in North America,”
“No,” I said, shaking my head and staring at my sandals.
“That’s what I told her. One thing I asked them, and that I don’t understand, is why the parents want to force the children to join. The only way to be protected is to have your parents support you in refusing. And I asked U., and K., and A.S.,” U. and K. being other surveyors, both male, “why, if the young people are so against it, do the parents support it so much? U. said that he thought it would never change, that it would always be there.”
“No, it’ll fade gradually,”
“Yeah, I agree. But I asked them why it would continue, if the young people don’t support it now, and then they will grow up to become the adults. It doesn’t make sense.”
I grunted assent and stared gravely at the gravel. “Maybe it’s because the cost is all upfront, and once you are in, it’s not so bad.”
“I just don’t understand how the pain of that can ever go away.”
“The scars for the guys, that pain will go away.”
“Yeah. But for the girls, I just don’t see how it can ever go away. And even if it didn’t hurt all the time, I don’t see how it wouldn’t hurt every time you have sex.”
I kept shuffling my feet through the gravel, and trying to work out the occasional stone that crept under my foot. The sun was really bright. I'm glad North America doesn't have secret societies like the Poro and Bondu.
Sunday, July 19, 2009
Palm Oil Business Plan update
We have finished a first draft of the palm oil plantation business plan, and it was very interesting. Working through the budget in detail revealed that fuel will be the major expense in all areas – fuel for transport, fuel to run the machines, fuel for the generator. With the machines we priced, fuel for 200 hours (approximately one month) of operation is about eight times as expensive as the production manager, security / cleaning person, clerk, and production workers’ monthly salaries.
The relatively sterile world of Excel spreadsheets and business plans is so different from the reality here. Every day we see the National Organization for Welbody struggling to keep the mechanics and farmers it employs working hard and working honest. We see the tractor break down in fifteen different ways. We see the mechanics making gaskets out of bristol board, and holes in the tractor where tubes used to be that are filled with sticks. We went out to the farm and saw it when it was thick, eight foot high brush with bushes and wild palm trees, and afterwards, when the workers gathered round to quench their thirst, they drank from a plastic motor oil container. The water inside smelled like gasoline. They laughed when Katie, Allan and I were appalled.
We’ve seen the workers clearing brush with machetes and sticks, some of them amputees, some of them not. Last Thursday we returned to the farm, and now there are large piles of burnt sticks and sticks waiting to be burned all around the ploughed area. The tractor driver himself is a middle-aged man who wears a pink hat and few teeth. Planting and ploughing is going on, and I’m pretty sure that Katie, Allan, and I are the only ones who know that it costs almost 3 million Leones (1000 dollars) to use the tractor for a month. Just to give you an idea:
Tractor fuel, 6 gallons a day, 25 days a month, 15 000 Leones per gallon: 2 250 000 Le
Tractor driver, Leones/month: 250 000 Le
Tractor apprentice, Leones/month: 100 000Le
Tractor maintenance, Leones/month, inevitable: 500 000-1 500 000 Le
Altogether, in the best case, about 3.1 million Leones, or 950 USD, per month. That’s about 40 dollars a day (using 25 days in a month; Sierra Leoneans work most Saturdays).
1 Laborers for 1 day: 8000 Leones.
So we could employ 15 laborers for 25 days for 3 million Leones.
When we were visiting the palm oil plantation in Yele, and furiously jotting down notes about prices, quantities, logistics, and details, I thought of my grandparents. I call them Poppy and Buzz. When Poppy was younger, his first job was out in the middle of nowhere in Alberta, working for an oil company. I can hear a sound byte in my head of him telling me about being asked by the workers what to do – “Is this enough pipe?” He says that he looked at where the pipe needed to go; about thirty feet was needed. Then he looked at the pipe, three lengths of about ten feet. He didn’t know anything about oil pipelines. “Yep.” I think he’d do well in Katie and my advisory/number crunching/research/reality check role here in Kono. Buzz and him might not appreciate the bumpy roads as much anymore, though.
Here’s the first draft of the “Executive Summary” of the business plan. The business plan itself serves two purposes: operating statement for the farm, and convincing appeal for donors. It’s not a business plan in the sense that GAF is looking for investors; instead GAF is looking for donors.
The Kono Amputee Clinic Demonstration Farm is a project that will combine the long term profit potential of palm oil with an existing successful project that works to improve the quality of life of marginalized peoples in Kono District. It will be administered by the National Organization for Welbody (NOW) to provide income to fund the operating expenses of a primary health care clinic that provides modern medicine free of charge to amputees, war-wounded and their dependents.
The plan is to plant 100 acres with oil palms, purchase oil production equipment and then produce palm oil for the local and national market. Another non-governmental organization based has enacted a very similar plan with great success: the palm oil mill in Yele began producing oil in 2008 and continues with great success, funding the Magbenteh hospital in Makeni with the proceeds.
Through the planting, harvesting, production and sale of the palm oil the Kono Demonstration Farm will involve workers from the amputee and war-wounded communities to provide opportunities both for employment and development of business skills and entrepreneurial thinking.
Palm oil is a staple in both food and soap in West Africa, and so it is effectively a commodity. There are two types of oil, red and yellow. The red is more popular for cooking in West Africa, but if processed with a low moisture content, consumers will also use the yellow oil for cooking. Only yellow oil is used in soap-making. The Yele Palm Oil Mill is the only other mill in the country, so competition is mainly against traditional processing methods. The oil palm itself is native to the area, and resilient to pests, wind, rain, and dust after reaching maturity. They require little upkeep and have a long producing life (25-50 years). There are many different varieties, but we have determined that imported Tenera seedlings are the most profitable. Moreover, we will purchase these seedlings from the Yele Palm Oil Mill in order to further our relationship with them and enlist their educational capacities to improve our farming techniques.
We expect the farm to recoup profits equivalent to the initial donations by 2016, and to be able to fund the operating expenses of the clinic (~70,000 USD p.a.) by 2015. Future expansion is a possibility, because land is very cheap.
Production is a multi-step process, requiring approximately 30 – 50 thousand USD of equipment. Fruits are removed from their bunches, sterilized, digested, pressed for oil, and then the oil is clarified by passage over and under barriers and last heated to reduce the moisture content.
According to experience at the Yele Palm Oil Farm, sales are not difficult, because many middlemen come directly to the mill to buy oil. Otherwise, oil will be stored in a storage tank or in five-gallon jerry cans for sale in local markets. Some oil will be sold to the amputees and war-wounded and their dependents at a discounted price to encourage entrepreneurship on their part.
The Kono Demonstration Farm has access to and the leadership of many experienced individuals and institutions. Edward Ngegba, the farm manager, has local farming experience, scientific knowledge, and an appreciation for modern farming techniques. There are also other local farmers directly advising the farming, including Pastor Kanawa of Wardu. The Yele Palm Oil Mill runs educational programs to help farmers increase their fruit yields. Dr. Mohamed Bailor Barrie, director of NOW, possesses a remarkable ability to run a clean and transparent organization in the midst of a stagnant and often corrupt economy.
The production facilities will be registered with the Ministry of Trade and Industry in Freetown, as per regulations, and will not be one of the ten exporters of oil.
The future growth strategy encompasses different possibilities including further planting, agricultural education, crop diversification, expansion of processing capabilities to allow the processing of other local farmers’ palm fruits, manufacture of downstream products such as soap or biodiesel, and business leadership development for NOW and the local community.
In effect, NOW is funded by an American non-governmental organization known as the Global Action Foundation (GAF). The two organizations were funded by a Sierra Leonean and American doctor respectively to work in partnership to help the marginalized peoples of Sierra Leone. The director of NOW, Dr. Barrie, is passionate, hard-working, and well-educated. He has consistently passed up opportunities for higher paying, easier jobs; instead he works day and night for the amputees, war-wounded, and poor of Sierra Leone. Dr. Dan Kelly, the director of GAF, is his American counterpart, pursuing his residency at the Baylor School of Medicine in Houston. Dr. Kelly and GAF head up the fundraising that makes the projects of NOW possible.
NOW has an illustrious list of accomplishments and projects including the Kono Amputee Clinic, the UNICEF malnutrition project in Portloko District, and the recent awarding of the contract to create a similar malnutrition program in Kono District. Future projects include a peer education program focusing on teenage pregnancy.
The Kono Demonstration Farm boasts a number of primary success factors: a well known farming product, a resilient crop, local expertise and leadership, North American business acumen, cheap land, cheap labor, a product that is a staple food, low upkeep after initial capital investment, and last both the amputee community and NOW have emotional and financial stakes in the success of the venture.
There are many different ways in which you can help support this dynamic and powerful combination of business savvy and humanitarian goals. Through the palm oil farm, your donation will transform into a consistent source of income for the Kono Amputee Clinic, which will allow amputees, war-wounded, their dependents and the people of Koidu Town to be provided affordable care for many years to come.
The relatively sterile world of Excel spreadsheets and business plans is so different from the reality here. Every day we see the National Organization for Welbody struggling to keep the mechanics and farmers it employs working hard and working honest. We see the tractor break down in fifteen different ways. We see the mechanics making gaskets out of bristol board, and holes in the tractor where tubes used to be that are filled with sticks. We went out to the farm and saw it when it was thick, eight foot high brush with bushes and wild palm trees, and afterwards, when the workers gathered round to quench their thirst, they drank from a plastic motor oil container. The water inside smelled like gasoline. They laughed when Katie, Allan and I were appalled.
We’ve seen the workers clearing brush with machetes and sticks, some of them amputees, some of them not. Last Thursday we returned to the farm, and now there are large piles of burnt sticks and sticks waiting to be burned all around the ploughed area. The tractor driver himself is a middle-aged man who wears a pink hat and few teeth. Planting and ploughing is going on, and I’m pretty sure that Katie, Allan, and I are the only ones who know that it costs almost 3 million Leones (1000 dollars) to use the tractor for a month. Just to give you an idea:
Tractor fuel, 6 gallons a day, 25 days a month, 15 000 Leones per gallon: 2 250 000 Le
Tractor driver, Leones/month: 250 000 Le
Tractor apprentice, Leones/month: 100 000Le
Tractor maintenance, Leones/month, inevitable: 500 000-1 500 000 Le
Altogether, in the best case, about 3.1 million Leones, or 950 USD, per month. That’s about 40 dollars a day (using 25 days in a month; Sierra Leoneans work most Saturdays).
1 Laborers for 1 day: 8000 Leones.
So we could employ 15 laborers for 25 days for 3 million Leones.
When we were visiting the palm oil plantation in Yele, and furiously jotting down notes about prices, quantities, logistics, and details, I thought of my grandparents. I call them Poppy and Buzz. When Poppy was younger, his first job was out in the middle of nowhere in Alberta, working for an oil company. I can hear a sound byte in my head of him telling me about being asked by the workers what to do – “Is this enough pipe?” He says that he looked at where the pipe needed to go; about thirty feet was needed. Then he looked at the pipe, three lengths of about ten feet. He didn’t know anything about oil pipelines. “Yep.” I think he’d do well in Katie and my advisory/number crunching/research/reality check role here in Kono. Buzz and him might not appreciate the bumpy roads as much anymore, though.
Here’s the first draft of the “Executive Summary” of the business plan. The business plan itself serves two purposes: operating statement for the farm, and convincing appeal for donors. It’s not a business plan in the sense that GAF is looking for investors; instead GAF is looking for donors.
The Kono Amputee Clinic Demonstration Farm is a project that will combine the long term profit potential of palm oil with an existing successful project that works to improve the quality of life of marginalized peoples in Kono District. It will be administered by the National Organization for Welbody (NOW) to provide income to fund the operating expenses of a primary health care clinic that provides modern medicine free of charge to amputees, war-wounded and their dependents.
The plan is to plant 100 acres with oil palms, purchase oil production equipment and then produce palm oil for the local and national market. Another non-governmental organization based has enacted a very similar plan with great success: the palm oil mill in Yele began producing oil in 2008 and continues with great success, funding the Magbenteh hospital in Makeni with the proceeds.
Through the planting, harvesting, production and sale of the palm oil the Kono Demonstration Farm will involve workers from the amputee and war-wounded communities to provide opportunities both for employment and development of business skills and entrepreneurial thinking.
Palm oil is a staple in both food and soap in West Africa, and so it is effectively a commodity. There are two types of oil, red and yellow. The red is more popular for cooking in West Africa, but if processed with a low moisture content, consumers will also use the yellow oil for cooking. Only yellow oil is used in soap-making. The Yele Palm Oil Mill is the only other mill in the country, so competition is mainly against traditional processing methods. The oil palm itself is native to the area, and resilient to pests, wind, rain, and dust after reaching maturity. They require little upkeep and have a long producing life (25-50 years). There are many different varieties, but we have determined that imported Tenera seedlings are the most profitable. Moreover, we will purchase these seedlings from the Yele Palm Oil Mill in order to further our relationship with them and enlist their educational capacities to improve our farming techniques.
We expect the farm to recoup profits equivalent to the initial donations by 2016, and to be able to fund the operating expenses of the clinic (~70,000 USD p.a.) by 2015. Future expansion is a possibility, because land is very cheap.
Production is a multi-step process, requiring approximately 30 – 50 thousand USD of equipment. Fruits are removed from their bunches, sterilized, digested, pressed for oil, and then the oil is clarified by passage over and under barriers and last heated to reduce the moisture content.
According to experience at the Yele Palm Oil Farm, sales are not difficult, because many middlemen come directly to the mill to buy oil. Otherwise, oil will be stored in a storage tank or in five-gallon jerry cans for sale in local markets. Some oil will be sold to the amputees and war-wounded and their dependents at a discounted price to encourage entrepreneurship on their part.
The Kono Demonstration Farm has access to and the leadership of many experienced individuals and institutions. Edward Ngegba, the farm manager, has local farming experience, scientific knowledge, and an appreciation for modern farming techniques. There are also other local farmers directly advising the farming, including Pastor Kanawa of Wardu. The Yele Palm Oil Mill runs educational programs to help farmers increase their fruit yields. Dr. Mohamed Bailor Barrie, director of NOW, possesses a remarkable ability to run a clean and transparent organization in the midst of a stagnant and often corrupt economy.
The production facilities will be registered with the Ministry of Trade and Industry in Freetown, as per regulations, and will not be one of the ten exporters of oil.
The future growth strategy encompasses different possibilities including further planting, agricultural education, crop diversification, expansion of processing capabilities to allow the processing of other local farmers’ palm fruits, manufacture of downstream products such as soap or biodiesel, and business leadership development for NOW and the local community.
In effect, NOW is funded by an American non-governmental organization known as the Global Action Foundation (GAF). The two organizations were funded by a Sierra Leonean and American doctor respectively to work in partnership to help the marginalized peoples of Sierra Leone. The director of NOW, Dr. Barrie, is passionate, hard-working, and well-educated. He has consistently passed up opportunities for higher paying, easier jobs; instead he works day and night for the amputees, war-wounded, and poor of Sierra Leone. Dr. Dan Kelly, the director of GAF, is his American counterpart, pursuing his residency at the Baylor School of Medicine in Houston. Dr. Kelly and GAF head up the fundraising that makes the projects of NOW possible.
NOW has an illustrious list of accomplishments and projects including the Kono Amputee Clinic, the UNICEF malnutrition project in Portloko District, and the recent awarding of the contract to create a similar malnutrition program in Kono District. Future projects include a peer education program focusing on teenage pregnancy.
The Kono Demonstration Farm boasts a number of primary success factors: a well known farming product, a resilient crop, local expertise and leadership, North American business acumen, cheap land, cheap labor, a product that is a staple food, low upkeep after initial capital investment, and last both the amputee community and NOW have emotional and financial stakes in the success of the venture.
There are many different ways in which you can help support this dynamic and powerful combination of business savvy and humanitarian goals. Through the palm oil farm, your donation will transform into a consistent source of income for the Kono Amputee Clinic, which will allow amputees, war-wounded, their dependents and the people of Koidu Town to be provided affordable care for many years to come.
Samba's Meningitis / Cerebral Malaria
The little boy was silent. He stared at me, and looked scared. “Wetin na you nem?” I asked him, and his mother answered.
“Samba,” and she looked at him when she said it. He was bald, with a big head, but his arms were healthy and not too thin. One of the best indicators of malnutrition for young children is the circumference of the mid-upper arm. If it is less than 8 or 9 cm, they are malnourished. Samba’s upper arms were full and well padded.
I pressed the button on the thermometer and moved it towards him. It was one of the under-arm thermometers, the same kind I’ve used in my house my whole life. His eyes widened and he fidgeted, and started to cry. “A no de choku! A no de choku,” I repeated, and his mom confirmed. He had thought it was a needle. I slipped it under his arm. Heat was radiating from him.
Yusuf proceeded with his questions. “Why you de bring dis pikin ya (here) today? Wetin make you de bring de pikin?”
“Dey body dey wam...”
As Yusuf gathered up Samba’s symptoms – fever, nausea, weakness, lack of appetite, difficulty sleeping – I watched him. When I looked closer, he wasn’t in fact bald. There were small scatterings of black curls, growing stealthily into tight rings. His lips were dry, so maybe he was dehydrated. I picked up his hand and looked at the palm. It was pale, almost as pale as my hand. The paleness is often a sign of anemia, or a reduced concentration of red blood cells in the blood. It often happens in malaria, because the malarial parasite reproduces inside and then kills the red blood cells.
The thermometer beeped; 39.82 C, or about 104 F. That’s a high fever. Without noise I showed it to Yusuf, who noted it on his chart.
I stood up from my seat, picked up the stethoscope, and walked around to the bed in the consulting room. As always, the consulting room was crowded. When I turned back towards Samba, his mother was already lifting him up onto the examination table and removing his clothes. He lay down, and gave a few weak cries, but then he let me listen to his lungs. I heard the clean and quick roar of his inhale, followed by the lower flooding noise of his exhale. He was breathing quickly, but not alarmingly fast, just noticeably. Before I handed the stethoscope to Yusuf, I checked the soles of his feet. They were also very pale, mostly white with a tint of yellow on the edges.
“De feet, dey pale,” I commented to Yusuf. He grunted and nodded.
“Dat is a sign of anemia,” he announced. After motioning for Samba’s mother to dress Samba, he continued. “So, a de order some tests. But first, you go wass (wash) de pikin, becos ‘e got fever, bad fever,”
“You go use de water na well, nado (outside). Dat water na cold,” I added. We didn’t have running water in the clinic, and even if we did, she might not have known how it worked.
“Okay, den a come back?” We nodded. They stood up and left. The whole time, I hadn’t paid much attention to the daughter, who looked about three. As they left, however, I recognized her. Her name was Kadiatu, and I had met her and her father in consulting one week prior. She was a vibrant three year old, even when sick with malaria, and she had big dark eyes beneath a thin and wispy covering of curls. While meeting her, I’d learned that her father was an imam at a mosque in Koidu Town. He had been wearing a distinguished navy blue shirt and pants. They might have looked like pajamas on me or my dad, but together with his white brimless hat and curly black beard, he had looked regal.
I was jotting down the patient number of the lab results form someone had just passed me, when suddenly Samba and his mother returned. There was a lot of commotion in Krio, and Samba’s mother dropped him onto the consulting room bed.
He was convulsing. It was very disconcerting. His eyes were rolling around like doll’s eyes, and his hands and legs were beating pathetically up and down like wings. Every breath was coarse with effort, and his jaw muscles were clenched.
But on the bed, with Yusuf in the room, was the best scenario. So I calmly finished writing down the patient number, and then stood.
Other patients surged into the room, wanting to help. Katie came in. Yusuf stood up and left, inexplicably. Later I figured that he must have been looking for diazepam, a muscle relaxant for use in seizures and convulsions. The mother started to hold him down, and I stood up to try and prevent her from doing that. Then she picked him up, and I tried harder to tell her to leave him on the bed. It’s not a good idea to pick up a convulsing baby; the convulsions alone will not kill the child, but dropping him headfirst onto the corner of the desk just might. But my Krio was powerless. The room was packed with colorful dresses and loud voices.
Then, just as fast as she’d entered, the woman left.
“Ousai she de go?” No one paid me attention. “Where’s she going?” I asked Katie. I don’t recall if it was Katie or Yusuf that told me, but one of them told me they were leaving because we had no diazepam.
“Wait, Yusuf, what does that do?”
“It is a muscle relaxant. You know,” he sounded a bit regretful, “we have training for this situation in nursing school, but we need the diazepam to do what we were trained to do. If we no have diazepam, we cannot sedate the child,”
“But we’re just letting them leave? We could wait for the convulsions to subside, couldn’t we?”
“They are going to the government hospital. They can do transfusions as well, there.”
I sat down again. It was frustrating; the government hospital was going to be expensive and of questionable quality. However, if they could indeed do transfusions while we could not, perhaps that was the best place for a very anemic and sick boy to be.
“Why don’t we have diazepam?”
“Oh, we don’t have. No pharmacy, we looked, we should have [it here in the clinic], but no pharmacy, nowhere in Koidu, they don’t have.” That gave me pause.
Yusuf had been singularly unassertive during the whole situation, and I was frustrated. But he was right – diazepam or the ability to give transfusions were essential to the treatment Samba needed.
Nonetheless, the general conclusion of the staff was that Samba was going to die.
“That little boy, the one with the convulsions, he has returned.”
What? “What?” Yusuf and I were already walking out of the consulting room, and Katie appeared as well.
“The parents, they have returned, and they say they put full faith in our care,”
Hm. My initial reaction was disbelief. All the reasons why he had initially left were still valid, except now Samba was three hours of convulsions and fever sicker.
A few minutes later, I walked to the back of the clinic and saw Jalloh leaning over Samba and his mother. Samba was rigid and unbending, his eyes still randomly adrift. He was breathing fast, there was thick fluid in his lungs that crackled and wheezed with every breath, and he was still noticeably radiating heat.
“Jalloh, let me see your watch for a moment,” Jalloh tilted his wrist so I could see his fancy silver watch. It had a second hand; that was all I wanted. I counted off Samba’s breaths and calculated 60 breaths per minute. Dr. Lenny Smith had made it clear that the life of any sick child breathing over 60 breaths per minute was in danger. I also took his pulse, but it was difficult to find beneath the swollen and tight muscles in his arm. Then I noted the time and recorded all three.
3pm – 60 breaths per minute, 120 beats per minute.
The stuff in the lungs and the respiratory distress were both new, and both worrisome. I thought that Samba might die. He was too tiny, and he was breathing so hard. With every breath I could see his ribs flaring out against his skin. When someone is having trouble breathing, it’s usually because the flow of air is impeded on the exhalation, and it was no different for Samba. Humans use their diaphragm to create space, which lowers the pressure inside the lungs and causes air to rush inside. The diaphragm is a big strong muscle. But there is no equivalent strong muscle to help with exhalation. So every breath was causing Samba to get further behind on the amount of oxygen he needed, and his breathing rate was climbing. I went back into the consulting room and told Katie. She went out to look, then came back.
“He’s not just breathing fast. His eyes won’t follow a finger, he doesn’t recognize when you move towards him, he doesn’t respond when you touch him, and his muscles are still convulsing,” Her voice was urgent.
I breathed in. “But he’s not shaking, it’s just that his muscles are clenched. Is that still the same thing?”
We didn’t know.
“I don’t think you can convulse for that long,” Katie said.
There was some commotion in Krio and then Bori and a group of colorfully dressed spectators moved Samba into the observation room. They placed him on the first bed, and then stood, watching. Bori was standing beside a plastic bowl filled with Samba’s medications.
Yusuf came in and sat down on the edge of the bed. Samba was small, so he didn’t take up very much bed. Yusuf tied a rubber elastic around Samba’s forearm, but the vein didn’t appear. The forearms looked very swollen. It’s true that babies often have chubby forearms and no wrists, but Samba’s forearms and wrists looked tight and uncomfortable.
“’E no dere...” Yusuf said to himself. He asked Bori for a razor. I tried to think of why he needed a razor, and couldn’t.
While Bori was gone, Yusuf and I told the spectators, including the parents, to leave. They shuffled out. All of their expressions were hard to read. I couldn’t tell if they were watching from concern, or from the morbid fascination with which we all watch car accidents. Samba’s eyes were half closed, and his breath was still gurgling and croaking at 60 breaths per minute.
Bori was back with the razor. Yusuf turned Samba’s head to the side and shaved off a couple square inches of hair above and behind his ear. Then he laid the elastic flat across Samba’s head, above the ear. It wasn’t an elastic like you find on broccoli at the grocery store, it was about an inch thick.
“Hold.” I nodded, glad to be helping, and then held down both sides of the elastic. Was this to keep his head in place? After a moment, a vein appeared under his scalp, in the area Yusuf shaved. Then Yusuf inserted the IV needle, pulling back the metal and leaving the plastic tubing.
Samba didn’t react at all.
In a couple of minutes Katie came into the room. She sat down beside me, and we took another set of vitals.
3:10pm – 60 breaths per minute, 120 beats per minute.
Jalloh let us hang on to his watch.
Katie updated me on the convulsions. “Anemia doesn’t cause convulsions, not according to Wikipedia. But cerebral malaria does.”
“Is that just malaria that infects the brain? I hope it’s not malaria inside the brain, behind the blood-brain barrier where we can’t get any drugs,” I know almost nothing about the blood brain barrier. That’s probably the only individual piece of information that I know about it.
“I don’t know,”
“But I’m really worried about the crap in his lungs. Is that cerebral malaria? How does malaria infect the lungs? Where did it come from?”
Katie shrugged. “I read that convulsions can cause loud breathing.”
“No, but don’t you think that loud breathing is just like panting, or like this,” I demonstrated some loud breathing, “not like gurgling mucus and crap in the lungs? I don’t believe that convulsions can magically cause a whole bunch of fluid to enter the lungs,” In my mind’s eye I imagined fluid surging out through the membranes of cells in the alveoli, some kind of inflammatory response. Something was missing. I later learned that when people convulse, they can vomit some stomach acid and then inhale both saliva and stomach acid, causing something known as ‘aspiration pneumonia.’
“I don’t know, but that’s just what it said, loud breathing.” We didn’t know, and it didn’t make sense.
So we looked at Samba. He was propped up on pillows, with his chin on his chest. His eyes were half closed and lolling from side to side like googly eyes on arts and crafts day at camp. I pinched myself a couple times to measure how much it hurt, then I pinched him. Nothing.
“He didn’t respond to the needle, Katie,”
Katie just looked deeply worried. We felt his feet. They were cold. His hands. They were cold.
Yusuf came back and strung up the first round of drugs – a cocktail of antibiotics. “Gentamycin and ampicillin,” he said. Vincent came in and pricked Samba’s finger to test his hemoglobin concentration. That sounds fancy, but all it actually involved was pricking his finger, putting a drop of blood on a piece of special litmus paper, then holding the litmus paper up to a color gradient and reading off the numbers corresponding to the color. We never found out what it was. It was probably low, given that his palms and feet were almost as white as mine.
“Why isn’t Vincent doing a malaria test?” I asked Katie.
“They did one this morning. He was positive, two plus,” two plus is a severity designation that accords with the concentration of parasite that Vincent sees under the microscope. Two plus is medium severity in an adult, but can be very dangerous for young people (Samba) or people who’ve never had malaria (Katie and I).
“Oh, man, I didn’t even know. Well, your cerebral malaria idea makes a lot of sense.”
We took more vitals.
3:20pm – 66 breaths per minute, 120 beats per minute.
Then Yusuf gave him a shot of something, perhaps adenosine? to make his heart beat faster, to help him in his oxygen distress and get some blood back into his hands and feet. It was magical. Just a minute or two later, his hands and feet were warm and his heart was racing.
At some point, I don’t remember when but it was near the beginning, we started holding his airway open. It wasn’t easy, because his muscles were so clenched. But the only thing I know about respiratory distress is that you must do everything you can to aid the person in breathing. Any extra challenge could be too much, and they’ll go unconscious or worse. In the hospital in France, they would give tracheotomies to elderly people with bad pneumonia simply to get rid of the obstacle of all the dead air in the mouth and throat. I slipped my thumbs against the sides of his jaw and pushed up, gently. His mouth refused to open. We waited, and Samba filled the room with desperate breathing.
Yusuf returned. Katie wanted to know what he was injecting.
“What is that? Yusuf, what is that?”
“Diazepam.” Yusuf uncapped a tap on the IV drip line and then injected a syringe of yellow fluid. “Dissolve half a milliliter in two milliliters.” Then he was gone again. We waited for the diazepam to slacken his muscles, so that we could possibly open his airway better, or at least get his mouth open and try and get him to cough up some of the noisy crap in his lungs and airway.
The diazepam made his eyes roll around and close in a very scary way. He looked possessed, and his muscles hardly relaxed at all.
I laid my hands on his chest. “Feel that,” I said to Katie. His entire ribcage was rumbling and vibrating with every breath he took. “You can feel the stuff, it’s all through his lungs.” Later, Yusuf told us that he thought the mucus and fluid was mainly in one of the two lungs, which makes sense because the branching from the windpipe into the lungs is not the same on both sides. When fluid – or a tube, or anything else – goes past your esophagus, it’s much more likely to go into one lung than the other. I forget which one is which, and I certainly didn’t notice that one lung was more impeded than the other.
3:32pm – 72 breaths per minute, 180 beats per minute.
His heart was racing because of the heart drug Yusuf gave him, but his breaths were also increasing. I had to change the position of my hand, because it was getting tiring leaning over him in such an awkward way. As the diazepam filtered through his system, he started moving his left leg. He would pull his knee back towards his head and then kick it out, and he’d do that two or three times then stop. A few minutes later he also started making some noises with every breath, small cries.
“Where are they? Where is everyone?” Katie wanted to know why we were so alone in the observation room.
“I don’t know,”
“Well, Yusuf’s seeing patients. But where is Bori?”
Could Bori help that much? What could we do? The staff, it seemed, were not as optimistic as Katie and I. Although, I’m not sure if I was optimistic. In my head I was running through what would happen if he stopped breathing altogether. I decided that I would begin artificial respiration, and since his mouth was clamped shut, I would do it by sealing my mouth around his nose and mouth. But beyond that, what could we do if he stopped breathing? Nothing except hope that he started again. Ambulances exist, but when I’ve asked Amhidu about emergency numbers he told me the only number was the fire department (300). I may have seen an ambulance in Freetown, but Yusuf already held such a low opinion of the pediatric department at the government hospital in Kono. If he had felt they would kill Samba an hour ago, I didn’t have faith they could revive him if he stopped breathing.
As Katie and I sat on the bed, the spectators filtered back in, and they began to have a conversation about the government hospital. They all agreed that at the government hospital they would let your ‘pikin’ die and not care in the slightest, especially if you didn’t have enough money.
The rest of the afternoon is more of a blur, and I don’t remember the vitals so clearly. I’ll put them in to give you a sense of the progression, though.
3:49 – 69 breaths per minute, 160-180 beats per minute.
Katie took more and more of the vitals. My arms and hands were slick with sweat where they were resting against Samba’s skin. Samba panted along with uneasy stability, though now his breathing was becoming more irregular. I couldn’t decide whether or not it was good if his condition remained the same for an extended period of time. I was scared that at some point he would just give up.
And then he did. He stopped breathing, just for a moment. “No way, buddy,” I clapped his ribs, and he started breathing again. Katie stared down at him, eyes wide.
“I’m going to go get Yusuf,” she said.
One of us went to get Yusuf. When he returned, Samba stopped breathing again. Yusuf looked at Samba for a moment, then placed his hand firmly across Samba’s chest and pushed and massaged. Samba sputtered back to life, and Yusuf kept massaging. Samba’s eyes opened most of the way and then closed most of the way, and then stabilized. Yusuf waited a moment and then returned to consulting. Before he left, he said, “You’re doing a good job.” Maybe, but I don’t think we knew what we were doing. I certainly didn’t. I was applying standard first aid and CPR to an infant cerebral malaria case with respiratory distress in rural Sierra Leone.
Samba stopped breathing several more times, each longer than the last. Every time, I talked to him, to comfort myself, not him. “I don’t think so, Samba,” or “No way, no way,” or “Nice try,” as my hand or Katie’s hand pushed the life back into his lungs.
Afterwards, I’m not sure whether or not he would have continued to not breathe if we hadn’t palpated his chest like that. Maybe, maybe not. It wasn’t a chance we were going to take at the time, and not one I would take now. The times on the vitals are getting more approximate in my memory.
4:10 – 84 breaths per minute, 180 beats per minute.
He was starting to hiccup. Normally I wouldn’t be worried, but he was hiccupping every third or fourth breath, and so he was effectively losing 20-25% of his oxygen intake. I tried pinching him and slapping him on the chest to surprise him out of it, but he was still unresponsive. I’m sure Katie tried something too, but I don’t remember what.
The thing is, I hadn’t eaten since 8am, and at 8am I had eaten a hamburger bun and a boiled egg. So my awareness, both at the time, and in my memory, was shrinking. When I think back to the events, to sitting on the edge of Samba’s bed, feeling his swollen and rasping chest under my hands, seeing his legs kick futilely against the malaria in his blood, it’s like the edges of the image start receding inwards, and I see less and less.
4:40 – 72 breaths per minute, 120 beats per minute.
Around now I started to think that the worst had passed. His breathing was coming down, and he wasn’t trying to stop breathing every couple of minutes. Katie even managed to get his eyes to follow her finger, sort of.
“That’s better,” she said.
“He follows your finger?” I tried it.
“No, but when I move my finger, his eyes jump to it.”
She was right. Maybe Samba wouldn’t die. But I couldn’t tell if I thought that because of real reasons, or because I didn’t want to see him die. I didn’t want to see my first death today.
5:10 – 69 breaths per minute, 120 beats per minute.
The hiccupping was gone. Katie and I moved him around a bit, trying to combine an upright position with an open airway, all while not damaging his IV connection. Back around 3:30 he had taken his first dose of quinine, so now he was just on maintenance glucose drip. Hopefully that would keep his blood pressure high, according to Yusuf. That made sense, because blood pressure is related to how much fluid volume there is in your blood. If you take a pipe and you put more water through it, the pressure increases.
At some point, Katie told me this. It might have been after, as we sat eating dinner under the stars and clouds at Uncle Ben’s.
“You know, I had to force them to get the diazepam. They weren’t going to do it. They weren’t going to get it.”
“Wow. Good job making them get it,”
“It doesn’t make sense, I wish they would have tried harder for it,”
“Yusuf did tell me that it was hard to find, that it was very rare in pharmacies in Kono. But I guess not, because Bori found it pretty fast.”
“Yeah.”
His muscles weren’t as rigid anymore, and by that I mean that we could bend them without considerable effort. His mother and father were in the room now, watching. I wondered what the father, the imam, was thinking. I wondered whether he was praying for his son, or what he said to God about him.
“The dad’s an imam,” I said, at some point.
“I saw him outside, praying,” said Katie. There was a prayer mat beside the desk. It was the only medical equipment in the clinic that we hadn’t considered using yet.
5:40pm – 60 breaths per minute, 120 beats per minute.
Eventually, we had to think about what to do that night. Samba hadn’t tried to stop breathing in well over an hour, and his breaths were slowing. He seemed to be stabilizing. My stomach was empty, and the emptiness was spreading through my whole torso and making me very spacey. I’m useless when I’m very hungry. “Katie, what do you want to do?”
“What do you mean? What do I want to do now, or what do I want to later?”
“What do you want to do for food. I’m really hungry.” And I was very spent. The combination of hunger, adrenaline, and urgency was tiring.
We showed the imam and his mother what to do, how to keep Samba upright against the pillows, how to keep his airway open, and what to do if he stopped breathing. Then we left.
Before we left, we talked to Yusuf.
“Do you think he will be okay, Yusuf?”
“I don’t know, maybe he will. I’m doubtful, doubtful. The boy is very sick, he is very sick, and we don’t have the salbutamol or the oxygen or the machine,” He was referring to a nebulizer. Salbutamol is a popular asthma drug, it was the active ingredient in inhalers for many years. It’s a steroid that dilates the bronchioles in your lungs, allowing the easier passage of air. I wasn’t sure that it would really do all that much for Samba, given that his problem seemed to be that his lungs were full of fluid and mucus. The oxygen would be good, though, and I guess would have the same effect as the salbutamol. The bottom line is, I’m not a doctor, but at that moment I wished I knew what we could do. Or that Katie knew what we could do. Or that anyone knew. Yusuf had injected some folate earlier today to deal with the ‘crepitus’ – the fluid in the lungs. It hadn’t had a noticeable effect, unless it had stopped the situation from getting worse. In France I had helped the respiratory physiotherapists aspirate the lungs of elderly people that had been prone for weeks and couldn’t clear the mucus from their lungs by coughing. If we had one of those tubes and suction apparatuses, we could have aspirated Samba’s lungs.
My head was numb, and I tuned out from Yusuf. Katie later told me that Yusuf had ended his monologue with “Maybe we can ask God.”
We left in the dark. My head, stomach, and every other part of me felt empty.
The next morning we arrived, and Samba was sleeping normally. The mucus and fluid was gone. He looked sick, felt warm, and was unhappy, but it was all very normal. He wasn’t going to die. I was happy, but I was still a little raw inside from the previous day’s effort. It was a quiet happiness, a tired one.
The dad came up to Katie and I and thanked us vigorously. “Tenki, tenki,” his eyes were large, dark, and almost watering.
“’E de get welbody,” I nodded encouragingly at the dad. He’ll get healthy.
Later I measured his breathing rate. 40 breaths per minute, much better.
Samba stayed the whole day, and the next night. He left healthy, and his parents were happy. I wonder if he’ll remember it. During the first night, after we returned to Uncle Ben’s, I looked up all the symptoms, trying to figure out if what we were doing was correct. Everything seemed to line up with cerebral malaria, and one of my previous posts is a segment of instant message conversation with my friend Veronica right after I found that cerebral malaria accorded with almost everything we saw.
But when we spoke to Bailor, he said, “That sounds like meningitis. The [clenching teeth], the convulsions. Usually when it’s cerebral malaria, the patient convulses for a little while then goes unconscious. Yusuf, he treated with antibiotics, right?”
Yes, he did...
“So if it was bacterial meningitis, then that takes care of it too. That’s why you treat like that, when you don’t know. And that’s why when you see these symptoms, first thing, you do a lumbar puncture, so that you know. But when you can’t know, you can’t do that, then you have to give antibiotics and quinine. You can do the [names of two people that I forget] signs, where you get a sharp thing, and you trace along the palm and around, and if the hand flips up, it’s positive.”
Positive for what? Bailor didn’t say. Why didn’t we phone Bailor? I don’t remember. I’m glad that Samba lived.
“Samba,” and she looked at him when she said it. He was bald, with a big head, but his arms were healthy and not too thin. One of the best indicators of malnutrition for young children is the circumference of the mid-upper arm. If it is less than 8 or 9 cm, they are malnourished. Samba’s upper arms were full and well padded.
I pressed the button on the thermometer and moved it towards him. It was one of the under-arm thermometers, the same kind I’ve used in my house my whole life. His eyes widened and he fidgeted, and started to cry. “A no de choku! A no de choku,” I repeated, and his mom confirmed. He had thought it was a needle. I slipped it under his arm. Heat was radiating from him.
Yusuf proceeded with his questions. “Why you de bring dis pikin ya (here) today? Wetin make you de bring de pikin?”
“Dey body dey wam...”
As Yusuf gathered up Samba’s symptoms – fever, nausea, weakness, lack of appetite, difficulty sleeping – I watched him. When I looked closer, he wasn’t in fact bald. There were small scatterings of black curls, growing stealthily into tight rings. His lips were dry, so maybe he was dehydrated. I picked up his hand and looked at the palm. It was pale, almost as pale as my hand. The paleness is often a sign of anemia, or a reduced concentration of red blood cells in the blood. It often happens in malaria, because the malarial parasite reproduces inside and then kills the red blood cells.
The thermometer beeped; 39.82 C, or about 104 F. That’s a high fever. Without noise I showed it to Yusuf, who noted it on his chart.
I stood up from my seat, picked up the stethoscope, and walked around to the bed in the consulting room. As always, the consulting room was crowded. When I turned back towards Samba, his mother was already lifting him up onto the examination table and removing his clothes. He lay down, and gave a few weak cries, but then he let me listen to his lungs. I heard the clean and quick roar of his inhale, followed by the lower flooding noise of his exhale. He was breathing quickly, but not alarmingly fast, just noticeably. Before I handed the stethoscope to Yusuf, I checked the soles of his feet. They were also very pale, mostly white with a tint of yellow on the edges.
“De feet, dey pale,” I commented to Yusuf. He grunted and nodded.
“Dat is a sign of anemia,” he announced. After motioning for Samba’s mother to dress Samba, he continued. “So, a de order some tests. But first, you go wass (wash) de pikin, becos ‘e got fever, bad fever,”
“You go use de water na well, nado (outside). Dat water na cold,” I added. We didn’t have running water in the clinic, and even if we did, she might not have known how it worked.
“Okay, den a come back?” We nodded. They stood up and left. The whole time, I hadn’t paid much attention to the daughter, who looked about three. As they left, however, I recognized her. Her name was Kadiatu, and I had met her and her father in consulting one week prior. She was a vibrant three year old, even when sick with malaria, and she had big dark eyes beneath a thin and wispy covering of curls. While meeting her, I’d learned that her father was an imam at a mosque in Koidu Town. He had been wearing a distinguished navy blue shirt and pants. They might have looked like pajamas on me or my dad, but together with his white brimless hat and curly black beard, he had looked regal.
I was jotting down the patient number of the lab results form someone had just passed me, when suddenly Samba and his mother returned. There was a lot of commotion in Krio, and Samba’s mother dropped him onto the consulting room bed.
He was convulsing. It was very disconcerting. His eyes were rolling around like doll’s eyes, and his hands and legs were beating pathetically up and down like wings. Every breath was coarse with effort, and his jaw muscles were clenched.
But on the bed, with Yusuf in the room, was the best scenario. So I calmly finished writing down the patient number, and then stood.
Other patients surged into the room, wanting to help. Katie came in. Yusuf stood up and left, inexplicably. Later I figured that he must have been looking for diazepam, a muscle relaxant for use in seizures and convulsions. The mother started to hold him down, and I stood up to try and prevent her from doing that. Then she picked him up, and I tried harder to tell her to leave him on the bed. It’s not a good idea to pick up a convulsing baby; the convulsions alone will not kill the child, but dropping him headfirst onto the corner of the desk just might. But my Krio was powerless. The room was packed with colorful dresses and loud voices.
Then, just as fast as she’d entered, the woman left.
“Ousai she de go?” No one paid me attention. “Where’s she going?” I asked Katie. I don’t recall if it was Katie or Yusuf that told me, but one of them told me they were leaving because we had no diazepam.
“Wait, Yusuf, what does that do?”
“It is a muscle relaxant. You know,” he sounded a bit regretful, “we have training for this situation in nursing school, but we need the diazepam to do what we were trained to do. If we no have diazepam, we cannot sedate the child,”
“But we’re just letting them leave? We could wait for the convulsions to subside, couldn’t we?”
“They are going to the government hospital. They can do transfusions as well, there.”
I sat down again. It was frustrating; the government hospital was going to be expensive and of questionable quality. However, if they could indeed do transfusions while we could not, perhaps that was the best place for a very anemic and sick boy to be.
“Why don’t we have diazepam?”
“Oh, we don’t have. No pharmacy, we looked, we should have [it here in the clinic], but no pharmacy, nowhere in Koidu, they don’t have.” That gave me pause.
Yusuf had been singularly unassertive during the whole situation, and I was frustrated. But he was right – diazepam or the ability to give transfusions were essential to the treatment Samba needed.
Nonetheless, the general conclusion of the staff was that Samba was going to die.
“That little boy, the one with the convulsions, he has returned.”
What? “What?” Yusuf and I were already walking out of the consulting room, and Katie appeared as well.
“The parents, they have returned, and they say they put full faith in our care,”
Hm. My initial reaction was disbelief. All the reasons why he had initially left were still valid, except now Samba was three hours of convulsions and fever sicker.
A few minutes later, I walked to the back of the clinic and saw Jalloh leaning over Samba and his mother. Samba was rigid and unbending, his eyes still randomly adrift. He was breathing fast, there was thick fluid in his lungs that crackled and wheezed with every breath, and he was still noticeably radiating heat.
“Jalloh, let me see your watch for a moment,” Jalloh tilted his wrist so I could see his fancy silver watch. It had a second hand; that was all I wanted. I counted off Samba’s breaths and calculated 60 breaths per minute. Dr. Lenny Smith had made it clear that the life of any sick child breathing over 60 breaths per minute was in danger. I also took his pulse, but it was difficult to find beneath the swollen and tight muscles in his arm. Then I noted the time and recorded all three.
3pm – 60 breaths per minute, 120 beats per minute.
The stuff in the lungs and the respiratory distress were both new, and both worrisome. I thought that Samba might die. He was too tiny, and he was breathing so hard. With every breath I could see his ribs flaring out against his skin. When someone is having trouble breathing, it’s usually because the flow of air is impeded on the exhalation, and it was no different for Samba. Humans use their diaphragm to create space, which lowers the pressure inside the lungs and causes air to rush inside. The diaphragm is a big strong muscle. But there is no equivalent strong muscle to help with exhalation. So every breath was causing Samba to get further behind on the amount of oxygen he needed, and his breathing rate was climbing. I went back into the consulting room and told Katie. She went out to look, then came back.
“He’s not just breathing fast. His eyes won’t follow a finger, he doesn’t recognize when you move towards him, he doesn’t respond when you touch him, and his muscles are still convulsing,” Her voice was urgent.
I breathed in. “But he’s not shaking, it’s just that his muscles are clenched. Is that still the same thing?”
We didn’t know.
“I don’t think you can convulse for that long,” Katie said.
There was some commotion in Krio and then Bori and a group of colorfully dressed spectators moved Samba into the observation room. They placed him on the first bed, and then stood, watching. Bori was standing beside a plastic bowl filled with Samba’s medications.
Yusuf came in and sat down on the edge of the bed. Samba was small, so he didn’t take up very much bed. Yusuf tied a rubber elastic around Samba’s forearm, but the vein didn’t appear. The forearms looked very swollen. It’s true that babies often have chubby forearms and no wrists, but Samba’s forearms and wrists looked tight and uncomfortable.
“’E no dere...” Yusuf said to himself. He asked Bori for a razor. I tried to think of why he needed a razor, and couldn’t.
While Bori was gone, Yusuf and I told the spectators, including the parents, to leave. They shuffled out. All of their expressions were hard to read. I couldn’t tell if they were watching from concern, or from the morbid fascination with which we all watch car accidents. Samba’s eyes were half closed, and his breath was still gurgling and croaking at 60 breaths per minute.
Bori was back with the razor. Yusuf turned Samba’s head to the side and shaved off a couple square inches of hair above and behind his ear. Then he laid the elastic flat across Samba’s head, above the ear. It wasn’t an elastic like you find on broccoli at the grocery store, it was about an inch thick.
“Hold.” I nodded, glad to be helping, and then held down both sides of the elastic. Was this to keep his head in place? After a moment, a vein appeared under his scalp, in the area Yusuf shaved. Then Yusuf inserted the IV needle, pulling back the metal and leaving the plastic tubing.
Samba didn’t react at all.
In a couple of minutes Katie came into the room. She sat down beside me, and we took another set of vitals.
3:10pm – 60 breaths per minute, 120 beats per minute.
Jalloh let us hang on to his watch.
Katie updated me on the convulsions. “Anemia doesn’t cause convulsions, not according to Wikipedia. But cerebral malaria does.”
“Is that just malaria that infects the brain? I hope it’s not malaria inside the brain, behind the blood-brain barrier where we can’t get any drugs,” I know almost nothing about the blood brain barrier. That’s probably the only individual piece of information that I know about it.
“I don’t know,”
“But I’m really worried about the crap in his lungs. Is that cerebral malaria? How does malaria infect the lungs? Where did it come from?”
Katie shrugged. “I read that convulsions can cause loud breathing.”
“No, but don’t you think that loud breathing is just like panting, or like this,” I demonstrated some loud breathing, “not like gurgling mucus and crap in the lungs? I don’t believe that convulsions can magically cause a whole bunch of fluid to enter the lungs,” In my mind’s eye I imagined fluid surging out through the membranes of cells in the alveoli, some kind of inflammatory response. Something was missing. I later learned that when people convulse, they can vomit some stomach acid and then inhale both saliva and stomach acid, causing something known as ‘aspiration pneumonia.’
“I don’t know, but that’s just what it said, loud breathing.” We didn’t know, and it didn’t make sense.
So we looked at Samba. He was propped up on pillows, with his chin on his chest. His eyes were half closed and lolling from side to side like googly eyes on arts and crafts day at camp. I pinched myself a couple times to measure how much it hurt, then I pinched him. Nothing.
“He didn’t respond to the needle, Katie,”
Katie just looked deeply worried. We felt his feet. They were cold. His hands. They were cold.
Yusuf came back and strung up the first round of drugs – a cocktail of antibiotics. “Gentamycin and ampicillin,” he said. Vincent came in and pricked Samba’s finger to test his hemoglobin concentration. That sounds fancy, but all it actually involved was pricking his finger, putting a drop of blood on a piece of special litmus paper, then holding the litmus paper up to a color gradient and reading off the numbers corresponding to the color. We never found out what it was. It was probably low, given that his palms and feet were almost as white as mine.
“Why isn’t Vincent doing a malaria test?” I asked Katie.
“They did one this morning. He was positive, two plus,” two plus is a severity designation that accords with the concentration of parasite that Vincent sees under the microscope. Two plus is medium severity in an adult, but can be very dangerous for young people (Samba) or people who’ve never had malaria (Katie and I).
“Oh, man, I didn’t even know. Well, your cerebral malaria idea makes a lot of sense.”
We took more vitals.
3:20pm – 66 breaths per minute, 120 beats per minute.
Then Yusuf gave him a shot of something, perhaps adenosine? to make his heart beat faster, to help him in his oxygen distress and get some blood back into his hands and feet. It was magical. Just a minute or two later, his hands and feet were warm and his heart was racing.
At some point, I don’t remember when but it was near the beginning, we started holding his airway open. It wasn’t easy, because his muscles were so clenched. But the only thing I know about respiratory distress is that you must do everything you can to aid the person in breathing. Any extra challenge could be too much, and they’ll go unconscious or worse. In the hospital in France, they would give tracheotomies to elderly people with bad pneumonia simply to get rid of the obstacle of all the dead air in the mouth and throat. I slipped my thumbs against the sides of his jaw and pushed up, gently. His mouth refused to open. We waited, and Samba filled the room with desperate breathing.
Yusuf returned. Katie wanted to know what he was injecting.
“What is that? Yusuf, what is that?”
“Diazepam.” Yusuf uncapped a tap on the IV drip line and then injected a syringe of yellow fluid. “Dissolve half a milliliter in two milliliters.” Then he was gone again. We waited for the diazepam to slacken his muscles, so that we could possibly open his airway better, or at least get his mouth open and try and get him to cough up some of the noisy crap in his lungs and airway.
The diazepam made his eyes roll around and close in a very scary way. He looked possessed, and his muscles hardly relaxed at all.
I laid my hands on his chest. “Feel that,” I said to Katie. His entire ribcage was rumbling and vibrating with every breath he took. “You can feel the stuff, it’s all through his lungs.” Later, Yusuf told us that he thought the mucus and fluid was mainly in one of the two lungs, which makes sense because the branching from the windpipe into the lungs is not the same on both sides. When fluid – or a tube, or anything else – goes past your esophagus, it’s much more likely to go into one lung than the other. I forget which one is which, and I certainly didn’t notice that one lung was more impeded than the other.
3:32pm – 72 breaths per minute, 180 beats per minute.
His heart was racing because of the heart drug Yusuf gave him, but his breaths were also increasing. I had to change the position of my hand, because it was getting tiring leaning over him in such an awkward way. As the diazepam filtered through his system, he started moving his left leg. He would pull his knee back towards his head and then kick it out, and he’d do that two or three times then stop. A few minutes later he also started making some noises with every breath, small cries.
“Where are they? Where is everyone?” Katie wanted to know why we were so alone in the observation room.
“I don’t know,”
“Well, Yusuf’s seeing patients. But where is Bori?”
Could Bori help that much? What could we do? The staff, it seemed, were not as optimistic as Katie and I. Although, I’m not sure if I was optimistic. In my head I was running through what would happen if he stopped breathing altogether. I decided that I would begin artificial respiration, and since his mouth was clamped shut, I would do it by sealing my mouth around his nose and mouth. But beyond that, what could we do if he stopped breathing? Nothing except hope that he started again. Ambulances exist, but when I’ve asked Amhidu about emergency numbers he told me the only number was the fire department (300). I may have seen an ambulance in Freetown, but Yusuf already held such a low opinion of the pediatric department at the government hospital in Kono. If he had felt they would kill Samba an hour ago, I didn’t have faith they could revive him if he stopped breathing.
As Katie and I sat on the bed, the spectators filtered back in, and they began to have a conversation about the government hospital. They all agreed that at the government hospital they would let your ‘pikin’ die and not care in the slightest, especially if you didn’t have enough money.
The rest of the afternoon is more of a blur, and I don’t remember the vitals so clearly. I’ll put them in to give you a sense of the progression, though.
3:49 – 69 breaths per minute, 160-180 beats per minute.
Katie took more and more of the vitals. My arms and hands were slick with sweat where they were resting against Samba’s skin. Samba panted along with uneasy stability, though now his breathing was becoming more irregular. I couldn’t decide whether or not it was good if his condition remained the same for an extended period of time. I was scared that at some point he would just give up.
And then he did. He stopped breathing, just for a moment. “No way, buddy,” I clapped his ribs, and he started breathing again. Katie stared down at him, eyes wide.
“I’m going to go get Yusuf,” she said.
One of us went to get Yusuf. When he returned, Samba stopped breathing again. Yusuf looked at Samba for a moment, then placed his hand firmly across Samba’s chest and pushed and massaged. Samba sputtered back to life, and Yusuf kept massaging. Samba’s eyes opened most of the way and then closed most of the way, and then stabilized. Yusuf waited a moment and then returned to consulting. Before he left, he said, “You’re doing a good job.” Maybe, but I don’t think we knew what we were doing. I certainly didn’t. I was applying standard first aid and CPR to an infant cerebral malaria case with respiratory distress in rural Sierra Leone.
Samba stopped breathing several more times, each longer than the last. Every time, I talked to him, to comfort myself, not him. “I don’t think so, Samba,” or “No way, no way,” or “Nice try,” as my hand or Katie’s hand pushed the life back into his lungs.
Afterwards, I’m not sure whether or not he would have continued to not breathe if we hadn’t palpated his chest like that. Maybe, maybe not. It wasn’t a chance we were going to take at the time, and not one I would take now. The times on the vitals are getting more approximate in my memory.
4:10 – 84 breaths per minute, 180 beats per minute.
He was starting to hiccup. Normally I wouldn’t be worried, but he was hiccupping every third or fourth breath, and so he was effectively losing 20-25% of his oxygen intake. I tried pinching him and slapping him on the chest to surprise him out of it, but he was still unresponsive. I’m sure Katie tried something too, but I don’t remember what.
The thing is, I hadn’t eaten since 8am, and at 8am I had eaten a hamburger bun and a boiled egg. So my awareness, both at the time, and in my memory, was shrinking. When I think back to the events, to sitting on the edge of Samba’s bed, feeling his swollen and rasping chest under my hands, seeing his legs kick futilely against the malaria in his blood, it’s like the edges of the image start receding inwards, and I see less and less.
4:40 – 72 breaths per minute, 120 beats per minute.
Around now I started to think that the worst had passed. His breathing was coming down, and he wasn’t trying to stop breathing every couple of minutes. Katie even managed to get his eyes to follow her finger, sort of.
“That’s better,” she said.
“He follows your finger?” I tried it.
“No, but when I move my finger, his eyes jump to it.”
She was right. Maybe Samba wouldn’t die. But I couldn’t tell if I thought that because of real reasons, or because I didn’t want to see him die. I didn’t want to see my first death today.
5:10 – 69 breaths per minute, 120 beats per minute.
The hiccupping was gone. Katie and I moved him around a bit, trying to combine an upright position with an open airway, all while not damaging his IV connection. Back around 3:30 he had taken his first dose of quinine, so now he was just on maintenance glucose drip. Hopefully that would keep his blood pressure high, according to Yusuf. That made sense, because blood pressure is related to how much fluid volume there is in your blood. If you take a pipe and you put more water through it, the pressure increases.
At some point, Katie told me this. It might have been after, as we sat eating dinner under the stars and clouds at Uncle Ben’s.
“You know, I had to force them to get the diazepam. They weren’t going to do it. They weren’t going to get it.”
“Wow. Good job making them get it,”
“It doesn’t make sense, I wish they would have tried harder for it,”
“Yusuf did tell me that it was hard to find, that it was very rare in pharmacies in Kono. But I guess not, because Bori found it pretty fast.”
“Yeah.”
His muscles weren’t as rigid anymore, and by that I mean that we could bend them without considerable effort. His mother and father were in the room now, watching. I wondered what the father, the imam, was thinking. I wondered whether he was praying for his son, or what he said to God about him.
“The dad’s an imam,” I said, at some point.
“I saw him outside, praying,” said Katie. There was a prayer mat beside the desk. It was the only medical equipment in the clinic that we hadn’t considered using yet.
5:40pm – 60 breaths per minute, 120 beats per minute.
Eventually, we had to think about what to do that night. Samba hadn’t tried to stop breathing in well over an hour, and his breaths were slowing. He seemed to be stabilizing. My stomach was empty, and the emptiness was spreading through my whole torso and making me very spacey. I’m useless when I’m very hungry. “Katie, what do you want to do?”
“What do you mean? What do I want to do now, or what do I want to later?”
“What do you want to do for food. I’m really hungry.” And I was very spent. The combination of hunger, adrenaline, and urgency was tiring.
We showed the imam and his mother what to do, how to keep Samba upright against the pillows, how to keep his airway open, and what to do if he stopped breathing. Then we left.
Before we left, we talked to Yusuf.
“Do you think he will be okay, Yusuf?”
“I don’t know, maybe he will. I’m doubtful, doubtful. The boy is very sick, he is very sick, and we don’t have the salbutamol or the oxygen or the machine,” He was referring to a nebulizer. Salbutamol is a popular asthma drug, it was the active ingredient in inhalers for many years. It’s a steroid that dilates the bronchioles in your lungs, allowing the easier passage of air. I wasn’t sure that it would really do all that much for Samba, given that his problem seemed to be that his lungs were full of fluid and mucus. The oxygen would be good, though, and I guess would have the same effect as the salbutamol. The bottom line is, I’m not a doctor, but at that moment I wished I knew what we could do. Or that Katie knew what we could do. Or that anyone knew. Yusuf had injected some folate earlier today to deal with the ‘crepitus’ – the fluid in the lungs. It hadn’t had a noticeable effect, unless it had stopped the situation from getting worse. In France I had helped the respiratory physiotherapists aspirate the lungs of elderly people that had been prone for weeks and couldn’t clear the mucus from their lungs by coughing. If we had one of those tubes and suction apparatuses, we could have aspirated Samba’s lungs.
My head was numb, and I tuned out from Yusuf. Katie later told me that Yusuf had ended his monologue with “Maybe we can ask God.”
We left in the dark. My head, stomach, and every other part of me felt empty.
The next morning we arrived, and Samba was sleeping normally. The mucus and fluid was gone. He looked sick, felt warm, and was unhappy, but it was all very normal. He wasn’t going to die. I was happy, but I was still a little raw inside from the previous day’s effort. It was a quiet happiness, a tired one.
The dad came up to Katie and I and thanked us vigorously. “Tenki, tenki,” his eyes were large, dark, and almost watering.
“’E de get welbody,” I nodded encouragingly at the dad. He’ll get healthy.
Later I measured his breathing rate. 40 breaths per minute, much better.
Samba stayed the whole day, and the next night. He left healthy, and his parents were happy. I wonder if he’ll remember it. During the first night, after we returned to Uncle Ben’s, I looked up all the symptoms, trying to figure out if what we were doing was correct. Everything seemed to line up with cerebral malaria, and one of my previous posts is a segment of instant message conversation with my friend Veronica right after I found that cerebral malaria accorded with almost everything we saw.
But when we spoke to Bailor, he said, “That sounds like meningitis. The [clenching teeth], the convulsions. Usually when it’s cerebral malaria, the patient convulses for a little while then goes unconscious. Yusuf, he treated with antibiotics, right?”
Yes, he did...
“So if it was bacterial meningitis, then that takes care of it too. That’s why you treat like that, when you don’t know. And that’s why when you see these symptoms, first thing, you do a lumbar puncture, so that you know. But when you can’t know, you can’t do that, then you have to give antibiotics and quinine. You can do the [names of two people that I forget] signs, where you get a sharp thing, and you trace along the palm and around, and if the hand flips up, it’s positive.”
Positive for what? Bailor didn’t say. Why didn’t we phone Bailor? I don’t remember. I’m glad that Samba lived.
Subscribe to:
Posts (Atom)