Sandals in Sierra Leone

Home again

2009-08-22T09:53:00.002-04:00

So I'm back in North America, as of about a week ago, and now I wanted to write a bit about the future of this blog. For those of you that are new, there are many different stories about many different aspects of my experience in Sierra Leone. I hope it can serve as a resource for people who are considering interning with GAF/NOW, or for anyone interested in going to Sierra Leone, or for anyone curious about what volunteering in a country similar to Sierra Leone might be like. Beyond that, perhaps it's a vanity, but I hope that some of the stories are interesting and thought-provoking in their own right. So if you are new, please take a look around, and don't be confined to chronological or reverse-chronological order. And if you think you know someone who might find the blog interesting, let them know. If you have any questions or comments for me, an email to cyarnell(at)princeton.edu is a good way to get in touch. Cheers, Chris.

Lost Child, Beach, Metaphor

2009-08-16T23:03:00.000-04:00

The clinic isn’t very spacious. There is a table in the corner of the patient registration area, and that’s where Katie and I set up our laptops when we need to use them. Lately we’d been using them often, because of the survey data analysis and the business plan second draft.
We usually go to the clinic with full batteries and then work until one of our computers runs out of power. Then we turn on the generator until the batteries are charged, turn off the generator and work on battery, turn on the generator to charge... When the generator is on it’s easier to work because the screen brightness doesn’t matter. But to charge our laptops we need about two hours of generator time, and that costs about 7500 Leones. So we often turn down the brightness of our screens to conserve battery power and use less fuel.
The result is that when we work on our laptops, there is usually a large crowd of kaleidoscopically clad mothers, sometimes fathers, and always children sitting on benches, sleeping on benches, standing silently beside us, or arguing with the registration desk. The children sometimes fight and sometimes cry, although the sickest ones are eerily quiet. And our screens are so dim that we can hardly read anything; we’re typing half blind.
Sometimes I wonder if I turn down my screen brightness so much as a subconscious punishment for working on a laptop while there are so many sick children in the room. There’s a definite level of abstraction to the help that our work on the survey and the business plan provides, and a definite sense of immediacy in the fevered brows of the malaria victims. I can’t help but think about how the mothers and fathers perceive us, typing furiously on fancy machines with our backs turned to the waiting room.
It was our last Tuesday in the clinic. I was working on data analysis, and that means I was squinting at computer code trying to write a program that would print out and save bar graphs with titles and p-values of all 260 different parts of questions on the survey. Katie was editing the second draft of the business plan, which means she was wading through a mess of “Track Changes” comments in a Word document. Bori was manning the registration desk, with help from Mohamed T. Koroma, one of our surveyors who had returned to volunteer.
Then, I heard a woman crying softly. She was down the hall, but moving towards us. She walked past, and then out the door.
“Katie, what’s going on?”
“I don’t know,”
“The women never cry. The kids cry, but the mothers never do.” My laptop felt treacherous, like it was tricking me out of helping where help was really needed. Katie turned to Bori, who was surrounded by three other mothers wearing babies on their backs. One of them was trying unsuccessfully to get her child to stand on the scale.
“Bori, what’s wrong? What’s happening?”
“I don’t know,” said Bori, without looking away from the registration form.
We kept working. I hit another frustrating bug in the program, which should have been simple, and spent thirty more minutes squinting through the code. Then Bailor emerged. He looked tired.
“Bailor,” we clasped hands. “How are you? Did you sleep?”
“Fine. Yeah, yeah, I slept.” He was holding a chart and a stethoscope. “Do you have a pen?”
“Yeah,” I reached for one, but he had already found one.
“We lost a child today,” he announced, while looking down at the desk.
“Oh,” I said, just to say something.
“What happened?” asked Katie.
“Well, I don’t know. I was not treating the child, Yusuf saw this child, and probably it was just too late, probably he came to us too late. I am looking at the charts now.” He walked away.
Katie and I turned back to our laptops, but I just stared at it for a few minutes. I felt the laptops had betrayed us.

Later that night I was very cold. I gathered up all the blankets around me as I lay in bed, under the white gauze of the mosquito net. My teeth were chattering, and I was shivering, but I had no idea why. It was the kind of cold that tingles painfully all down your back and the backs of your arms. So I was curled up in a ball under my blankets.
Slowly, I felt the heat from my core radiate outwards, and my shivering calmed down.
I thought about the child that we “lost.” Bailor’s instinct was probably right; he probably had come to the clinic too late. But it was frustrating, because he probably didn’t have a tough problem. Maybe malaria, complicated by malnutrition. Maybe meningitis; scary but treatable with an intense course of intravenous antibiotics. Maybe just a diarrhea that dehydrated him to death. Maybe a respiratory infection that deprived him of too much oxygen. Bailor never told us, and we never asked. I’m not sure why not.
The bed at Uncle Ben’s is bowl shaped. I was curled up in the center of the bowl. The generator hummed impersonally in the background. Eventually I stretched out diagonally, so that I fit on the bed, and my thoughts dissolved from the lost child into sleep.

On Saturday before we left, Katie, Lois and I stayed at No. 2 River, a beach place south of Freetown. The beaches south of Freetown have easily the smallest ratio of development to beauty that I have ever seen. The sand is white and fine, the surf is enthusiastic, the water isn’t cold. Behind the beaches the land rises quickly into multiple small hills, each covered in a thick layer of jungle. Old growth deciduous trees mix with thick undergrowth and palm trees. However, the road to get to No. 2 River requires at least half an hour of potholes. At some points we were driving through ponds at least a foot deep. It was enough to make Ali, the driver, chuckle and announce “Welcome to Africa.”
It’s the rainy season, so it poured the entire night. It was also very windy. When I woke up on Sunday morning, it was still raining. But I was determined to go for a beachwalk. So I pulled on my rainjacket and walked out.
The sky was grey, the water was grey, and the beach was grey. The foam and spray of the leftover waves from the wind were grey. The tops of the nearby hills were hidden by misty clouds. Even the palm trees leaning over the beach looked grey. It was beautiful.
First I walked north. There wasn’t much beach in that direction. There was another “beach house” as Sierra Leoneans call them, and a few rocks that created more interesting spray, but that was all. So I strolled back towards the south. I was walking with my feet in the surf, so a couple of times I got soaked almost to my waist. Where the surf crashed into the beach it was very sloped, so there were fine lines between ankle deep, knee deep, and thigh deep.
At the end of the beach to the south was the mouth of a river, presumably river No. 2. There was two hundred yards of beach separating a freshwater lagoon from the ocean, and it was at the far end of this little beach peninsula that the river escaped to the ocean. I didn’t know whether the tide was going or coming, but as I stood at the river mouth, the water was flowing both ways. The water from the lagoon was warmer, but the water from the ocean was colder, and together they swirled around my feet. Sometimes it was warm, sometimes cool.
The surf was crashing just outside of the mouth of the river, and so every now and then a foamy whitecap would roll into the lagoon. But then a small succession of tiny waves would ricochet back out of the lagoon into the ocean. They would crash, if six inch waves can be said to crash, at the shallowest point of the river mouth.
Most of the time during the walk I was just watching the beach and the ocean and the jungle all around me. But sometimes I thought about how footprints in the sand are a perennial metaphor for impermanence, and how a drop in the ocean is such a common metaphor for not having enough influence or power to affect real change. Impermanence and inability to affect real change are deep and abiding concerns of Lois, Katie and me. I would hazard that most people worry about them to some degree. But the nature of our summers has made us think about them more than usual.
As far as the impermanence and effectiveness of our efforts this summer, time will tell. The survey itself will not be too useful, but the lessons learned by the interns and the organization during the survey may prove very valuable. The health education had mixed efficacy, but perhaps both the interns and organization have learned lessons that will benefit many in the Kono District and elsewhere. And the health education itself is part of a broader fabric of education wherein repetition is vital. The business plan for the palm oil plantation and mill is ambitious, and in rational terms the project is on sure footing. But the irrational elements of Sierra Leone are difficult to control in advance. If all goes according to plan, the revenue contributions of the palm oil plantation and mill will probably be the most lasting contribution of our summer in Sierra Leone. And if, despite our best efforts, the plan becomes irrelevant... well, we’ll have to make a new one.
But the best metaphor for our efforts this summer is not footprints, not drops, and not backflows from the lagoon. It’s the waves from the ocean. The contributions Katie, Lois and I made and tried to make this summer were the first of many for the three of us. I’m sure that our future efforts with both GAF/NOW and other organizations will have moments of success and futility. There will be lost children, treacherous laptops, and miraculous recoveries. Perhaps more beaches, more revolting toilets, and more rice. More IV changing by flashlight, and more treatment by desperate hope, attention, and prayer mats; there will be more moments of terrifying ignorance against the spectre of death. There will be thoughtful plans, and woefully flawed plans. More mistakes, and more painful lessons. More walks under the African sun, and more crowded “Africa-style” road trips. More potholes and more corruption, more generosity and more eagerness to learn. More red earth, and more blue sky.
So let this be the first wave, if I can carry the metaphor a bit. Here’s hoping that we can contribute more waves in the future, both abroad and at home, after more education of both the academic and nonacademic kind.

Local Tax! Taxtaxtax!

2009-08-07T05:07:00.000-04:00

Local Tax

There was a rope across the road. It was actually a few black ropes tied together, with small paper tags hanging from it in random places. There were people clustered around the sides of the rope, and two or three police officers in tan-colored uniforms.
“Hm. Local tax,” I observed, as Katie and I walked towards the rope. It was across the intersection of the Kainkordu and Post Office roads, the main intersection in Koidu Town.
Local tax is relatively new in Sierra Leone. It’s a flat tax of 5000 Le (~1.50 USD) that all residents of Sierra Leone must pay. When you pay, you get a receipt that looks about as official as a receipt from a garage sale, and in order to pass the checkpoints that are (as best I can tell) randomly scattered in time and space throughout Sierra Leone, you need to present your receipt.
It wasn’t our first encounter with the local tax. We’d passed through this same checkpoint the day before, and been allowed to pass without too much trouble.
“Tax, taxtaxtaxtax!” A bunch of men gathered around the edge of the rope looked at us with interest and each started calling out the word tax repeatedly in fast succession. None of them were in a uniform of any kind. However, as we approached and ignored them, the crowd thinned down to one man, who apparently was the man in charge of this rope.
“Hello sir. Local tax!” He said. He was not wearing a uniform either.
“We no faut pay. We no local.” Katie explained.
“No, everyone pay. Local tax, taxtax!”
“No, we no faut pay, we no de reside na Sierra Leone,” Katie continued.
“No, pay, pay local tax. Everyone must pay.” He shook his head definitively. I decided to use a Krio-style debate tactic – raise the volume.
“We no de pay becos we no local. A de reside na Canada, e’ de reside na America, we no de pay. We no de live ya.” Ya means here.
“But you are here right now!”
“Yes, but we nota from ya.”
“But you are not leaving today,”
“That doesn’t matter. We are not residents of Sierra Leone.” I switched to English, because he was using English, and because it’s more intimidating.
“Everyone must pay.”
After our first run-in with local tax the day before, we had talked to Bailor. He had said, “Those guys! They make us look stupid. They don’t know the rules, they don’t know that you pay visas for enter the country, they look like they have no idea what they are doing. I wish I could have talked to them.” We wished that too. It’s really fun to watch Bailor yell at someone who is being ignorant or corrupt.
I remembered something Amhidu told me about officials in Sierra Leone.
“I want to talk to your boss. Take me to your boss.”
“No, I am my own boss, you talk to me.”
“No, let me talk to your boss.” He shook his head. “Do you want to talk to my boss?”
“Yes! Phone him!”
Well, I didn’t actually want to wait for Bailor. We were walking to the clinic.
“Let me talk to your boss or we will leave.”
“Then I will arrest you.” Katie jumped in with an interesting fact from Allan.
“It’s illegal to arrest Americans in Sierra Leone!” It’s nice to be invincible. Unfortunately the man didn’t respond. He also stopped looking at us, so we decided to go. We stepped over the ratty rope and into the intersection, Katie leading the way.
“Arrest them!” The man yelled. I looked back at him, curious. There was a female police officer beside him. She immediately dropped her gaze to the ground, tiptoed around me, and tugged on Katie’s shirt with two fingers. The most feeble arrest attempt ever.
Another male police officer came striding over, and he seemed more in charge. By now we were in the middle of the intersection. He looked at me, and I started explaining.
“We do not need to pay local tax because we are not local. We do not reside in Sierra Leone.”
The police officer didn’t say much, but he also didn’t have the chance, because suddenly we were in the middle of a huge crowd of people, all shouting in Krio. The police officer started listening to another man, and nobody seemed to be paying us any attention. Katie and I exchanged an amused and puzzled glance. An official had commanded our arrest, and instead we were standing in the middle of a huge crowd of people yelling in Krio, none of whom were actually talking to us.
The din subsided for a moment, and an older man stepped towards us. “Please, I know these people,” he said to the police officer. We didn’t know the man. “They work in the clinic in Dorma, they are very good people, here to help, this is all a misunderstanding.” His tone was placating and sycophantic, and kind of annoyed me. It sounded like he wanted to smooth things over because we were special, not because the rules said we were right. He turned to us, “So, you must have some identification, some papers...?”
Well, we had only our National Organization for Welbody ID cards, and I didn’t think Katie had that. Furthermore, that was not how I wanted to work this out, nor did it seem that Katie wanted to settle for ‘special treatment.’
“Thank you sir, I appreciate your help, but we don’t pay local tax because we are not local, not because we are special. Tenki.”
The crowd dissolved back into a cacophony of Krio.
I pulled on the policeman’s shoulder, and Katie said, “Don’t do that!” which was good advice. But I wanted to tell him that we pay about fifty times the local tax for our visas to enter the country.
In a moment, it didn’t matter. The roar of Krio didn’t recede one bit, but the policeman turned to us and nodded that we could go. So we left. The crowd stayed put, yelling and arguing in Krio. Katie and I were bouncing with adrenaline.
“One man said ‘White or black, all must pay!’” Katie told me. That’s frustrating on a couple of levels. On the other hand, it’s nice to be invincible.
Two minutes later we passed Christopher, a Sierra Leonean friend from conducting the surveys. He called out to us “Hey! Christopher, Katie! I hear you have some trouble with the tax collectors,”
We stopped and smiled. “Wow, news travels fast,” said Katie. In the distance we could still hear the dull roar of the crowd yelling in Krio.

Pharmacy

2009-08-07T05:05:00.000-04:00

“This, three times per day. You de take’em 8 o’clock, 2 o’clock, 8 o’clock, okay?”
Bailor waved his arms, bounced his head, and generally spoke with his entire body. The gaunt old man in front of him nodded. Bailor looked around and grabbed another small plastic bag full of white and yellow pills.
“Okay. This one, this white one and yellow one. You de take’em two-two, two tem per day. You de take ‘em 8 o’clock, 8 o’clock, okay? One white, and one yellow, four tablet per day.”
“Yessir,” The old man was wearing a white brimless hat, like many Muslims in the area do.
I was counting pills with a spoon. Bailor had asked me to count out thirty pills of ferrous sulphate, multivitamin, folic acid, and something else that I’ve forgotten. The way we do it is by emptying out a bunch of pills onto a piece of paper or cardboard. Then we separate out thirty pills into easily countable piles, say, six piles of five, then we sweep the rest back into the bag. The paper gets scooped up carefully and then gently creased to guide the pills into the small plastic bag.
Bailor held up a packet of oral rehydration salts for the same man.
“Okay, now this one, you faut us clean water. You de get satchet water, you de use’em, and wey you no de get satchet water, you boil water, boil insigh pot and den you drink ‘e.”
I was sitting in the lone chair in the pharmacy, pulled up to a small counter. The walls are covered in shelves, and the counter is just an extension of these shelves. All around the counter were small containers of the most commonly prescribed medications – praziquantel for schistosomiasis, doxycycline for malaria and other infections, various analgesics, generic Tylenol, anti-hypertension drugs like nifodipine, multivitamins, and many other small unmarked pill bottles. A bit higher on the shelf, in front and back to the left, were the packages and boxes of medication. I could see the box of quinine that Bori had broken open to help Samba (earlier post).
“Okay Pa, so how many tem per day you de take dis one?” Bailor held up the yellow and white pills.
The old man narrowed his eyes, opened his mouth, shut his mouth, widened his eyes, and shook his head.
“Two-two, two tem per day. One white, one yellow. Okay?” Bailor looked at the younger man accompanying the patient, “You de understand? You de help ‘em?” The younger man nodded. He was also wearing an elegant brimless hat above a matching colorful shirt and pants.
The back of the pharmacy had a small window, but it was tinted so that the whole room was slightly shadowed, even at 2 in the afternoon. The shadows didn’t hide the boxes in which the medicines came, however. They were apple boxes – ‘Mountain grown from Virgina,’ ‘Golden Delicious’ with an unmistakably cracked Liberty Bell just below. There were also tomato boxes – ‘Sunripe Bell Roma Tomatoes.’
Above the stacked fruit and tomato boxes were the plastic bottles of glucose maintenance and saline solution. They looked like water bottles, maybe water bottles from a trendy new company called ‘D5.’
Bailor bent over pulled the next file from the pile of folders. “Okay, now we need,” he paused and grabbed a rectangle of individually wrapped pills, “we need fifteen of these, cut in half.” He handed me nail scissors, then scribbled on a small plastic bag and pushed it towards me.
I counted out fifteen pills and started cutting them in half, wondering whether it was worth trying to save the dust that fell to the paper after every cut.

Edits and Interesting Posts on Katie's Blog

2009-08-01T22:18:00.002-04:00

After speaking with a reader or two, I've added some edits to the two entries on transparency and trust. If you have read them already, please glance at the edits - I tried to make it clearer why what NOW is doing is special.

Katie has a number of interesting new posts, including one that puts into words one of core principles we are learning: how to find balance in various situations in Sierra Leone. Please take a look at perambulating.wordpress.com.

We are entering our last few days in Kono - on Thursday we return to Freetown, and then the following Tuesday we fly back to North America.

Data Analysis Update

2009-07-30T02:56:00.003-04:00

So, Katie and I have finished entering survey data and are now analyzing it.

Our knowledge of statistics is a bit patchy, especially in the classical statistics domain. On the other hand, I know a fair bit about how to quantify information and manipulate probability distributions. That means that we're using pretty rigorous math to find correlations in our decidedly un-rigorous data.

Amhidu is using some of the survey data for his Fourah Bay College thesis. We sent him some of our preliminary results. For those information theory junkies out there (are there any?) , I sent Amhidu a color plot of the mutual information between the answers to every question, and tried to explain it to him. My explanation wasn't long, though, so it's probably useless to him. Katie, on the other hand, generated a bunch of highly useful bar graphs. Much more practical.

I just posted a two-part entry that deals with transparency, honesty, and their converses. It's a few different stories gathered over the past few weeks. Whenever people are implicated I replaced the names with a single letter. At the start of the first one and the end of the second one there are short framing paragraphs, but otherwise they're mostly narrative. Enjoy!

Cheers, Chris.

Trust and Transparency II

2009-07-30T02:50:00.004-04:00

EDIT, Aug 1: This post is the second in a two-part series. Because of the delicate nature of trust and transparency, I recommend that you read the first part before the second one. If you insist on beginning with this post, please read it while keeping in mind that 1) Corruption is endemic in government, industry and non-governmental work in Sierra Leone, 2) All organizations have a choice with corruption: tolerate and ignore it, or actively discourage it through policies and systems, root it out, and enforce consequences. 3) NOW has chosen the second pathway, despite the fact it makes day-to-day business much more difficult.

In my mind, it is much better to acknowledge corruption exists and occurs and then outline real strategies for its reduction and consequences for its occurrence than to erect fake policies to appease donors and then ignore it. However, donor attitudes towards corruption shape the organizational responses as well. Think of it analogous to a personal problem in a close friend, say alcoholism. The first step to recovery for the friend is acknowledging the problem. If, however, you respond by getting very angry, then your friend may decide that in the future it is best to simply hide the problem from you. It is much better to support your friend in coming up with and implementing plans for improvement. Similarly, it is much better to encourage organizations like NOW, which have an active and powerful drive to eliminate corruption, than to encourage large (unnamed) organizations, who often completely ignore the corruption present at lower levels, and perhaps higher levels as well. With that in mind, please enjoy the following stories. END EDIT.

“Can I see, V.?”
“Yes.” V. moved aside from the microscope, and I peered through the lenses. I could see purple-stained white blood cells, but no malaria parasite. The parasite was smaller, maybe one one-hundredth the size of the white blood cells. “No malaria.”
“Oh.”
I’d been hoping it was malaria, a little bit. While we were waiting for the slide to dry I had looked through the patient files, and this particular one was a four year old boy. He had a fever, and he had been vomiting, both textbook signs of malaria.
“But the WBC count is elevated, maybe.” An elevated number of white blood cells is an indicator of infection.
“Is there a way of letting Yusuf know that?”
V. laughed with a tight-lipped smile, and said nothing. I tried again.
“How do you let Yusuf know when you see something like that, something that isn’t a direct result of one of your tests?”
“Well, sometimes, people don’t like to know things they didn’t ask for,” V.’s answer seemed cryptic for a moment, then I caught on. But I pretended that I didn’t know anything.
“What do you mean? You couldn’t tell him, and then maybe he would order a white blood cell count?”
“No, even if it helps the patient, sometimes people don’t want to know tests that haven’t been ordered.” V. put uncharacteristically melodramatic meaning into his words. I left it at that.
Later, I told Katie about the exchange.
“I think Bailor said that sometimes they were undercharging the patients, in the cabal. So then, maybe V.’s view that ‘people don’t want to hear test results they didn’t ask for’ is actually a kind of excuse for the corruption.”
“Well, I don’t know,” Katie wasn’t convinced, “I don’t remember Bailor saying that. I don’t think he did say that they charged less,” I wasn’t sure either, especially not if Katie didn’t remember.
“Or maybe, I mean, it’s not that possible, but what if some of the members of the cabal were using the justification that by undercharging the patients, hiding tests, pocketing the difference, and reporting the results, they were giving more humanitarian medicine at a better price, and maybe that’s how they pressured someone into doing it, or how they rationalized it themselves...”
“It’s not the simplest answer,” Katie elaborated, but in essence she wasn’t convinced. Neither was I. But V. had made me think a bit, about the different layers and perspectives on corruption.

“Amhidu, why do you always go to the garage?” Amhidu had been spending a lot of time at the garage, and missing out on substantial portions of the work on the business plan. It was his own loss, but it was also Sierra Leone and NOW’s loss, because there was much to learn, and he could be learning it beside Katie and me.
“I go, because they will not work if I do not go,”
“You don’t go for any other reason?” I thought Amhidu was going because, on some level, he preferred to hang out with the guys at the garage than work on the business plan with us.
“No,” We were sitting on the bed in Allan’s room at the clinic. Amhidu was lying back, with his hands behind his head.
“Amhidu, I think that sometimes you go because you want to hang out with the guys there.”
“No,” his tone was neutral, but I was being less than diplomatic.
“It’s a shame, though! There’s so much for you to learn from the business plan, and from doing it with Katie and me, and I don’t want you to miss it. It’s also very helpful to have you here when we’re working on it.”
Amhidu was quiet, and breathed in deeply. “Let me say, if I do not go to the garage, Sahr B. and E. will be corrupt.” Sahr B.? The liaison to the amputee community? What?
“What?”
“When we went to Freetown, I left them money to buy eight gallons of fuel per day, for the tractor. They told me they needed eight gallons per day, so I left them money for that.”
“Okay...”
“But when I came back, I went with them to the fueling station. And I asked the man how much fuel they usually get. He says eight gallons. Then I told the man to fill it, to fill the tractor. When it was full, it held 7.2 gallons. So I asked Sahr B., where is your reserve container? And he held up a container that was one liter. So I said no, tell me the truth, you have not been filling eight gallons each time. But Sahr B., he cried that I did not trust him, and that because of that he will no longer do anything I ask him,” Amhidu had sat up during his monologue, but his tone had stayed calm.
“Wait, so Sahr B. won’t do anything you ask now?”
“He said, that since I do not trust him, that I should do all the things I want him to do, because I do not trust him to do them.”
I shook my head. “So Sahr B. won’t work for you. Did you tell Bailor?”
“I did, and I suggested that he tell Sahr B. that I was wrong, and that he is coming on Friday and he will sort everything out then. That way Sahr B. will continue to work, until Friday.” My eyebrows rose in appreciation of the Amhidu’s wily decision. Without Sahr B.’s help, it would have been difficult to do much on the farm for the next three days. With planting season drawing to a close, that time was precious.
“So that’s what Bailor told him?”
“Yeah,”
“What about E.? Where is he?” E. is the farm manager. Sahr B. has no official position with the farm. He has some farming expertise, however, and I had thought that was why he was always around. Perhaps not only that, though.
“He is there, he is there. E., I don’t know,” Amhidu shook his head as well, “he is not in charge. I think, maybe that Sahr B. is making him corrupt, and without Sahr B., he will not be corrupt.” I shook my head again.
“E. seems smart, and he tries hard, for example when we were asking him questions, but I just can’t see him being assertive, and he doesn’t seem to make any decisions,”
Amhidu had a more relevant contribution. “I think, the problem is, in the amputee organization, Sahr B. is E.’s boss. E. is secretary, Sahr B. is chair. So I think E. is still used to taking instructions from Sahr B..”
“Can we just tell Sahr B. to go away, that it’s not his farm?”
“Yes, we will tell him that,”
“Maybe we should find some job to distract him, so he doesn’t get hard feelings,” Amhidu laughed.
“Yeah, maybe,”
Katie came in, and we updated her. She picked up a piece of paper from the corner of the room. “Is this the record?” It was an A4 page, with dates and two columns under each date. In one column was the item, in the other column was the expense. Receipts don’t exist in Sierra Leone. Some of the items on the list stuck out.
“Breakdown, 20 000? What does that mean?” Katie was in disbelief.
“Or how about ‘tractor bolts, 20 000.’ What are the chances that cost exactly the same as the breakdown?” The two items were on different days. We scanned the list some more. “Gear oil, at 35 000 leones per gallon? That’s suspicious. How much gear oil does the tractor need, Amhidu?”
“When we first got the tractor working, the mechanic he said it needed one gallon. But then it leaked, and it was gone, and he said that now we need maybe two gallons.”
“But they fixed the leak?”
“Yeah, now, it is not leaking.”
“There’s six gallons of gear oil here, two on one day, and four on another.” Katie was suspicious. So was I. It seemed like none of these numbers could be trusted. And who could be trusted within NOW? Sahr B. was the amputee liaison. If he couldn’t be trusted, what did that say about the amputee organization? And if so many people were corrupt, how could we run a transparent, honest NGO?
“Amhidu, who do you trust in the organization, in NOW?” Amhidu didn’t seem surprised by the question.
“In Kono, I trust only Yusuf. Only Yusuf,” he added emphasis. “In Masiaka, I trust all of them, Amadu, Sahr James, Andrew, they are all good.”
“And Ali?” Ali was the driver from Masiaka. Amhidu laughed.
“Yes, Ali.” Ali was smiley, spacey, and not a great driver. But he was a simple, nice guy.
It’s a big problem. At the end of the summer, Amhidu has to return to Freetown. He can’t stay on in Kono in his current job of intern manager / honest employee. Many of the problems that NOW faces are financial, but the problem of honest staff members is perhaps harder to solve. Corruption is endemic, accepted, and uncontroversial, to the extent where Sahr B. has no qualms cheating a few thousand leones from the NGO doing the most for the amputee community, and to the extent where the only gossip-worthy part of the whole cabal corruption incident was that M. was actually fired.

One day, Katie and I were walking home, and it started to pour. Instead of just getting soaked like we usually do, we decided to duck into the Kono Bookshop. Our American friend Bremen recommended it to us.
We were immediately confronted with two long tables full of men yelling in Krio. After a moment of standing awkwardly, we sat down on the edge of a bench.
So, it’s not a bookshop. It’s a tea shop. I think these guys gather there every day, to yell in Krio about philosophy, politics, anything. At the back there was a dimly lit bar, but no one was actually drinking any tea. I figured I would wait until someone demanded that I make a purchase.
Katie and I watched the debate for a minute or two. Then I ventured in.
“What are you guys debating?”
The man across from me looked startled for a moment, then he answered. “We are talking about diamonds. About how the companies can take diamonds and give nothing back to the country. What do you think about it? What can we do?”
Whoa, talk about putting me on the spot. “Well, what have you guys already discussed?”
In general the discussion was very chaotic, but all of what follows happened at some point.
“Well, first, the diamonds are all inspected by only three people, a government representative, a chieftain representative, and the company representative. They all go into the vault, the vault where the diamonds are, and then they value them.”
“Nobody else goes in with them?” Katie was incredulous.
“No.” Other men were jumping in.
“And maybe they go with something in their pocket, some 20 000 dollars, and when they see a very good diamond, the company representative gives the chieftain and government representatives some 20 000 dollars each, and then he puts the good diamond in his pocket, and nobody knows,”
There was a chorus of incomprehensible noise, that I took to be agreement. Some people at the end of the table took up the debate again in Krio.
“But how do the diamonds leave the country?” Katie asked.
There was more yelling amongst themselves. One man claimed to understand what Katie was asking.
“No, she want for know, why, in the airport, we just let the diamonds fly away, why we don’t have better security,” I smiled. I imagine that illegal diamonds from the Kono District did not leave by way of Lungi airport. Neighboring Liberia has no natural diamond reserves, yet has been a diamond exporter for years.
Some more loud Krio discussion quieted this man, then the first man answered. “All the diamonds must pass by the government valuator, and he certifies how much they are worth. But he is paid very little, perhaps 2000 dollars a year, and the diamonds are worth very much. So the company must give three percent of the diamond’s value, right?”
“Right,” Katie egged him on.
“So if they have a diamond they know is worth 7 million dollars, they will say, here, let us give you fifty thousand dollars, and then you just say the diamond is worth only 1 million dollars. And he does it, of course,” We later learned that this is the real way that companies scam Sierra Leone, because by going through the government valuator the diamonds retain their legitimacy. That increases their value.
“Well, is there really only one government valuator? What if there were more valuators?” Katie had to shout her question to be heard. The men raised their eyebrows in surprise.
“Hey-hey! Of course, of course!” They were momentarily jubilant. Katie and I looked at each other, puzzled. Had they really not thought of that?

“So now, UNICEF is giving us the Kono District contract instead of the Portloko contract, so all those guys in Masiaka are going to be moving to Kono.”
We were having an impromptu meeting with Bailor before he drove back to Freetown. It was on the porch of Uncle Bens, and we were being both illuminated and serenaded by the efforts of the generator. The topics Katie and I had wanted to talk about were the peer education plan and the more general problem of leadership development within the National Organization for Welbody. Most of all, we wanted to talk about the necessary and desirable characteristics of the unhired and unnamed leader of the peer education project.
I looked at Katie, and she looked at me. Amhidu was across the table, and he looked bored. This was a surprise. I spoke.
“Wait, they’re all coming to Kono?”
“Yeah, in one, maybe two weeks. Sahr James, Andrew, Amadu. The plan is, we will convert Allan’s room into cubicles, to have two offices there, and then maybe we can have one office out where your desk is, that can be another office.”
Katie furrowed her brow, trying to think about how so many offices would fit into such little space. Bailor continued.
“So I’m thinking, that maybe Amadu will take M.’s job, because Amadu, he is very honest. All those guys in Masiaka, they are honest. So if Amadu is in charge of the money, there is no way that C. or V. or anybody can be corrupt.”
“Yeah, yeah,” Katie and I nodded and murmured encouragingly.
“And then, UNICEF has given us money to hire ten new staff, two managers and eight workers for malnutrition field work. So, Sahr James and Andrew, they will be the managers, and then we will use the money that we would have used to pay them to hire two more people, one for the peer education,”
“Fine,” Sierra Leoneans say ‘fine’ to mean ‘okay’ or ‘sounds great.’ I’ve picked up the habit.
“Okay, and for C., I was thinking we will switch her over to the malnutrition project, so she is not handling money, because there, she doesn’t have chance to be corrupt,”
“Right, and she’s a nurse?”
“Yes. And V., well, hiring a new lab tech is not so easy, so he will stay in the lab. But with C. in the field and M. gone, the cabal is broken. And Amadu and Sahr James and Andrew and Yusuf, they are all honest, so maybe V. will go along with it. It’s like this,”
Bailor pulled his ‘Battery’ energy drink closer to him and smiled at us in a conspiratorial way. He straightened his fingers and held his hand above the drink as if his hand were balancing on the can.
“So this side is corrupt, and this side is honest.” He motioned to the two directions his hand could fall, if it were actually balancing. “Bori, he was like here,” he tilted his hand over until it was almost toppling to the corrupt side, “but because of Yusuf, he’s here,” he rotated it back so that it was perched precariously over the honest side. “V. is maybe here,” he held his hand lower on the corrupt side, “but it won’t matter if he’s the only one, when Amadu controls the money. And Yusuf, you know, he’s like here,” Bailor put his hand on the table on the honest side.
“So we’ll get a critical mass of honesty going here in Kono, so that any new employees will just be pulled along,”
Bailor’s eyes were smiling and wide. “Exactly.”

“You know what I did, when we were just building the clinic?” This was later in the meeting, in the aftermath of Bailor unveiling his grand new plan.
“What?”
“The guy, the guy I hired out in Kono, he was corrupt. I would tell him to buy 100 bags of cement, he would buy twenty. I would send him money for six trips of sand, he would get three, maybe two.”
“That sucks,”
“So I phoned Sasseko, and I asked Sasseko how many bags of cement, how many bricks they made. And Sasseko said he didn’t know, maybe thirty. So then I came, and I’m friends with the building supplies store, so I came inside, and I talked to the owner. Then I picked out the hundred bags, and I signed them all with a marker. Then I said to Sasseko, ‘Sasseko, at the end of the month, I want to see all these empty bags, all these signed bags.’ And then the end of the month came, and there were only thirty, and so I had proof, I fired him.”
“That’s wily,” I was impressed.
“And you know, he had bought a generator and a fridge and started up a shop, selling cold drinks,”
“Ooh,” Katie and I winced.

These stories capture some of the ways that Bailor and NOW detect and counteract corruption, as well as just some of the ways in which corruption can occur. There is another dimension to corruption in NGO work in Sierra Leone, one that is (fortunately) not explored here. That is corruption in the awarding of grants. Large agencies such as the government or UNICEF (although I point no fingers here) often have competitive grant processes and it can be difficult to gain the financial support of the agency if you do not provide bribes, appreciations, or kickbacks to the right people. NOW never does this, and so sometimes we run into problems. Katie and I don’t have direct experience with them, however, and they are more delicate, so a discussion of those problems will have to wait.

Trust and transparency I

2009-07-30T02:48:00.004-04:00

Bailor and the National Organization for Welbody are committed to building a transparent, honest organization. It is not always easy. EDIT, Aug 1: Some reader reactions have reminded me that I need to provide more background on this issue. Corruption is endemic in Sierra Leone, at both low, medium and high levels. Corruption is endemic in industry and in non governmental organizations (NGO). Few people make a real effort to reduce corruption on the individual level, and while many organizations have anticorruption policies, few such policies are enforced. As an NGO, there are two options regarding corruption: tolerate its existence and ignore it, or actively discourage and punish it. Large unnamed NGO's, the government, and most other organizations choose the former path, but NOW has chosen the second option. It is a difficult choice that makes the day-to-day operations of the clinic more difficult, but in the long run it is both admirable and necessary. Sierra Leone needs model transparent organizations.

Given that corruption is so endemic, I put my faith in the organizations that acknowledge this fact and show a track record of transparency and rooting out corruption. You cannot always stop corruption before it occurs, but you can always mitigate its damage, punish the offenders, and recalibrate the organization to avoid it happening again. END EDIT.

The following are a series of narratives that might give you some insight into the problem – and the solutions that Bailor and NOW put into action.

We piled into the car, coconut-flavored sugar cookies and water bottles in hand. There were four of us in the back, so we had to fit in around each other. In Sierra Leone (and Africa in general, I’ve been told), the general rule is if the person can possibly get in the car, then they’re in the car, even if the trip is ten hours long. Our trip was ten hours long.
“Things were tense this morning at the clinic.” Allan told us. It didn’t seem particularly important, just a general update. Katie and I responded somehow, but it was the conversational equivalent of a shrug.
We bounced our way out of town. Bailor was in the front passenger seat, and Ali in the driver’s seat. I don’t remember how, but somewhere amidst the potholes, exhaust, and Bailor’s cigarette smoke, we asked him why things were tense at the clinic that morning.
“Well, we discovered that some of the staff have been engaging in corruption.”
What? The clinic staff? Katie, Allan, and I were silent. The vehicle rattled through a large bump, and my head awkwardly bounced against the ceiling.
“What...what kind of corruption? If you don’t want to tell us, that’s okay,” I added the last part quickly. But Bailor didn’t mind telling us.
“Well, there is a cabal. Three of the staff conspired.” Three? There were only five. “It was the lab, the pharmacy, and the front desk.” V., C., and M., respectively. C. was smart, V. was quiet and weird, but M. was kind of slow. He must have been pulled in by the other two. “You see, what they were doing, is Yusuf would order tests, would order lab tests. Then they would charge the patient 10, 12 thousand leones, like the tests cost, but only mark down some of the tests on the sheet. But they would do all of the tests, so all of the results would be written on the receipt. So the patient was still getting care, still getting the right care.”
“Oh, I get it.” Allan nodded. I didn’t get it.
“Wait, how did it work?” Allan opened his mouth to explain, but Bailor was all over it.
“No, so, the consulting room [Yusuf] would order all the tests. And when the chart comes back from the lab, all the results for all the tests that were ordered would be recorded on the patient chart. But at the front desk, only two of the tests are recorded. Say I order a malaria test, a stool test, and a widal [typhoid test], maybe M. only records the malaria test as paid for, but the patient pays for all three tests, and then V. fills out the results for all three tests, but then they split the money.
“The way I know, is that one time, I just decided to keep track of all the tests I ordered for a day in the consulting room.” Bailor works in the consulting room when he’s in Kono. Otherwise Yusuf, the head of the clinic when Bailor’s away, decides the diagnoses and treatments. “And when I looked at the charts, some of them were not there. And Yusuf, he told me that he suspected something.
“Bori, he was corrupt at first. He was going to be corrupt, but Yusuf said to him, ‘Bori, don’t be corrupt. We are working for the amputees, for the community, don’t do this.’ And Bori didn’t join the cabal.
“So then, I asked Yusuf to just write on a paper, all the tests he orders, for the whole month. And at the end of the month, we compared it to the charts that M. uses, the ones where M. keeps track of things. And it was clear, that he was corrupt.
“So this morning, we had a meeting, and I confronted him. I asked him if it was true, and he said no. But then I showed him the charts, I showed him all the records. And he just said he was sorry, so he’s guilty, he’s guilty.”
I had a lot of questions. So did Katie and Allan. One of us asked,
“So what will you do?”
“M., he’s fired. I will fire M.. I don’t have proof yet that C. and V. are corrupt, but M., he’s been working for us for almost the whole time, and C., only three months.”
“How long has V. been working for you?”
“Two months, only two months.”
“And how long has the corruption been going on?”
“A month and a half.”
Hmm.
“You know, M., I’m very disappointed, because he’s from the amputee community, he’s from the amputees, he knows why we are doing what we are doing.” M. lives in one of the amputee camps. I think his mother is an amputee. “Because, you see, he’s in charge of the money. If M. is not corrupt, then there is no way V. and C. can be corrupt. But M., he’s not smart, he wouldn’t do this on his own. So they made him corrupt, I’m sad. I thought that by putting someone from the amputee community handling the money...” Bailor trailed off, then continued.
“C., I think she is smuggling drugs out from the clinic. I think that maybe when the prescription says to give five days, she gives three, and she keeps the two. And I think that guy, I don’t know his name, the one who’s always hanging around, I think he is the one who is taking the drugs out of the clinic. He mainly comes on Thursdays, when Yusuf and Bori are gone at the outreach clinic.”
I knew who he was talking about! “Yeah, that’s the guy I was trying to describe to you, Allan, the one who was watching Katie and I on the computers. The one who wasn’t M., or Bori. And it was a Thursday that we saw him, too...”
“There you go.” Bailor smiled thinly and shook his head. “You know, when it started, it was only me and Yusuf, and it was fine. Yusuf, he is so honest, he is only honest, and he is so hard working. When it was just the two of us, everything was fine, we did all the lab tests ourselves, all the charts ourselves.”
But the clinic was growing, NOW was growing, and Bailor couldn’t run the clinic himself.
“You know, though, I have to protect Yusuf. In fact, I decided to suspend him for two weeks. The thing is, he will get in trouble if people find out he is so honest.”
Allan looked at us significantly. “Bailor doesn’t mean, like, people will be unhappy. He means actual physical danger. Yusuf could be beaten up, or worse.”
“Yeah.” Bailor confirmed. What? I hadn’t even imagined. My mind pictured Yusuf’s friendly smile, his teeth sticking in all directions, and I heard his lisped voice. He was walking on the path towards his house, the same way Katie and I walk to get home from the clinic. And then three or four young men stepped through the grass towards him, and he stopped walking. They moved ominously closer, and then a pothole smacked my head against the ceiling and distracted my imagination. I shuddered.
“That’s smart, to protect him like that. Does Yusuf know that’s why you suspended him?”
“No, I haven’t told him. I will maybe tell him when we return, on Monday. But as far as the staff know, I am suspending Yusuf because he didn’t tell me about the corruption sooner.” Bailor was silent for a while, and his cigarette burned down a bit more. The cigarette smoke mingled with the exhaust; the windows were all wide open, and humid, dusty air mixed with the various smokes and blew hard against our skin and hair. It’s better than no wind, but by the end of a day in the car, our faces are completely covered in a thin film of dirt.
The top of my head bounced against the roof again. In some places on the road between Koidu and Makeni, there are more potholes than asphalt. Sometimes there are drainage ditches right through the road, or deep runoff streams, or big rocks, and we often have to come to almost a complete stop to get past some ditch without bottoming out the vehicle.

Later in the day, we took a half-hour detour to see a waterfall. It ended up being a lot more than a half hour, but the waterfall was beautiful, so it was worth it. We had to drive through a pond to get there. After the waterfall, however, we realized we had almost no diesel left. So we stopped at a stand that sold cellphone units and cigarettes to ask where we might find some. Bailor yelled out the window in Krio, and a few young men gathered round. Ali, Amhidu, and Bailor conferred with the young men for a minute, and then Ali hopped out of the car. Bailor got out a few minutes later.
“What’s up, Amhidu?”
“There is no diesel in this town.” Oh. I thought I’d heard that, but I’d hoped it wasn’t true.
“Seriously? That truck that drove past wasn’t running on vegetable oil.”
A massive mining truck had just driven past.
“Well, they work for the dam.”
“Right.” The waterfall was also part of a large hydroelectric dam project. The project had been going on for almost twenty years, and I wouldn’t be surprised if the contractors were trying their hardest to get it to draw out for a few more. “Don’t they have diesel at the dam?”
“It’s the company’s diesel.”
“Oh.”
“They think we are security, so they [the people in the town, not the company] will not sell us diesel.”
“Do they steal it from the company?”
“Yes.”
“Did they just tell you this, or did you guess it?”
“I overheard it. They said it in Temne,” Temne was a local language that Bailor, Amhidu and Ali spoke.
“So are Ali and Bailor working on it right now?”
“Yes, they are talking on the phone with the people who sell diesel.”
“Cool.”
A few minutes later, we pulled out, following a motorcycle. We turned into a laneway and then backed in next to a house. A couple of teenage men and an older man emerged. After a brief conference with Bailor, they disappeared and then reappeared with yellow five gallon jerry cans of diesel. They handed me the gas cap through the window, and I held it delicately. Then Ali grabbed a plastic bottle that had been cut up and reborn as a funnel. He held it in place as one of the teenagers poured the diesel into the tank. It wasn’t that easy; he had to rotate the can around the opening of the jerry can as he poured to prevent bubbles from making the flow uneven. Then they opened a second can and started pouring it. Bailor, Amhidu, and Ali were all circling the car with smiling, conspiratorial faces.
“I guess the price is good,” I said to Katie, “because we’re getting five more gallons.” A few minutes ago we only needed five gallons, not ten.
They stopped pouring, and Ali started rearranging things in the trunk. Allan looked concerned. “Are we taking it with us? Tell them to get a plastic, a piece of plastic to seal it.” I nodded.
“I think they’re using a piece of grass. Apparently it’s better. I heard them talk about it out the window.” Allan looked skeptical, to say the least. In a moment, Amhidu, Ali, and Bailor piled back into the car, grinning at their success. It was indeed cheap – half price!
“Amhidu, isn’t that because it’s stolen?” Amhidu’s grin widened.
“Yah...”
Later, when we arrived in Kamakwe, Bailor’s village, Bailor, Amhidu and I were gathered around a plate of rice and sauce. It was dark, but there were a couple of candles flickering.
“Bailor,” I hesitated, “I have a question.”
“Mmhm?” He was eating.
“Why is it not okay for M. to take money from the clinic, but it is okay for us to buy stolen diesel?”
Amhidu almost choked, and Bailor smiled. But he kept looking down at his rice. A part of me really enjoys using my ‘confusing foreigner’ status to say ridiculous things.
“You know, it’s because it was cheap.”
“Because it was cheap?”
“Yeah.”
I didn’t push it.

Inspiring Visitors

2009-07-24T20:21:00.003-04:00

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.

Scars

2009-07-22T19:47:00.002-04:00

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.

Palm Oil Business Plan update

2009-07-19T06:31:00.000-04:00

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.

Samba's Meningitis / Cerebral Malaria

2009-07-19T06:29:00.000-04:00

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.

An Intense Day: instant messaging with Veronica

2009-07-13T18:25:00.004-04:00

My computer clock is off by six-ish hours. It's actually about 10:30pm. I'll probably write up the day's events in more detail in the next few days, but for now I'm going to post a conversation I had on Skype chat with one of my friends, Veronica. I think it

[4:44:42 PM] Veronica Pillar says: yarnface!
[4:46:50 PM] Christopher Yarnell says: hey v!
[4:47:38 PM] Veronica Pillar says: how's africa?
[4:48:06 PM] Christopher Yarnell says: it's okay. we had an intense day. look up cerebral malaria.
[4:48:34 PM] Veronica Pillar says: that sounds bad. did somebody have it?
[4:48:46 PM] Veronica Pillar says: (does)
[4:49:03 PM] Christopher Yarnell says: yeah. i think they'll be okay. i was pretty scared though.
but there's so much uncertainty, nobody diagnosed that. i just spent 40 minutes online and now i'm sure that's what it was.
[4:50:27 PM] Veronica Pillar says: yikes, just looked it up. not fun sounding
[10:03:49 PM] Christopher Yarnell says: yeah. it's a 16 month old.
he had a 104 fever,
then we sent him to go be washed with cold water by the mom,
then he started convulsing,
coughed/vomited a bunch of crap into his lungs,
then the mom freaked out
and tried to take him to another hospital
which wasn't stupid, because we can't transfuse blood and we had no diazepam for sedating his convulsions
but then she came back two hours later
with the kid still breathing > 60 times per minute, his lungs bubbling with stuff, burning up with fever, his eyes unfocused and dazed, unresponsive to pain,
(i pinched him, and katie and i were the only ones interested in his vitals)
[10:05:50 PM] Veronica Pillar says: oh my gosh that's so scary
[10:07:02 PM] Christopher Yarnell says: so katie and i spent three hours beside him on his bed, holding him down in his convulsions, which at that point were just muscles completely clenched, and trying to keep his airway open to help him breathe, while the nurse administered the malaria medication, and some antibiotics, and some diazepam (we went out and found some)
and something for the stuff in the lungs.
one of the symptoms of cerebral malaria is teeth clenching, and he's too young to know how to cough.
so we can't get the crap out of his lungs.
a couple of times he stopped breathing, so we would push on his lungs and massage them hard, really hard, and then he would start breathing again
but eventually he cooled off abit
and his breathing went back down to 60 breaths/minute (still way too fast, but it was up to 84 at one point)
and for the last hour and a half before we left he didn't stop breathing.
we showed his parents how to keep him upright with his airway open, and then we left to get food. i was almost passing out, i hadn't eaten since 8 in the morning. neither had katie, but i think it affected me more
actually katie ate a bunch of peanuts.
[10:09:55 PM] Christopher Yarnell says: i still feel really weird about it. not only do i not really know what to do, but i already know enough to use every option at the clinic - there are no options! i feel weird because i had to leave, i needed to leave, but the kid might have been helped by katie and i, but probably not, but i was sooo hungry and spacy
we talked about going back for the night but we are too spent.
[10:11:21 PM] Veronica Pillar says: ....wow that's so intense
[10:11:23 PM] Christopher Yarnell says: for a while i thought he was going to die. i was really sad inside.
[10:11:39 PM] Veronica Pillar says: (if you don't take care of yourself you can't help others, you know this)
but you think he'll be okay now?
[10:12:25 PM] Christopher Yarnell says: yes, i know this, but there's no food anywhere near the clinic. anyways, yes, i think he has stabilized, and he is getting the right treatment - intravenous quinine. apparently there are many relatives at the clinic with him, so they told us not to come back.
[10:12:54 PM] Veronica Pillar says: my gosh i would be terrified
have you seen any other patients in that bad of a shape?
[10:13:09 PM] Christopher Yarnell says: they are scared. the parents, at least. no, not that bad.
the dad is an imam. i met the dad and the kid (samba) 's older sister (three, kadiatu) last week when she had malaria.
she's fine now. but that's so insane. the poor family.
cerebral malaria has 25-50% mortality rate.
[10:15:11 PM] Veronica Pillar says: yeah i just read that, heh
that's way high, wow
[10:15:27 PM] Christopher Yarnell says: yeah.
i'm going to go tell katie some of this, she doesn't know how all the symptoms fit together with cerebral malaria yet. although she is the one who first thought it could be cerebral malaria.
[10:17:31 PM] Veronica Pillar says: cool
that's kinda cool she thought of that (and i guess was probably right)

A conversation with Katie

2009-07-10T21:14:00.002-04:00

A conversation with Katie.

Katie and I talked about my blog post from yesterday about health education in Yomandu. She said that it was interesting that I thought my advice was more practical and direct, because she thought that hers was too! And then I explained how I thought her advice was really valid, but that when someone asks a question, I want us to present some options that they haven’t already pursued. Katie said again, that she thought she was doing that. So we talked about it for a while.
By the end of the discussion, a few things were clear. First of all, we don’t understand the Sierra Leonean culture very well, and so it’s difficult to determine which if any of our advices are effective.
Second, Katie’s repeated advice to redouble efforts to communicate comes from her much deeper experience helping people resolve similar personal problems. For instance, her response to the first young man was an exhortation to try and communicate more with the girl about the consequences of not using contraception. In Katie’s experience, people often haven’t tried very effectively to communicate with the other person, and doing so is the best way to solve these problems. To me, that sounds like the best first course of action, and perhaps the best second, third and fourth one as well.
Third, we both agree that my recommended action of recruiting help from others can be dangerous. If a person feels like they are being betrayed or ganged up on, then they are liable to close down and ignore otherwise good ideas and advice. However, the society here is very hierarchical. That advice is an attempt to work around and capitalize on that hierarchy for a positive benefit.
We decided that it’s still good to give many perspectives, because we don’t really know how rural Sierra Leoneans will implement either, and we figure that whichever works will be the one that catches on.
In any case, I decided to share the discussion we had with you readers because, at least for me, it’s very difficult and scary to think that Katie and I are giving such personal advice to people in such a different culture. The problems that people ask about are difficult, and there aren’t any easy answers; the best answers would be tailored to each situation, and what we really want to be teaching is how to understand the problems so that people know which strategies to use for which problems. Unfortunately, it’s not that easy. So we go, ‘small small’ like they say in Krio, and try and figure it out. Hopefully I haven't dramatically misrepresented Katie's perspective! Cheers, Chris.

Diagnoses, Education, and Update

2009-07-09T20:38:00.000-04:00

Lois Park posted an incredible entry on her blog, loispark.blogspot.com. She’s the third intern working for GAF and NOW this summer, and she has designed, implemented, and is now running a feeding project for malnourished children in Masiaka, near Freetown. She’s living in much more hardcore conditions than Katie and me, and is always upbeat and positive.
Katie blogged a bit about the appalling maternal mortality and female genital mutilation practices of this country. Together with domestic abuse and an overtly patriarchal society, it’s a perfect storm for women. We know hardly any women, and most women we have seen are laden with babies and work. We walked back to the clinic with Siah Sumana, Sasseko’s wife. She had walked the two kilometers to and from the market with her eight-months-pregnant belly, and on the way back she was carrying a bundle of sticks on her head and a bag of food in her hand. We carried the sticks for her, but while she walked she placed her free hand under her belly for support.
There is hope. Many of the young Sierra Leonean men and women we speak with are very concerned about making sure and allowing “the girl child” to go to school. Education is essential to help the women of Sierra Leone. If the local economic climate can improve through agriculture – perhaps palm oil? – then there will be more money, more jobs, and more incentive to allow women to pursue careers of their own.
Currently we are working on finishing up the community health education for the survey we are conducting, then we are going to complete a draft of a business plan for the palm oil farm that will fund the clinic operating expenses, and then we are going to write out a framework for a peer education program that NOW will put into action in the fall. The focus of the peer education program, to start, is teenage pregnancy, and both Katie and I are very excited by its potential. Everywhere we go, the people ask us to speak directly with their children about this issue, and the recognition of the importance of education is almost unanimous. One of my new posts is an account of our recent health education in Yomandu, and it gives some insight to the type and nature of questions we field.
We’ve also been spending some more time in the clinic, and I love it. I’ve posted a couple of stories of diagnoses, because I think the progression of learning about a patient and what is troubling them and then trying to formulate both a diagnosis and a treatment is very interesting.
Comment freely! Cheers, Chris

Tough Questions: Health Education at Yomandu

2009-07-09T20:37:00.001-04:00

“Hey guys.” Jalloh and Bori pulled up the path on a motorbike. The saddlebags were full of drugs and files – today we were educating in the same place as the outreach clinic.
“Hey Jalloh. How you sleep?” We clasped hands in the enthusiastic Sierra Leonean way. Katie did the same.
“Fine. But you know, we are going to Yomandu.” Oh. We were in Kania.
“Did plans change?”
“Yes. Because Sahr Bindi, he told both people the same time. And Ahmidu had to go with the tractor,”
“Oh. Sahr Bindi told both camps the same time.” We had specifically told him to arrange for us to meet the Kania community at 9am, and the Yomandu community at 2pm. But as long as we did the health education for both groups of people, it was fine.
“Yes, he did.” Jalloh was wearing a baggy, nylon Chicago Bears jacket and artistically pressed jeans. I was wearing shorts and a running shirt. “How will you go to Yomandu? Will you walk?”
“Well, we don’t know where it is.” I tried to be diplomatic.
“Mmm, I have to go back for Sasseko, and then I will come. It is just there, by the road.” There were only two roads, none particularly close, but Jalloh’s nonspecific hand motion was unhelpful.
“A will show you.” A small boy skipped ahead of Katie and me with a big grin on his face. Katie shrugged, and we followed him.
“See you, Jalloh!” Katie called, I waved. Then we followed our guide. He wasn’t gangly, but his head was all a little too big for his torso.
“Wetin na you nem?” I asked, walking behind him.
“Aboi,” he said, softly. I leaned closer. “Aboi!”
“Aboi. Me nem na Christopher. Glad to meet you.”
The path wound between small, square houses. Each one had a porch, and each porch was wrapped with a waist-high wall. The wall was always cement, but there was also always a lattice of holes in the wall to let air through. There were people around on most of the porches, and I murmured hello to most of them. Some of them were quite happy to ignore us, and that was a welcome change.
There was thick, light green grass on either side of the path. It grows tall, almost as tall as me, and the blades are wide, maybe three quarters of an inch. They’re not sharp, but they are fibrous. The path itself was tamped down red earth, smooth and well-worn. We passed a grayish-brown water hole that made me think of parasites. We also passed a meeting of people out front of a patent medicine store. “Aboi – why dey de have meeting?”
“Dey talk about nourish.”
“Oh, about nutrition, and malnourished children?”
“Yeah.”
“Okay...”
At this point we were walking on red-dirt road. Apparently there are red-dirt roads throughout Africa, and I think they are often lined with green, bushy grass. It’s a nice scenery that’s growing on me. Aboi and I walked in silence, but Katie was chatting up a couple of little girls that had started trailing her. Their names were Matellani and Marie F. Jimusa, I later learned. We also picked up a lady who thought that Aboi didn’t know where he was going. He did, but that was okay. At one point when we were walking down a very nondescript path between bushy grass, Katie said to me, “We totally would have been able to find our way...”
After a while we were walking through a big market area. There were lots of small tin sheets propped up with sticks serving as stands and booths, and lots of different vegetables laid out on blankets and platters. I could see green bananas, peppers of many different colours, yams, cassava, roasting corn, peanuts, cloth, fuel – standard Sierra Leone market fare. The bustle was a bit more subdued, and we got a lot more attention than usual. I guess white people are much rarer twenty minutes outside Koidu.
On the other side of the market was where we were scheduled to do our education. The village was called “Yomandu.” We were in a small flat area in front of one of the amputee camp houses, and some people brought out benches and plastic lawn chairs. Katie and I waited around, smiling at the growing crowd of children. Eventually Jalloh and Sasseko pulled up on the clinic motorbike. We said our hellos, and Jalloh sat down. Sasseko drove off to Kaniya to join the outreach clinic.
“Sit down, yeah?” Jalloh told me to sit down. Only Katie and him were sitting down, but there was a large crowd gathered.
“They won’t sit down until I do?” I asked, but I already knew the answer.
“No,” Jalloh switched into a lecturing tone, as he often does, “you see, they have habits, of respecting their elders, and they don’t sit down until...” I zoned out.
“I’ve never been respected as an elder before,” I smiled.
Some more community members arrived, including some we remembered from our previous visit to Yomandu. By the time Sahr Bindi arrived and told us we could start, there was a crowd of about fifty gathered around. And by around, I mean that we were in the center of the group. We’d tried to direct it so that we would be at one end of the crowd, but then more people gathered behind us. It wasn’t a big problem. Also, the benches had initially been placed in front of a small flowerbed, but the edge of the flowerbed could be a seat. So we moved the benches. It’s important to make sure there are both desirable and undesirable seats around, because the children will take the undesirable seats. If there are only good seats, the adults tell the children to leave. But the children have the best understanding of English, and the children are the ones with the most potential to put our education into action.
Jalloh began by introducing us and himself. “Okay. Na morning,” the crowd murmured good morning, “Me na student, me comot na Fourah Bay College na Freetown for de do internship na Dorma Amputee Clinic.” A tip for reading Krio: to conjugate a verb, you just put “de” in front of it. If you can’t tell what something means, say it aloud, and listen closely. For example, “comot” is “come out,” so it means “come from.” Jalloh looked at Katie expectantly.
“Me nem de Katie,” Katie always says “nem de” but I’m not sure why, “me na student, a comot na America.”
Sahr Bindi piped up, “Kumba Katie!” Every second daughter in Kono district is named Kumba. Everyone laughed; our Kono names are very popular.
“Me nem na Christopher, an me na student, a de study na America, but a comot na Canada. We comot na Amputee Clinic for de teach una (you) about health education.” Jalloh nodded, and then explained why we’d come in Krio. Then Katie gave the malaria module.
“Okay. So una de get malaria wey de mosquita, dey bet. So if me na mosquita...”
I looked around the crowd, caught the eye of as many people as I could, and returned their smiles. After giving these health education modules a few times, it seems like the best way to retain interest is to let the audience members know that you are paying attention and interested in them, and so I decided to try eye contact for this, even while Katie was speaking and not me. Aboi and Marie (his sister) were sitting across from us on the edge of the flower bed, along with fourteen or fifteen other children.
The health education went off without event until the family planning section. In the family planning section we talk about how smaller families (having fewer children) is better because it allows the family to focus more resources in terms of money for nutrition and school and time for attention on each child.
“I wan for ask, if dem small small girls, dem pikin, can use injection.”
The woman asking the question was middle aged and dressed in bright blue African garb. She held herself with confidence, and asked her question with a gregarious smile to the crowd. Jalloh translated, but I had understood the Krio. Katie and I conferred briefly, and the woman added some detail. Jalloh translated the detail, “She says, many women think that it is not safe to have the injection until they have two-three children. That if they have it before having two-three children, they will be infertile.”
“The injection, the condom, these methods are safe. It’s not true that you need to have two or three children before it will work. If it doesn’t work before two or three children, it won’t work after. You should consult your doctor, because every woman is different.” Katie gave her answer with a very concerned look on her face. Jalloh translated it. The woman nodded. I added something.
“It’s better to use condoms for the young girl because there are no chemicals. But using the injection is much better than getting belle (getting pregnant). Wey you done get belle, you could die.” The woman nodded again.
Katie kept forging ahead until the end of the family planning module.
“So, una de got any question?” Katie asked if anyone had questions. Jalloh repeated her, and added some Krio to explain.
“Me de got question.” A young man behind our right shoulder spoke. We turned. He told a long story about a girl and a guy, involving various attempts by the guy to get the girl to use contraception. First he tried condoms, and she refused, and then she agreed to use injections, but then when the boy took her for injections she again refused, and told him she had too negative a perception of these contraceptives to use them. Jalloh said,
“Okay, so he is asking about what to do when the girl won’t listen, won’t use contraception.”
“Jalloh, he told an entire story, and I didn’t understand all of it. What did he say?” I had understood enough to recognize that it wasn’t so simple.
“No, it’s just that, he wants to know how to convince her.”
“Jalloh, I want to know the entire story. He talked about trying different methods, and negative perceptions... Can you just translate what he said?” Katie nodded. We both understand Krio to a certain extent, but I’m much more willing to guess at what was intended.
“Okay, he just said, that the boy tried to get the girl to use condoms, and she refuse, and then he try to get her to use injections, and still she refuse, and what does he do?”
Katie responded. “So it’s very important that he talk to her, and that she understands that he is worried not just for her health but also for his, and it’s really best to use condoms. He needs to be very clear with her why it’s so important to prevent pregnancy, and really make it clear that he is concerned, and that it’s very important.”
Jalloh translated this. Then I added something. Usually Katie answers first, because she is very good at emphasizing communication and its role in resolving many of the questions that arise. My answers tend to be more direct and practical, and I try and say them in simple Krio/English mix that doesn’t require translation to be understood. Jalloh translates them anyway, but sometimes he adds a lot of words that disguises the crux of the message.
“If de woman, she no de listen to you, den you faut go talk na someone she does listen to, some elder. Or, you de go talk wit’ her friends, and tell dem why you worried, and ask dem to talk to her. You need to recruit allies, make sure she is hearing about why contraception is important from many different sources.”
When Jalloh translated, he added a line about taking the girl to the clinic or the doctor. The young man nodded and listened carefully with a concerned look on his face. Some of the best and most difficult questions at these health educations are asked by young men. They seem genuinely and passionately invested in helping their friends and family, and they give me hope for the future of Sierra Leone.
“A de got question.” While Katie was speaking, I had been watching all the people around me, counting heads and taking note of who was listening. A tall woman in an iridiscent solid blue dress had been standing directly behind us, but she had orbited around the group to the front, and was now asking a question. “You de work for send you pikin na school...” [Krio I didn’t understand] “but you no can walk wit you pikin na school, and dey go get belle, and den...” [Krio I didn’t understand] “but de man, e’ say why you no tell ‘im, why you hide de pikin belle?”
“Okay. So the woman,” Jalloh paused, “she says, what do you do when your husband accuses you, of hiding the girl’s pregnancy, but you didn’t know? He says, that you, the wife, you should know what your daughter is doing, and he gets angry, because you don’t know.”
My mind flashed, and I got distracted by what “gets angry” meant in this small village outside Koidu. Until two years ago, beating your wife was legal in Sierra Leone.
Then, my mind switched to a question we had fielded yesterday, from a local chief. He was tall, and dressed in a grey pea coat (let me remind you that this is Africa). He owned a motorcycle, and demanded that the meeting proceedings follow a certain protocol. And, he had set up the seating so that the women were out in the rain and the men were under the porch. This was his question:
“What do you do, when you know the daughter is pregnant, and you want to find the father, but that woman, the mother, she knows too, and they conspire against you! What do you do when she no de tell you who de papa? Wey you wife no de help you? Wetin you faut do?” He said the question with force, vehemence. It was backed up by the stern nodding of other men. Indeed, what do you do when women are constantly conspiring against you? I had let Katie answer that question. I didn’t know where to begin.
Now, we were facing the opposite question, the other perspective.
“It’s not only important to have a trusting relationship with your children,” in my mind’s eye, I blinked in disbelief at where it looked like Katie was heading with this. It’s difficult to tell a woman in a society with endemic domestic abuse that she needs to have a more understanding relationship with her husband. But at the same time, what else can we say or do? “It’s also important to have a trusting relationship with your husband. He needs to know that you care about the daughter, just like him, and you need to say ‘Why would I hide it? I am concerned above all for her health, it is most important, and we need to help her stay healthy and well.’ He has to know that driving the daughter and the mother from the house is not going to help the health of anyone.” Jalloh translated. Sometimes I worry that the feminist nuance in our answers is lost through his translations. On the other hand, sometimes he does a good job of making our answer culturally relevant. There’s no perfect system.
The woman nodded. Her eyes were deeply set, and her cheeks were drawn down such that her mouth’s neutral position was a frown. But when she had spoken, her features had animated significantly, and she had looked like a different woman. I wondered how she interpreted the answer, and whether it was useful to her.
There was a moment of general talking, and Katie and I glanced at each other to check if we should proceed. But Jalloh said, “She has another question.” The woman in iridiscent blue spoke again. I didn’t understand her question, but she was gesturing wildly. At one point she reached out and grabbed an eight year old boy on the head, and he looked sheepish. Everyone laughed. I think she said, “and dis de papa...” Jalloh translated the question, smiling.
“Okay, so she asks, she says that herself, she is a widow. Her husband is dead. And she has many children to take care of, but she can’t stay home and watch them. So when her daughter goes and gets pregnant, and the father is a little boy like him,” Jalloh pointed to the sheepish eight-year old. I laughed, but was not totally willing to think there was no kernel of truth to the question. “Then, what can she do? She has no money for the child.” I raised my eyebrows. Again, I had no idea. What do you do? It’s a tough question for a North American family, for a North American single mother. It’s perhaps a tougher question for a widow in a relentlessly patriarchal and poverty-stricken society.
“I don’t know, that’s a really tough question.” Katie nodded at me, concerned. She had a better answer than ‘I don’t know.’
“She needs to make her daughter understand that the family can’t afford to have that happen. She can’t say ‘don’t get pregnant,’ she needs to be honest with her daughter and say ‘we can’t afford it if you get pregnant, so you need to use proper contraception,’ and she needs to make that contraception available.”
Jalloh translated. Again, I think some of the nuance was lost. Sierra Leoneans often ask about how they are to discipline and control their children, and Katie’s answers all focus on imparting an understanding of the bigger picture to the children. They are idealistic responses, but from the perspective of changing behavior here in Sierra Leone, I think they are very appropriate. It’s true that not all children are able to understand what is important for their family, and sometimes even when they do, they don’t do it. But teaching children how to consider the bigger picture of what a family needs as opposed to what an individual wants is one way of helping the much-needed societal shift from considering very narrow, small short-term views to considering how one’s actions fit into the society as a whole.
Then, Katie proceeded with the teenage pregnancy section of the health education. By now there were around eighty men, women and children in the crowd. I was especially happy that Aboi and other children around his age (twelve) were in the audience, because teenage pregnancy was lurking dangerously near in their future, but they were still young enough to be both impressionable and ignorant. At the end of this section, there were a few more questions, although many of them had already been asked. It’s both troubling and reassuring that questions related to teenage pregnancy arise so spontaneously out of discussions of family planning.
“A de got question. Now, we de got dis human rights, wey you discipline you pikin, dey turn an go na police. Eh, eh?” It was the first woman again, the gregarious one. She asked the crowd for confirmation and got it.
In fact, this was almost identical to a question the motorcycle-riding, peacoat-sporting chief had asked yesterday. Apparently in Sierra Leone, many parents are worried that the increasing prevalence of human rights is being taken advantage of by their children, and that if they try to control their children in any way the children will go to the police. I have no idea whether this actually happens. Katie thinks that the kids probably just threaten, she doesn’t think they actually do. The police are not exactly a powerful or respected institution in Sierra Leone.
“Jalloh, tell them that we struggle with problems of how to control children like this, even in North America. Tell them we understand that it’s very hard, but that change needs to happen gradually. In the past, corporal punishment was acceptable, and was used, but now times are changing, and it is not always easy.” I tried for a bit of crowd appeasement. It seems to work well – if you throw in a “Jalloh, thank her for asking such a smart question,” or something similar, the audience laps it up. After Jalloh translated that, the woman nodded emphatically, and everyone else seemed to agree. Then Katie added something more substantive.
“It’s very important to have an understanding relationship with your children. Jalloh, can you tell them the story about the water, from yesterday?”
“Yes, yes, I know it.” The story about the water was how Katie answered the chief’s question yesterday. She created a hypothetical situation where a child refuses to get water, and the parent needs the child to do so. She said that instead of hitting the child, yelling at the child, or forcing the child, the parent should explain and educate the child from a young age that fetching water is important for the family.
Katie also said something very interesting to the chief that she didn’t say to the crowd at Yomandu. “I am from America, but my parents are Chinese. In China, corporal punishment was common. But in America, it is not allowed. So in America, if they see a Chinese child with bruises, then they think they are beating the child. So I have some Chinese friends where the parents beat their children, and some Chinese friends where their parents did not beat them. And from my experience it was much more efficient and better for the child as they grow up to not beat them.”
After this woman’s question, another woman, and then a man, confirmed the community’s desire for us to speak directly with the children. They seemed at a loss for how to stop teenage pregnancy amongst their children, and for how to get their children to listen to them. Katie and I mentioned that we are designing a peer education program to be implemented after we leave, but more importantly, we emphasized that change requires that teens hear the message of communication, contraception, and responsibility from many different sources. From parents, from teachers, from friends, from people like Katie and me. They seemed to understand.
Throughout the presentation, I kept turning around. During the health modules, Aboi and the other children had migrated behind me. There were about twenty of them. Every time I looked back, they would stare at me, faces expressionless. But if I gave them even a millimeter of smile, their eyes would open wide and their faces would dance with big grins. All these questions and all this education was for them.

Diagnosis II

2009-07-09T20:34:00.001-04:00

Where was Katie? I wondered. We needed to work on the database for the survey we were conducting, a survey about health education. There wasn't really a rush, though. I set out through the clinic to find her.
There were many people waiting to be seen, waiting for lab tests, and waiting for medication. They were sitting on benches in the waiting room and in the halls, their clothes blending together in my peripheral vision. Part of me is afraid to be too friendly lest they get the false idea I am going to give them something or pay for their care. Another part of me is annoyed that I don’t spend more time listening to them, learning their syptoms and stories. Deep down, I worry that I am just unwilling to reach across the divide between us. I wish the divide wasn’t there, but between languages and between continents, it is. As Allan said a few times, in this clinic the fifteenth century meets the twenty-first.
I walked past the consulting room, figuring that Katie was probably in there with Bailor, but deciding to look in the other rooms first, to avoid disturbing the consultation unless absolutely necessary. To be honest, hardly anyone else afforded the consulting room so much respect, so it probably didn’t matter. She wasn’t anywhere else, so I knocked on the consultation door and said, “Hello? Is Katie in there?”
“Come in!” was the response. So I did.
Katie, Dr. Lenny, Bailor, Bori, and Yusuf were all already in the tiny room. Seated in the patient chair was a young mother, holding her daughter. Her daughter was nearly naked, and perhaps a year old. I could see her ribs struggling against her skin as she breathed. She looked sick. Bailor welcomed me with a nod.
“Look at this pikin. She so pale, she is anemic. You see?” I didn’t see. I couldn’t tell that she was pale. But she had pale lines and red lines on her neck. Maybe that’s why Bailor could tell? More likely was just that I wasn’t observant or experienced enough. I looked at her palms, because they are usually a tell-tale sign. They did look a little pale.
“An’ you see how she breathes – she uses the intercostal space. Beside her ribs.” I moved around the mother to peer at the side of the baby. She began to cry when Bailor touched her side, and she started flailing her arms. “Well, now you can’t see it, she’s crying. But when she’s still, you watch.” In a moment, she was still. But her eyes were liquid with distress. I could see the intercostal breathing – her ribcage flared out instead of merely up and down. Her body was using different muscles than usual to draw in as much air as possible. “And you see how her nostrils, dey flare? She’s not breathing fast, but she’s breathing hard. I think it’s pneumonia.”
“The most dangerous things for a child are respiratory infections, like this, and dehydration.” Dr. Lenny addressed Katie and I.
I nodded and murmured the word dehydration. The little girl had her hair braided upwards around her head, with all the braids ending in short stubs in a circle on the top of her head. It’s a popular style among little girls in Sierra Leone.
“Why are they dangerous?” Katie asked.
“Because they kill the child quickly.”
Bailor turned to the mother. “Oustem de pikin ‘e ge’ sick like dis?” When did the child get sick like this?
“Saturday. No, Friday.” Bailor made the peculiar high-pitched “eh!” noise that all Sierra Leoneans make when they are suprised, appalled, or angry.
“Why you de wait so long for come de gi’ de pikin care? Dis pikin ve’y sick, ve’y sick. Why you no de come Saturday?”
The woman shrugged. Behind Bailor, Bori was shaking his head and looking concerned. It was serious, but Bailor and Bori’s scolding faces were a little comical.
“Now we faut gi’ de pikin drip. Wey you de come na Saturday, we jus’ de gi’ em amodiaquin, she de go ge’ welbody quick quick. But now, we faut gi ‘em drip, i’ more dear,” Bailor was telling her off for waiting because now it would be more expensive, “and you no de make de pikin suffer so, wey you de come na Saturday,” and because it would have been easier on the child.
I looked at the little girl, shaking in the arms of her mother. I was glad she was at the clinic at all, even though Bailor was right.

Diagnosis I

2009-07-09T20:27:00.000-04:00

“Oh, this woman, she no look well.” Bailor’s voice was concerned but matter-of-fact. The consulting room was cramped, with Katie, myself, and Dr. Lenny crammed into different corners. Bailor was behind his desk, and Bori was in front of it, waiting to translate.
The woman entered the room. There was a practical desperation in her movement; it clung to her and hid in the way she sat down and settled into a vacant stare. Her eyes were wide but sunken, and hunger had tightened her wrinkles against her bones. She was robed in a magnificent turquoise and lime green diamond patterned dress. As Dr. Lenny would later point out, she did not look like she was having a good day.
“Wetin na de problem, mama?” Bailor asked her what was wrong. I fiddled with the “Children’s Hospital Care” book on the corner of the desk. Bailor later called it his bible. “Why you come today?”
She rubbed her stomach and looked plaintive. Bori translated. “E’ belly de hurt, e belle de hurt... she de feel snake insigh, crawling insigh, crawling... e’ de hurt beaucoup...” and after some prompting, “e’ body de wam, de joints dey hurt...” While translating, Bori began gathering vitals. He motioned for her to remove her shirt and then slipped a blood pressure cuff around her arm.
“What did she say?” Katie asked. Bori had translated into Krio, which sometimes needs further translating.
“Her stomach hurts,” I slipped in, rather unhelpfully.
“She say, that she feels a snake inside, that her stomach hurts,” Bailor had the real answer, “you know, these people, they will tell you that there is a snake, and they feel it crawling,” his hand traced snake-crawling around his belly, “and then it will bite them here,” his hand made a biting motion at the center-bottom of his ribcage. I nodded sagely. Gastritis, or ulcers, or heartburn, I thought to myself. “Tha’s why you need to know your patients, you need to know where they are coming from, so you can understand,”
“Well, not to downplay the role of understanding,” Dr. Lenny held his hands up and looked bashful, “but I think any good clinician would think of gastritis when a patient mentioned upper chest pain,”
“Does malaria cause that?” Katie asked, about the gastritis. Asking about malaria is always a good idea here; since the parasite attacks the red blood cells, the disease can manifest in many different ways. Bori had written down the blood pressure cuff results on the back of the patient registration card and then pushed it across the table. I eagerly peered at the numbers. Pulse 87 bpm, blood pressure 100/78.
“No, is probably peptic ulcer disease,”
“Well even giardia can cause gastritis, though,” Dr. Lenny added, with a humble shrug of his shoulders. “And even in the US it’s hard to tell whether or not it’s H. pylori, peptic ulcer disease,” he added, “here I bet it’s just that much harder.”
“Yeah, yeah, you know, that’s why, that’s why, I’m not sure, but I will prescribe her [some antibiotics and an antacid].”
“That’ll take care of the giardia too.” Lenny replied, but I was looking at the patient. She didn’t look healthy, and even though she had come in because of the pain in her stomach, that might be masking a more chronic problem. Hmm. Should I say something? I wondered. I was sure the experienced clinicians have already thought of what I wanted to say.
“But, are we going to test for malaria? Maybe the peptic ulcer disease is masking something else, something more important?”
“Well yeah, yeah,” Bailor motioned for her to lie down on the consulting room mattress. He listened to her pulse, “I know we have the pulse, but I’m just listening for to see if it’s irregular, if there’s a gallop,” and then he palpated her abdomen. Then he listened to her lungs. The woman was now sitting up, hunched over. Her head was wrapped in cloth with a similar but not identical pattern to her dress. To me, it looked like it was randomly tied, but I was pretty sure it was very intentional. I could see her ribs, but she wasn’t emaciated. Along her belly there were folds of skin, empty of fat and water. It looked to me like she had been losing weight.
There were several loud knocks on the door while Bailor was doing his exam. He yelled at the door in Krio. Soon he was done.
“Katie, you want to listen? See if you can hear what is in her lungs.” Bailor’s Krio accent always sounded informal and cool. He dropped all kinds of final consonants, and said “I” with an “ah” sound.
Katie started, surprised at being switched from observer to participant. “Yeah!” Bailor handed her the stethoscope. She held it for a moment, and looked back at him. “Well, I don’t really know what to do.”
“Oh! Sorry Katie, I jus’ think you are medical student, that you already know all these things. The idea is to listen symmetrically, okay? Here, here, then here, here, then here, here...” Bailor placed the stethoscope in four spots on each side of the patient’s chest, starting near the armpits and moving down around the ribcage in a J shape. Then he switched to the back and pointed out four spots on either side of her back, the first three moving down the spine and the last one out to the side.
There was more loud knocking. They needed the calculator out at the reception desk. The calculator was sitting on the desk in front of me. Bailor sounded a bit annoyed when he said “Le ‘im come, gi’ ‘em calculatah.” Bori passed the calculator to Dr. Lenny, the door opened a crack, and the calculator disappeared out of his hand. It was more respect for the door than usual – a week ago when Katie had been sick, the clerk had walked right in during her exam, after Yusuf had asked her to remove her shirt so he could listen to her heart.
After he gave up the calculator, Dr. Lenny said, “So, this lady, this woman, one of the ways you know she’s not well is that she is breathing very quickly, and she really doesn’t look like she’s having a good day.” In my mind’s eye I saw her sitting down in the chair at the beginning, her shoulders heaving weakly. Dr. Lenny was right, she had been breathing fast. Katie had put down the stethoscope, and Dr. Lenny picked it up. “Do you mind if I listen?” He asked Bailor.
“No, no, go ahead,” Dr. Lenny went through the same steps. But when he reached the outside of the ribcage, on the woman’s back, he asked Bori to get her to make an “eeee” sound, and then an “aaaa” sound.
“I think there is something wrong with the air intake,” said Bailor, “something wrong. When you listen, you are trying to compare both lungs, to see if there is some problem. But her right lung, it’s not well. I think maybe she has tuberculosis, even though she’s not coughing.” Bailor looked back at Dr. Lenny. “So what you listen for, is some kind of crepits, some weird sounds, like a whistle,” he whistled, “or sounds like hair moving, or,” he gurgled. I was a bit impressed he could make those noises. It was actually pretty helpful.
Dr. Lenny finished, and the woman turned and sat with her legs dangling over the bed, shirtless. I wished I could speak Kono, to find out how she was doing, and what she thought of this mess of doctors and students and nurse inside the tiny consulting room. Dr. Lenny told us what he thought.
“I think there is some blockage in her right lung, at the bottom,”
“Yeah, that’s what, that’s what I heard, and so I think maybe tuberculosis.” Bailor agreed. “But the next thing, is an x-ray, and you know...” He trailed off. During the previous patient consultation we had met a sixty year old woman who had a bullet in her foot. The wound had healed, but her foot always hurt, and was often swollen. Then Bailor told us that there was no x-ray machine in the Kono District; the closest was three and a half hours by driving, or 30 000 Le round-trip by public transit. The x-ray itself was also 30 000 Le. The sum is enough to feed a poor family of six for ten days. At the end of her visit, I asked when she had been shot. After a brief debate about the year of a particular event in the war, I got my answer: 1998.
Dr. Lenny continued. “But you know, the left lung is not so good either. I here a whistle, some kind of a wheeze.”
Then Bailor held up the woman’s hand. “And look, here, you see this, this clubbing.” Dr. Lenny nodded. I remembered that Bailor had told me about clubbing a couple days ago. Katie asked him about it, and he answered, “It’s when there is not enough oxygen in the blood, and the fingers straighten out. This one is not so bad, sometimes they are like drumsticks.” Bailor straightened his fingers for dramatic effect. The woman’s fingers looked a bit swollen, too.
“Why does that happen?” I asked.
“Well, it’s when the blood oxygen is not high enough for a long time. It’s a sign of chronic illness, maybe tuberculosis.” Dr. Lenny’s answer was interesting, but not an explanation of why.
“You know, I was reading in some papers, some scientific papers, that they don’ know,” said Bailor. Okay, I nodded. There you go – a basic clinical exam finding, largely inexplicable.
Katie and I took turns listening to the woman’s lungs. I fitted the stethoscope into my ears, but it was kind of uncomfortable. The woman was impassive and her stare was vacant. But the moment I touched the stethoscope to her back, my ears were filled with a soft, low hum. It was full of life. I could hear the soft roar of air intake, with a small bump at the beginning, and I could hear what sounded like a wheeze. I couldn’t tell that there was something in her lower right lung, and it was hard for me to tell what was general background noise and what was something going on in the lungs. But it sounded like millions of tiny processes, millions of tiny cells transporting proteins and energy in and out, fluids flowing around and through, splitting from arteries to arterioles, perfusing out of capillaries. My head was alive with the cartoons of biology textbooks, but my ears were alive with the sound of life.
“I couldn’t really hear all the things you mentioned,” I told Bailor, a bit sheepish.
“That’s okay, you don’t even know what normal sounds like yet.” True.
Dr. Lenny gestured to the woman that she could put on her shirt again. She took her shirt and bra from him, but didn’t look at them. She looked at him the whole time. Then she sat down in the chair again.
“Bori, thank her for being so patient while we all examined her,” I had no idea if this thank you would be understood, even if every word was translated. Bori told her, and she made a small nod. Then Bailor spoke rapidly in Krio to her, and I didn’t catch it. But Bori translated the answer.
“No, she done sick li’ dis na ten years now. Ten years, she say,” Bori’s eyes were wide. Ten years sick, losing weight, tuberculosis... it sounded like it could be HIV.
Bori said more Krio, that I didn’t understand. Bailor translated. “She say, that you know why she is coming today? Only because her brother came and got her. She lives in the village, and it’s only because her brother came and got her and she is staying with him, and he is paying. That’s why she is here today.”
“Ask her if her husband is sick.” Dr. Lenny had a good idea. Bori asked her.
“She de say yes, ‘e sick, an he done ge’ sick befo her, but ‘e body no done done like ‘e,” Yes, he was sick, and he was sick before her, but he wasn’t losing weight like her.
“Does she have children – are they alive?” Dr. Lenny asked again. Bori asked her, and then translated.
“Ten, six alive, four dead.” Her face was still quite impassive. I didn’t understand. How did this look, from her perspective? She had been sick for ten years. And had not gotten better, had not been healed by traditional medicine. And now she was here, in Koidu, brought by her brother, to this strange clinic, staffed with strange doctors, and even white people. She’d been poked, prodded with strange devices, made to take off her shirt, and questioned. What was she thinking?
Bailor explained to her that he was ordering a bunch of tests. Urinalysis, malaria, typhoid (two types), white blood cell count and differentials, hemoglobin concentration, and a tuberculosis test that the clinic was not certified to administer because it did not have the treatment drugs on hand. It was almost every test the lab can do. Then he explained to her that he wanted her to go to the goverment hospital for HIV testing.
“Mama, okay. So you faut de go na government hospital for testing, okay? You no de go’ pay 100 Leones, test na free. But you faut de go na dere.” She nodded, and asked a question – today? “Yeah, if you go able for go today, i’ betteh. Den, you faut come back na ya, you faut come back ya.” You must go to the government hospital, today if you can, and then you come back here. Bailor slid the form back into her folder, gathered up her registration card, and handed them back to her. She stood up to leave, and her dress unfurled around her. The diamond patterns were edged with gold thread.
“Bori, can you ask her if I can take her picture?” Dr. Lenny had his camera out. Bori told her. She shrugged. “And can you tell her it’s not because she’s sick, but because her clothes are so beautiful. She looks beautiful in this dress, it is one of the most beautiful dresses I have ever seen.” Bori looked bewildered, but translated, and she hardly reacted. Languages can be translated much more easily than cultures, I think. She stood stoically and awkwardly for Dr. Lenny’s photo, in the particular way of someone who has never had their picture taken. Then her dress followed her out the door in a flash of color.

From Computer Class

2009-07-01T19:48:00.001-04:00

From Computer Class:

In computer class today, we were learning about the internet. We were looking at allafrica.com, a good source for African news, and there was a link with a picture of Obama. It read “Ask President Obama about Africa.” Upon clicking the link, we discovered that allafrica.com was going to compile a list of questions for Obama from its readers’ submissions and then present the questions to him when he visits Ghana on July 10-11. Here is our question:

We are employees of the National Organisation for Welbody,a Sierra Leonean NGO. We run a clinic that focuses on giving free health care and education to the amputee community in Kono District, Sierra Leone.
As you may know, Sierra Leone suffered a terrible civil war for eleven years, during which amputation was used to intimidate and torture innocent people. These amputees continue to face great challenges in their daily lives and the climb out of poverty is even more difficult for them.
Africa is home to many different groups of marginalized people. Fortunately, there is now plenty of funding for the largest groups, for example HIV/AIDS victims. However, we want to know: how will you include smaller marginalized groups, like the amputee community, in your development plan for Sub-Saharan Africa?

We brainstormed together, and then wrote it together, and then after they typed it in (a process that took about twenty minutes) I edited it. To be honest, though, the issue for a group like the amputees is not just money. It’s opportunity and options as well. Like anyone else on the planet, amputees and their dependents need education and capital to get ahead, to make their ideas work. Handouts are not helpful, but sometimes foreign policies like cotton subsidies crush the economic possibilities of a West African farmer without him ever knowing it. It’s also important to remember that even the amputee communities are not free from corruption*; any aid needs to be monitored to make sure that it is being used in good faith. In the end, there is no single idea or perspective that will catapault areas like the Kono District from the fifteenth century to the twenty-first. It’s going to be a slow process, with many disappointments. With NOW, Katie and I have front row seats to (we’re even participating in) the struggle to eradicate poverty and provide all human beings with the opportunity to have a healthy and fulfilling life.

*I’m compiling a longer blog entry on corruption that I will post eventually. It’s a subject that requires care, and I want to give an accurate picture of both how corruption fits into the Sierra Leonean society and how Bailor and NOW interact with it. For now, suffice it to say that Bailor’s passionate desire to keep NOW a transparent and honest role model organization is effective and inspiring but not without challenges.

Malaria by Moonlight Part II

2009-07-01T19:47:00.000-04:00

“It’s twelve.” Abu’s father woke us up three minutes before my alarm. Bori was instantly on his feet, and I followed suit, grabbing my headlamp. Actually, the strap of my headlamp is broken, so it’s just an oddly shaped flashlight now. Nonetheless, I’m glad we had it. It was dark; no moon yet.
First was Fanta. The medication schedules for each patient were written in pen on A4 paper. There were three ruled columns: time, medication, and signature. Fanta’s treatments were scheduled at 4, 8, 12, 4, and 8, alternating between quinine and glucose. This one was quinine. Abu’s treatments were at 4:25, 12:25, and 8:25, only quinine. Fatmata’s treatments were at 5, 1, and 9.
We moved the lantern on to the bed. If I hadn’t been there, that would have been the only light. Bori said, “Shine the light,” and motioned to the plastic bin containing the medications for Fanta. I complied.
A bug landed on my leg. Then, another bug. Another one. I looked at the lantern. There wer bugs everywhere. Big, stupid flies, dropping out of the darkness and flying straight into the light with sickening insectile crunches. Then they crawled around stupidly on the bed. And they were on the floor too. And not just big flies, but small, biting ones too, like large fleas.
Fanta stirred a bit while we changed her medication, but not too much. Bori kept passing me things to hold, and summoning my light around. Fanta’s mother watched silently. I checked Fanta’s pulse, and gave an encouraging murmur and nod to her mother. It was mostly so that she believed her daughter was in good hands.
We moved over to Abu. Bori wasn’t moving quickly, but the shadows from the lights gave the jars of medication a surreal cast. The needle on the end of the syringe was very difficult to see in the dim light, even though glints off of its metallic surface bounced around the room. I think the soft but distressed noises Abu was making also contributed to the tense atmosphere. Bori himself was quieter, concentrating very hard.
Bori gave Abu an injection while I held Abu’s shoulder. Through my hand I could feel Abu respond to the bizarre and painful feeling of having fluid injected. First his shoulder shuddered, and then it switched to rhythmic attempts to get free. But he didn’t cry out very loud.
“You’re very brave, Abu.” I think I was the only one in the room who knew what the word brave meant. But I hoped that my tone would communicate enough.
“Shine the light here.” Bori gave me a curt command. He was looking at the small chamber beneath the jar of medicine. I shone my light straight down into it, taking care not to flash Abu or his father in the eyes with the light. Bori and I looked at the droplets forming. I fumbled in my pocket for the watch; in France we always timed these; but Bori was already convinced it was okay. We headed back to our beds for a twenty minute nap.
We lay down. Abu was crying, louder. I thought about getting up to see if he was alright. Abu kept crying. I thought again about getting up. Then Bori got up, so I followed him.
We looked around for a moment with the flashlight. I stopped on the medication jar, which had been full of neon yellow fluid ten minutes ago. It was empty. Bori breathed in sharply. “It’s too fast, too fast.” I flicked the flashlight down the line. No leaks. So I guessed that the medication had drained into Abu too quickly, causing him pain. I can only imagine what the quinine feels like, coursing through his veins. A grown adult has only a few liters of blood; a thirty pound three year old has far fewer. There wasn’t a lot to dilute the quinine. I could feel it burning in my own veins, just thinking about it. I wiped his brow with my bandana.
Bori unhooked the line and Abu’s father gathered him up into his arms. We checked on Fanta’s drip. It wasn’t empty yet, but not much remained. Bori instructed Fanta’s mother in Krio, and she nodded. Then Bori strode back over to Fatmata.
“Why so hot? We faut open de windows so le’ cool some.” I agreed. It was a gorgeous cool night outside. The instant I pulled back the window, the sound of crickets filled the room. I noticed that the moon was climbing in the sky. “Dere a net?” Bori was referring to the screen, which was in place.
“Yes.”
“Shine the light.” Bori was peering at the medication instructions. The columns on this form were a little crooked, but the instructions were clear. Bori filled three syringes with the three different antibiotics. Fatmata’s mother secured her baby on her lap. Then Bori held out the capped tip of a syringe to me. I pulled the cap off. “No.” Oh, he wanted me to take the cap and the needle. I carefully replaced the cap and then twisted the cap and needle combination. It came off. Bori opened up the line and injected the antibiotic into Fatmata. We repeated this for two more syringes, and then I handed the caps back to Bori.
“One, two, three.” I dropped them in his hand in order. He replaced them all.
Cooler, drier air was filling the room now that the windows were open. The moon was bright enough now to cast shadows. Before returning to sleep, Bori and I hung the bag of glucose solution for Fanta, so that at 4am all we would have to do was turn on the drip. She was still asleep and rarely stirring. Bori and I lay back down on our worn out mattress. I set my cellphone alarm for 4am.
“You set de alarm?”
“Yeah. For 3:53am.”
Instead of counting sheep as I went to sleep, I counted Abu’s breathing rate. More than 30 breaths per minute. I was worried about him, but I knew his pulse was still normal. I didn’t know what I could do; so I drifted off to sleep.
When the alarm went at 4am, I experienced a vague moment of haughty dislike for the owner of that annoying cellphone ring. Then I realized it was mine, and that it was in my pocket.
“Do we get up now?” Bori asked. I thought, no, we’re done. A sleepy thought.
“Yeah, it’s 3:57.” Bori was on his feet, fumbling them into his flipflops. I followed with my light.
“Shine the light.” Bori motioned to the highest drip chamber on Fanta’s IV. We watched a few drops fall. “Okay.” I checked Fanta’s pulse. Abu’s breathing had lessened in intensity and decreased in speed. I carefully shone the light on Fatmata, and I could see her stomach rising and falling. Then we went back to sleep.
In the morning, Sasseko woke me up with his cleaning. The sun was coming up, and it was 6:36, according to the cellphone. I sat down and wrote most of this, before the new patients for today arrived.
By 7:30, Fanta was awake and laughing. Abu was awake and silently staring out at the world. His belly was still distended and round, with his belly button protruding. I spent a moment with Fanta because I was amazed at how fast she had gone from semi-conscious at 4pm the day before to laughing and alert at 7:30am.
“Good morning, Fanta. How de body?” I sat on the edge of Abu’s bed, facing Fanta. She was standing beside her bed.
“E’ done greet you now,” said Fanta’s mother, to Fanta. Fanta didn’t look scared, but she looked wary. I reached out and shook her hand with my thumb and two fingers.
“You de get welbody, Fanta. A proud.” You’re healthy, Fanta. I’m proud.
A few minutes later we gave Abu his final round of quinine. He whimpered a bit at first, when the quinine started coursing in his veins, but his dad whispered, “Abu, Abu, be man, Abu, hush...” and Abu was quiet.
On the other hand, Fanta was making up for her silence the day before. I carefully kept her legs in place, and her mother kept her shoulders and arms still, but nothing was stopping her impressive cries. I took that to be a very good sign; she was healthy enough to throw up such a spirited resistance.
Fatmata was also awake, and very suspicious of me. However, she too looked much better. Soon she went home with her family.
Fanta had another round of glucose solution maintenance for her hydration, so she stayed around until about 1pm. Abu’s father was 2000Le short on payment, so Yusuf refused to take out the IV line from Abu’s hand until the dad found the money. As both Bailor and Allan have told me, although there is plenty of poverty in the Kono District, there is also plenty of family support. If someone really needs 2000Le for health, they can almost always find the money somewhere in the family.
Soon the clinic was back to being hot and sweaty. When Abu said goodbye, he didn’t take my hand, he only looked intensely at me, as if he hadn’t noticed I was expecting him to greet me back. But I didn’t mind. It was much better to see the three pikin (Krio word for children) walking around than sweating from malaria under the moonlight.

Malaria by Moonlight Part I

2009-07-01T19:45:00.000-04:00

I sat down on the edge of the bed and took hold of the little boy’s arm, firmly but gently. He was radiating heat, even in the hot African afternoon. He was sweating, and he was scared.
According to the medical form, Abu was three years old. (Out here in Kono, using only first names to identify people provides an unprecedented level of anonymity; there are more repeated names here than in A Hundred Years of Solitude.) His father had brought him to the clinic about 2pm that day, just as Katie and I slipped out for lunch. The chief complaint was his distended abdomen. As I quickly noticed, he also had an intense fever.
Almost every patient who comes to Yusuf, the nurse, gets a malaria test. It is common, dangerous, and the test is cheap. It’s especially dangerous for children who have nutritional problems. Abu’s malaria test came back ‘++’, which meant that he had between 10 and 20 malarial parasites per viewing field on the microscope. His hemoglobin concentration, however, was 7.0g/dL. That’s about half of the median recommended value.
Yusuf had prescribed him a course of quinine during an overnight stay, and now we were all gathered round the middle bed in the observation room, trying to put in the IV line. Yusuf, Bori, Confort, were all buzzing around the bed with jars, vials, and syringes. Abu’s father was quietly holding Abu’s legs with both hands. I was holding Abu’s arms.
At this point all I knew was that Abu had severe malaria. This confused me a bit, because while the malarial test result, fever, and hemoglobin concentration all matched, the distended abdomen didn’t fit. The next morning I learned that Abu had been given a large quantity of traditional herbs by someone, but Bori couldn’t tell me whom. I’m not sure if Bori knew but couldn’t say, or if Bori didn’t know but the father knew.
I’m no doctor, but usually the liver filters and otherwise deals with chemicals entering the blood, and when large quantities of strange chemicals come through, it can get temporarily damaged. When it’s damaged, it filters at a slower rate, which increases the blood pressure and causes water to be forced out of the blood into the spaces between cells, especially where the pressure is highest – right by the liver. Bori told me that it could take Abu weeks to recover from the damage from the herbs.
I could feel a slick layer of sweat forming between my hand and Abu’s forearm, which I was controlling. Confort handed me an alcohol pad to open and then hand to Yusuf. Yusuf carefully wiped the area above Abu’s wrist. Then he pulled a syringe device out of a package. It was a syringe with a rubber tube on the inside. All the adults braced, but Abu just kept crying at the same intensity. He didn’t know what was next. Yusuf had already tied off Abu’s arm with rubber just below the elbow, so I guess Yusuf could see where the vein lay. I couldn’t.
Yusuf stuck in the needle. Abu screamed more, and tried a bit harder to get free. When the needle was in, Yusuf slid the rubber tube through the needle into Abu’s vein. Then Yusuf removed the metal needle and attached a small plastic apparatus, kind of like a tap, to the end of the tube. A bit of blood came out of the apparatus before he could close it. “Gloves...” Yusuf shook his head. No one was wearing any. I actually hadn’t seen a pair since I arrived.
Confort and Bori, I think, were setting up the small jar of medicine. Confort was busily uncapping syringes, inserting them through rubber seals into small glass jars with long scientific names on them, withdrawing some small quantities, removing the syringes and capping the needles. Sometimes she diluted with water after drawing some chemical into the syringe. This involved holding the plastic water container at an angle, inserting the syringe through a small hole in the top, and pulling in water to the right amount. The largest glass jar was already hanging from the IV stand, and every now and then Confort would inject something right into this jar, through its rubber seal. The Krio all around was loud and argumentative, but it was mostly gibberish to my ears.
“Hold on. A de go for de get towel, a de soak towel an putam na de pikin.” I parroted a section of our malaria health module to Yusuf and the dad, and then motioned for the dad to hold Abu’s arm as well. Yusuf was in control of the arm with the IV.
I ducked outside and soaked my bandana in well water. I shook it off a bit, then came back in and wiped Abu’s brow a few times. It may have been coincidence, but he calmed down quite a bit. Amhidu was reclining on the third bed in the observation room, and he laughed. “You de soak towel, an’ putam na de pikinbody.” He quoted part of Katie and my health module on malaria.
After a while, the line was hooked up and the yellow medicine was dripping slowly down into Abu. Yusuf went back to the consulting room for one last patient, but Bori and Abu’s dad stayed. Abu’s dad and I kept him from flipping and twisting to prevent him from hurting the IV connection.
Abu actually wasn’t the only patient in the observation room. The first bed was occupied by Fanta, also three. I’d found all my computer class students while they were putting the IV into Fanta’s wrist. She also had ++ malaria, and she was very dehydrated. Later on that evening, her mother explained to me that Fanta had been in another hospital for two days, but she wasn’t getting better, so the mother pulled her out and brought her to our clinic. Putting in her IV had been much less eventful; she was very dehydrated and weak. I think there was something in the medicine that was making her sleep. Her treatment was a four-hour alternation between quinine for malaria and glucose solution for her dehydration. Every now and then I watched carefully to see if she was breathing, and took her pulse. It’s all I really know how to do, but it’s a good warning sign. If it’s too slow and weak, something is wrong. If it’s too fast, something is wrong. Otherwise, at least the heart is working alright. as Abu went to sleep, Fanta began to stir, so I moved over and made sure she didn’t damage her IV while flailing in her sleep. Her mother had gone home to get some things for staying the night.
“Wait. So Bori, you are going to stay with the patients tonight?”
“Yes.” Bori looked at me with his trademark wide-eyed excited look.
“Okay.” An idea was forming. Why couldn’t Katie and I stay too? We’d just need to duck back to Uncle Ben’s for a couple of things. That would only take two hours of walking, or twenty minutes of forbidden motorbiking.
“Hey Amhidu, could Katie and I stay here tonight, to stay and help Bori?” Amhidu laughed at me. I think he finds Katie and my enthusiasm a bit entertaining.
“Doctor Chris, you want to stay close to the patients?”
“Well, I’m just wondering if there will be enough places to sleep. I figure there’s the third observation bed, Allan’s room, the consulting room, and is there a mattress?”
“Hmm?”
“What do you guys do when there are more people than beds here?”
“There is a mattress that we use only when we have too many people.”
“Perfect.”
In a few minutes, I asked Bori.
“Hey Bori. Could Katie and I stay here tonight and help you take care of the patients?”
“Hmm. Ask Yusuf.” I was a bit surprised that Bori hadn’t immediately thought it was a good idea, but there was a good chance he just didn’t understand me, or that he didn’t want to overstep his authority.
When Yusuf finished his consultation, I asked him. “Yusuf, could Katie and I stay here tonight and help Bori take care of the patients?”
“You want to stay to help with the patients?” I nodded. “Till daybreak, all the way?” I nodded again. “Well, that is a great idea! Great, great. Bori!” Yusuf yelled for Bori, and told him what was happening. Bori was excited.
So Katie and I headed back. We picked up grilled meat and bread sandwiches on the way. We were back at the clinic by 7:45pm, just as the sun was vanishing. There were three tiny women bowing and praying on a rug on the porch of the clinic. Each one was wearing a different African pattern of yellow, green, and blue.
Inside, Fanta was still asleep, but now her mother was sitting beside her on the bed, cradling the arm with the IV. “How de body?” I asked.
“No’ bad.” She looked worried.
“How Fanta?”
“She sleep nomo.” She only sleeps. I nodded.
“I’ good. She de get welbody.” That’s good. She’ll get healthy. Fanta’s mother looked unconvinced.
Abu was asleep, but breathing noisily.
Abu’s father was out in the waiting room with a black plastic bag. I assumed he had some food inside. “You de sweat!” He said. I laughed.
“No, a been wass!” No, I washed! He seemed confused.
Out in the waiting room, I met the third patient, Fatmata. She was bouncing on her mother’s lap. Her mother was one of the women I had seen bowing outside, and she was slight and young. The other two girls were also her daughters, I think. Fatmata was a very chubby 10-month-old. I won’t lie, I don’t mind seeing chubby children in Kono. She seemed pretty unhappy, however. According to her chart, she had been brought to the hospital simply because of her fever. We gave her a mix of three antibiotics at 5pm, 1am, and 9am, so I inferred that she had some kind of bacterial infection. Her IV tube went in on the inside of her elbow, and she seemed much healthier than the other two.
Before we left to go back to Uncle Ben’s, Katie had been recruited to help with Fatmata’s IV placement. Unfortunately Katie was most unpopular with Fatmata, who may forever associate ‘white’ people with terrible pointy needles. In any case, Katie was trying really hard to comfort her.
Fanta never stirred, but Abu eventually woke up and walked around a bit. We disconnected his IV when he awoke. Katie and I worked a bit on OpenMRS, occasionally checking in on the patients, and Bori took advantage of the power to try the typing program Allan installed on the desktop. He loved it.
Eventually Bori pulled out a double-bed-sized mattress and tossed it on the ground at the door to the observation room. In the process he unplugged the generator power cord. I winced, because the desktop had been on. Oh well... Bori said to me, “You can sleep here.”
“Well, where will you sleep?” We had already decided Katie would sleep in Allan’s room.
“Don’t worry about me!” Bori clapped me on the shoulder.
“I can just sleep like this,” I lay down the wrong way on the mattress, so that my feet hung off the edge and there was an obvious space for another person. Bori liked that.
“Okay, good.”
We turned off the lights. I set up a small lantern in the observation room so that no one tripped over any cords, and then I lay down to sleep. I offered Katie her watch, but she let me keep it. I set the alarm for 11:57pm. There were a lot of bugs; it was the first time in Africa that I’ve been legitimately annoyed by bugs while going to sleep. I also thought about how glad I was that I took my Malarone (malaria prohpylaxis) – there were plenty of mosquitoes. The buzzing annoyed me to sleep.

House and Machete

2009-07-01T19:32:00.003-04:00

I was restless. It was dusk, and I was alone at Uncle Ben’s. Yann Martel’s Life of Pi was lying on the bed beside me, spent. So I went for a walk. That is, I went for a stroll, as Krio speakers are liable to look at you as if you are crazy if you tell them you are going for a walk, and if you instead mention the word stroll, they instantly understand.
Case in point: To begin my stroll, I left Uncle Ben’s and turned right instead of the usual left. I followed the road along a ridge around to the west of Uncle Ben’s, through a schoolyard with a red dusty field, past maybe fifty different steaming pots of rice and twenty unabashedly fascinated children. That landed me amidst a narrow grid of orange-red clay houses. The path was very narrow, and I walked through more than one front yard, and had to graciously decline a dinner invitation. Then I turned a corner and was face to face with three girls, about my age.
“Eh!” One of them made the peculiar high-pitched squeak that is ubiquitous in Sierra Leone. “Ousai you de go?” Where are you going? She looked affronted.
I shrugged. “Jus’ strolling.”
“Ohhhh.” All three nodded in agreement. It was a fine night for strolling. Nothing amiss here. I proceeded on, over a narrow path through a swamp, and then found my way back to Uncle Ben’s.
But I was still restless, so I left again. This time I walked down the main road out of town. Perhaps ten minutes southeast of Uncle Ben’s, the main road dips into a kilometer wide valley. The valley floor is a checkerboard of swamp, bush grasses and boulders, with rolling hills in the distance. Some are bald save the light green fuzz of freshly planted rice, and others have a smattering of palm trees. Tall old growth trees are rare, and from a distance it’s hard to tell whether the bush grasses at the feet of the palms and trees is two feet high or ten feet high.
The main road itself is typical of Koidu Town; somebody paved it once upon a time, but now the pavement bears more resemblance to the moon than the 401 and so all the vehicles drive with one wheel on pavement and the other wheel on the shoulder. This road isn’t as bad as some; on the Kainkordu Rd. in town, the pedestrians walk on the pavement in the middle of the road and the vehicles use the shoulder. It’s a strange inversion, as strange as the backwards development that has left Koidu Town with these roads. It was the diamonds, the locals will say. Before the war, they go on, with a clichéd widening of their eyes, Koidu was very big, with lots of money. Everyone was coming, and you could find diamonds just walking along the road after a rain. But the rebels took it all, they end. I’m never sure how much to believe the fairytale vision of Koidu. I believe the part about the rebels.
In the middle of the valley, off the road to the right, I noticed a shell of tiny house. It was made from orange-brown clay bricks, but all that remained was most of the exterior walls and window frames. One of the two corners closest to the road was smashed, and it looked uninhabited. That last point was a bit odd, because throughout Koidu there are similar ruins of houses brimming with people that clearly still live there. Amhidu confirmed my suspicion that by and large the inhabitants of such ruins are not the original owners.
The house was perched on a rocky promontory, above the valley, set back thirty paces from the road. At the end of the valley the sun was sneaking away into hazy obscurity instead of broadcasting a sunset across the sky. It seemed kind of fitting in the humidity. I thought about going to sit down on the edge of the promontory as I first passed the house, but didn’t.
A little further along I came to a bridge. I stopped, pulled out my cellphone and looked at it with purpose so that my fellow pedestrians wouldn’t think I was lost, and then turned around and walked back to the little house.
There was a path going past the house that was quite well-worn. The fork that headed towards the house, however, was very overgrown. I cut around to the left of the house, paused, and then sat down on the rock face.
First I considered the clouds. Some were puffy cumulonimbus clouds, filling out like anvils just as the textbooks say they do. But layered between those clouds were hazier white clouds, obscuring the sun. I don’t know the name for these clouds. Katie often points out how majestic the clouds are here, but I didn’t think they were very different from clouds anywhere else until I could think of a good reason for the difference – the humidity. Poor Katie, she’s very patient.
Those clouds weren’t majestic, though. They were calm. The hazy white clouds cast a fog over the hills, so that as they shrank into the distance they also vanished into the mist. For some reason palm trees stand out particularly well against hazy fog, so I could see many spiky palm trees silhouetted against the sky. For a few minutes, I was calm too.
All around me cricket chirps competed with car and motorbike engines. My mind kept wandering back to the idea that I was just far enough off the road, with my back to the path, the sun going down and no one else around, to be a great target for robbery. In general Koidu Town is safe, but the unspoken rule in Sierra Leone is that you don’t present an opportunity for crime, not if you’re wise.
I waited a minute longer. There’s some youthful pride in me that hates to let quasi-rational fears dictate my actions. At least right away. After thinking about it for a moment, and promoting the idea to fully-rational status, I stood up to leave.
Immediately I was face to face with a small boy, maybe eleven years old. He was staring at me intently, with a very serious face. In his hands was a giant machete. He was hugging it absentmindedly.
In retrospect, the machete wasn’t giant; he was small. At the time, though, my brain filled with images from A Long Way Gone, a book written by a former child soldier from Sierra Leone. And I heard the voice of Bailor, explaining about the amputations. “Foday Sankoh recruited the youths. And the small boys, they were too small for guns, but you can give them a knife, you can give them a machete, and then you give them some drugs, and then...” He says the word ‘machete’ with only two syllables. There’s no “eee” on the end – it sounds like “mash-et.”
“Good evening, sir.” I spoke deeply and firmly.
“Good evening,” he mumbled back, eyes still wide and fixated on me. We paused a moment. Then he set off down the well-worn path, and I walked back up to the road, restlessness gone.

Health Education Modules: Tricks we've learned

2009-07-01T19:24:00.000-04:00

In presenting the health education modules in the amputee camps, Katie and I have learned a bunch of tricks. This post is going to be all the tricks that I’ve learned or that Katie told me she learned, or that I noticed Katie uses effectively. She probably knows a bunch more that I just haven’t noticed. I’ll have to ask after I finish the list!

1. It’s planting season, so it’s better for us to gather as many people together at one time as possible and then for all four of us (Jalloh, Amhidu, Katie, me) to present together. Initially we were going house-by-house, with the goal of keeping the audiences small. The audiences were non-existent, so we switched to the group method. Another asset of the group method is that the entire community can here the questions that other community members ask.
2. There are some questions that get asked every time, and so we now incorporate those right into our presentation. For example, “Can you get HIV from a mosquito?” – No, although that is a perfectly valid, even insightful question. I think the reason why is that the mosquito ‘needle’ is far too small to carry enough virus to infect another person. We explain that the mosquito doesn’t inject any blood, because it wants all the blood for itself, and that malaria is specially suited to living in mosquitoes’ mouths, and that’s why you can get malaria but not HIV from a mosquito. The scientist in me makes a face when we say that, but I’d rather not start a trend of uninformed amputee camp members thinking that small exposures to HIV are okay...
Another common question in our teenage pregnancy section goes as follows: “What do you do if, even though you try and try and try to watch your pikin (child), they still run off with boys and do business (have sex)?” The answer: It’s really tough, but you have to have patience and teach them how to use and where to get condoms and birth control. I don’t have any more experience with that situation than most other 22 year old Canadian guys, so it feels weird to answer such a question, but it’s important nonetheless.
3. Our translators sometimes extemporize and go into the next part of the presentation before we say it in English. We’ve learned that it’s not a big deal; it’s only when people are asking questions that we demand precise translations. Otherwise, Amhidu and Jalloh act as good cultural as well as linguistic translators.
4. English acronyms don’t work in Krio. I’ve given up trying to explain the ABCD prevention system for HIV/AIDS (Abstain, Be faithful, use a Condom, Don’t use unsterilized skin piercing instruments). Instead I just explain and number each point.
5. It helps to position ourselves in the obvious exit to the space we have been given for teaching. That makes it much more difficult for people to wander out when they get bored.
6. Similarly, learning a couple of names can go a long way. When a person whose name you know tries to slink away, we just call out nicely and they usually come right back.
7. The order of presentation needs to be flexible to the situation. For example, a fight nearby once attracted fifteen or twenty teens and preteens. We called them all over and immediately cut to the teen pregnancy section.
8. Make sure that all audience members are in the shade and will be in the shade throughout the presentation. Otherwise they will leave when the sun reaches them.
9. Learning and then using some of the Kono vocabulary for our modules always gets a big laugh and wakes up the audience. Katie does this very well. For example, she always uses ‘chima’, the Kono word for fever.

That’s all for now. Tomorrow morning Katie and I are presenting in the Motemas, the last two camps. We’re not sure whether that will take one or two days, but soon we will be changing over to the surveys that we will use to assess how much the amputee communities retained the information in our modules.

Photos

2009-06-27T21:06:00.001-04:00

Katie posted a bunch of photos at perambulating.wordpress.com!

Sierra Leone lite, for my roommates.

2009-06-26T20:19:00.002-04:00

Dear Sajid, Will, and Jacob,

Ten points about Sierra Leone.

1. It's a great country for doing stuff. For example, the car breaks (often), we have to jump out and push it. And how do I get in and out of the car, you ask? Oh, the window. I grab on the roofrack and jump in... It's fun for someone who knows absolutely nothing about cars. Another reason that it's a great country for doing stuff is that none of the Sierra Leoneans know how to second guess the North Americans. So when we suggest something that seems ridiculous to them (like me helping to make peanut butter) they just look bewildered and make it happen.

2. It's also a good place for figuring stuff out. I found Katie's guest house the other night by noting that one street at the nearby intersection was called "Siaka Stevens" street. That happens to be the first leader of Sierra Leone after colonialism, so I figured it was a major street. It is! Of course, I still got lost on the way.

3. And it's great for hanging out. Long journeys and tons of cultural differences to spark conversation. Unfortunately I still fall asleep in the car on occasion.

4. Water comes in bags. Yep. And we don't even put it in a "what-the-water-should-be-in" for drinking, we just bite off a corner and suck it dry. I think I'll drink my milk like that when I get home.

5. I saw a cobra. Need more be said? (Yes. We were in the car, it was slithering away into the grass. The driver had a typical Sierra Leonean response: he tried to run over it.)

6. I get to pretend I can understand Krio. I'm about as good at pretending to speak Krio as I was at pretending to speak Italian.

7. We went to the north, and then CANOED with HIPPOS. Katie even listened to me be a canoe snob about how the locals weren't using the jay stroke. She even still speaks to me. Whenever I feel bad about being a canoe snob, I just remember that my grandmother was a canoe snob, and so it must be okay.

8. When someone says "White man!" I can respond "Black man!" without getting prosecuted or hurt.

9. Next year, our room is going to be a chiefdom. I want to be paramount chief.

10. There's lots more things to test my invincibility. For example, while I was chilling on the porch at Uncle Ben's a couple weeks ago, I squished a toxic/acidic bug between my shins. That resulted in nasty blistering burns that then got infected. I cleaned them out, and then my immune system did its thing, and now it's healing fine. Apparently this bug ("The Champion") likes me - it also crawled on my arm, and earlier, on my face. But neither of those were as bad. At the time, I thought the one on my face was some kind of disfiguring tropical disease. Fortunately it was not.

Cheers, Chris

Some snapshots of gender roles in Sierra Leone

2009-06-26T20:08:00.010-04:00

In Kamakwe, the village of Dr. Barrie.

“How de body?” I gave our small guardian a measured look. Her name was Asinatu. She was probably about ten years old, with carefully braided hair, a big piece of African cloth that she kept readjusting around herself as she talked, and a serious look.
That morning she hadn’t said a word to me; she had only produced the key to the locked room when Katie, Allan or I needed it. I’d woken up just as dawn broke, and gone outside to sit on the steps of the house. Mist was still thick over the other houses and grass-roof cooking huts. Asinatu moved all around me, carrying buckets and brooms back and forth from the house to the cooking hut. She hadn’t even batted an eye when I first said good morning.
Now we were sitting in the house, waiting. Amhidu had more or less abandoned Katie and I in this house in the corner of Kamakwe, and we were firmly stuck behind a fence of cultural and linguistic barriers. I was sitting on the floor, treating the toxic burns from “The Champion,” a bizarre acidic bug that had visited my legs a few days ago. Apparently it trails the acid as it walks.
Katie was doing something in the room with our stuff, and Asinatu was sitting on a chair, watching us.
In response to my question, she murmured “No’ bad.”
I gestured to my burns, “Me de get burnt na champion. You de know wetin na champion?”
She shook her head. She didn’t know about the champion. At least, that’s what I thought I had asked her. ‘Wetin na’ means what, more or less, but my Krio is quite unreliable. We lapsed into silence. Asinatu continued to stare me down with a very regal gaze, as I sat amidst a couple of alcohol pads and some Purel.
“You de go na school, Asinatu?”
She nodded.
“Which class you de study?”
She held up an open palm.
“Fifth year?”
Nod. We were quickly approaching the end of my Krio, given that I didn’t think she wanted to hear about malaria prevention.
“You de got favourite subject na school?”
She looked confused. I tried again.
“Wetin subject you de prefer, wetin subject you de like?”
Her eyes glimmered for a moment. “Math. Me de like math.” Her voice was much stronger this time.
“Math! Math i’ good. I de like math too. Math will take you very far.” I suppose the last part was a vanity; she didn’t understand my English. “Wetin you wan’ for do after SS?” I thought that meant ‘What do you want to do after secondary school?’
“I’ not for long tem.” She was more reserved again. I heard a note of wistfulness, but I could have imagined it. She was right, however. That was a long way away.
“Ousai you de go for SS?” Where are you going to go to high school?
The confidence was back. “Freetown.”
“That’s good,” then I recalled my first Krio lesson – ‘fine’ means ‘good’ – “fine! Fine.”
We fell back into silence. I dabbed some ointment on my burns, and then capped the tube.
Later Katie and I told Allan about Asinatu. He said “We probably don’t want to know what happens in her life.”

“So Amhidu, your sister lives here?”
“Yes.” Kamakwe was a giant labyrinth of familial relations – as far as we could tell, everyone was related, and none of the Sierra Leoneans seemed to be very careful about using the correct terms. Cousins were sisters, aunts were ‘Mama,’ as were pretty much all ladies older than thirty, and I was confused. However, I did know which girl was Amhidu’s sister.
“Does she have kids? I think we met her last night, on the porch, with a couple of other young women and a huge bunch of kids.”
“No, she does not have children. She takes care of my grandmother.”
“So your sister stays here, taking care of your grandmother?”
“She is not my sister, she is my cousin.” Well, I guess I didn’t know which one was Amhidu’s sister. I did know which one was his cousin.
“Right.”
Katie jumped in. “So wait. Do the girls in this town go to university?”
“No, they stay in the village, and they hope to marry.”
“Do they think that is unfair?”
Amhidu shrugged.
“What about your sister? Will she stay here?”
“She hopes to go to university. But her WASS is not so good.” WASS is the high school diploma (West Africa Secondary School, I believe).
“So she’ll just study, and then retake it?”
“Yes.”
“But wait. What if she just gets married, and can’t go to university?”
Amhidu turned his head a bit, as he often does when thinking. His turning face and eyes draw you along, and give the conversation a moment to pause.
“As for me, I will not let that happen to my sister.”

“What about rape?” We were talking about capital punishment. I had asked Allan about his stance, and then quickly realized that asking Sierra Leoneans would be more interesting.
“No, rape is nine months.”
“Nine months!” Wow, that’s terrible.
“No, no! Eight years, eight years!”
They debated in Krio for a moment, and I couldn’t follow. But I could feel the curiosity and questions oozing out of Katie. She asked, in careful warm tones, “Are there a lot of cases of rape in Sierra Leone?”
“No, not so many. You know, you know, many of these rapes, many of these cases, they are just reported by the families, they are not real rapes.”
“What do you mean?” Katie was the soul of diplomacy. I was silent.
“They just happen because the girl, she is a virgin, most of these things they happen to virgins, and she doesn’t think, she doesn’t expect it will hurt, so then she cries out, and the family comes and says that the guy raped her,”
Katie said something to get him to keep going.
“I used to work in the rape unit in the hospital, and we would examine the rape victims when they come in, to see if there is damage, any tears. But most of these girls will not say they were raped, the family will say it,”
“Why?” Again, Katie’s impressive self-control.
“Because they wan’ money. Most of these things, in Sierra Leone, they are settled out of court, for money, so the girl’s family can get money.”
“So these are the reported rapes?”
“Yes, the reported ones. Most of the reported rapes are not real rapes. Maybe one percent.”
I asked a question. “What percentage of Sierra Leonean women would you say have been raped?”
“I don’t know,” someone else answered, “ve’y small. Maybe one percent.” The popular one percent statistic.
Later, I asked Katie what she thought they would say if we told them that a quarter of North American women are sexually assaulted by the end of university (the statistic told by SHARE, one of my favourite student groups at Princeton).

“The thing is, we have to make sure Katie gets well. It’s not just for Katie, I mean, I’ll be really sad if she’s sick.” I actually thought that Katie was already sick. She was standing off to the side, and I was being pushy, trying to make sure the outcome I thought was best was the one that happened. We were in Freetown, and Katie was very rundown after several days of not sleeping well and being well beyond her comfort zone in terms of hygienic conditions. At Uncle Ben’s everything had been fine, and so I thought we should try and head back a day early. Beyond that, Katie couldn’t sleep well at Dr. Barrie’s because there was only one mosquito net, it was noisy, and it was very hot. She has pretty severe reactions to mosquito bites and doesn’t naturally adapt to heat that well. That means that she is constantly facing much more adversity than me, and so I’m completely in awe of her determination. But it was too early in the game to get run down, so right now the best course of action was for her to stay in the hotel we had stayed in the first two nights. It was quiet, it had A/C, it had clean washrooms, and it had power. Katie wanted this too, although she doesn’t like to miss out on things nor to see groups split up.
“Oh yeah, that’s okay. It’s different for girls.” Dr. Barrie’s reply. I can’t believe I hadn’t seen that this was the first place the whole situation would go, but I tried to save it.
“No, it’s not a question of guys and girls, it just happens that I’m lucky that I can sleep on the floor and I’m not bothered by the mosquitoes or the heat.” And I also have dulled hygienic standards, not usually an asset. But for now, the damage was done. I had been the one speaking up in the first place anyway, right? Damn.

So I got lost while trying to find Katie’s hotel. I eventually found it, and we had a sumptuous meal of bread and fresh peanut butter. Calling palm oil repetitive is an understatement, even for my unambitious food tastes.
A couple days later, Alimamy, Katie and I were getting ready to return to Kono. “Keddie,” that was how Sierra Leoneans say it – it’s a Sierra Leonean name, “can you get back to your hotel? Walking?” He had a mischevious gleam in his eye.
“No.” Katie was honest about it. Alimamie laughed.
“Chris is much more clever, haha!” Damn.
“No, not at all, Alimamy. Allan just drew me a map.” I had even gotten lost on the way. But Alimamy’s attention had wandered.

It was very late at night, about one in the morning, and I was waiting to work with Bailor. The power was out.
He works very late. So does Binta, his wife’s younger sister. She’s a secondary school student. Her and Asma, Dr. Barrie’s wife, look like twins, so for a while I thought Bailor and his wife were huddling over some finances. I could hear arithmetic every now and then. But then I noticed, no, it was Binta, not Asma. So he was tutoring her. And I remembered that Allan said he tutored her every night. Given that Bailor usually gets around three hours of sleep a night, that’s a pretty special investment of time.
“No, greatest common factor na...” snippets of math jumped out of the Krio and caught my attention. Eventually I let Bailor know that I was fading, and that if he wanted to review the Open MRS form drafts I had concocted, we’d better do it soon. Binta kept working, and then I went to bed, and as I slipped into sleep I could here the two of them debating greatest common factors.

“Keddie!” Katie and I were walking to the clinic, a week or so ago. We were walking up the hill on the main road, towards the center of town. Two women wearing colorful African dresses were calling her from the righthand side.
“Hi! How de body?” Katie is always very friendly to the people that speak to her. I’m more stony. But these two women often call out to Katie, and it’s much less likely that women will take a friendly wave to mean that they can come tell you a story ending in a plea for money.
“Fine, fine. How de body?”
“Fine!” Katie was smiling from ear to ear. We hardly ever get to even talk to women in Sierra Leone, but they seem to love Katie. These women knew her name from stopping us in the street the week before – I think. But it may have been simply through word of mouth.
It’s not hard to guess why seeing Katie, a ‘white woman’ would be so exciting to these women.

A Wrong Turn

2009-06-24T19:46:00.002-04:00

A Wrong Turn.

Allan had drawn me a map; Bailor had approved it. And now I was
there, at the clock tower, one of the main landmarks in Freetown. The
best word I can think of to describe Freetown is "thrown-together",
and that's really two words. Allan has used noisy, dirty, crowded, and
hot, when he's feeling favourably towards the place. But he doesn't
like big cities anywhere (save London, England), because those are
pretty common characteristics of big cities.
The clock tower circle was thick with people. There were fruit
stands, bread stands, piles of crackers and cookies on shelves, on
wheelbarrows, on heads. Cell phone minutes, boiled eggs, roasting
meat, and bags of water, all on top of each other. Everything was
being sold at every height from head height to the ground. The market
chaos was creeping out into the road, getting as close to the traffic
as possible, and there was no room for the pedestrians in between. Of
course, there were piles of pedestrians, four or five across, circling
the clock like a whirlpool.
Five streets come together at the clock tower. I plunged down the first one.
I had to watch my feet, and my hands were glued to my pockets. This
street was much narrower, and there were people everywhere. Women and
men of all sizes and ages were all squished together in a giant
claustrophobic mess, wearing traditional African clothes, or
secondhand North American t-shirts, or both. Some people told me off
in Krio, others stuck with "Wan' to be you friend!" but overall
everyone left me alone. Somehow, in the calm but sweaty crowd, I was
more anonymous than I've been in days.
The road narrowed and immediately curved to the right. The ground was
dirt, not paved, and smelled vaguely of sewage in places. I tried not
to step on anything wet. At this point I'd become a bit numb to the
kaleidoscope of sellers and salesmen. But then I noticed the
poda-podas.
Poda-podas look like old Volkswagon "hippy vans." They are usually
painted in bizarre colors with equally bizarre slogans – everything
from "Man suffer" to "Believe in God" to "Honor thy sister." They are
also all packed with people, sometimes on the outside as well as the
inside. Although you probably have some idea of the size of the
poda-poda, you also need to know that they were exactly as wide as the
road. So we all hustled over to the sides, fitting in around the
boiled eggs and flipflops like the last clothes in a suitcase. A
couple of poda-podas went past. They left a terrific cloud of exhaust
that went nowhere in the humid Freetown dusk.
As I walked, there were more and more poda-poda, and also the odd
industrial truck. Sometimes I had to take my backpack and put it over
my head to squeeze between poda-podas and trucks, and I was lost. So I
turned around. People were crushed together, being carried through
tiny and exhaust-filled gaps around poda-podas. Then,
"White man! White man!" There were more people shouting for me than
usual. Wait... I noticed that everyone had stopped. And there was
music. Orchestral music, playing from cheap speakers. So I stopped.
Some people laughed. Everyone stood still. There was space on the
street, and I looked around. Religion? What was this? National anthem?
The music stopped with a crackly cadence, and all the open space
filled with movement and sound. There was mud and sweat and exhaust
everywhere. But I couldn't see the speakers!

After a few more steps, I was back at the clock tower and not lost. It seemed like it had taken far longer to wind my way down the market streets then to find my way back. From the clock tower intersection, I found the right road - it was paved, and less crowded.

It turns out that every day at 6am and 6pm, the national anthem of Sierra Leone is played in the streets of Freetown. That corresponds to the raising and lowering of the flag for the day.

Funky formatting

2009-06-23T18:50:00.001-04:00

To save bandwidth (kilobytes per second is a wild ride) I've been
submitting my blog entries by email. Unfortunately it looks like the
email submissions end up being formatted like bad free verse poetry.
Well, it's not intentional, and I'm not fixing it until I get home.
Enjoy! Cheers, Chris.

Pastor Kadie's Farm Part I

2009-06-23T18:46:00.001-04:00

"So, Eddie, what is... what exactly is the difference... is
masangke... what is masangke?" I tried several different questions in
short succession, as soon as we got out of the car. Eddie, the farm
manager, just looked at me with wide, uncomprehending eyes. I'd
already tried this question many times, and gotten many answers that I
already knew and were not what I wanted.
We'd spent two afternoons coming up with a business plan. Katie and I
had been trading off between saving web pages and reading them on our
computers, passing the USB wireless back and forth. Tenera, Dura,
Psifera... we even knew the genetics that determined the different
breeds of oil palm. We knew the percentage of oil by mass of a fruit
bunch for each breed. We knew the global price per metric ton of palm
oil over the last three years, by the month. We knew the expected
yield of a hectare of Tenera palm every year for 16 years out. We knew
the steps of the process, in theory, and we had some leads on where to
get equipment. I was particularly proud of our discovery that we
should lay out the palm trees in a hexagonal pattern to maximize the
density. The reason why I liked this innovation was that it agrees
exactly with the mathematical fact that if you want to pack the
largest number of identical circles – say, palm tree canopies – into a
given area, each circle touches six other circles.
But most of all, we knew that there was a crucial decision to be made:
which palm should NOW plant on its 10 acres?
Planting season ends at the end of June, and the tractor can plow 1
acre per day. The field has to be plowed before we can plant the oil
palm seedlings, but as the plow works other workers will fill in and
plant in the already plowed land. So the decision about which tree to
use had to be made now; tomorrow at the latest. That left Katie, Allan
and I trying desperately to connect our internet-researched knowledge
with local terminology and wisdom, in order that our research could
inform Bailor's decision. I was trying to decipher the mystery of
masangke, the yellow, less desirable palm oil.
Eddie is the farm manager. He was wearing a shiny blue African shirt,
and his eyes were wide and a bit scared above his sunken cheekbones. I
was trying not to intimidate him by laughing and apologizing for my
barrage of questions. It wasn't working at all.
The car had stopped, for some reason that I wasn't able to understand
from the fast Krio in the front seat. Amhidu, Sahr Bindi, Eddie,
Allan, Ali (new driver), Katie and I had all driven out to see the
nursery where the palm seedlings were kept. I was fervently hoping
that we would resolve our question of which type of palm to plant. At
this point the options ranged between four different varieties, a mix
of two varieties, and a single variety. As I got out of the car, my
brain was firmly engaged in mental calculation about what masangke
might be, and whether it was a product of specific varieties of palm,
or whether any palm could produce it.
The road was gravel and dirt, and cutting across a slope. There was
green everywhere else, both uphill on the left and downhill on the
right. A palm plantation sloped away to the right. It looked like a
valley bowl with a few palm trees and a sparse cassava ground cover.
At the far side of the valley, the land curved upwards again towards a
bald but green hill. In the center of the valley there stood a massive
tree. Its bark was a shiny light grey, and it had no branches for the
first sixty feet of trunk. At that height, the branches arced out like
a menorah, turning gradually upwards and ending in dappled green
leaves.
I gave up on Eddie for a moment. "Wow, look at that tree." I gestured
to Katie and Allan, they didn't hear me. "Look at the tree!" Still no
response. Okay, well, it's a nice tree anyways. Eddie heard me; if he
understood, he might have agreed.
"That's what all of Sierra Leone used to be." Allan did hear me. "But
then they cut it all," Allan made a small 'cutting' shake of his head,
"Look at the grove up there." Further up the hill, on the other side
of the valley, a thick grove of the same type of tree had turned the
hillside dark green. I could see graceful grey branches reaching
sideways through the canopy.
"Wow."
Something caught my attention up on the left. The slope was pretty
steep, but there was a small family a short ways up the hill. There
were fewer trees on the left. A tall black man unfolded from the small
group and began ambling down the hill towards us. He had the answers,
I knew it.
"Eddie, just elbow me or something if I'm being obnoxious." I don't
think Eddie understood me. We were having communication problems, and
they were exclusively my fault. But they could be resolved later – for
now, I was dying to find out as much as possible about oil palms.
"Oh, okay... this is the farmer, the one with the trees..." Eddie
motioned back up towards the nursery. It was in a small town at the
top of the road.
"Right. Maybe we should get Amhidu so we can translate..." I still had
no idea how this meeting was going to go.
"No, no, he is a learned man. A pastor."
Alright, a pastor.
The most striking pastor I've ever met. He wore dusty black rainboots,
olive dress pants, a yellow and blue patterned African shirt, small
round glasses and a faded dark grey baseball cap. He was tall and
skinny, and age had tightened the skin on his bones and deepened the
smile lines around his mouth. By now he was right in front of us,
wearing a wide gap-toothed grin and laughing, and he wrapped up my
hand in a big African handshake. "Pastor Kadie Kanawa."
"Me nem na Chris... Christopher... Sahr Christopher, like Kono."
Pastor Kadie laughed with deep rolling chuckles, slapped me on the
shoulder, and then gathered both Eddie and me up into a greeting with
Allan and Katie.
"Oh, so good to meet you! You know, I had some friends once, some
European friends once. They came and they show me how to do all this
farming." He motioned at the farm. I looked at the big tree. Pastor
Kadie's voice was warm and quavered slightly, but I was impatient.
Answers, answers.
After a moment the pastor swept past and pulled the Sierra Leoneans
with him. Alan caught my eye.
"Chris, slow down on the questions." I was instantly sheepish; Allan was right.
"I know, I know."
"It's just like," Allan let his facial expression finish the sentence.
Katie was up ahead walking right behind Pastor Kadie, and Amhidu, Sahr
Bindi, and Eddie were right behind. Ali had stayed with the car. I
caught up to Katie in a few steps, and then we all turned down the
slope on to a path.
Suddenly I noticed a machete in Pastor Kadie's left hand. It was the
kind with a steak knife handle and a narrow straight blade with a
curve right at the end. The point is at the end of the curve,
perpendicular to the long direction of the blade. The blade itself was
worn and tarnished.
Whenever I turned my head I caught a glimpse of tall oil palms against
blue sky, and the rounded green hill in the distance. But mostly my
eyes stayed down on the path, determined not to put my sandaled feet
in anything spiky or poisonous. My brain was deeply embroiled in
trying to calibrate itself to Allan's advice. I had been too
voracious, so voracious that I might be preventing us from getting the
information. So how could I choose my questions judiciously so that we
learn exactly what we need?
Or maybe I didn't know what we needed to know? I took some deep
breaths, and watched Pastor Kadie for a moment. He moved with an easy
gait through the farm. He didn't move that much, but he covered
ground, and the steps he took looked very familiar and comfortable.
It wasn't a farm in the North American sense, not at all. There were
no rows of anything, no fences, and no immediately apparent
organization. But there was cassava under the palms, to shade out the
weeds, and worn pathways linking the trees.
First Pastor Kadie took us to a short, young oil palm. Its trunk was
maybe four feet high, and the fronds extended out like a fountain.
Clustered around the base of tree were two fruit bunches, one black
and one red.
"This one..." Pastor Kadie swung half heartedly at a couple of plants
between him and the tree with the point of his machete, "is Dura." He
touched a couple of the fronds with the point of the machete, and then
gestured to the fruit. We paused in silence for a moment, and the
Pastor Kadie made a step to continue.
"Wait," I couldn't contain myself, maybe this was the answer to the
masangke mystery, "why is this one red, and that one black?" Maybe
it's ripeness? I thought.
"This one is ripe." He tapped the red one with the point of his
machete. Then we continued down the path.
The fruit bunches are quite alien. They look like large pinecones,
perhaps the size of pillow, except there are many palm fruits stuck in
the spaces of the pine cone. The palm fruits are smooth, shiny and
football shaped, yellow near the points and darkening to crimson red
or maroon in the middle when ripe. As they grow, they are first olive
green, then black, then red or purple. The fruits generally fit in the
palm of your hand, and a fruit bunch has between 50 and 150 fruits.
These are just ballpark numbers to give an idea; even the few fruit
bunches and palm fruits we saw varied widely in size, number, color,
and texture.
After a couple more turns, a bit closer to the big tree, we came to
another squat palm. "She is," Pastor Kadie poked at the palm with his
blade, "she's also Dura."
Eddie came forward, excited. "This one," he pointed to a small bunch
with olive green fruit, "this one will be masangke! It will have
yellow color when, when we make the oil."
"Oh, okay." I nodded. It didn't fill in all the blanks. Could the same
palm tree give both red and yellow palm oil? The red was more
desirable, the yellow was masangke, I thought. To be honest, I'm still
not totally sure, but I'm much more patient about it now.
We walked onwards. The grove was quiet, completely different from
Koidu Town. The palm trees, even the squat ones, had majestic crowns
of palm fronds, and the big tree in the center kept arresting my gaze.
"I'll take you to a place where I have recently harvested." Katie and
I both murmured that that would be great. After a quick turn back up
the hill, I was completely disoriented; I thought that maybe I could
pull out my compass and look at it, but I didn't.
Pastor Kadie glided off to the side, revealing another squat palm
drooping over a pile of fruit bunches. There were about ten or eleven
fruit of them. I stepped off to the side so everyone else could filter
in.
"Can we eat them?" Allan asked. Katie was already eating one. Allan
took a bite. Amhidu and Sahr Bindi reached down and grabbed some. I
leaned over, touched one, and stood up again.
"Mmm, doesn't taste like much." Allan wasn't impressed.
"Well, it's interesting. I'm not sure if I like it or not. It's very
oily." Katie's fruit was half eaten. Inside it was yellow, with plenty
of fibers. I was trying my best to remain impartial, but failing.
Amhidu was clearly relishing his, and Allan revised his opinion
upwards.
"Actually, I like the taste of this oil much more than the palm oil
after it's processed."
The pile of fruit bunches looked a bit like a pile of beehives to me.
I picked up a safe looking red one. It was smooth in my hand, firm and
clearly alive. In my mind I could feel the palm oil inside, see it go
into the pot to be boiled, see it crushed for the oil, see the oil
boiled dry, see the oil bottled into containers, lifted on to trucks,
and bounced six hours into Freetown, where they might wait on a
loading dock for a crane to lift them on to a boat. I could see the
amputees piling the bunches, machetes in hand. What would it be like
to use machetes for their livelihood, and for the livelihood of the
clinic, instead of the nightmare ways that machetes had been used on
them? And how did the machete sit so comfortably in Pastor Kadie's
hand; how could a machete sit comfortably in anyone's hand in Kono?
The palm fruit was firm with vitality in my hand.

Pastor Kadie's Farm, Part II

2009-06-23T18:45:00.001-04:00

I took a bite, and pulled back without removing any fruit. It was
gross. Oily and pretty much tasteless. A couple drops of oil fell on
to my fingers, reminding me of the way I get oil on my hands when I
pick out fishbones from my beef at Sunshine, the restaurant. It looked
the same. Allan and Katie were on their second fruits, and Amhidu and
Sahr Bindi were wolfing them down in their speed-eating way. With a
deep breath, I ripped off a chunk. To be generous, let's say I chewed
it for ten seconds before discreetly removing it and dropping it on
the ground. There was a mess of yellow fibers strung across the fruit
where I had bitten off the skin. The kernel in the middle was visible.
"I can show you how we process the oil too." Pastor Kadie's smile
revealed that his lower teeth were curved like a roller coaster.
After a moment, we set off again. My mind was moving much slower,
calmed by the green foliage and wind and palm trees. It was also
calmed by the palm oil taste; this was a real idea. Maybe we couldn't
wreck it by making the wrong decision. The simmering mess of facts and
processes in my mind was receding, slowly. The accompanying adrenaline
was also going.
The path twisted a bit and went up and down a couple of bumps.
Suddenly we emerged into an encampment of some kind. There was a
triangular grass roof held up on thick sticks, and five or six
children. Just beyond the grass hut there was a silver lidded pot
spewing steam above hot coals, and a set of colorful plastic bowls.
Behind that there was a square pit, maybe three feet deep and six feet
by six feet in area. The floor of the pit seemed to be a mix of
flagstone and mud. At the far edge of the pit there was a hole that
drained out into a ditch; the ditch drained into a marsh. We were down
at the bottom of the valley, and I couldn't see the big tree anymore.
The grove of big trees, however, was plainly visible.
"So here," he gestured to the pit, "we process the oil. You have to
plug the hole."
"With this one. Plug with this one." Eddie had clambered around to the
other side of the pit and was touching a big stone that was roughly
the size of the hole.
We gathered round. Pastor Kadie spoke. "First, we boil them. Then we
put them in the pit and we step," There was some excited Krio, then
laughter. Somebody pointed to the boots. "Yes, with these ones."
Pastor Kadie pointed to them. "Then we add water. And the oil, it
floats, so we jus skim it." The last was said with a conspiratorial
smile. The three 'white' people oohed and aahed in amazement.
"And there is the nuts." Eddie pointed excitedly to a giant pile of
nuts beside the pit. He had been explaining to me earlier that even
though Tenera produced 30% more oil, Dura was also good because its
nuts were bigger and thus it produced more nut oil. Pastor Kadie
nodded towards the nuts.
"Yes, you can also crush these ones and get oil. But," he shrugged,
"we don't have time, so we just leave them. You know they want to make
fuel from these ones."
"Oh really?" Allan has a great friendly prompt.
"Yes, people came by, and talked of making fuel from these ones. It's,
it's like a vegetable oil. It's the one you had." He turned to me. I'm
not sure how he knew, but yes, in the town I had been shown the
difference between palm kernel oil and palm oil. The former is brown,
the latter red or yellow. Both are used in cooking, but the palm oil
is more expensive.
Pastor Kadie handed Katie a nut."Thanks." She looked at it, and Eddie
explained to her what was going on. A little girl appeared, cracking a
nut with a rock. She handed it to Katie.
"You eat this one." Amhidu encouraged her. Katie didn't need
encouragement. She ate some.
"Tastes like coconut!" I tried some. It tasted like wood.
"Yeah," I agreed. My tastebuds aren't great.
Then a yellow squash-like fruit appeared in front of me. "Cocoa." I overheard.
"Wait – this is cocoa? Chocolate."
"Yes." Amhidu said. It had a couple of holes in it.
"You dry the one inside, and then you eat it." Sahr Bindi explained.
"Okay,"
"Here," Eddie already had Allan's attention back near the grass hut.
he had some dried cocoa. It was in a small nut, maybe the size of my
fingernail. I tried some and handed it to Allan. It tasted bitter,
vaguely intoxicating, and similar to dark chocolate.
Then we were back at the edge of the pit. Allan took in a deep breath
and prepared to ask a question.
"Pastor Kadie, why didn't they cut down those trees?"
"What?"
"The trees. They're very big, and they're gone all over Sierra Leone.
Why did they spare those trees?"
"Oh, the forestry."
"Yes, the forestry. Why not take those trees too?" Pastor Kadie chuckled.
"Well, the thing is, we have so many. They can't take all them. We
just have so many. But it is nice to still have some."
"They're beautiful big trees. It's really something to think that the
country used to be covered in them."
Eddie reappeared, two palm fruits in hand. One was big and round, the
other smaller and more square. The round one had a strong yellow color
at the base, while the square one was more evenly red. "This one," he
shook his right hand a bit, "is macocaia. You see how there is yellow
there, that means it has yellow oil. This one is tenera," he shook his
left hand a bit, "and it will have a nice red oil, you see, from the
color, the red here."
"The macocaia is these ones," Pastor Kadie motioned to a pile of palm
fruits at the edge of the dirt clearing. They were noticeably bigger.
"They have very big fruits, very big."
"The nut inside, it's very large." Eddie added.
"But the oil, is not so much as the other ones."
Okay, so macocaia gives yellow oil, and tenera gives red oil? And the
difference in yields – that matches up with what we know about tenera
and dura. But does tenera always give red oil, and macocaia always
give yellow oil?
Pastor Kadie's family had faded into the background to watch. A few
times I tried to say hello, but they remained politely impassive.
Sometimes they were pouring water, or washing something, and one girl
cracked some nuts for Katie, but other than that they remained at the
edge of the clearing and watched.
"So Pastor Kadie, do you process the different oils separately or mix
them all together?" Allan asked a question.
"No, mix them all together." Pastor Kadie gave a brief dismissive shrug.
"And the color is red?"
Pastor Kadie nodded. "It's red, dark red. But we have some variety,
the local palm," he gestured back behind him to a medium sized palm,
"this one is not so good, I don't mix it in. It gives a thicker oil, a
different oil, it is not so red."
Dura? Was that old Dura? Supposedly Dura was native to West Africa,
and there was also an improved variety of Dura.
"And Pastor Kadie, why do you plant all four varieties?" Allan asked
another question.
"So I can harvest all the time, all year."
"Oh, so it gives fruit throughout the year."
"Yes."
I briefly conferred with Katie and Allan. "Should I try one last time
to figure out what masangke is?"
"Yeah, it's worth a try." So I turned to Pastor Kadie.
"Pastor Kadie," he looked at me through his small, round glasses,
"where does the masangke oil come from?"
"Oh, masangke. Well, I tell you where the name comes from. There is a
village, a region, somewhere called Masangke. And they were the first
to have the masangke tree, the first to use them, and so the local
people they just call them masangke."
"So masangke is a type of tree?"
"No, masangke is a name for the five varieties that produce the two oils."
I thought for a moment, then turned to Katie. Pastor Kadie moved away.
"So the masangke is..."
"It's a blanket name for all the varieties of tree that make the oil, I think."
"But no, that doesn't make sense. He said it was the five varieties...
of oil? No, that doesn't make sense either," I was confused. Masangke
was the varieties of tree? It turns that is indeed the case – all the
improved varieties of palm are known as masangke. Katie was right.
"This is the palm oil," Pastor Kadie was back, with a yellow plastic
container. It was almost completely empty, but he poured out a bit
onto the lid. The oil was opaque and orange-red, with sparkling
suspended particles. It wasn't very viscous.
"Pastor Kadie," Allan wore his questioning look again, "I have a question."
"Yes?"
"Who lived here 100 years ago?"
"Ha! Well, I don't know. They say the Limbe, the Limbe at the coast,
told the Kono to come here and wait, and so Kono, it means wait. Wait
for what, I don't know!"
Soon after we set out. We weren't sure about the plan, so we thanked
Pastor Kadie profusely before we all began to walk out together. I
turned to Allan. "I really love it here. I would love to spend a day
here."
"Yeah, there's something very special going on in this place."
Not ten steps out of the clearing we stopped. "This is cocoa tree."
Pastor Kadie motioned.
"Oh! Wow, a cocoa tree..."
The cocoas were dangling from the branches like Christmas tree
ornaments. On the tree they were a frosty green color.
"Cocoa tastes like sweetsap." Katie was comparing cocoa to another
alien fruit we'd tried. She thinks it's also called cheremoya. If
someone smashed a cheremoya on my doorstep I would think that aliens
were invading. But the insides of the fruits look similar – white,
with a translucent juice.
"Pastor Kadie, does it like sun, or shade?" Allan's baseball cap was
very similar to Pastor Kadie's.
"Well, it likes both. Too much sun, and the breeze blows the fruits
down, but too cold, and he gets black pore disease."
Katie missed what he said, so I explained it back to her. Then she
said, "So, are we going to ask him the rest of our questions?"
"What questions?" I meant which questions.
"The ones we were planning to ask!"
"Oh, well, like which ones? I feel like a lot of my questions have
been answered."
"Well, like what exactly is the yellow oil?"
"Oh... I guess I don't know that."
We followed the pastor up the hill, out a different path than we
entered. When we reached the top, we were on the road again, a ways
above the vehicle.
'Now we will talk. We will arrange the trees." Amhidu told Allan,
Katie and I. I guess we were giving down payment on the trees without
fully deciding which ones we would buy. Okay...
Sahr Bindi, Eddie, Amhidu and Pastor Kadie conversed rapidly in Krio.
I wasn't listening. I was thinking about the giant tree in the middle
of the valley, currently obscured by brush, and looking at the palm
trees right in front of us. Did they really hold the key to financing
the clinic? Were we really going to turn the fruit into chloroquinine,
via plastic jerry cans and loading docks in Freetown? Local lore holds
that the palm oil is an antiseptic; that it heals wounds. Allan put
some on his cut earlier, and had told us that it stung a bit. I wish I
had asked Pastor Kadie about that.
Someone picked up that they were discussing numbers, so I blinked away
my reverie. "Wait. It was 60 per acre?"
"Yeah," Allan agreed.
"But using hexagons, we get 15% more. So," we get 15% more in the same
area, while keeping the minimum 30 feet between trees.
"So 70?" Close enough. "Okay, 70. And add 20%, for the ones that won't
take when we plant them. So 83 or 84."
"That means we need 840 for 10 acres."
"Right. Amhidu,"
"Yes?"
"Make sure you get 830."
"Okay, I will tell him."
Amhidu turned back and told Pastor Kadie, in Krio. Sahr Bindi took the
increased number of trees to mean that we were now planting over
twelve acres. Eddie seemed confused. Allan, despite his lack of Krio,
picked up on it.
"Maybe we're going to have to explain the hexagons?" I grinned. I
really like the hexagons. After a moment, I added, "I really like this
place."
Katie agreed. And Allan put a supernatural spin on it. "Yeah, let's
just say there's something very good going on over there. And yes, I
do mean weird shit." Alan grinned, his eyes dark in the shade of his
dorky hat brim.
Then Pastor Kadie broke out the price. He must have said it in Krio,
but memory has translated it to English.
"So, the ministry, they sell for 5000. For 4500. At the ministry. But
me, I want to help out my fellow farmer," he clapped Sahr Bindi on the
back, "so I say 3000."
Amhidu translated. "He says 3000 per tree." That's about 92 cents per
tree. I nodded, but no one needed my opinion. Allan nodded, and that
was what counted.
"Wait, Amhidu?" Allan caught Amhidu just as he turned back. Both of
them were well framed against blue sky and green foliage.
"Hmm?"
"Tell him we'll give him 3500. And I'll tell you why." He motioned for
Amhidu to tell Pastor Kadie. Amhidu did. There was laughter, and
controversy.
"Amhidu," Allan was explaining, I guess, "we did that to invest in the
future. This man knows a lot. We need him on the farm advisory board,
and we need his help. Tell him that. Tell him that's why he's getting
3500." Later Allan made clear that this was a one-time deal; that the
price does not go up in the area as a result of this.
Amhidu told Pastor Kadie, and Pastor Kadie seemed overjoyed to help.
"Actually, Amhidu, the first thing we need from him is we need him to
come survey the land before we plant." This was relayed to Pastor
Kadie. I wasn't sure why Allan was talking through Amhidu, because
Pastor Kadie hadn't had trouble with our English thus far.
"That's fine, that's fine, because there is something I must show
you." Pastor Kadie took a pair of long strides out into the dirt road,
machete in hand. He began tracing with his machete. The hairs on the
back of my neck rose. "When you plant the trees, you don't plant them
like this." He had traced out a square pattern, and then circled the
space in the center of the square. "Because this space is wasted.
Instead, you plant them in triangles."
He proceeded to draw the hexagons on the ground, with the tip of his
machete, while he explained them in terms of triangles. I was grinning
maniacally.

Mango pool and brief update.

2009-06-16T15:37:00.001-04:00

We're taking bets on how much mango we eat from now until the end of
June. There's a separate tally for small and big mangoes. Today we
have already eaten 3 big mangoes. Closest guess wins an unsatisfying
North American mango, next time I can get you one. I tried to think of
ways to turn this into a fundraiser for GAF, but it didn't seem
appropriate...

Just so you thought we were bored, here's a brief list of the projects
Katie and I are doing, all of which are at wildly different stages of
development.
1. Health education in amputee camps
2. Business plan for the palm oil farm that is meant to eventually
fund the operating costs of the clinic.
3. Prototype the OpenMRS system.
4. Enter and analyze the survey data.
5. Helping a peer educator program get started in the nearest secondary school.
6. Designing handouts and booklets that go with the health education.
7. Teaching some basic computer skills to the clinic staff.
8. Eventually, conduct a second round of the survey
9. Possibly health education in schools
10. When Bailor returns, some shadowing and clinical work.

Comment freely – it's nice to see who is reading!

All the sizes and shapes.

2009-06-16T15:35:00.001-04:00

First, a disclaimer. I've heard people talk about how it's important
to refer to people with disabilities as 'people with disabilities' not
'disabled people.' The same conversation can (and perhaps should) be
had about the term 'amputee.' The main point is to emphasize that
amputees are first people, then amputees. They didn't lose that
personhood when the machete fell. However, it's a useful shorthand,
and I think it's okay, as long as we all carefully consider and remind
ourselves that an amputee is a PERSON with an amputation. I'm going to
write a bit about the amputations that I have seen, and I wish that I
could do so while better preserving the individuality of these
amputees. However, I think it's important to understand the
physicality of this, so I'm going to describe it. Please read it while
keeping the individuality and personhood of the amputees firmly in
mind.

After you've placed your hand awkwardly around a few smooth forearms,
or slipped your thumb in between a couple of thumbs and knuckles, you
begin to notice the different ways that the human body heals these
wounds. To be honest, there is much more that is constant about the
guarded but warm greeting of the amputees then there is about the
shape and size of their stumps.
The forearm stumps, for instance, are usually a bit wider than the
forearm bone, as if while healing, a substantial amount of new bone
developed. One of my favourite women that I have met here is a double
hand amputee in the Wardu camp named Kumba. She gave us a basket of
green oranges, and when we returned to do education in Wardu she still
had that same friendly spark about her. When I shook hands with her,
she stepped closer than most people do and then extended her right
arm. I clasped it gently. Even the third time we met, I was surprised
by the tininess of her forearm. Her skin was also very smooth, but at
the heel of my hand I felt that the tissue around the stump at the end
of her arm was stiffer. As soon as I clasped her forearm, all three
times, she brought her other forearm around to lightly brush the back
of my hand. I'm not sure if it was my imagination, but I felt like I
could feel the healed bone through the scar tissue surrounding the end
of her arm.
Some of the forearm stumps look more like someone twisted the skin
into a cone-shape at the end of the arm, and those don't seem to have
any extra bone. Instead the arm seems to narrow to a point. I've also
noticed forearms with deep scars and irregular bone structure,
probably from unsuccessful amputation attempts. It makes me wonder
what I would do without hands, or arms.
The patriarch of the Wardu amputee camp has two thumbs and eight
knuckles. He also has very dark brown skin, drawn taut with age
instead of wrinkly, but the deep crow's feet around his eyes are
friendly. Shaking hands with him was almost normal, except that the
palm of my hand, just above the heel, closed around his knuckles a
bit. They felt very smooth and rounded, and they moved independently,
like fingers. It was a bit disconcerting. But I soon learned that he
is a determined patriarch – despite the fact he speaks only Kono, he
stayed for the entire health education program. Most of it was
translated from Krio into Kono, but not all. Apparently he has 20
children.
Out of the corner of my eye, finger amputations like his look like a
normal hand that is half clenched in a fist. Try it – clench your hand
in a fist, and then straighten only the knuckle where the finger meets
the hand. That's more or less what it looks like, except a bit
shorter.
When I first met the chair of the Dorma amputee camp, I didn't notice
that he was an amputee. He was seated, and shook my hand with vigor.
But soon he pointed out that he was a double leg amputee. The moment
he mentioned it, I could see the mechanical knees pressing identical
patterns into his thin cloth pants. He can even walk, with crutches,
but it wasn't until a couple of days ago that I saw how he covers long
distances – with a bike contraption. It's a small three-wheeled bike
with a chair instead of a seat. The chain is attached to the front
wheel and it goes up to a hand crank in front of his eyes, so that he
can pedal with his hands. When I first saw it, an eight year old boy
was helping him up the gentle incline outside the clinic by pushing
the bike-chair from behind. He stopped to say hi to Bailor, and then
continued on up the hill, under the blazing sun.
Many of the leg amputees, however, don't have fake limbs. While
walking home from the clinic one day, there was a game of soccer going
on just to the right of the path as we walked through Sinnah Town.
There were three boys playing, each somewhere between 9 and 14 years
old. The eldest was on one crutch, and he had only one leg. I saw the
boy on the other side kick the ball over towards the boy on crutches.
It rolled past him.
Without hesitating, the boy on crutches took three big strides towards
the ball. He tapped it into place with his foot, stepped forward onto
his crutch and then unleashed a kick. It was better than any kick I've
ever done.

Sunshine

2009-06-16T15:34:00.001-04:00

Okay, so you may have noticed that we eat at the same place every day.
Or you may be curious how one of the most successful businesses in
Koidu Town works. Or you might just be wondering what people in Kono
District eat. Well, here's all that and more. We're going to Sunshine.
We went there on the first day I arrived in Kono, and I've gone back
almost every day since. I have yet to spend enough money to buy me a
plate of rice and sauce at Masala Grill, the most legitimate Indian
restaurant in Princeton.
The entrance to Sunshine is not obvious to the uninitiated. From the
street, there is a nice-looking sign. By nice-looking, I mean that it
is rectangular, white, and the letters are large and black: Sunshine.
It's oriented perpendicular to the road, so you can see it as you walk
towards it from either side. As a side note, throughout Sierra Leone,
advertisements aren't on billboards. They get painted on to houses,
roofs, doors, gates, and any other static surface. The owners of the
house or whatever sell the space to a company, usually a cell phone
company, and then someone comes and paints it. Apparently the cell
companies come around to make sure you haven't cheated them by
painting over their ad. The two most common are Zain, which paints
buildings neon green, and Africell, which paints buildings orange. It
makes for colorful streets.
The road is red, dusty, and lined with market stalls and houses. Both
the market stalls and houses are based off of a row of broken down
single storey cinder block rooms, each about 150 sq ft. They all have
some combination of corrugated tin roofing, wooden sticks for support,
and planks to provide shelves, surfaces and counters. In general it's
pretty obvious that nobody every needs to seal up for winter.
The sign doesn't actually sit in front of Sunshine. It's about fifteen
feet short of the alleyway between broken down cinder block walls that
leads there. So you have to step across the gutter (jump if you're
Katie and 5 foot few) and then duck into the alley. Sometimes when
someone describes something as an "alley" I think of tall, Gotham City
style alleys, dark and full of criminals. This alley is different.
None of the buildings in Koidu Town are tall, and few of them provide
any shade beyond their immediate footprint, so it's very bright. The
ground is still light brownish red dirt, like the road. On the left
there is a collection of young men selling sunglasses, and two steps
further back is a lady who lays out forty odd small mangoes on a
blanket. They're 100Le each (3 cents). You have to make a zigzag
pattern around the right hand side of the sunglasses and the lefthand
side of the mango lady, because the alley isn't wide. Nonetheless,
motorbikes go through there all the time. Today there was also a baby
goat lying under a small, dead-looking tree just beyond the woman
selling mangoes.
There's also usually a small crowd of children milling around behind
the mango lady. Once, when Katie and I came to Sunshine, we passed the
mango lady and a small boy stepped out in front of us. He stopped,
looked up at us with a thoughtful expression, and said to himself in a
matter of fact tone, "Chinese man." So as you pass the children, you
may be assigned multiple ethnicities or genders, and you'll probably
create a stir. My favourite part is when there is a teenager nearby
who sneers at the excitable children. It's nice to have some cultural
constants.
After the mango lady you pass two more of those square cinder block
enclosures on the left, both growing some kind of grass and much more
broken down then the others. There's an open space ahead that's full
of market stalls and people, but to get to Sunshine you have to turn
left. Between Sunshine and the market stalls there are probably a few
motorbikes as well, waiting with their handlebars locked to one side.
The first time I went to Sunshine, after we made this lefthand turn I
seriously thought we were going somewhere else instead of a
restaurant. It looks like it dead ends twenty feet in, with a one
storey building under construction on the right, a couple of unused
ovens or kilns straight ahead, and rusty corrugated tin on the left.
But no, there's a door-shaped hole in the corrugated tin, and when you
duck through it, you're there. You have to duck – I'm 5'10, or 5'11 if
someone near me is shorter than me and claiming 5'11, and most people
I've met in Kono are shorter than me. So sometimes I hit my head on
stuff. It's a new experience.
On my first visit, I was skeptical, and I would be worried if you
weren't as well. It's dark, the floor is dirt, and the air is heavy
with water and food smell and person smell. There's a table on the
left with two benches, and a table on the right with two benches.
There are peeling plastic tablecloths on both tables, but only the
lefthand one has napkins. Well, it has a plastic bag tissue box. Most
times there is a crowd, but we can find a place to squeeze in on the
bench. The tables aren't really higher than the bench, so you have to
awkwardly figure out where to put your knees.
At the opposite end from the entrance sits a woman, with three
gigantic pots in front of her. One holds rice, one holds "soup", and
one holds "sauce." It turns out that Sunshine is also the name of the
woman who runs the place, so it's often her holding court above the
three vats of food. Other than that, one of her daughters is usually
buzzing around, getting water from a cooler sitting off to the side
for customers that request it. Around the corner about ten feet away
is where they prepare the meat. The restaurant is more open to the air
on that side, and that opening leads to the cooking area. My first
time there I saw a preteen boy chopping up a side of beef into a
bucket, and I think the side of beef probably outweighed him. The NOW
staff assured me it was clean, and I tried not to think about it.
"Soup" is groundnut soup. It's brown, slightly spicy, and vaguely
nutty. There's both stewing beef and fish in the big vats of sauce and
soup, but if you don't specify Sunshine will just spoon you beef. I
prefer the beef because I'm a wimp when it comes to fishbones. If you
ask for fish, you're liable to get a pile of rice, a dollop of sauce,
and a fish, cooked but intact.
"Sauce" is either based in potato leaves, cassava leaves, or "green"
leaves. I have no idea what green leaves are. The liquid in the soup
and sauce is mostly palm oil. The sauce tends to be spicier. It's
spicy in a sneaky way, too – if you swallow it right, it just has a
very strong taste. But if it somehow stays on your throat, then it
burns. I once had an embarrassing spate of sneezing and coughing
brought on by exactly that. The sauce is my favorite, because it has
so much taste. I'm getting hungry just thinking about it.
It's worth mentioning the rice, too. Sierra Leoneans call it "rais."
The Sunshine rice is imported, Jalloh tells me. It's rounder,
fluffier, and more satisfying than normal rice. It has enough flavor
of its own that it doesn't taste watery, and it soaks up the soup and
sauce very well. Most important, there's always mounds of it.
You can order three sizes: 3000Le, 4000Le, or 5000Le. You get the same
amount of rice with each, but they give you more meat with the more
expensive dishes. It's a bit unclear, but there's some kind of
equalization that goes on. I've only ever ordered 3000 plates, and I
have never left Sunshine feeling hungry.
If you want water, you catch the attention of the extra woman just
hanging around and just call out "water!" I've tried please and
thankyou, but that just adds confusion. Then she dips into the cooler
and fishes you out a bag of water. That's right, a bag of water.
They're called "water sachets." Each one has between 450 and 500 mL of
water (a pint, for the Americans) and is square. They look a bit like
mini couch cushions. You have to bite off the corner and then squeeze
it into your mouth. I still embarrass myself with regularity while
trying to do this. Once, at the clinic, I sprayed Katie's keyboard
with water. No worries, it was fine...
After Sunshine scoops you your food, it gets passed to you via the
seated clientele. Nobody waits for everyone to get their food before
they start, and I've already switched over. Not only do people not
wait, but they eat very fast, even faster than me. It's a small
reminder that most Sierra Leoneans have a very different relationship
with food than myself and most North Americans. I don't pretend to be
super skinny, but it's worth mentioning that probably 80% of the
people here are noticeably skinnier than me. Allan tells me that every
one of the NOW staff has been hungry, truly hungry, at some point in
their lives.
Wolfing down the food doesn't take that long, unless the spice causes
you to spray it all over the place and embarrass yourself. When you're
done eating, it's my second favourite part. The meal's 3000Le, and the
water is 500Le. So, altogether, that's 1.10 USD. What a bargain.

What is it like to be a teenager in Kono District?

2009-06-15T12:37:00.001-04:00

"So, Amhidu, did you phone the school?"
"A phoned dem, but a tol' dem dat we would be late. So dey are
waiting, waiting fo' us."
"You didn't tell them we were coming at 10am?"
Katie, Amhidu, Jalloh and I were scheduled to present at one of the
local secondary schools at 9am. But it was 9:09am, and we were
printing the handouts we planned to bring with us. I was a bit
annoyed, because I don't like being late. But Katie had made some
magnificent handouts, and they were probably going to go much further
than our spoken message. Poor Amhidu seemed a bit beleaguered by the
sudden schedule disaster. The problem was that power and internet are
so scarce, and it had taken a very long time for us to find pictures
for the handout. And the car was broken down, so we had had to walk to
clinic, which takes about an hour. And then, the printer was slow. Not
a great start.
"Maybe," Amhidu went on, worried but still friendly, "you and Jalloh
will go to the school, and start, and Katie and I will come after with
the handouts."
"Oh, OK. But I won't start until you and Katie come."
"Yeah, yeah, you jus' go dere an tell dem dat we are still coming."
So Jalloh and I set off at a mild sprint. At least, Jalloh thought
so. "This is how fast people walk in New York, Jalloh. Everyone."
We slowed down to Africa speed – as fast as you can go without
breaking a sweat. It was hot.
The school wasn't far away. It was concrete, and only the classrooms
were indoors. The hallways were basically porches, partially shaded by
the roof. We met the teacher that had invited us, Mr. Komba, and we
met the vice principal, Mr. Koti. Then the head boy rang a bell,
everyone assembled, and they were herded into the classroom. The kids
were really loud and really excited. I was pretty excited.
What was I going to do with the time until Katie arrived?
"Hello."
Silence, then a few reluctant hellos.
"My name is Chris. Sahr Christopher." My Kono name always gets a
laugh. Jalloh tells me that sometimes I confuse people because British
people are often "Sir", and so they think I'm a knight...? I didn't
really pursue that one.
"I'm a Canadian – I come from Canada – but I study at a university in
the United States."
"Slower, Chris." Jalloh was leaning against the window at the side of
the class. The students agreed with Jalloh.
"OK. My friend Katie and I have come today to talk to give you some
education about how to keep yourself and your loved ones healthy." I
gave an exaggerated nod. No one responded. "But she is not hear yet,
she is coming with some handouts."
The students were piled into the class. The desks were four or five
students wide, in rows, and there were five or six students at every
desk. There were also many chairs around the side of the room. There
was plenty of natural light, and the room was painted some neutral but
bright colour like white or light blue. In the front there was a
blackboard on a wooden stand. It looked like it had been broken off of
a giant blackboard rock and then affixed to the stand; the edges were
completely irregular and it was more or less flat. The eraser was a
sponge. The chalk, however, was long and pristine. Maybe they had
gotten out the special chalk for the exotic visitors? I didn't flatter
myself for too long with that thought.
"So we have some time to spend together."
They were a little bit restless. It was the entire secondary school,
about eighty students. They were right in the awkward age group where
the girls have begun to grow up but the guys look anywhere from 9 to
15.
"So, I haven't been in Sierra Leone for very long, and I don't really
know anything about it, so I was thinking that I could start by asking
you guys a bit about Sierra Leone."
There was a lot of noise, and the teacher gave a combination
translation-reprimand.
"First, you guys are all in secondary school. Why do you think that
secondary school is important?" I wouldn't be caught dead asking a
North American class of 12-14 year olds that question, but I wanted to
know the answer and didn't really have any idea how a class in Kono
District would behave, so I figured that I might as well try. There
was uncomfortable silence, followed by Jalloh translating the question
in a scolding tone, followed by the head boy walking primly up to the
front. He turned to face the class, and Jalloh and the teachers made
approving noises.
"Secondary school education is important. One, it is important becos
we are learning more things, more particular things. Two, it is
important becos we have more interaction with professors. Three, it is
important because we meet many more people than in primary school, and
we make mo' friends." The teachers made deep approving thank-you
noises and the head boy returned to his seat. I still don't know
hardly anything about Kono District classroom dynamics, but I was
pretty sure that the best way to bridge the gap between foreigner and
student was not getting the head boy to spout answers to the approving
murmurs of the professors.
"Okay, let's try this a different way. Put your hand up," I put my
hand up, "if you walk less than ten minutes to get to school." Mass
confusion. Mr. Komba translated my "ten" into "very short." I like
numbers much more than every single Sierra Leonean I have met. About a
quarter of the class put up their hands.
"What about, twenty minutes? Put your hand up if you walk twenty
minutes or more to get to school." They understood this one.
Two-thirds of the hands were up. "Thirty minutes?" Almost all. I
thought we were done. Mr. Komba said,
"Oh, but some walk very far, very far-far!"
"Oh, okay, who walks more than thirty minutes?" Some hands. "More
than an hour?" A few hands. "Wow. That's a long way. I'm impressed –
you must have real dedication." I'm not sure if my praise got through
at all.
"What about... malaria? Put your hand up if you have ever had
malaria." Two-fifths of the hands went up. "And dry cough?" Dry cough
is the African name for tuberculosis. Everyone laughed, no hands went
up. Okay, so no dry cough here. "When Katie comes, we will talk more
about both of those."
I stalled a bit by walking up the row and then back.
"Hmm... okay, put your hand up if you have a boyfriend or
girlfriend." Raucous laughter, and then Jalloh said,
"Everyone! Everyone have a boyfriend or girlfriend!" What? Well, all
the hands went up. I shrugged it off and made a mental tick in my 'I
don't understand Sierra Leoneans at all' column.
"Alright, alright. How many of you have brothers or sisters that went
to university?" Mr. Komba translated, no one's hands went up. Jalloh
said,
"It's very hard, very hard."
"Yeah, it is... what about college?" College means trade school, like
carpentry or plumbing. Three or four hands went up. "And how many of
you hope to go to college or university?" A solid eighty percent. I
stalled for a bit more time, walking up the row and back. "What about
me, do you have questions for me?"
They asked me about my educational background, but nothing else. Then
I had an idea.
"Okay, now I have a question only for the girls." That was mildly
controversial, but soon the class was quiet again. They wanted to know
the question. "What do you plan to do after high school?"
At first, no one answered. But I kept quiet and waited. Then one girl
spoke up. "Engineer."
Another girl. "Lawyer."
And another girl. "Nurse."
I threw in some patter about how those were all excellent choices.
Then I asked the boys.
"Doctor." I asked him if he knew that nurses are the ones who really
run the show. Nobody understood. It's hard to be a comedian across
language barriers.
"Trader." That's someone who buys the goods and distributes them to
the local merchants. I only know because I asked. Then I had another
idea.
"Alright, another question only for the girls." Less controversial the
second time around. "What is the biggest problem facing Kono
District."
Momentary silence, then one girl jumped to her feet. I later learned
her name was Fanta.
"Teenage pregnancy!"
The girls nodded. I nodded too, and filled in a bit of space with my
verbal agreement. Then I motioned to another girl with her hand
tentatively raised. "Teenage pregnancy." Her voice was small. Hell,
she was small. They were all small, just beginning to have to worry
about teenage pregnancy.
"Teenage pregnancy is definitely a very serious issue. It can destroy
a girl's life. We will talk more about it when Katie comes."
Katie came almost immediately after that. We got through our modules
with more or less success, and our novel skin color almost offset the
boring information we were force-feeding them. I tried to involve the
class to a certain extent, but mostly I just got confused looks and
people that pretended to understand. So I stuck to writing things
clearly on the board. Then, we came back to teenage pregnancy. Fanta
was participating again. Katie asked a question, half to Fanta, half
to the class.
"Why, why does teenage pregnancy happen?" Fanta jumped to her feet again.
"Becos you don' have any money, you don' have any thing, and der is
some boy, and 'e will give you money if you go with him, and maybe you
don' know what will happen, an you need de money fo' you school, and
den..." Fanta trailed off into the class's murmured consent. Katie
responded.
"Yeah, that's very serious. We'll come back to that, but thanks for
answering." She looked around for other answers.
"Maybe becos you man 'e don' wan' to use a condom." Katie nodded
again. No more answers were forthcoming. She turned back to Fanta.
"So, I understand that it's very hard, and that you don't have money,
and that it's very hard to pay for your school fees. But it's so
dangerous, and it can be so destructive to your education, and it's
not healthy for the baby, and you won't be able to take care of it,
because you will have even less money when there are two of you..."
Katie is impressively empathetic. I could see her trembling in front
of the monumental poverty that must drive someone to engage in sex for
money, whether it's explicit (prostitution) or implicit (more well-off
boyfriend).
"If you get pregnant while trying to get money for school, you can't
go to school." I kept my contribution simple, but there's nothing
simple about this. The girls don't have options. The poverty here is
heart-breaking. People live and smile and laugh, same as everywhere
else, but nobody knows how many girls are getting pregnant – only that
so many of them are getting pregnant that it is the first problem
cited by these secondary school girls. The blame lies perhaps more
with the men than the women – condoms are often looked down on here.
There is so little work that very few women work. It's telling that
there is only one female employee of NOW, a very progressive NGO. My
thoughts are quite disorganized on this, but they are still
passionate. Every one of those girls could be my little sister, or her
friends, or soon, my cousins. It breaks my heart.
The class was riveted by the discussion, but it wasn't clear how to
continue it. And we still had to cover the tuberculosis module...
I can't get used to how extreme poverty and desperation gives way to
the everyday in this place.

Note: we are trying to put together a peer educator program for this
school as a result of this event. Our good friend Christine Prifti is
helping us with the research – she is a self-described health nut, and
she is especially inspired and motivated to work on family and
reproductive health issues. The internet here is so dinosaur-slow that
it's very difficult for us to do any research – we can't even open
pdf's. So a big thank you to Christine for all of her help. If anyone
else would like to help us, here's how. If you find something that you
think we would like to read, copy the text into a Word document or a
text file. Then email us the (much smaller) text file or word doc,
with as little formatting as possible.
You know what else? Let me know your reactions to this challenges this
young group of Sierra Leoneans faces. I'm curious to hear them.

Gas station at night.

2009-06-15T12:35:00.001-04:00

It was dark. Darkness in Koidu town is completely free of
streetlights. But it's not empty; motorcycle headlights swept by often
enough to prevent our eyes from fully adjusting to the dark.
It was also raining. The motorcycle headlights lit up all the
raindrops around us, leaving their pattern on the back of our retinas
for a heartbeat after they went by. It wasn't raining very hard, but
it was still raining hard enough that the sound of the raindrops
wrapped around us and kept us from hearing anything else. Except, of
course, the motorcycles.
We were walking down the Main Rd. in Koidu Town, but it was emptier
than I've ever seen it. Our dinner meeting with Allan had started as
the sun went down, and we'd spent all the time before the rains
sitting around and talking. It was nice, but now the nightly
thunderstorm was coming down around our ears in the midst of the
twenty-minute walk home.
"White man an' a white woman..." A young man in hoody walked past us,
his hood pulled up. His tone was observational, not surprised. It
seems that while we sometimes elicit conscious surprise, the response
of many seems completely unconscious, as if they see us and then say
"White man!" or "China!" or "Chinese man!" without thinking.
We walked a few more steps. The roads in Kono are a bit like holes on
a golf course; they have fairways, where the motorcycles drive, and
rough, where the pedestrians walk. Katie was completely silent, and I
thought she was scared. In retrospect, that was probably just some
kind of macho projection of the fact that I was pretty uneasy.
"Katie, would you please just walk on the inside? My backpack is
reflective." Katie switched to the inside. But it was a lot messier
there, lots more potholes where she could twist her ankle.
Don't get me wrong, Koidu Town is very safe during the day. I've never
felt threatened, and hardly anyone has even tried to get their hands
in my pocket. On the other hand, it was colder, darker, wetter, and
stranger at night. It's fair to say that I may have been a little
unsettled.
It started to rain harder, with big, soaking drops, just as we
approached the gun intersection. The gun intersection is a roundabout
with a big artillery cannon in the middle, painted white and
ostensibly a memorial for the rebel occupation of Koidu Town for the
entire civil war. The war is another story, one that I don't know
outside of what I've read, but suffice it to say that almost every
building in Koidu is new, and the old ones are identifiable because
they are burnt out broken down shells.
"Do you want to duck under some roof somewhere?"
"Yeah!"
We walked (fast) up to the gas station. There were two pumps under a
big circle of concrete. A large crowd of motorbikes and young men were
gathered underneath. We jumped up on to the curb between the gas
pumps, and said nothing. The young men were talking in Krio. After a
minute or so, one guy gestured to me.
"You wan' go insigh (inside)?"
"No, it's fine out here!" I'm really leery of the 'privileges'
afforded me because I'm white, both because I'm worried that someone
will later seize them as a grounds to ask me for money and because
it's not fair that simply being white guarantees me special treatment.
A couple more motorbikes rolled in, to take shelter from the
accelerating downpour. One was wearing an aqua blue down jacket and
another was wearing a Santa Claus hat with a 'P' on it.
"Hey, hey, hey! White man!" A young guy in a white muscle shirt was
getting my attention in the usual way. I looked at him and nodded for
him to go on. "Do you have your local tax papers?"
"What?"
"Your local tax papers! You have to pay a local tax in Kono!" Clearly
trying to scam me for money. Don't misunderstand, the vast majority of
people in Kono have been unbelievably kind and generous to both Katie
and me. For instance, yesterday as we walked through Sinnah Town, a
small village on our route from town to the clinic, a delightful old
grandmother in a colorful blue and purple dress summoned us to her
doorstep to give us mangoes. She gave us five excellent, ripe mangoes.
Then, as we walked back towards the clinic, Jalloh gave one of them to
a small girl walking home from school. The girl was carrying a bunch
of sticks under her arm, but wearing her dark green school uniform,
and Jalloh thanked her and tucked the mango into her other hand.
"I don't live here."
"Oh, you didn't pay the local tax?"
At this point a skinny older man chimed in. "He's a tourist! He come
to see Kono! Probably from Korea or something, right?"
"Uh, Canada and the USA..."
The first guy was a bit annoyed. "No, everyone must pay the local
tax!" I decided to say nothing for a bit, to see what would happen.
The wind was now blowing, and the concrete circle fifteen feet
overhead wasn't really sheltering us anymore. Katie looked really
cold.
"No, he no got to pay no tax," then he turned to me, "I be your
lawyer, I do the talking for you."
"Thanks. Hey, wetin na you nem?" (What's your name, in Krio.) I nodded
back at the first guy, the one in the muscle shirt. He took my
outstretched hand.
"Osman. An' you?"
"Chris."
"What?"
"Christopher." The extra syllables help.
"Ok."
I looked back at my lawyer. "Thanks, sir. But I don't need a lawyer,
though I'm happy to meet you." He smiled and said something
unintelligible in Krio. Katie spoke with him about the fact that we
were from the USA and Canada. People are always amazed that Katie is
not from China.
"Hey, hey!" Osman was getting my attention again. He had the
exasperating tone of a testosterone-overloaded young man looking to
show off. "Have you ever seen one of those before?"
"One of what?"
"The gun!"
The gun. It was sitting in the middle of the roundabout, white,
getting rained on and getting lit up by the occasional blast of
lightning.
"Uh, well,"
"When it's working? You ever see it when it's working?"
"No, not when it's working."
"It's amazing."
I attempted to damage his credibility a bit. I won't claim to be
immune from testosterone myself.
"Who made it? Where's it from?"
"It's Russian."
"Oh."
A moment of silence, only pounding rain.
"It killed a lot of people, that one. During the war." Osman was
smiling, and his tone was reverent. I replied without thinking.
"What, are you happy about that?!" Luckily he couldn't parse the fast
and angry English. It really wasn't the ideal time to create a
confrontation. "That's not good." I'm not sure if he heard that
either.
"It was an amazing thing, to see it working."
I let the conversation trail off. It kept raining, and it was pretty cold.

Share the file, not the virus.

2009-06-15T12:34:00.001-04:00

'WARNING! Infected files found. Win32/...vcab.dll...' NOW has three
computers. One middle aged Dell desktop, one inconsistently-functional
Eee, and one Acer laptop. The Acer is the newest of the three. When we
arrived, the Dell's back was broken with viruses and Microsoft popup
window terrorism. Microsoft constantly gave us warnings that it may
not be a genuine copy of Windows XP. The Acer was mostly functional,
although the mouse buttons were slow and the internet didn't work. And
the Eee was lovely – worked like a charm. That's when we came.
Then we brought all the computers out to the clinic to figure out
which ones would stay here and which ones would go back to Freetown.
Before we could decide that, we needed to breathe some life back into
the Dell and fix up the Acer. So we began by wiping the hard drive of
the Dell and then reinstalling Windows. It took a couple of tries of
different Windows CD's that Bailor procured, but eventually we found
one that worked, sort of. It left the screen with 4-bit color and the
smallest resolution. Katie's described the disaster of typing in Word
– the screen just turns black. But after finding some drivers, loading
some antivirus software, and installing the printer, this desktop is
now the flagship of the NOW computer armada.
The Acer had also been wiped and reinstalled sometime in the past, and
since then the network connections had not functioned, hence no
internet. We downloaded and reinstalled some drivers, and then it
worked too, with the printer and the internet.
The Eee, on the other hand, now gives mysterious messages on boot and
then dies. So we are returning it with Allan, and we will get a more
conventional laptop. Our experiment in adventurous technology has not
been a success.
With the help of the Avast antivirus software on Allan's laptop, we
installed solid antivirus protection on our own computers and the
clinic's computers. And then we uncovered the depth of the virus
problem.
Bailor keeps large chunks of his important data on USB flash drives.
These flash drives get passed around between computers, and have
picked up most of the worms and trojan horse viruses that the Dell
carried before we cleaned house. So immediately after plugging in his
USB to the desktop yesterday morning to pass our updated health
education handout to him, the desktop went haywire over his USB. We
deleted a couple of files, but then he became worried we were deleting
his only copies of important info. So then we just began to quarantine
them. There were 21 viruses in the 900 odd files on his USB, and I
haven't had the chance to give it a real scan. It was stressful.
I'm going to teach some classes on how to keep the Avast software
registered so that NOW doesn't run into this problem again.

Catchup posting

2009-06-10T08:46:00.001-04:00

If you didn't know already, Katie is keeping a better log of what we do than I am. It's at perambulating.wordpress.com . Sporadic internet until now means that these first blog entries are all going to come in a rush. In general, please comment freely, and I will try and read them all in good time. If you just want to email me your comments and reactions, that's cool too. Tell me what you would like to hear about that I haven't mentioned, and what you would like to hear more about that I have mentioned. In particular, if you have any questions for any of the characters, or about any of them, let me know. I recommend reading in chronological order, but you're welcome to jump around.

Diamonds and infants in the road.

2009-06-10T08:45:00.003-04:00

June 9

Today we got lost. It happens, especially when the streets are not straight, maps don't exist, and you've only walked the pathway once before. Nonetheless, it set off some cartographical aspirations – we're going to make a map of Koidu Town. Or at least those parts that we use to get to and from the clinic and Sunshine, my new favorite eatery.

So we started late on our morning of health education. Jalloh and I were going to set off to finish all the houses in Domah, but no one was home. So we trekked down the road back past the clinic to Koyou-1.

"You know, in Kono, de people dey always walk with dere eyes down." The Krio accent sounds very cool.

"For diamonds?"

"Yeah, for diamonds, cause you never know, you never know. Maybe I'm a lucky man, maybe I find a diamond."

"Huh. Maybe,"

"Before, before the war, you could just walk along a road like this and find diamonds, just right dere. But den de rebels came, and dey took everything."

"Oh... they traded them for guns, right?"

"Yeah, dey did."

Silence, walking, hot. The sun is really hot. There's not really any shade near the clinic, which was nearby. We were walking at 'Africa speed' – just a step per minute short of breaking into a sweat.

"You know, my family, we used to spend a month every summer, at a big lake two hours from where I live."

"Oh yeah?"

"Yeah, it was so big you can't see across it, it looks like the ocean. And there's a big beach, too, kind of like the beaches in Freetown. On the beach there are strips of rocks, and once some guy told us that we should look for rocks with holes in them."

"Rocks with holes in them?"

"Yeah, holey rocks. They're really good luck, apparently. So at first we never found them. But eventually we got really good at seeing them, and it's the same, we were always looking down, looking for holey rocks."

Jalloh laughed.

A bit later, Jalloh bent down and picked up a little pointy speck of glass. I'm pretty sure it was glass; he thought it was a diamond. Maybe it is a diamond. I'm no expert.

Eventually we got to Koyou-1. Katie and Ahmidu were sitting, surrounded by a small crowd of Africans. We skipped over them and went to the furthest house. Koyou-1 is very much in the middle of a larger community, but it's only six houses. We sat down with an old woman, a single amputee. We shook hands in the African way, grip, change the grip upwards, grip again, squeeze as you pull away, and then place your palm firmly on your heart. "Me nem na Sahr Christopher." I mostly introduce myself with my "Kono name." Most people laugh; unfortunately this lady was just confused.

"Me nem na Jalloh."

"... nem na Kumba." She mumbled, but it wasn't a senile old-person mumble, more of a wary, suspicious, no longer strong but whip-smart mumble.

I explained to her in halting Krio, with help from Jalloh, that we were there to talk about some health education topics, and that I was trying to learn Krio but that Jalloh would translate for me when it was necessary. Then I launched into the module – the malaria module – that I had memorized the night before. I'll post it as its own blog entry.

"Me na student, we commot amputee clinic... How for stop malaria, you fo sleep unda mosquita tent... I wan ask two-three question for know if you done understand..."

At the end of the malaria module, a young woman, Maryam, came and sat on the corner of the porch with us. As she sat down she pulled her little girl out of the fabric-tie-snuggly and held her in her arms. Most kids are absolutely fascinated with my skin; they touch me and then quickly pull back their hands and look at them, to see if the white rubbed off. But teenagers are apathetic (what a surprise) and very small children are terrified. Sometimes slightly older kids will torment the smallest ones by dragging them near me. I like to see that, it puts things in perspective. By that I mean, the children here are not the starving stills with soulful eyes that you see in WorldVision ads; they're mean and cute, curious and sweet, playful, loud, messy, excitable.

Again we explained the nutrition module very carefully, finding out all about the woman's daughter. The daughter was 16 months old, and completely terrified of me. Fortunately she overcame her terror and fell asleep, and then when she woke up she seemed not to remember that I hadn't always been there.

All of sudden everyone stood up.

"Stand up." Jalloh told me softly.

I stood up. My mind was suddenly racing. Some women, dressed in magnificent colorful African dresses, were walking slowly down the side of the road. Rebels? Soldiers? Procession? Should I be scared? Run? What's going on?

The woman in front was holding a mat, rolled up.

"A baby has died." Jalloh spoke softly.

I guess the baby was in the mat. They passed slowly, and I was struck by one young woman at the end. Her cheekbones were very bony, and her hair was pulled into tiny tight braids. She wore a brilliant blue dress with orange and green patterns, and her face was wet; perhaps with tears.

Eventually everyone sat down again. "Where do they take the baby, Jalloh?"

"To the cemetary, jus down the road."

We continued with out modules. The attendance fluctuated; we were only briefly interesting to a group of schoolchildren in green uniforms, and then interesting for a bit longer to a talkative, smiling woman and a man wearing a UN AIDS shirt. The woman asked, "What do you do when you know your man has not been faithful, but he refuse to wear a condom?"

Uhh... I said something meaningless, I forget what.

"No, I mean, does the woman have the right to abstain?" Wow, cultural minefield. How do I answer without alienating her, without her thinking that I know nothing about her situation? It was hard; I knew almost nothing about her situation. Well, Jalloh is a good filter.

"Yes, you have the right. But you have to be smart. It's like when an employee is bad, you have to go to the boss. So you have to convince his family he is wrong, you have to go talk to doctors at the clinic, you have to get his friends to convince him. You have to be strong and smart."

The woman was momentarily satisfied; I'm not sure if I helped at all. The man in the UNAIDS shirt thought it was a good answer. I hope he wasn't the man in the question...

Later, the young woman in the brilliant blue dress returned. Her named, it turned out, was Elizabeth. She was carrying a bunch of cloth in a bowl on her head, and the infant's mat in her hand. When we introduced ourselves she smiled at us, and I couldn't figure out how she had fit into the procession. It seemed important, especially given that the precise section I was discussing was the "Family Planning" module, wherein we try and convince the amputees and their dependents of the economic advantages of small families.

Some people here think that AIDS is a white man conspiracy to prevent black people from reproducing. So you can understand why, right after the death of an infant, I was a bit uneasy about stating the advantages of small families, especially in front of someone directly involved.

In the end, Elizabeth waved goodbye, in the middle of one of Jalloh's translations, and she walked away. The bowl never moved a millimeter, and the mat was gathered under her arm.

We made a map of the route across Koidu Town from the clinic to "Uncle Ben's Guest House" where we are staying, using a compass, clipboard, and pen. Soon we will time the sections to get a more accurate sense of scale. Near the end of our walk home, which takes about an hour, we were being followed by four kids, for about ten minutes. They were just following us and saying "White man." in thick Krio accents. I once heard Allan respond to someone calling him "White man" by saying "Black man!"; I like that, and I've used it a couple times. No one seems to notice. When the kids were following us, after I noted that they really had nothing else to do, Katie said with a smile, "Well, it's like if you saw a purple man. Would you trail him and shout 'Purple man!'?"

I love mangoes

2009-06-10T08:45:00.001-04:00

June 9

I love mangoes. They are cheap (6 cents each, for the small ones, free from the tree in front of the clinic), gorgeously ripe, and everywhere. Katie loves buying food from random street vendors; I think that's a short road to a long time in the bathroom, but we can rinse off mangoes. So, the last couple nights we sat down around 8pm to feast on the mangoes that we got earlier in the day. They are incredible, albeit a bit stringy, and we're going to have to get more tomorrow. I say that because I spent about fifteen minutes making sure there was not even the tiniest scrap of edible mango remaining on the peel; it was a bit over the top. We had a big mango today, the biggest one I've ever had, and it was also the best mango I've ever had. Katie, however, is a veteran of traveling in China and Taiwan, and was not nearly as impressed. She told me I will definitely have better mangoes before leaving. That's okay with me.

It's a bit odd to me, though, that we don't see more people eating mangoes. They're delicious and they're everywhere, and in some spots the ground is covered with mango pits, but in general I haven't seen people eating them.

Greta – enjoying her comeback tour. Technology – not doing so well.

2009-06-10T08:44:00.001-04:00

June 9

Greta is doing well. One of the songs I like to sing on her is the synth-heavy "Africa" by Toto (it sounds very different on acoustic guitar; I think better), and one of the lines in that song is "I heard some rains, down in Africa..." Well, tonight, we heard some rains. It was intense. The tin roofs magnify the sound of all the raindrops and wind, and the end result is somewhere between a dull pounding and a pulsating roar. It's very hot and humid during the day, and almost every night we've had low-level thunderstorms roll through. Tonight, though, it was a pretty serious one. I stood out on the porch, supposedly safe from rain but actually getting pelted with spray off the ground and from the rain. The wind and rain ripped across the opposing building in sheets, filling the air with gray mist. The outdoor lighting on the opposing building is mostly incandescent bulbs hanging by their cords; they're given about a foot and a half of cord, so the wind was playing havoc with them. They bounced around behind the gray sheets of rain. The only other person outside was a very disgruntled looking security man who was sitting and watching the entrance for cars. I think he shook his head at me once, as if to say "You're crazy. Go inside." Eventually I went in, and not long after the rain died away.

Greta may be doing well, but rumour has it the Eee is not. Bailor took it back to Freetown, and it's experiencing some sort of bizarre hard drive error, right when it boots up. That's pretty annoying, because we chose the Eee specifically for its reliability. At this early stage it's definitely a manufacture error. On the other hand, it may work out alright, due to the fact that Amazon has a 30 day guarantee, and Allan is returning to North America on the 26^th of June, 29 days after we bought it. To be honest, I've definitely encountered more tech problems than I've solved since arriving. Let me just enumerate some of the (more or less) unexpected obstacles:

No one has legitimate copies of windows. They are all weird, virus-ridden, and inexplicably lacking important drivers, such as monitor drivers that let you have anything more than 4-bit resolution.
The internet connection, when it isn't in Freetown like it has been for the last four days, has a download speed of 1 kb/s, and 4 kb/s when it's raging. I never thought I'd ever care about kilobytes again; I was wrong. Incidentally, that may limit the number of photos posted to the blog. More importantly, it prevents us from downloading drivers for the desktop computer and Bailor's old laptop.
Despite the slow internet, somehow every computer has managed to download some of the internet's finest hard-drive slowing filth. Using them is a bit like running in quicksand. We improved the desktop by wiping it and then reinstalling windows... but now the resolution is 4 bits. Just like I never thought I'd meet a real kilobyte, I also never thought I'd meet a single digit screen resolution.
There is no power unless we turn on the generator, which costs about one USD per hour to run. That's not small change here in Kono. Plus, the generator often runs out of oil, and then it has to go off for an hour and a half while someone gets oil...
Bailor's old laptop doesn't have the right drivers to use the wireless modem, our internet, which is effectively a cellphone on a USB cord. That's created a bit of a chicken and egg problem.
Even if we get the computers working, there is no one at the clinic full time who could even find the "Control Panel"; they are learning how to use Word and Excel.
Tech support? In Kono? To be fair, there are some reps in Freetown. But I don't think NOW has ever used them. The main computer problem-solving tool is really the internet, and when the problems take down the internet, or when it's not around,

That's made me revise my hopes for setting up OpenMRS here at the clinic. They need a reliable, cheaper source of power and one or two people with more computer expertise, or else a computer system is just a disaster waiting to happen. Nonetheless, we'll still make a prototype version; by that I mean we will design all the forms and set it up on the computers, to wait for the day when it makes sense.

I'm keeping a list of some possible tech solutions for the clinic, solutions of the kind that would attract an Engineers Without Borders group from a university. Near the top is definitely some solar power – the clinic gets sun all day when it isn't raining, and presently it only rains at night. If you have any other ideas, please post them – we're all in this together, and the people of Kono and NOW need the help.

Health education broken telephone

2009-06-10T08:43:00.001-04:00

June 8

The vehicle has gone to Freetown, so we had to wake up early to walk to the clinic. It takes about one hour to do the walk, and since we don't yet know the way, Amhidu came to meet us. There isn't a map of Koidu Town, but my plan is to wander around with my compass a bit and see if I can make a rough sketch for Katie, me and any future interns.

The reason we woke up early was to give education modules at the amputee camp nearest the clinic. It's called Dorma. Dorma has 16 houses, and is just ten minutes walk from the clinic. To speed up our progress, we split into two teams: Katie and Amhidu, Jalloh and me. The idea was that Amhidu and Jalloh would serve as interpreters from English to Krio. Of course, some of the amputees only spoke Kono and Krio, so sometimes we needed to add a third layer of translation. I'm not new to teaching material similar in style to the health modules, but I found it difficult to keep the attention of the amputees and their dependents while we played our game of health education broken telephone.

It's the planting season, so many of the houses were mostly empty. According to Bailor, the idea was that we would go from house to house, and give the presentation before a rapt audience of at most ten people. That way everyone would see the presentation and remain attentive throughout. In reality, the first presentation was well attended simply because of the "white man." (Katie is also a "white man" for many Sierra Leoneans, despite the fact she is Asian.) Note: Katie is also 'Libanese,' Bengali, 'Chinese Man!,' and 'White Woman!' as far as globalization goes, she's the real deal. But even that attendance was fluid and inconstant, with people wandering over and wandering away. The next three houses at which Jalloh and I presented were almost empty, with one or two people in them at most. There were also few people near by to bring over to listen. One house was inhabited only by a women in a multilayered pink and patterned dress. At first we thought she spoke only Kono, which was right, but when we found a young woman perhaps my age to translate, she explained to us that the real problem was that the woman's ears had been chopped off, and so she couldn't hear well. The young woman, Rebecca, didn't seem too interested either – she was holding a one month old baby wrapped up in cloth on her back.

"I think we probably should make it shorter... there are two challenges, one is that the woman cannot hear well, and one is that she," Jalloh gestured to the rail-thin young interpreter into Kono, "will have to yell whatever we say to her [the older woman]." I nodded. Okay.

Bailor had given us a pretty comprehensive outline of six modules to cover – malaria, nutrition, iodine, HIV/AIDS, family planning, and tuberculosis. I figured that the most important were probably malaria and nutrition, and Jalloh figured HIV/AIDS was also very important. So we gave the malaria module, alternating between my English, Jalloh's Krio, and Rebecca's shouted Kono. It was slow, and pretty much impossible to keep Digba's (the old woman's) attention. I was fascinated by how the woman had tied the baby on to her back – it was nestled in the small of her back, supported by a wide swath of cloth tied tightly around her middle. Rebecca herself had high cheekbones and a slightly listless gaze. For most of the time she seemed as if she wasn't paying attention, but every now and then she would spark to life and laugh at Digba's attempts to understand.

"She no understand." We were asking about how HIV/AIDS spreads. Apparently Digba didn't understand the idea that it spread through unprotected sex.

Before the HIV/AIDS section, we covered the nutrition section. A large portion of the nutrition section deals with the importance of breastfeeding.

"How old is he?" Jalloh translated –

One month on the twelfth.

"So you breastfeed him?"

Yes.

"That's good... it's the safest, right? The breastmilk is completely clean, free from germs. And it's free, and easy to get, and it has everything the baby wants to be strong." Sometimes Jalloh's Krio phrasings slip into the English versions of the modules. I figure there is no point in using words like sterile, or nutrition, because Jalloh translates them down into terms like "clean" and "food to make you strong."

Rebecca nodded, slightly disinterested. She wasn't translating for Digba, because Digba was too old for children. We didn't argue.

"How long will you breastfeed him?"

A year and six months, eighteen months. I started to ask if she fed the baby water or food yet, but Jalloh translated something Rebecca had said.

"They are doing much education about this at the hospital now, that's what she says."

"Oh, okay. That's good. Well, ask her when she will first give her son food and water."

Eight months. That's perfect – in this place, the germs from food and water can prove too tough for infant immune systems.

"And when you feed him, make sure you use cup and spoon, not the hand, because the hand is dirty. It's much easier to clean the cup and spoon." Jalloh translated, plus adding in that another reason for using a cup and spoon is that with hand feeding you can sometimes choke the child. He turned back to me.

"She's going to translate for her[Digba]. It's the way of things here, you know. She might feed the baby, she has to know."

Rebecca shouted at Digba in Kono, then excused herself to put the baby to sleep. She returned shortly, now wearing a beige T-shirt like you would find at the Goodwill store.

TIA continued. We meet the amputees.

2009-06-10T08:42:00.001-04:00

June 5

The first day in the clinic. Dr.Barrie will be referred to as Bailor from here onwards, because we asked him what he would like us to call him and he chose Bailor. Bailor planned us an ambitious day – visiting al nine amputee camps. I'll try my best to describe what visiting an amputee camp for the first time is like. But first, three important new characters.

Allan Mayfield. He is a 59 year old American, who first volunteered in Africa a year and a half ago with Partners in Health in Burundi and has barely left since. His daughter went to Albert Einstein medical school with Dan Kelly, and according to Allan she is both his inspiration to volunteer abroad and a much better person than either him or her mother. He has been in Sierra Leone for two months helping NOW staff – and in particular Bailor – learn management skills, learn how to make budgets, learn how to make business plans, and in general has been helping out in any way he can.

Hamidu Barrie. I think his name is actually spelled Amhidu, or Ahmidu, but everyone says Hamidu. He is Dr. Barrie's nephew, and a fellow student of Jalloh's in the Peace and Conflict program at the University of Sierra Leone. He is quiet, soft-spoken, and very idealistic. He hopes to eventually work in the Democratic Republic of the Congo or Sudan to help those regions achieve peace. His official responsibility at NOW is to manage Katie and I, but in reality he is not so much a manager but instead a coworker who keeps us safe and makes sure we don't accidentally get into any trouble. So far he also seems to grasp careful business-like thinking very well; other than Allan, he is the main architect of the business plan for the palm kernel farm.I'm sure that many of my stories this summer will have Hamidu in them.

Sah Bindi. In Kono, the local language, "Sah" is the name of the eldest male child. "Siah" is the name of the eldest female child. Sah Bindi is the amputee liaison. He is the first amputee I met, and he is a very kind man. He has a bunch of children and lives in one of the concrete huts constructed for the amputees in the area. Sah Bindi named me "Sah Christopher" and named Katie "Kumba Katie" (because Katie is the second daughter)

Now, the story of the amputee camps. I'm typing this from memory, and it happened a couple days ago. In the interest of narrative, I'll use dialogue, but none of it is word for word what was actually said. I'm not trying to record the precise events; more like capture the experience in words.

Alimame turned up the road (barely a path by North American standards; there was more growing on it than there is some gardens I've seen) and we bounced our way up a short steep hill. Even though the road was bad and we are seven hours of bumpy road outside of Freetown, there were ramshackle houses on all sides. The vehicle pulled to a stop, and we piled out over the front seat, leaving our bags carefully in the back. The amputee camps are not isolated from other people or habitation; they are right among the clay and tin houses of the other residents of Kono District.

Katie, Hamidu, Sah Bindi and I all stepped out into the sun. Alimame reclined his seat and went to sleep. I'm sure he is also passionate about helping amputees, but that day he was a little annoyed that he we had arrived in Kono at 2am the night before and were working at 8am the next morning.

There was already three or four children, tiny and probably less than eight, gathered round us. They just stood and stared, sometimes whispering to one another, until Katie reached out her hand and introduced herself warmly. "Hi..." The reactions of the kids varied – a couple of the girls' eyes burst wide open, and one stepped forward to put her hand in Katie's. One of the little boys was very purposefully not looking at us, but he was still very curious out of the corner of his eye. After Katie shook the hand of the first girl, two more girls came up and shook her hand quickly and then retreated back across the small space between us.

The amputee camp itself was not large, but perhaps a little more organized than the average collection of houses in Sierra Leone. Hamidu told me "Perhaps seven houses in this camp..." I counted nine, but seven was close enough. Each of them were 26 by 22 ft (Jalloh and I paced them on Monday), and built out of concrete. They each have a shaded porch that is about seven feet deep by ten feet wide, and then three rooms on the inside, one twice as big as the other two. There are a number of windows in the concrete, but no electricity; when you look inside on a sunny day, it's dark. The roof was a sheet of siding, perhaps tin. Each was painted with a sky blue stripe just below the roof, and then beige for the remainder.

"Sah Bindi, who built the camps?"

"hmm?" Sometimes I have to ask my questions a couple of times. Allan tells me that Sierra Leoneans don't like a lot of questions; I think it's because I ask them out of the blue in English, and Krio comes a lot more naturally to most people here.

"Who built the amputee camps? And when?" I like a lot of questions. Some more good advice Allan has since given me: Ask a general question, because Sierra Leoneans love to talk. but numerous questions make them feel threatened and suspicious.

"Ah, a Norwegian NGO built them. The first... in 2002... finishing 2003... then one in 2004, finishing 2005..."

"So did they build all the camps?"

"Yes, yes, all de camps."

By this point a couple of older women had gathered. to be honest, there aren't many old people in Sierra Leone. The majority of people – and there are a lot of people – seem to be my age or younger. They introduced themselves; I don't remember their names. Katie and I smiled warmly and shook their hands. A boy brought out a couple of wooden chairs and a bench for us to sit on. Usually the adults shoo the children away, as if Katie and I would be offended by them. They're really cute, and especially in the amputee camp I felt their curiosity was completely genuine, not colored by a desire for our money. So I was kind of pleased when the older women didn't shoo them away. One little girl in particular was rocking back and forth on the bench where I was supposed to sit. So we didn't sit.

Hamidu and Sah Bindi began relaying our message. Today was a whirlwind tour of amputee camps. We were planning to visit all nine. So at each one we stopped only for a few minutes – just long enough for Katie and I to introduce ourselves, and then for us to explain to them that we would be returning the following week to give some education about malaria, nutrition, pregnancy, and other health topics. Hamidu would say the message in Krio, which I can barely understand, and then Sah Bindi would translate into Kono, which I can't understand at all.

It's not exactly clear to me the advantage gained by having Katie and I do the education modules instead of, for example, Sah Bindi or Hamidu. Perhaps it is that we can learn the content faster, or perhaps it is that our "whiteness" confers an authority to our words that is very important if we want the amputees and their dependents to learn the content. Note: On Monday Jalloh confirmed that this is definitely one of the reasons we are doing the health education and not just him and Amhidu.

As we were talking, another woman, the oldest, came out. She was a double amputee, and dressed immaculately in a purple, green and black patterned dress. Here eyes sparkled with intelligence. Then, when we turned to go, and said goodbye to the shy and not-so-shy children, Hamidu softly grabbed my attention.

"Chris, they have given you a gift, dees fruits. Maybe you should thank them." He handed me a black plastic bag of green oranges.

"Oh, yeah! I'll go thank them." I went back around the vehicle and Hamidu pointed to the woman in purple.

"Her, she is de one." She was already returning to the shade of one of the porches, so I caught up to her.

"Thank you so much!" She nodded, smiling. I grasped her right stump in my two hands, and then turned to go. We woke up Alimamy and jolted our way out of the camp. Note: the oranges, although green as limes, were excellent.

TIA continued. The long journey.

2009-06-10T08:40:00.000-04:00

June 4

We drove out to Kono today. We meant to leave around twelve, but instead we left around five. During the journey, we met a couple more important characters.

National Organization for WellBody: Okay, we didn't actually meet during the drive. But it's an important character nonetheless. NOW is the Sierra Leonean twin of GAF. It's administered by Dr. Barrie, and employs drivers, nurses, pharmacists, amputee liaisons,

Jalloh: Jalloh is a Peace and Conflict student from the first graduating class of the program at the University of Sierra Leone. He's not right out of high school, but since he is bashful about his age I'll be guarded here. In order to complete his degree he needs to do an internship, and since he is a neighbor of the Barries in Freetown, he is doing his internship with NOW this summer. He's very outgoing, tells lots of stories, and calls me "Christo!" with a great big smile on his face. I think we may be doing some education modules together next week. Otherwise he works at the clerk's desk. His true interests lie in anthropological-style investigation of the amputee population; in particular he is writing about the impact of school fees on the amputees and their dependents. School fees, you ask? Yep. This is a note from the future, but on June 8 we met a 45 year old man with 7 children. He pointed to 100 USD per year in school fees in five children, all while sitting on the porch of his two room concrete box with no electricity, no running water. And he pointed with his only hand. It's not hard to imagine what the effect of school fees might be on such a family. On the other hand, it's fair to point out that perhaps the fact that school is expensive filters out the families and children that would not take it seriously. It's hard to think of ways that we could measure which strategy will be better for Kono and Sierra Leone in the long run. It's very emotionally compelling to advocate for free education for all, and that's certainly my position; it comes from thinking about the problem from a perspective of margins of error. Given that we don't have data about the long term effects of the two systems, to which side would we rather err – giving education too easily, or too reticently?

Alimamy, aka Cuyba (Ky as in sky, ba as in bah humbug). The driver. He used to drive "poda poda", which are the crazy Volkswagon hippie vans that rocket around the country with passengers on both the in and outside. He drives NOW's 1994 Nissan SUV, and threads it through some impossible situations. Sometimes we'll be driving in the right hand lane, coming up on a slower moving van on the right. In the oncoming lane are two motorbikes and a car. It looks like a disaster, but Alimamy honks, zips out into the middle of the road, and the motorbikes get the heck out of the way. Everyone zooms by with centimeters to spare, and nobody bats an eye. The rules of the road in Sierra Leone are guidelines at very best. He loves to eat, and always lurks around Allan, the expat you will meet soon, during meals, because Allan can't always finish all his food.

TIA continued. Not in Kansas...

2009-06-10T08:39:00.001-04:00

June 3

Today I learned that you wouldn't believe the things people can carry on their heads. Baskets, nuts, towels stacked five feet high, bags of sand, entire palm trees, construction materials, dozens of eggs, half-empty trays of food. It's incredible.

What struck me today are both the incredible barriers between Sierra Leone and the simplest efficiencies of North American life. We drove to a hospital, Lakka. It was at the end of a thirty minute long, pothole stricken dirt road (still in Freetown). At no point along the road were there less than ten people in view. There were construction sites, campfires, shacks, goats, pigs, kids, adults, motorbikes, eighteen-wheelers with bumpers tied on by rope, little Volkswagon hippie vans emblazoned with religious slogans and carrying small armies of people. It was an adventure. When we arrived, we knocked on the door of the reference lab for all of Sierra Leone. They make the media for all the TB sputum test conducted in the country. There were two men working there, one of whom was just sitting at an empty desk. Dr. Barrie discussed an idea for collaboration – specifically, he had gone to the Gates Foundation to ask about upgrading the lab in Kono, and they had responded by saying they wanted to upgrade the labs everywhere. So Dr. Barrie went to the reference lab.

The man in charge was proud of his work. The reference lab held labs all across Sierra Leone accountable. The lab was clean, the equipment pristine albeit old, and the lone lab tech in sight was working industriously. The man in charge came across as competent and careful, fully aware of his responsibility.

Dr. Barrie, on the other hand, just wanted to know what the clinic lacked; where it was weak.

Perhaps you can see the issue? Any attempts to ask about areas where updgrades might be needed were construed as mild insinuations that his lab was insufficient in some way. At one point, Dr. Barrie asked the manager how many people worked in the lab. Before responding, he thought for a moment. Then he asked his lone worker. "Six." replied the worker. Nonetheless, the manager later maintained that all of his (six?) workers were fully trained in every possible way, and that there was probably more of a need for equipment than training from the Gates foundation.

Luckily Dr. Barrie was roundabout enough, and no feathers were ruffled. He left the lab manager with his number and some time to let him come up with the idea of upgrading on his own.

During the conversation, Dr. Barrie's phone rang. There was already a phone on the table, his, and then he took two more phones out of his pockets. You might ask why (I did, mentally. We didn't find out until later.) It turns out that there are three major cell carriers in Sierra Leone – Africell, Zain, and (I forgot). Calls work on a pay-as-you-go basis, but rates are much higher for calls between carriers as opposed to within them. Dr. Barrie gets a lot of calls. And so it saves him and his friends, coworkers, and whoever else phones him if he has a phone from each major carrier.

TIA: for better (the goal of GAF and our internships) or for worse (the end of my day today.)

2009-06-10T08:22:00.001-04:00

June 2

Today was actually about forty hours long. The night before we left, I stayed up until the sun chased me to bed for a bit, making sure the printer and computer were compatible. The Eee computer looks like it will be a good choice, but I had to change it to a different distribution of Linux because the preloaded one was not being widely maintained. In any case, now I’m lying in a bed in an International Hostel in Freetown, Sierra Leone. There’s fork lightning across the sky, and sparks from what is probably some kind of power surge coming from the outlet. Don’t worry, my computer’s running on battery.

When Katie and I landed in Freetown, they popped open the doors and a blast of hot, humid air immediately overwhelmed eight hours of air conditioning. The airport itself was about the size of the 60m jet in which we flew, and had an assortment of tacky yellow signs welcoming us to Sierra Leone. With little trouble Katie and I were through immigration and customs, and we walked out directly into the welcoming handshakes of Dr. Barrie. We also met Amadu, the project manager for the nutritional feeding clinic that the Sierra Leonean face of GAF (called National Organization for Wellbody; NOW) runs. From this moment until the moment I got into my hostel room, we were almost constantly surrounded by people trying to help us for a price (at best) and trying to rob us (at worst). A driver in an old SUV took us back to the ferry at breakneck pace, past stacks of houses that clearly never see winter. You can tell by the way the corners don’t totally match – that would be very unpleasant at -10 C. There’s loads of palm trees around, but the vegetation in general wasn’t very thick. Mostly I was struck by the number of people everywhere.

We missed the 6:30pm ferry, so we had to wait until 9. We wandered over towards a stand that seemed to be selling drinks and then a woman pulled out a table, tablecloth, and chairs for us. We all talked until the ferry came, occasionally shooing away beggars and intrepid phone card salesmen. At some point, Amadu chuckled and said “TIA... this is Africa.” I’m not sure whether he was explaining the dilapidated yet overworked cars, the scores of people trying very hard to help us in return for the right to guilt us into giving them money, or something else. It could have been any of them. In any case, as the sun set through the haze, Africa made a strong first impression on me; that of foreignness. I’ve had the good luck to travel a bit, but I have never been somewhere where my knowledge, habits, and identity are so blatantly foreign.

My second impression of Africa comes from the ferry. We had first class ferry tickets, which meant we sat in a large square lounge in plastic lawn-chairs with diner-style red carpet on the floor and loud music videos on a small TV. The room was packed and humid. When we finally arrived at Freetown around 10pm, there was a huge crowd clamoring at the door to the first class lounge. A small fight started, and a couple of people complained to someone who may or may not have worked for the ferry. We decided to wait. A concerned businesswoman in a white pantsuit warned me to watch my shoes, which were stuck into the waterbottle holders on either side of my backpack. I thanked her and Dr. Barrie helped me tie them on to my bag even tighter. I had my passport in my left pocket, shielded by my guitar, and my wallet was in a pocket in my jacket, which was bunched under my arm. Dr. Barrie and Amadu were worried, and it looked to me like waiting until the obvious crowd of thieves dispersed might be wise. But we went ahead, and it was intense. The corridors and passageways from the first class lounge to the dock were lined with boys and young men, and their hands were desperately trying to take our stuff – either legitimately, so we would pay them for carrying it, or illegitimately, without our knowing. The stairs were metal, sharp-edged, and steep, and even though we had extra help it was hard to carry our bags down them. When I got to the bottom I tossed my jacket in my hand to make sure the weight of my wallet was still there. It wasn’t.

A brief yelling match between Dr. Barrie and the owner of the ferry ensued. It’s pretty clear that the crowd of pickpockets were not passengers on the ferry; they were probably the bag boys that just waited around. The ferry owner seemed interested in keeping this incident quiet, and assured me that this was the first wallet ever stolen on his ferry. That’s a little unbelievable. I may get it back, if the thief pilfered the cash right there and then dropped the wallet. But I probably won’t get it back.

The wallet contained ~83 USD, ~5 CAD, my American and Canadian bank cards, two credit cards, my health card, my student card, my driver’s license, the medical insurance card from GreatWestLife, my London library card, and my family’s Roger’s membership, which I accidentally took with me to Sierra Leone...

The thing is, I wasn’t angry at all. First, it didn’t seem like getting angry would do anything. Second, while it sucks to be robbed, I didn’t lose all that much money, none of the cards are needed while I’m here in Sierra Leone (save possibly the medical insurance card. I still have the Princeton travel insurance card), and everything can be replaced in August when I come home. To be honest, I just hadn’t expected to be in a situation like that immediately after arriving; I was planning on cleaning out my wallet into my “important stuff” folder tonight.

They also stole Katie’s glasses, which turns out to be much more inconvenient than my wallet!

I wonder what the thief is doing with the cash. While I’m not condoning his theft at all – I would love to still have my ID cards and cash – it’s pretty clear that he needs it more than I do. More than anything, this has made me think of the weird parallels between begging, theft, and aid. That’s all for now.

Quick disclaimer for all those who are now worried: I’m getting all my money for the summer from the NGO, and my passport, student visa, and travel insurance are all being stored safely at Dr. Barrie’s house for the entire summer. This was already the plan; I would have given him the contents of my wallet as well. He has given us ID cards for in-country use.

The tech circus - computers in rural Sierra Leone

2009-05-29T21:09:00.003-04:00

We have a new character to meet - the clinic's new laptop!

One of the obvious logistical problems with setting up an electronic medical records system in Sierra Leone is the "electronic" part. It turns out that fixing computer problems in Kono is not as easy as just taking your computer back into the store. You can't order computer-related stuff online and have it delivered. Power is not a public utility and prone to unexpected blackouts. Heat and humidity are hard on fans and hard drives. Even simple problems with a charger can leave a computer useless. And the problems are not merely environmental - malware and viruses seem to be a constant problem.

So what are Katie and I going to do about it?

Recently an American man currently working at the clinic donated the money for a new laptop for the clinic. So Dan Kelly tasked Katie and I with buying one and bringing it with us to go to Sierra Leone. This means that we have a chance to try and address many of those logistical difficulties through our choice of laptop.

Our first thought was to get a simple Dell laptop. But then we did some research. It turns out that there are computers built to resist the heat, humidity, dust, and power inconsistencies common in developing nations - the XO, designed by the One Laptop Per Child foundation. The XO uses a solid state flash hard drive instead of the more common spinning hard drive, because the fewer moving parts, the better. It's small and energy efficient to increase the battery life. The smallness and compactness also contributes to its durability. It doesn't have much processing power, nor does it have much onboard hard drive space, because solid state hard drives are slower. But it doesn't need that for its purpose; instead, the lack of high speed processing or graphics capabilities means that the production cost is low: ~200 USD.

Of course, they're not exactly what we want for the clinic. So we went in search of commercial laptops that approximate the durability, battery power, and minimalism of the XO. That lead us to a segment of the laptop market known as "netbooks." Netbook is a term that describes a small laptop primarily designed for surfing the web, checking email, and using web applications. The first netbooks to become widely known were produced by Asus; this New York Times article describes netbooks as "the Honda Fit" of the laptop world.

After a couple of hours reading product comparisons and looking at Amazon to determine which laptops could feasibly be delivered by today (this was yesterday; we leave Monday!), we settled on the Asus Eee 901. It's tiny - only 9 inches. But Asus is arguably the most reliable brand out there. (I like this story, which briefly tells about two guys that trekked across the Canadian Arctic for 70 days with Eee 901 computers). It also runs on a 20 GB solid state flash hard drive, has great battery life, and wireless capabilities. And, it runs on Linux.

Don't worry about it if you have never heard of Linux. It's an operating system, analogous to Windows, except that it is open source. That means that both Linux itself and all of the computer code used to make it work are freely available for anyone to edit or use. And when I say "freely", I mean "free" - Linux costs nothing. Even better, Linux computers don't get viruses. I won't pretend to be a tech expert; I can't explain all the reasons why Linux is so much more secure.

In the context of the clinic, Linux has the edge on Windows for a few reasons. First, the security. Second, Linux will always be free, and updates itself. Third, while one of the major obstacles to more widespread use of Linux is the fact that it is not always easy to port files from proprietary systems (ie Windows) to Linux, the clinic has hardly any preexisting files to be ported. Last, OpenMRS is a web application - it is written in Java and runs out of Firefox, so it can run perfectly well on either Linux or Windows.

So our new baby laptop arrived today, and she looks great. The hinge for the monitor is sturdy; the chassis is solid. I'm excited that we've had the chance to "buy outside the box" in order to make sure the clinic has a computer that will last.

Let me close by thanking my primary tech consultant, my roommate Sajid. He knows much more about computers than I ever will and is also very happy to help me muddle through. He actually has a blog of his own, where he writes about neat tech policy issues. Take a look, and don't be intimidated by the seeming difficulty of the subject matter - the issues he writes about are very pressing and often don't get the attention they deserve.

The chorus

2009-05-26T22:37:00.005-04:00

Let me introduce you to some of the characters.

Sierra Leone. That's okay, I've always had a hard time remembering where exactly it is. It's here, in West Africa. European involvement began in the late 18th century when the British established Freetown (the capital) as a territory for impoverished and free former slaves. Of course, before, during, and after that there were many tribes in both the coastal and inland regions of Sierra Leone. But it is the legacy of the freed slaves that colors Sierra Leone's common language, "Krio", a mix of English and several African languages. In fact, the foundations of both Freetown and Krio were laid by Nova Scotian former slaves, and their journey is chronicled in the recent historical fiction novel The Book of Negroes by Lawrence Hill. I haven't read it yet, but I wish I had; it was nominated for a Giller Prize in 2007 and recommended to me by a good friend from Pearson. It's a bit amusing that in the USA it was published under the name "Someone Knows My Name."

So while Sierra Leone's distant past was full of inversions - British freed slaves sent back to Africa, Jamaican militias (the Maroons) of freed slaves brought in to put down rebellions by the British freed slaves - its present is more tragic. A horrific civil war tore the country apart from 1992 - 2002. The rebel faction, also known as the RUF, quickly established themselves in the Kono region and traded its diamonds for weapons for the duration of the war. The RUF is infamous for its inhuman practice of amputating innocent civilians. It's hard for me to even begin to understand their depravity. They would ask their victims "Short sleeves or long sleeves?" (cut at the wrist or the elbow) to force the victim to take part in the torture.

Perhaps more horrific is the widespread use of child soldiers by both the RUF and the government armies. The children were recruited at gunpoint, forced to kill, and then kept intoxicated on a nonstop cocktail of cocaine, marijuana, Rambo movies, and violence. A Long Way Gone, by Ishmael Beah, is the heartbreaking yet inspiring account of Beah's own forcible recruitment into the government army at age 12, his time in the army, and his rescue and rehabilitation by UN agencies.

The civil war burned out by 2002, and the country has retreated from the middle pages of the Globe and Mail to work towards democracy in private. Great strides have been made, for example the first democratic elections in 2007. But as the UN Human Development Index shows, the country still has a long way to go.

Amputees in Sierra Leone. Soon I will be able to put some names into this general category; for now I put them here to symbolize their transition from the fringes of society to the focus of the Global Action Foundation's programs in Sierra Leone.

The Global Action Foundation (GAF). The Global Action Foundation funds initiatives to eradicate extreme poverty. It was founded in 2005 by Dr. Dan Kelly and a few of his friends at the Albert Einstein College of Medicine. Through one of those friends, Dr. Kelly met Dr. Barrie, both characters you'll meet shortly, and together they created, among other things, a clinic to serve the amputee population in Kono district, Sierra Leone. That's where the majority of my internship will be. One thing I like about GAF is that I think Kathy Kelly, co-founder and chairperson, is Dan Kelly's mom.

Dr. Dan Kelly. Currently a medical resident at Baylor in Houston, Texas. He is Executive Director and one of the founders of GAF, and raises the money the organization requires. He is a Princeton alumn and he created this internship through the International Internship Program at Princeton. Both me and my fellow intern Katie Hsih obtained this internship through that program. Apparently he is also a marathon runner; I know graduate students older than him. With a smile and an optimistic outlook, he's covered some ground in the five or so years since he graduated from Princeton.

Dr. Bailor Barrie. I haven't met him yet, but just take a look at the embedded video here. Dr. Barrie is the guy on the ground for GAF, and he is my boss for the summer. I'm really looking forward to it. In my opinion, carefully targeted aid organizations with inspired leadership and few middlemen are the ones that can make the most efficient and effective differences, and Dr. Barrie seems to agree.

Katie Hsih. My fellow Princeton intern. She is studying Operations Research and Financial Engineering, and is very interested in issues of Global Health. She's also much more responsible and careful about planning trans-atlantic trips than I am (which may not be saying much).

The clinic. It's in Kono; more or less here; close to the Guinean border. It mainly sees malaria, acid reflux disease, and typhoid fever cases. It serves 158 amputees. I'm pulling this right off here.

The Survey. One of our main responsibilities is to finish conducting and analyze a survey that assesses the impact of the clinic's health education modules. We're going to look at whether or not people know more about typical disease transmission mechanisms (eg. how does one get HIV?) and prevention methods (how do you use a bednet? When do you bring your child to the clinic?).

OpenMRS. This is the open-source electronic medical records software we will implement at the clinic. I'm very excited about it, but I can see your eyes glazing over. Check out the description and the demo. Why am I excited? Because 1) properly implemented, it will be a more efficient and convenient method of monitoring patient records, 2) it gives the clinic the ability to conduct powerful analyses on its patients. Academic literature is starving for data on clinics such as this one. Furthermore, you cannot improve something (health) until you can measure it. Until I arrive in Sierra Leone and have more interesting things to write about, I'll probably bore you with the details of the planned implementation.

Greta. My guitar. She's coming out of retirement at my Aunt JJ's Bruce Beach cottage to fly 20 hours across the ocean to Sierra Leone.

My Mom. She's worried about me. And she's worried that I won't take any pictures. But she's always worried about me. I love you Mom!

I'm sure we'll meet many more interesting characters, and most of these characters will become more interesting. But that's all for now. In one week I'll be in Freetown.