The Hunter and his deer

On the same day as the cycle ride we met a man called Lawrence. He was a fine specimen of a human being; tall and athletic. He was wearing broken sandals, shorts and a rain jacket and carrying had a huge rifle. A little face of an animal just visible over his shoulder, carried in a drawstring bag on his back. Lawrence was a hunter and the animal was a dead "bisch". We think it is french for deer but I haven't actually checked that in a dictionary!

The evening before Lawrence had walked into the forest, about 15km from the village, in the direction of the Guinea Bissau border. He spent the whole night in the forest with a torch and his rifle waiting for a "bisch" to cross his path. Then as soon as it got light, he started to walk back. He was carrying no water or food with him. He could sell the bisch at the market for 5000CFA (£6.50). I got the impression, he made that journey too and from the forest a number of times a week.

The gun that Lawrence was using was illegally smuggled into the country from Guinea Bissau, so he was happy to pose for us with his bisch but not with his gun. I will upload the photo when I get it from Shani. We said goodbye and as he passed us I noticed that back of his shorts and legs were stained with the animal's blood, dripping through the bag.

The dependency on imported rice

On a cycle ride through the expansive rice paddies near the village of Oussouye in the Casamance I passed a man who was carrying a 50kg bag of rice from Hanoi, Vietnam.

Africans never used to eat rice. Only since the food shortages of the 70's have they started to import rice instead of using local cereals or tuber crops that take longer to prepare. Nowadays every single Senegalese traditional dish is served with rice! Senegal imports an average of 880 thousand tons of rice per year since 2000, and an average Senegalese person consumes 93kg of rice per year! The rice paddies I was cycling through only produce 15% of the country's rice demand. There are a few new incentives to increase local production - such as New Rice for Africa - "NERICA"

Oh, I just got quite interested in this subject... if you want to read more here are a couple of articles I've just read:
Rice imports in West Africa: trade regimes and food policy formulation
Drive to double African rice production
GAMBIA: Can farmers axe rice imports through ‘Nerica’?

Travels in the south - Casamance and The Gambia

I've just returned to Dakar having spent a lovely 10 day trip to the Casamance and The Gambia with two American girls - Shani and Laura, who work for a Family Planning NGO in Dakar.

The Casamance is the region of Senegal south of The Gambia, which is inhabited by the Djola tribe. The area has struggled with civil unrest in the 1990's and 2000's and so the tourist industry had suffered badly, despite it being the most beautiful area of Senegal. Although the miltary is still present we saw no signs of unrest and everyone we spoke to said the region was completely safe.

We took the overnight ferry from Dakar to Ziginchor, which took 16 hours. In 2005 the previous ferry had an accident where all passengers lost their lives so since then there is many security and safety checks to prevent overloading. We had out passports and baggage checked 11 times before we left the port! The voyage was not very enjoyable since it was pretty rough and various people were vomitting around us, but they did show a few American films (dubbed in french) to pass the time.

The Casamance is a great place to relax and just peacefully pass away the time- walking, cycling, sunbathing, reading and swimming etc. and we did just that. We took a beautiful 2 hour pirogue trip through the mangrove swamps between Ile de Karabane and Djembering, and an hour's walk through countryside to avoid a halfday nightmare journey of 3 or 4bush taxis. August seems to be the season of Catalonian tourists because there is a direct flight from Barcelona to Banjul in The Gambia. We met a couple of lovely girls from Catalonia who did not speak much french so we travelled together speaking English and translating into French or Wolof (Shani speaks fluent Wolof!), a linguistical challenge!

We then passed through into The Gambia on Thursday. I was intrigued by this tiny anglophone country of 1.5 million population, completely surrounded by Senegal. I remember being told years ago that the shape and size of The Gambia was determined by the distance the British canon balls were able to secure either side of their navy ships on the river. The river certainly seems the lifeline of the country. The Gambia has a vibrant tourist scene - in fact, in my opnion, maybe too much so! We had a surreal Saturday night on the Senegambian strip - take-away pizza on the beach, karaoke in a Irish pub (where I met 3 Geordies!), a couple of bars, followed by dancing til 4am in "Nirvana", and finishing up with a chips from a fast-food stand on the way back to the hotel. We literally could have been anywhere in the world.

The Gambian currency (Dalasi)is much stronger than Sengal's CFA. The cost of living more expensive too, nearly twice the price for simple food things such as water, eggs, bread. For tourists too, the accommodation was at least twice the price of the campements we were staying in Casamance. However, despite this I got the impression that the same problems of poverty, urban migration looking for work and limited healthcare access exists. Using WHOSIS (the global health observatory from the WHO) a quick analysis of health trends shows little difference between Senegal and Gambia - life expectancy identical (59 both sexes), HIV prevelance 1% or 0.9%, <5 mortality 106 or 108 per 100,000 respectively. There is more of a difference between maternal mortality, which is offered considered the best indicator of a efficacy of a healthcare system - 690 deaths per 100,000 live births in The Gambia, 980 in Senegal. One difference between the two countries surpised me, there seemed to be many more people in The Gambia that couldn't speak any English compared to the number of Sengalese who couldn't speak any french. Is this a consequence of the education system or a remnant of the different in colonial powers? or maybe an sampling bias due to the areas we were travelling through in Senegal compared to the Gambia?

I'm glad we took the time to visit The Gambia because it certainly is an interesting country, friendly people, easy to travel round, and a variety of activities - watersports, beaches, birdwatching, cultural villages. In fact, I think it would be a great country to visit with children as an easy introduction to Africa.

Ramadan

Senegal is the first Muslim African country that I've been to and its influence on all aspects of life is very apparent, no more so than during Ramadan.

In solidaritary, I attempted to fast for the first fews days, just to see what it is like. This involves getting up at 5am to eat breakfast before the first 'call to prayer', then not eating or drinking anything until 7:45pm that evening when dusk falls. To break the fast, it is traditional to eat a few dates and then wait another couple of hours to eat a big meal. I lasted two days. Eating a ton of bread at 5am and then going back to sleep for a couple of hours is a really unpleasant feeling! During the day, the worst thing was the thirst. I simply do not know how everyone is still fasting like this - day in, day out, and we are into the third of four weeks of Ramadan.

It's no wonder that, in the afternoon, you see hundreds of men asleep on the pavements, trying to ignore their hunger and thirst at the worst time of day. How much economic productivity is lost during the month of Ramadan? It certainly seems that most businesses slow down or even close. In fact, on global scale, with the whole Arab world fasting and working at a lower capacity, does this impact on global economics? If Senegal is anything to go by, then it must do!

I've just been travelling in Casamance and The Gambia (blog update to follow) and it's been difficult to find somewhere out of the public eye to take a long swig from a water bottle without feeling unbelivabley rude. We were worried that we would not be able find places open for lunch during the day, but in each town there was usually a single Christian-owned place still serving food. Nevertheless, we were never far away from a scornful look of someone longing for a drink or morsel of food.

Senegal - the hub of West African music? Part 1: the dance classes

So last week, I sent an email to Adrian (my worldy-wise, travel-agent owning brother: check out www.thestc.co.uk ) complaining that I thought Senegal, and especially Dakar, was meant to be buzzing with West African rhythms but i'd seen little proof of that since arriving.

Oh, how that has changed...

Jenna (an American girl I met here) and I have been on a mission for the last 3 weeks to discover Dakar's hidden rhythms. For a while, we were wondering why the city is so famous for live music but we thought we just weren't looking in the right places. We've been to a couple of evening concerts but the trouble is they all start at 11:30pm or later and easily go on to 3am. Simply impossible if I am to understand any french the following day! We were excited to go to see "Orchestra Baobab" a week ago, a cuban-influenced band, originally from the 70's who are still enticing large crowds, but it was disappointingly dull.

Then Jenna found this dance company that rehearse in a community centre not far from where I live. We went along to one of their rehearsals on Thursday, and Jenna (the little dark-horse) joined in... it turns out, she's been studying West African dance for 6 years in New Orleans! It was unbelievably captivating. There was a group of about 5-6 drummers, all different sizes who were also learning new rhythms during the rehearsal. The instructor, a man who could have easily been in his 60's, would build up a complex rhythms on the drums, starting with the bass, then the others. All playing something completely different and contradicting, yet together, the amalgamated texture was insane. For me, it was really helpful to hear the drums independently so that I could identify each of the textures in the completed ensemble.

I can't say as much in detail about the dancers, they just seemed to know what to do - including Jenna! The instructor would shout something and make a couple of half-hearted demonstrations, then somehow they picked it up! It was complex, too. And just as I learnt on Saturday afternoon, they had to listen to a call from the lead djembe to change step. The male dancers were especially eye-catching. Their dance was so energetic it was verging on gymnastics.

So along with my weekend of dance and music in Toubab Dialao (see "escape to the countryside" post below) and the dance rehearsal on Thursday I feel like I was suddenly understanding Senegal's reputation for dance culture, and that was before I went to the wedding last night...

Senegal - the hub of West Africa? Part 2: The wedding.

A friend of Alpha and Matilde (you really need to read the "escape to the countryside" post below first!) was having a wedding party last night in the suburbs of Dakar. They said it would be fine for us to tag along, so not giving up an opportunity to see the real-thing, Agathe, Julia (2 of the french girls) and I joined the others in this one taxi going to Dakar. I'm not joking, there were 12 of us in one taxi, though I suppose the toddler doesn't really count. Ok, so it was a sept-place, but still it was a squeeze!

We arrived at the party in the early evening. There were about 200 people all crowded in and around a big gazebo in the a dusty side-street in a residential area of Dakar. I was a little nervous how we were going to be received at this party- random white girls, curious to observce the goings-on, but we were warmly welcomed. The family of the groom, and especially the groom's mother, welcomed us with hugs and kissed. We were immediately ushered inside where we were given fruit juice.

All the women were dressed in their finest, brightly-coloured and elaborately decorated cloth. The groom was dressed in a colourful orange Muslim traditional dress, but the bride wasn't anywhere to be seen. I couldn't understand why until the end of the evening when I had time to ask Julia. The bride was German, and currently in Germany; this was the Dakar-based celebration for the groom's family and friends of a wedding that happened a few weeks ago. Large platters of delicious chicken and chickpea stew appeared for everyone. We all huddled round the platters on the floor in groups of 7/8, eating with our hands. Who knows how much everything cost? This was the Senegalese bourgeoisie!

The groom used to play in the same dance/music group as Alpha so there were many musicians there. It wasn't long before the djembe's were brought out and the musicians got down to business. The party was alive and kicking, literally. The crowd around the edge (now probably numbering 350-400 people) pulsating to the same rhythm, leaving space in the centre for individuals to dance. They, often the young women, took it turns to energetically flail their arms and legs in all directions, thrashing their hair around, and nearly always loosing their head-dress, sending sand flying at those sitting near by.

It continued like this for about 2 hours, until people started to disappear off. It was an incredible evening, a completely unprecedented opportunity to see Senegalese culture at its very best. I now have no doubt that this country deserves its rhythmical reputation.

An escape to the countryside

I have spent a welcomed break from the craziness of Dakar this weekend in Toubab Dialao, a fishing village about 50km south of Dakar. I went with a french girl from the hospital and her 3 french friends. "Alors, je parlais français tout le weekend!"

We stayed in a dormitory at the beautiful l'auberge de Sobo-Bade which is a classic back-packers hang-out. The french girls have a friend from university, Matilde, who lives there- she's going out with one of the lads in the local dance group. So we were immediately welcomed by all her local friends - mostly Rastas, reminding me of Ghana! We went for a long walk down the beach, absorbing the rhythm of daily life. The pirogues going out to fish, a man washing a goat in the sea, energetic games of football on the beach and kids jumping in the waves. We ordered lunch in this little sea-side cafe, the meal took over 2 hours to arrive, such is the pace of life!

Two of the girls and I took part in "un cour de danse", African dance lesson with Matilde's boyfriend, Alpha. I've wanted to have a go at dancing here since Senegal is so famous for it's music and dance. It's amazing, so energetic, so different to the 1,2,3,4 of 'normal' dance, not that i am an expert, whatsoever, having pretty much never had a dance lesson ever (I'm imagining Amy and Karin laughing at me right now!) The lead djembe (highest of the drums) gives a kind of call which you have to listen out for to change directions/movements, but there are so many drums all doing something different so it was tricky to identify the "call"! (i still have "les courbatures" (stiff muscles) two days on!)

We spent Saturday evening at Alpha's pavillion just next to the beach. They BBQ-ed freshly-caught fish on an open fire, and made this huge platter of fish and onions - "pimenté" (with chillies!) We all sat around this huge platter on the floor, tucking in with our hands, the traditional way. It was delicious but seriously HOT! All the locals were busking, singing a mixture of traditional wolof songs, reggae and rap late into the night. I learnt how to play the mbira (a kind of xylophone-thing, interested? google "lamellophone"). Then some hours after midnight, not sure when, we migrated to "la boite" (literaly, the nightclub - it didn't have another name!) and danced til it was nearly dawn.

Naturally, a lazy Sunday on the beach followed.

the best yoghurt ever?

I've discovered the most amazing yoghurt EVER that comes in these tempting little sachets for 20CFA (30p) I swear it is half full-fat creme, half yoghurt and my hips will regret it but I don't care!

An update re the french and medicine...

It's definitely getting easier - hurray!

I spent the first two weeks "á la consultation" (out-patients) where I was mainly observing the doctor see patients who were either coming with acute problems, often needing hospitalisation or follow-up appointments following a stay in hospital. The staff in "la consultation" are super friendly. Dr Youla comes from Guinea so he doesn't speak Wolof (the local Senegalese language) so the patients often needed a translator, this means- for the most part- I can follow the french. Quel-que-fois, other doctors were "á la consultation" who spoke Wolof, so I didn't understand much.

I was always encouraged to examine patients and ask any extra questions. Dr Youla often asked my opinion about patients diagnoses, what investigations to order etc. So gradually I picked up quite a bit. In general, the doctors and nurses are very patient with my french and comprehension difficulties! At the end of the day, well often about 2pm (!) we would often sit around and drink juice out of little bags together and chat. They never seem to be completely over-run with patients. Although a few times in the first two weeks there were patients who needed hospitalising but there weren't any beds left. In this situation, they would be referred to other hospitals in Dakar, to non-infectious disease wards.

For the follow-up patients, the ID service seems to have a good medical notes system. Each Wednesday there is a clinic to see patients who have recently been in hospital. There are about 15 patients scheduled for each Weds clinic and normally about 12 turn up. I wonder how this compares to the UK's "Did Not Attend" rate? An article from Sept 2009 (though not referenced) quotes a 11% DNA rate for NHS out-patients. So all things considered, in Dakar - the lack of post/telephone reminders, financial difficulties in getting to hospital, the cost of consultation itself and general awareness of what day of the month it is - a 20% DNA rate isn't so bad.

Last week, I moved upstairs to one of the wards - "La Lemière". There are 4 rooms, partitioned into 4 cubicles, so a total of 16 patients. There is one doctor - Ishmael, who is responsible for all the patients during the week. My responsibility "á la Lemière" has significantly increased compared to the first two weeks. I now have my own two patients who I see every day, as well as visiting other patients with other interesting signs. I update "le dossier" each day with "l'état general", suggest a care-plan, write "les ordonnances" (prescriptions) and requests for investigations etc. So my written french is improving fast as well as my understanding and speaking.

One of my patients is a woman of 38 years old who could easily pass for a teenager, (I find it so hard to guess people's ages here!) She is HIV+, known since Sept 2009, when she started ARVs. She stopped them in January because they were making her ill, instead she seeked a traditional healer for medicine, as a consequence her CD4 count has dropped to 3! Her family brought her to hospital last week because she couldn't move or speak (for the medics, GCS=6) She had a complete left hemi-paresis and meningism. The price of a head CT scan is 45,000 CFA (£60), the same amount would buy enough rice to feed a large family for a whole month, and the family weren't sure they could afford it. So we treated her for suspected toxoplasmosis infection and if those medications didn't improve her symptoms then we would think again... luckily after the weekend, she is sitting up in bed, eating, drinking, and asking to go home. So there are definitely success stories amidst the difficulties of healthcare in resource-poor settings.

price of cigarettes...

The "Framework Convention on Tobacco Control" gained wide press and international support when it became the WHO's first (and only) legally-binding treaty of its kind. During my internship, at the non-communicable disease department in Geneva (where tobacco control is kind of important!) it was upheld as one of the organisation's greatest successes. I do not disagree.

So how and why are the cigarette companies here allowed to get away with selling 3 cigarettes for 100 CFA (that's less than 13p) and throw in an extra mint for free?

I have seen no evidence of anti-smoking advice or campaigns since arriving. It's back to the era of smelling of smoke when you come back from a restaurant, bar or club. The doctors in hosptial rarely take "un histoire du tabagisme". Many, if not a majority, of patients I have seen so far at clinic have presented with a cough, weight loss, fatigue etc - TB? yes, probably epidemiologically, but when will lung cancer also be one of the top differentials?

elective students everywhere...

Je ne croyais pas! Including myself, there are 25 students here in the ID department of this hospital. 23 of them are French and one American girl who actually studies Public Health. Most of the french students came in 2s or 3s and had no idea that other students would be here. I wonder how many other students from Newcastle have found the same thing arriving at their hospitals?

My post a couple of months ago reflected a little on the impact of the migration of students between healthcare systems. Here I am - seeing it first hand. In the wards upstairs, each students looks after one or two patients. They see them every morning and depending on their stage of medical school, try and write in the notes what they think needs to be done. After that they check the medications and investigations (if the family can afford them) by the one doctor that is looking after all 16 patients on that ward. Ishmael, the doctor, is always under time pressure. Therefore the students are helping, but what happens if we miss something. Has this department become reliant on the number of stagiares (elective students)? Actually, I think not, since I know that at other times of the year there are far fewer, if any stagiares. but maybe more doctors take annual leave holiday now?

Some good things manifest themselves too because of the number of students. We have lessons every tues, weds and thurs mornings all together. This is either led by one of the doctors or the students themselves. (I am hoping that I don't have to embarass myself doing one!) Some of the doctors are also really good taking the time to explain things and teach the students, but to the detriment of which patient's care?

Beefburgers and fries à Dakar!!

So last week I was staying with this Senegalese lady called Sineta who runs a bed&breakfast ici. From the website it looked pretty authenitic senegalese, with lovely african room decorations and drumming lessons available etc. Dinner was included in the very reasonable price so I thought, "that'll suit me just fine- easy".

It turns out Sineta is originally Senegalese but has lived in Louisiana, US for most of life. So instead of eating the local food and learning traditional drumming rhythms, I've been eating Beefburgers, lasagne, noodles; and greasy french toast for breakfast and listening to her son's rap music! ahhhh! As many of you know I was vegetarian for the last year and half, or so, all this meat has been quite a shock to the system!

There's more... she's quite a character. Although Sineta has lived in Senegal for the last 12 years, she cannot speak either French or Wolof (the local language). She refuses to learn, complaining that everyone knows how to speak English, they are just to lazy too to try. ummm... slightly hypercritical? Instead, the other day... I was on the back of her scooter wearing un casket but she wasn't. As we came up to this big roundabout a gendarmarie walked out and held his hand to stop us. He tried to fine Sineta 3000CFA ($6) for driving a scooter without a helmet. She started shouting and swearing back at him, in english! So he just walked over and took her key right out of the ignition! it was classic. Amazingly, and I still don't know how she managed to do it (and I haven't heard the end of it since) she managed to sweet-talk her way out of paying the fine.

I have dozen more stories like this to describes this lady's attitude. Suffice to say, it was pretty tiring. Yesterday evening, however I moved to a new appartement. Anna, a US/English journalist who works for IRIN, is going on holiday for nearly 3 weeks so I am looking after her cats while she is away. It couldn't be more convenient for the hospital, being just around the corner and Anna is really friendly. So things are looking up for the next few weeks...

Arrivée au Sénégal

Wow, it's been a tough couple of days! My flight was delayed some 2 hours, then by the time my baggage had arrived, negotiated the taxi price and eventually found the appartment (not straight forward!), it was already 4:30am. After just a couple of hours sleep I had to leave in search of the hospital to meet my supervisor at 9am at the hospital.

One of the main things I have established since arriving is I CANNOT speak french when I'm tired! Oo la la, c'est tellement difficile! Although I'm sure it will get easier, but it's going to be challening and exhausting.

Hopital de Fann, where I will be working for 6 weeks, is one of the main government hospitals in Dakar, and has the only infectious disease department in the city. It has quite a juxtaposition of resources. I am sitting in an air-conditioned room with 12 brand new flat screen Windows XP computers, where the doctors and students have continual access to the internet. Just off the same corridor, there is 'les soins intesifs' (intensive care) where 8 patients are fighting for their lives. There is no ventilation machine, and only a couple of oxygen cyclinders. The beds are dirty and there is an overwhelming smell of urine in the heat of the day. The patients' families have to buy everything from medication to bed sheets. Gloves and masks are reused by the doctors, and in short supply.

Five of the seven patients currently in inetnsive care have tetanus. An infection that is completely preventable by a vaccination programme. The 14 year old boy who arrived this morning, already has developed severe rigidity, trismus and spasms and increasing breathlessness. What was his exposure to tetanus? Circumcision, 15 days ago.

So far, it's been exhausting speaking and trying to understand french all the time. I'd be lying if i said I was enjoying it! I've become this quiet little girl in the corner who doesn't really speak. Although I can understand a lot more that I can speak. When someone asks me a question I'm just embaressed by my inability to make comprehensive sentences!! It's really quite frustrating because the medicine is fascinating, with signs of such advanced disease that one would never see en Angleterre, but I'm concentrating so much on understanding the french I'm kind of ignoring the medicine at the moment. Therefore, many of the doctors must think that medical students in England are stupid and know nothing!

(hopefully more updates to come... sorry, i don't think my English is very "couramment" because i'm kind of thinking in French!)

WHO Internship

Desolée tout le monde... i didn't get a chance to update my blog while I was in Switzerland but I have many things that I would like to share about my experience at WHO... but also now is not the time. Suffice to say that I am really glad of the experience and insight into global public health and the activities of such a large organisation. I will try to update this blog when I have more time and a head that is not half thinking in french, comme actuellement!