The Hospital at Nhamatama

I visited a small rural hospital last week: Nhamatanda is in a town of about 10,000 (my guess) , and the hospital serves a district of about 500,000. There are two doctors, and six ¨technico´s¨, who are more or less like PA´s, but trained to do specific procedures like C-Sections. Currently there are also 6 medical students, which is (or is not?), a good thing, since both of the doctors are gone right now. The first photo is of a lab tech showing us their new CD4 counter, a piece of equipment which is essential for treating AIDS patients. It was purchased for the hospital by the Clinton Foundation.




The HIV rate in this area is 29%. About 10% of HIV(+) individuals are on anti-retrovirals (provided through funding from the US at a cost of about $100 per year per person).

The second picture shows family members of patients cooking food for themselves and the patients in an area set aside for this.



The most common reasons for hospitalization are malaria and childbirth . They do about 250 deliveries a month, and have a 3% C-section rate. (Maybe that should be a little bit higher, since Mozambique is tied with Sierra Leon for the highest neonatal mortality in the world!). There is also about a 1% incidence of uterine rupture, for unclear reasons (a study is in progress). The third photo shows pregnant women at a hostel on the hospital grounds where they come and stay when they are close to delivery. May live too far away to wait at home, especially during the rainy season.




The two most common surgeries are 1) hernia repair and 2) intestinal obstruction due to ascaris (pork tapeworm) infection. The fourth photo is of one of the medical students showing us around.




In addition to surgical, obstetrical, pediatric and general medicine wards, this hospital has separate wards for TB, leprosy, and malaria, and a tent for cholera patients. The last photo is the cholera tent.

Hey, it may be a dump, but it´s MY dump!

It´s a non-descript, neglected , 4 story structure in a crumbling city of elegant buildings that haven´t seen a lick of maintenance since the Portuguese left in a hurry in 1975. The building that I call home is just across the street from the beach, and a block from the city hospital (800 beds, 1400 patients). Like the rest of the city, it cries out desperately for a fresh coat paint. When I first entered it, climbing up 5 or 6 steps onto a small stoop, then into the building, I was a bit dismayed to find a homeless man living in the lobby- unkempt, smelling of urine, clothes in tatters. I later found out he was the night watchman. The smell of urine recedes you climb up the 5 flights of stairs to the top floor where we live. Along the way, you can catch glimpses of the street below through dirty and mostly broken windows. If you´re lucky, it´s still light out, otherwise you are left standing in the dark outside our flat, trying to find the slot for the key. Our main door, dead-bolted and latched in 2 places, is protected by an impressive padlocked gate of steel rebar.



As you enter, the circuit breaker panel is to your left. I found out yesterday, when I was investigating the non-functioning water pump (the city water supply had inexplicably failed), that the fuses had all been bypassed with strips of wire. The ceiling of the living room has a large crack that leaks when it rains. We are told not to leave the kitchen door open at night so that the rats won´t come in. The shower has two settings- cold ,and really cold! The windows don´t close tightly, so the mosquito´s get in at night (yup, malaria in the air). An industrial strength fan keeps the mosquito´s down and makes some white noise. The road between the building and the beach is extensively potholed and repaired, and the old death trap cars and busses that pass by all day protest loudly. Luckily, the traffic mostly dies down after 10 PM, and we hear mostly the waves on the beach at night (unless it is Friday or Saturday, when a bar magically appears in the building across the street and plays loud music till 2 AM.

The view from the deck is a fine one of the beach and bay to the south. I watch fisherman sail out in dugout canoes as I eat my breakfast, and watch them come back as the sun sets in the evening. You can cross the street to the beach, and buy fresh fish from the fisherman in the evening.



They street scene makes for good entertainment: lots of hospital employees, medical students, patients families, etc walking by. In the early morning poor African women gather in the street, bent over at the waist, sweeping sand that has blown from the beach into little piles, using a bundle of sticks for a broom. They load the sand into sacks and wheelbarrows, and carry it off to their houses in the slum, which is built in/on the swamp and has a lot of standing water. They put the sand on the ground to try to raise it up a bit and dry it out. (They are not allowed to collect sand from the beach.)



Mohammed and Achmed are the two brothers, both medical students, who live in the garage downstairs. Their “space” contains the large water tank for the whole building . On either side of them is a ”paderia”, a small shopfront that sells bread at irregular hours, and a small beauty parlor. Out back, in a sort of shack that may have been maid´s quarters at one time, lives a women with 3 or 4 small children. They hang out on the sidewalk most of the day next to a small stack of banana´s and tangerines (about 30 cents for 6 bananas, 5 cents for a tangerine)

Portuguese:

Portuguese is still a challenge to speak, though I have made progress. I´ve been able to see patients on my own in the clinic, and I am helping out with an epidemiology class at the medical school that is taught half in Portuguese. I still find it a pretty coarse and nasty sounding language, but knowing Spanish helps.

Yesterday, I met a doc from Spain. I opened my mouth to speak to him (in Spanish), and to my horror I vomited a nasty gumbo of spanish-portuguese-english gibbberish all over him. It took a while to clean up. I can still smell it on my clothes.

Pus and Parasites

At home, ear infections and hypertension and diabetes are the bread and butter of primary care. Here it´s abscesses and parasites. As a consequence, the Oxford Handbook of Tropical Diseases has become one of my best friends. I carry it with me and snack on it throughout the day. In the evenings, I snuggle up with it for more filling entrees about the diagnosis and treatment of various parasitic infections, as well as the “big three”: HIV, TB, and malaria.

Mozambique exceeds even Bethel in the number and size of nasty abscesses that we have to incise and drain. Not very appetizing work.

Parasites are rampant: the medical school here did a survey in the barrio next door and found that 40 to 80 percent of residents are colonized by each of the common parasites: tapeworms, ascariasis, giardia, etc. Though a diagnosis of pinworms sends shockwaves through American middle class communities, here they are an expected part of life. While the thought of carrying a colony of worms around in your belly may be discomforting, most of the time they cause little or no symptoms. When the number of parasites gets large, though, they can contribute to anemia, fatigue, failure to thrive, and a host of other complications. We routinely de-worm the kids when they come in with swollen bellies and vague GI complaints, or anemia and poor weight gain.

One curiousity is called "larva cutaneous migrans". This little worm enters the skin through barefeet, then crawls around just beneath the surface leaving a serpentine trail. It eventually dies, or pops out of the skin, but in the meantime it causes a lot of itching. A good reason to wear shoes when you visit Africa. ~

Schistosomias is another, more severe infection: this promiscuous parasite lives half it´s life cycle in snails, and the other half in people. People contract it when they spend time in fresh water: the parasite penetrates the skin, enters blood vessels, migrates to the liver, and matures to an adult. Then they set up residence in various locales in the body,depending on the particular subspecies. One type, schistosomiasis haemotobium (save that for your next game of SCRABBLE), favors the bladder, another, the liver, spleen and intestines. The disease is very common, not in Beira, but in many other areas of Mozambique( and all over Africa) Many of the patients here are from those areas, and I have seen a half dozen patients with various forms of the disease.

Yesterday, I saw a young man, about 24 years old, from the region called Zambezia, who likely had schistosomiasis. (The Zambezi river is the largest river around, and drains a huge area of Zimbabwe, Zambia and Botswana). He complained of pelvic pain, and bloody urine. Another, patient of similar age had abdominal pain, and blood in his stool. A third, older adult male had developed a distended abdomen from fluid collection (ascites) which occurred because the infection caused scarring in his liver that prevents blood flowing back to the heart (portal hypertension). In spite of their disease, they all appeared relatively vigorous and well nourished (in contrast to the HIV and TB and malaria patients, who look ill). All of these people were easily treated with Praziquantal in a single dose. I am curious to see them back after treatment to see how they respond.

Lest you get too complacent , schistosomiasis is a cousin to this parasite that causes “swimmers itch” that we Zimmer´s experience when we swim in Great Pond in Maine every summer. The difference is that that particular flavor of parasite lives alternately in snails and ducks. We humans are accidental hosts, and the parasite dies after penetrating the skin rather than enjoying a long and prosperous life in our liver.

Rather than posting a picture of a disgusting parasite, I put a photo of a beachside fishing village about 20 miles north of here. We biked to it yesterday. Nice spot!

Outdoor showers and rampaging elephants...

Back in the 60´s, Gorongoza national park , about 150 miles NE of Beira, was one of the premier wildlife parks in southern Africa, and was home to thousands of elephants, buffalo, hippo´s, impala, lions, etc. That all changed during the long civil war (a proxy war of the cold war), when it became a battle ground between FRELIMO (the government-socialist), and RENAMO (the rebels-fascists, backed by white Rhodesia ). Most of the wildlife was killed in the fighting, eaten by hungry soldiers or poachers, or killed by landmines. Since the civil ended, the park has reopened, and wildlife is slowly returning. We decided to head up there for a look.

Peter graciously offered us use of his car, and five of us- myself, Matt a US Vetrinarian (who coincidentally knows Steve Withrow out in Fort Collins), Matts daughter, Maddie, Matt#2, a medical student doing research here, and Phil, a 1st year medical student from Pittsburg- headed north.

The first challenge was to negotiate 40 miles of pothole-strewn road through the floodplain of the Pungue river. It reminded me of the old joke about how you can pick out the drunks in Kodiak because they are the only ones driving straight on the potholed roads. This stretch of road floods every rainy season causing lots of damage, and requiring continuous maneuvering back and forth across both lanes and shoulders.

At towns along the way, our car would be mobbed by kids selling great looking produce: eggplant, corn, lettuce, tomatoes, papayas, cashews, crawfish, live chickens etc, all pushed through any open window and offered for sale at very un-kodiak prices. A steady stream of foot and bicycle traffic delimited the two sides of the road; Women carrying every type of object on their heads, and old Chinese bikes laden with huge bags of charcoal or small mountains of firewood. Sharing the road with us were trucks carrying freight to Zimbabwe (this highway is land-locked Zimbabwe´s lifeline to the sea), overloaded Chapa´s ( passenger vans packed to the gills, with luggage, chicken coops, etc piled high on the roof), and shiny, late model SUV´s and pickups driven by Zimbabweans heading to the beach. We all wove drunkenly up and down the highway, flanked by pedestrians and cyclists on either side, driving as fast as we dared, while dodging potholes, and each other.
We stopped halfway in the town of Nametanda, to drop of Matt #2 who is doing research on uterine rupture during pregnancy (he was a peace-corps volunteer here before med school and knows the region well. factoid- the HIV rate in this town is 29%). After a lunch of rice and beef, we left Matt#2 behind, and continued on. The road started climbing up out of the flood plain leaving behind much of the traffic and potholes, and wound around villages of mud huts with thatched roofs.

After a few more hours, and a final 30 miles of dirt, we started to run into warthogs and baboons, and eventually arrived at the park headquarters in Chitengo. The walls of the facility are pockmarked with bullet holes from the war, but it is slowly coming to life again. There is construction going on at a sleepy pace, and a decent restaurant. The few cabana´s there were filled with research scientists and government officials, but few other tourists. The compound is surrounded by fencing to keep out the elephants, lions and other undesireables, but baboons and warthogs (together, they seem to be the local omnipresent pest population) had free range of the place. We spent a night there, enjoying phenomenal stargazing, the roars of lions in the distance, and games of Eucher (sp?) ( the other´s were all Midwesterners). It was easy to meet and talk with the others at the park, including a wildlife biologist who is working to transplant elephants and other species back to the park, a wealthy American philanthropist (Greg Carr- he invented voice mail, developed the concept, and sold his company for a bundle. He now spends his time and energy working to get Gorongosa going again), various government officials from the ministry of the environment, and scientists and grad students doing research.

The next day we met up with a friend of Peter´s, Rob, who runs a (the only) small eco-tourism ”lodge” in the park. Rob and his wife Jos are S. Africans, who now live in Zimbabwe and Mozambique. On the way into the park, we passed an immense amount of wildlife. Herds of antelope(probably 10 different types in all), baboons, warthogs, storks, etc., were thick. Rob and Jos opened up their “Lodge” 18 months ago as an experiment within the park. “Explore Gorongosa” is located several miles further into the park, (outside the fence), alongside a small river. You sleep in wall tents equipped with big comfy beds, and outdoor showers (they bring you hot water when you need it). It is set up so it can be dismantled and taken away without leaving any permanent changes to the environment.

My tent was located along side a large open savannah with a front-row seat to everything that was happening out there. Meals were really nice, well made and served outdoors. After dinner, we had to be escorted to your tent by an armed guard (he carried a .485 caliber rifle) because of lions. I felt a little vulnerable out there at night, alone in the dark, listening to carnivores in the distance, but took comfort in the fact that I had a small whistle to blow in case I got in trouble. Nothing will bring a large top-of-the-food-pyramid carnivore to his knees like a small whistle. (Right?!)


Turns out though that it wasn´the carnivores, but the herbivores that gave us the big thrill that night.

In the late afternoon, Rob took in his truck to go see hippo´s at a spot by the river. We never made it there. After driving about 30 minutes, we came around a corner and blundered into a herd of about 30 or 40 elephants. We pulled over to watch then, and Rob warned us not to get out of the truck. While we watched a couple of large bull elephants in front knocking heads and playing around, Rob explained that, while most of the elephants were pretty docile, some were pretty freaked out by humans. This is a remnant of being shot at during the civil war. We could see the largest group just ahead of us, and a smaller group of 5 or 6 more crossed over in front of us and to our side on the right. They were watching us and smelling us with their trunks lifted high up in the air. Suddenly, two of them came charging out of the trees straight at us, blaring away, heads and trunks down, ears flared out. Rob assumed it was a bluff charge, and stayed put, and pounded on the car roof. One of the two stopped, but the other kept coming at us, and when she was about 8 feet away, he finally started up the truck and took off across the grass. She kept coming at us, in a rage. He swerved around a palm, which she promptly ran right over, knocking it down. The car stalled once in the deep grass, and she came within a few feet before he could start it again (I was in the very back!) At this point, time has slowed down and I seemed to note the details of what seemed to be my last few moments with true clarity. Scenes from Jurassic park came to mind. With mad Nellie close on our heels, we circled around back to the road, and took off as fast as possible. Once we made it onto the road, I was hopeful that I might actually survive the experience. At this point I thought to turn on the video on my camera, and made the short film you can see below. Mad Nellie chased us about ½ mile at full speed, trumpets blaring before she stopped and backed off.

Chicken feet and Mendellian genetics....

Arlindo is a medical student who I am working with in the clinic. He is acting as my translator/Portuguese tutor while I see patients in the clinic. He failed a class last semester (more on that later) and, since he is waiting around for two months until he can resume classes, he was hired to work with me. It works out well: I blunder through taking a medical history in Portuguese, when the patient looks at me as if I´m from another planet, he tells them what I thought I was saying, and then corrects my grammar. In return, I like to think I impart a little teaching. There are certainly some things that I can teach him, but he has taught me a lot too, about tropical diseases, Mozambique culture, etc. He is smart, and has excellent communication skills, and has been fun to work with.

He invited me to join him tonight, first to meet his wife, Joaquina, and young son, and see where he lives, and after, to join him at the night school class that he teaches. He teaches 3 high school classes, 4 evenings a week. Inn one class he is covering Mendelian genetics. There is an albino in the class, and he asked if I would mind talking about the genetics of albinism(in Portuguese!). He apparently is not aware that it has been 23 years since I studied the subject, and must have a higher opinion of my ability to communicate in Portuguese than I do. Sensing a trap, of course I said yes.

In turns out that, In addition to being a full time, fifth year medical student (a six year program), he is married, has an 8 month old son, is the minister of his own church, teaches high school in the evenings, and, in his spare time, is building a new “house”. So, hard to understand how he could fail a class.

After clinic, he took me to see the new “house” he is building. He purchased a tiny postage stamp of a lot (pretty much someone´s driveway), and is putting up a small, two room concrete structure, probably about 200 square feet. The real purpose of the evening, I suspect, is to solicit a donation so he can complete the project. He needs another $100 or so, and has to finish before the end of the month when he will be displaced from the church (where he is living now) by several missionaries who are coming from Brazil.

Then he walked me through the ghetto to the church, where I met his wife and young son (photo). We had “cha”, which is tea and included a snack. The snack was left over rice, and a 2 Tupperware containers of “stuff” to put on top. The first container had a few small pieces of fish with sauce, but he said, no , there wasn´t enough, so he opened the second container. To my delight, this was stuffed to the brim with fried, many-fingered objects that, on closer inspection, looked suspiciously like chicken feet. I back-pedaled as fast as I could, so as to avoid falling off that precipice, and insisted that I really wasn´t all that hungry after all, and a little bit of fish would be plenty for me. The sound of Arlindo crunching through a pile of chicken feet (yes, that is what they were, and he ate them bones and all!) is one I shall not soon forget.

Peter had offered me use of his car to get to the class, since he wants me to learn to drive it (more on THAT in a later post), so the next challenge: driving in a wrong handed car, in the dark, during rush hour, while dodging thousands of people walking in all directions, including drunks, people in wheel chairs and even one guy with a hemiparesis walking down the middle of the street with a cane, all the while playing bumper cars with the other drivers. (Peter says that if the cop stops me, a “fine” of about 200 meticals would help lubricate the wheels of justice.) When we got there, I couldn´t figure out how to get the keys out of the ignition, and with the alarm blaring and lights flashing (in the school yard, students all around), I had to call Peter for instructions.

Class started (WHAT am I doing here?). The preacher in Arlindo came out as he started things rolling (He has a geat presence in front of a crowd). My turn came, and I stood in front of a sea of African faces, (and one albino), and dutifully gave what I shall pretend was an erudite discourse on Mendelian genetics and albinism. In what I hope was Portuguese. (as an aside, there has been a rash of murders of albino´s recently in neighboring Tanzania, and their body parts sold for their presumed magic properties). One thing I learned at Harvard was that if you stand up in front of a crowd and act like you know what you are talking about, then many people will think that you do. I did my best. Afterwards, I was asked a many questions, among them, “do albinos really die?- I heard that they just disappear”, and “if a black person and a white person had children, would they be albino?”. (I mentioned Barack Obama). Either I fooled them, or they were being polite, but I got a standing ovation at the end.

Another school yard car alarm-flashing lights fiasco (phone call to Peter again!), and a run around the bumper car circuit, and here I am.

I think I will make a donation for Arlindo´s and Joaquina´s new house.

Circumcision

(Sorry, no foto´s with this posting, in the interest of maintaining a PG rating)
Read no further, if discussion of male genitalia is not your cup of tea…
In the US, circumcision is one medical practice that I consider unecessary . Essentially, it is done for cultural reasons, or, as in my experience, for no good reason at all. Medical experts argue over the benefits of the procedure. Certainly, if you don´t have a foreskin, it can´t get infected, and circumcised boys have a lower incidence of bladder infections than the slight risk in uncircumcised boys. In the US, boys are usually circumcised if Dad is circumcised, and the practice varies widely by ethnic group (Caucasian middle class boys are always circumcised, Hispanics almost never, and other groups are all over the map). In some cultures, it is considered a right of passage to adulthood, and is done in early adolescence. Overall, about 50% of male newborn infants in the US are circumcised.
Female circumcision is practiced in some countries, and involves mutilating a girls genitalia to disempower women. It appropriately generates international outrage, but I have yet to hear a peep of complaint over the male version of the practice.
Now, after a decade of subtly discouraging (unsuccessfully) circumcision in Kodiak, I find myself back in the business of “male genital mutilation”. This is because, although there are few good medical reasons to circumcise a male infant in the US, there is a pretty good reason to do so in sub-saharan Africa: men that are circumcised have a 30% lower incidence of HIV than those that are not. With HIV prevalence ranging from 20 to 40%, that benefit could potentially add up to millions of saved lives. HIV rates are significantly lower in areas where circumcision is practiced. Every sub-saharan African country (EXCEPT Mozambique) has a government policy to encourage the practice. San Lucas clinic does them as a service, and to generate a little cash flow (a clinic visit costs 1 metical, or about 15 cents, and a circ costs 500mets, or about $16).
Every week we do a half dozen or so (just a drop in the bucket, considering the number of babies born. Interestingly, most of the infants are children of muslim families, who often would do the procedure anyway. They seem to be a little more sophisticated than the rest of the clientele: a bit cleaner, better dressed, more educated than the majority of the patients who come from the slum across the alley. We also do get a few adult Mozambiqan men. The people here are pretty stoic: while I cant imagine an American male ever consenting to a circumcision under local anesthesia, ´whereas they don´t even flinch here.

Harvesting Rice

Although Mozambique is officially one of the poorest countries in the world, most of the population lives outside of the formal economy and subsists on food they grow themselves.

Picking up a hitchhiker

Young Africa

Young Africa is an NGO whose mission it vocational education for youth in Africa. It teaches vocational skills like auto mechanics, sewing, computer skills, machine work, and agriculture. It is structured in an unusual and unique way: The project owns the buildings and shop space, but rents the space to local entrepreneurs in the various occupations, who then train the students while completing real projects. The students pay a small amount of tuition that also goes to the entrepreneur/teacher.
They also have a regular school, a (student-run) restaurant, an orphanage (for HIV orphans who learn job skills, then move out to live on their own), and a community hall for local meetings.
It was started in Zimbabwe by Raj (see the photo´s), originally from India, and his wife, Doreen, from Holland. Raj was a priest for 20 years, but he left the priesthood when they married. Together they started the project In Zimbabwe. After 7 years they transitioned the management to local hands, and moved to Mozambique to do it again, with the goal of starting one project in each of the sub-Saharan African countries. Now, after only 3 years in Mozambique, they have 1200 students enrolled in their programs. Truly inspirational.
It reminded me of the NGO I worked with in Guatemala (Common Hope) whose mission was to promote development through the education of the youth, although Young Africa seems better focused and to be having a more immediate impact. Both projects are self-propelled by youthful enthusiasm. When we visited a few days ago, you could feel the buzz of the place.

http://www.youngafrica.org/

A few more photo´s from Beira

The old Grand Hotel was once an elegant place on the beach, but now is occupied by squatters.

The view from the air coming into Beira

A view near the the harbor, of the riverbank market

Bednets: It´s not the rainy season (prime time for malaria), but we still see people with the illness every day in the clinic

The clinic in the afternoon. When we arrive in the morning, there is usually a crowd of 100 people or so on the porch

Life is pretty mellow: Wake up at 5, run on the beach when it´s light enough at 6, work hard at the clinic from 7:30 to 3, then chill out for the rest of the day. I haven´t had such a relaxing schedule for years!

This old town seems a lot like how people describe Cuba: elegant old buildings that haven´t been maintained in years.