Saturday, August 30, 2008

Pictures from Africa: Summer 2008

After I left Cameroon, I traveled to Kenya on my own, then met up with my parents and brother in South Africa for two weeks of family adventures.  Here are pictures of my time in each of those countries.

Cameroon (Climbing Mt. Cameroon): http://www.facebook.com/album.php?aid=2096465&id=1012910&l=4aa839992c

Cameroon (Buea): http://www.facebook.com/album.php?aid=2096765&id=1012910&l=f99c01e2d4

Cameroon (Mamfe): http://www.facebook.com/album.php?aid=2098884&id=1012910&l=ed286ac74c

Cameroon (Etoko & the health centers): http://www.facebook.com/album.php?aid=2098868&id=1012910&l=b82e0b97b0

Kenya: http://www.facebook.com/album.php?aid=2100001&id=1012910&l=d7c988449a

South Africa (Safari & Joburg): 
http://www.facebook.com/album.php?aid=2100185&id=1012910&l=62463a4f41

South Africa (Cape Town & around): http://www.facebook.com/album.php?aid=2100196&id=1012910&l=50a46f6543

South Africa (The Garden Route): http://www.facebook.com/album.php?aid=2100206&id=1012910&l=016785c1e7

Enjoy!

Saturday, August 23, 2008

Miscellaneous Observations: Part 2

After 3 months in Cameroon, I've got some more observations to share with you all.

-To do any job, the ratio of workers working to workers watching is 1:5.

-For a male between the ages of 8 and 68 a machete is a necessary accessory.

-Almost no one smokes cigarettes and it is considered uncouth to do so.

-Beer is an appropriate beverage at any time and at any occassion.

-There is a hierachy in the materials used to make houses, which reflects wealth. Mud is at the bottom, then tin/corrugated metal, then wood (which becomes gray in urban areas and orange in rural areas), and concrete is at the top.

-Pidgin (the most common language in the SW Province) = Jive + English + French + Jibberish - Helping verbs + Saying 'dey' a lot + Jamaican accent.

-There are no wild dogs, just wild goats, chickens, large rainbow colored lizards, vicious cats, giant ants, cocks that crow at all hours, and bugs and birds that make video game-like sound effects.

-The only setting on a TV or stereo is 'Max Vol'.

-Cameroonian men have zero game when it comes to women because they get all their moves from watching bad U.S. dating shows.

-Barbershops have strange names like: Decent Uncle, Dr. Paolo, Anty Unique, and Snoop.

-More women have facial hair (especially neck beards) than men do.

-Every time you drive down an unpaved road (which is 85% of the time) you have a 50% chance of getting a concussion or spinal cord injury.

-The smaller and more run down the exterior of a house (i.e. the poorer the family) the cleaner the inside of the home and the people.

-Children are given unfortunate names such as Gift (a girl), Precious (a boy), Bright (a girl), Prudencial (girl). We even had Elvis and Stella ran the inn in Mamfe.

-Slang terms: dash=to give or a bribe, chop= to eat or food, snap= take a picture, spoiled=broken.

-Eating a lot of peanuts is considered bad because they will make you break out but all food is cooked with a least a pint of palm oil, which is fine.

-The only time there is relative quiet is when the power is out.

-The standard outfit for women is a big, poofy maternity-like dress because they spend so much of their lives pregnant it doesn't make sense to have two sets of clothes.

-If you need to pee you say "I want to piss myself".

-It is possible to ride on the hood of car, as well as on the trunk.

-Every man and child owns a Cameroon national soccer team jersey, ideally one with the name Eto'o on the back.

-It takes 25 ununiformed men and 50 beers to man a road checkpoint (i.e. a bamboo pole on a string).

The Arrival of Zara Egbe

Warning: The following post is graphic and kind of depressing.

Right now, somewhere in Cameroon, there is a baby named after me who I saw delivered. It's really weird. But for the whole story lets go back to the beginning, to Etoko.

Etoko is a small village 20 miles from Mamfe, but 2 hours away because the road there is in such horrendous condition. (See below.) I went to Etoko (pop. 1,200) to evaluate and redesign its small, barely-functioning health center, which was currently being kept afloat by the NGOs I was consulting for. I was accompanied by Sharlotte, my wonderful, amazing, cheerful assistant, who is also an excellent (but currently unemployed) nurse. Etoko is a village of farmers, most of whom never went to school because the nearest one is four miles away. We spent four days living in the health center, which consists of four bare, concrete rooms, with the incompetent nurse, Rebecca. We hung out with local women, played with children, toured the lush countryside, fetched water from the nearby stream, and cooked some delicious porcupine. Overall it was an enjoyable but uneventful trip. Until the last day.

On the morning of June 17th, a Tuesday, Alice came into the health center. We had spent a few evenings chatting with Alice (or at least Sharlotte had done most of the chatting in the local dialect and I nodded politely) and she was quite funny and cheerful. always laughing about something. She was also 9 months pregnant and pretty uncomfortable given the extreme heat and humidity. Although rather articulate, Alice had stopped school after 6th grade because her parents wanted to marry her off, which they did, to a local farmer about 15 years her senior. Since then, she had spent most of her time helping with the farming and child-bearing. According to her health record, Alice is 20 years old, but she already has three children- a boy and two girls. This was her fifth pregnancy- one was a miscarriage.

When I woke up Tuesday morning at 7am Alice was already there, having come in as soon as her water broke. She was pacing, wincing, and chewing a stick which people use as a toothbrush. Her good friend, also named Alice, was with her. Alice2, age 22, was also pregnant, with her fifth child. While Alice2 swabbed the floor (being pregnant doesn't excuse women from physical labor in Cameroon), Sharlotte, Rebecca and I ran around the health center, preparing supplies for the delivery. This was only Rebecca's second birth and she was clearly nervous but luckily Sharlotte, all of 25 years old, is extremely competent and was helping her out.

At 7:30 Alice and Alice2 went outside to the outhouse to give Alice an enema, which Cameroonian women believe speeds up delivery. After they came back in I got trapped talking to a crazy old woman who wanted to take a picture with me while Alice was delivering in the next room. I go there just as the baby was coming out. It was incredibly messy because the enema clearly wasn't complete and the plastic mattress, scrap of sheet, and Alice herself were covered in shit, blood and various delivery-related fluids. The baby was out by 8am, a girl with a fair amount of hair and seemingly healthy, except for her eyes, which were red, puffy and swollen. It is recommended, especially in Cameroon where the prevalence of STIs is high, for babies to be given antibiotic or silver nitrate eye drops immediately after delivery to prevent blindness caused by chlamydia or gonorrhea infecting their eyes. But because this was a rural health center with such a lack of supplies that only two sets of gloves are allocated per delivery, there were no such medications.

In fact, the health center was so short on supplies that in order to clean off the amniotic fluid, Rebecca rubbed peanut oil all over the baby. She was then wrapped in a set of hand knitted clothes- shirt, pants, booties, sweater, hat, blanket. While all this was going on, no one asked Alice how she was doing, if she needed anything. She was simply left to soak in the mess on the bed. When she was given any help by Rebecca she was manhandled, and yelled for wincing when she was roughly given an injection of ergometrine (to stop post-partum bleeding). Alice asked no questions about the baby nor bothered to turn and look at her, check how she was doing.
Because there is no scale at the clinic, the baby was not weighed and measured, just given a once over to make sure she was alright. She barely cried, just giving a plaintive wail every now and again. Once she was wrapped up, I suggested that we give Alice a chance to see and hold her. Sharlotte tried to give Alice the baby but Alice just turned her head away, refusing to look at her. It was clear then that Alice was not happy about the baby being a girl. After all, Cameroon is still a place where girls are considered unecessary and expensive, since they must be married off and are less useful on the farm. Boys are highly valued and mothers are judged on the number of sons they produce. Alice now had 3 girls and just one boy, and she clearly upset about that. Women in Cameroon believe that the sex of their baby is determined by them, rather than their husband, and thus blame themselves if they have a girl.
Watching Alice refuse to hold, or even acknowledge her child, I had to conceed that this was definitely not the happy occassion that we, in the West, romanticize childbirth to be. This was a baby who was quite literally born into shit, was likely going to be blind, and had a mother who didnt want her. This was not a cause for celebration for Alice, but rather an extra burden for her to carry. Looking at the disappointment and resignation on Alice's face, I was both frustrated and heartbroken. I was frustrated with her for not loving her baby the way I expected her to and frustrated with the culture of girlchild hating that exists in so many developing countries. But my heart went out to Alice, who while three years younger than me, had more responsibilities and fewer opportunities than I could ever imagine. Her attitude towards her child was a product of history, culture, sexism, economics, and politics, and she was only responding as she was conditioned to. All she and millions of other women have to define themselves is their identity as a mother and they want to fulfill the ideal their society creates for them.
Eventually Alice got up and changed and went into the next room, which been decorated and prepped by other women to serve as a maternity room. It appeared that every woman in the village had come to the health center as soon as she heard Alice was giving birth and had brought some supplies for her. They were extremely efficient and everything was brought in and set up in a highly systematic way, which should not be surprising given how often they probably do it, as Cameroon as a birth rate of 4.5 children/woman. Everyone fawned over the baby while Alice sat, ignored, in a corner. No one congratulated her or asked her how she was doing- it was all about the baby. The mothers and their children all sang and danced around, clearly enjoying themselves. Alice's 35 year old, toothless, raggedly husband came in, smiling. He hugged Alice proudly, but got no response from her. Oddly enough, he wasn't dissapointed about having another daughter- he actually seemed extremely happy about it, but he may have been putting on a front for me.
While we cleaned and packed up, a friend of Alice's came in and told me that it had been decided that the baby would be named Zara Egbe, in honor of the 'white man' in town and the two nurses who delivered her, Sharlotte and Rebecca, both of whom have the Cameroonian name Egbe in addition to their Christian names. Alice herself clearly had had no say in the matter but didn't seem to care either way. She was in slightly better spirits as we departed and had agreed to hold the baby, which we considered great progress.
A few weeks later Rebecca came to Mamfe and I ran into her. I asked about Alice and baby Zara and found out that they had stayed in the maternity room for 5 days but left without paying a single franc. Why? Because the baby was a girl and not worth paying for.

Friday, August 22, 2008

Transportation: 4-Wheel Drive Anyone?

Q: How many adults can fit in a Toyota Corolla?
A: At least nine.

Yep, nine. Also, 7 in the cab of a small pickup truck, 26 men in a 12 seater van, 63 in a 25 seater minibus, three people in the driver's seat of any car, as many children as it takes in a school bus until one of them falls out. This is possible in Cameroon, where if both your butt cheeks are on the seat, you've got too much room.

Shared taxis, which are the primary form of transportation in towns like Buea, are usually Corollas and are supposed to hold no more than 7 people. They drive around town, picking up and dropping off at random locations but at least they only cost 100CFA, or 25 cents. After taking a lot of shared taxi rides, I noticed that they all seem to have the same accessories: an American flag air freshener, a sticker on the side window of an Asian woman, fake Hawaiian flowers across the dashboard, Jesus-related paraphenalia, green or blue lights inside, a furry cover for the driver's seat and an HIV-testing promotional sticker. This must be the Cameroonian cabbie starter-kit. Most cars have only 1 handle to roll down windows which gets passed around. And you know which cabs to avoid because the windshield will be cracked on the passenger side, where someone got thrown forward in an accident. (Seatbelts exist only for drivers.) But what really differentiates the taxis are the names or sayings painted on the side of the car. Below is a selection of my favorites from Buea.

-Bush Doctor
-The Spanish Lover
-Osama Billion
-Talk 2 My Lawyer
-Playboy
-Vatican Express
-Nice guy again
-James Bond
-Cockman
-Asshole
-I am covered in the blood of Jesus
-No food for lazy men
-Don Pedro
-No Satan
-Jesus for Life
-Maitre Julio
-Simple Chief
-Barcelona
-Nellyville
-One Mama
-Rabbi
-Red Bull
-Nazi Group
-Daddyroo
-Patience Express
-Loverboy
-Mitterand (like the former French President)

When not riding in strangely named taxis, I rode on 'Chinese mosquitos', known to the rest of the world as motorcycles. I have yet to convince the Cameroonians that most motorcycles they get are in fact Japanese, not Chinese. They are called mosquitos because they are small, fast, and deadly. They wouldn't be death on wheels if people consistently drove on one side of the road, there weren't potholes the size of swimming pools on the 15% of roads in Cameroon which are paved (and the rest weren't mud pits), people wore helmets, and there were such things as stop signs and traffic lights. I never saw an odometer or speedometer that worked, doors would jam so often window egress was a common sight, and to be a driver was to be a mechanic. As George, the head of UAC in Mamfe, said 'In Cameroon all drivers drink gasoline.' George himself drank gas many times during the summer in order to unclog the engine of his ancient, odometer-stuck-at-999,999, white station wagon. Even the driving school's car was in bad shape. It had no side mirrors, broken tail lights and deflated tires, and looked like it had survived a war. I guess if you can manage to drive that thing without killing yourself (or the driving instructor) you can drive anything in Cameroon. However, I still prefer my Chinese mosquitos.

Friday, August 1, 2008

Touring the Health Centers: Part 2

Malaria, malaria, malaria.

Thats what I heard from every doctor and nurse I met with in Cameroon. I visited 17 health care sites, ranging from large government hospitals to rural clinics staffed by a single nurse, but at each the most common ailment seen was malaria. Some providers estimate that nearly 60% of the patients they see suffer from malaria. (Other common problems were typhoid, respiratory infections, gastrointestinal issues, HIV and STDs, and accidents.) Malaria is a problem all over sub-Saharan Africa, but Cameroon is plagued by particularly virulent strains, which can turn into cerebral malaria and kill within 24 hours of the first symptoms. Despite the prevalence and severity of malaria in Cameroon, people quite blase about it. Whereas the thought of getting malaria strikes panic in the heart of an American, a Cameroonian thinks of it as an annual ritual, like Christmas. Most people have lost track of the number of times they've had malaria and view it as a minor nuisance. However, malaria is the number two killer of children in Cameroon, after neonatal causes, accounting for 23% of all deaths for children under 5. Only 13% of children sleep under treated mosquito nets. (http://www.unicef.org/infobycountry/cameroon_statistics.html). Among adults, malaria is the number three killer, which partially explains why life expectancy in Cameroon is 50 years, for both men and women.

The reason that so many die from malaria is not that treatment is expensive. In fact, it could hardly be cheaper. To treat a simple case of childhood malaria costs 140CFA, or the equivalent of 33 cents. A simple adolescent case costs 230CFA and an adult case 600CFA. In comparison, a 600ml bottle of domestic beer costs 550CFA. The Global Fund, the WHO, and UNICEF pour an enormous amount of money into subsidizing malaria treatment and are constantly researching, re-evaluating and recombining the medicines to make them more effective, as strains of malaria become drug-resistant.

So if cost is not the reason for lack of treament, what is? The first, of course, is poverty. While the drugs themselves may not be expensive, getting to a clinic may be. Most Cameroonians live in rural areas, where health centers are not conveniently located. To reach one people often have to walk through muddy fields for hours, or pay 550CFA for a liter of watered down petrol to fuel their motorbike, if they are so lucky to have one. In addition, people must also pay the 200CFA (or more) consultation fee just to see a nurse and for any lab tests that must be done.

The government, under extreme international pressure, has developed programs to subsidize all health costs. Highly supported by GTZ, the German aid agency, the Southwest Special Fund for Health (SWSFH) is designed to keep costs down and encourage people to use health services but this program has mixed success. Why? Well this bring us to the second reason malaria kills: skepticism.

This skepticism includes skepticism of Western medicines, skepticism of the health system, skepticism of any government related project, and even skepticism of malaria itself. Cameroonians, on the whole, believe strongly in traditional medicines, and employ natural remedies and the services of a traditional doctor (a.k.a. a witchdoctor) as their first line of defense against illness. While herbal medicines may well work sometimes, the usually just serve to delay people seeking treatment in the Western health system, as they wait to see if their symptoms abate. Other people are reluctant to see a doctor or nurse, but believe in the power of Western medicines, and so they self-treat by buying drugs from street vendors. These drugs are usually expired, mislabeled, and sold at exhorbitant prices. Whereas a paracetamol (Tylenol) is sold under SWSFH prices at 2CFA, a street vendor often charges 100CFA a tablet, claiming it is a fancy, powerful, cure-all drug. While self-treatment can sometimes be harmless, most of the time it does a great deal of harm because, again, it serves to delay real treatment. And in the case of fast-acting cerebral malaria, such a delay can be deadly.

As for the health system and the government, Cameroonians have legitimate grounds for their lack of trust. Cameroon is rountinely rated one of the most corrupt countries in the world. In 2006 they came in 138th in the world, right behind Zimbabwe in Transparency International's annual report. As Postwatch, another anti-corruption organization wrote "Corruption in Cameroon is a living thing, a monstrous slimy hydra: vicious in outreach, cancerous in spread and disgusting in reach." I'm not sure the hyperbole is necessary, but it is fairly accurate. There are anti-corruption drives going on in the government, but when your president has been in power for 22 years and is the hand-picked successor of your first president, there isn't must motivation to clean things up. Earlier in the year the Minister of Public Health was brought down in one of these drives as evidence that the government is taking action. He allegedly pocketed about $12-$13 million dollars of international donations intended for HIV/AIDS treatment. Most likely this was a drop in the bucket of funds he embezzled during his tenure, but it still represents enough money to treat 36 million cases of childhood malaria (in a country of 17 million). For another example, look to the post office system. According to my friend Mr. Oben, a retired professor, years ago the post offices in Cameroon used to serve as credit unions, where people could save their money. Then, suddenly, all the money was gone- embezzled by various post office officials. And the people had no recourse to get their money back. So of course they are wary of doing anything that involves them, their families, their health or their money with the government, even if that means potentially endangering their health.

The widespread corruption in Cameroon has severely inhibited the development of the health care system, as well as people's willingness to use it. Government health centers have sprung up around the country but these centers are little more than concrete rooms and lack running water, electricity or sanitation, or even basic supplies such as needles, gauze, foreceps and kidney dishes. The roads to these health centers may be impassable, or may even not exist. Usually staffed by nurses, they receive little supervision, which allows for mistreatment of patients, and corruption by the staff. Because typically only 1 nurse (the Chief of Post) gets paid a meager wage, the rest are volunteers. However, they may receive a small stipend to cover their transportation costs out of whatever profit the health center makes that month. In order to make a profit, these centers often charge for unnecessary lab tests and services. Nurses sell drugs to patients out of their own purses, charging them exhorbitant prices and with-holding the drugs if the patient refuses to pay. While this behavior seems despicable, it is hard to criticize a nurse who, because of encouragement from her government, went to nursing school, only to find a dearth of paying jobs when she graduated and still has to feed her family. (By the way, that $13 million the Minister embezzled could have paid the salaries for 1 year for 14,000 nurses.)

Despite all this, during my tours of the health centers I met many dedicated, hard-working, caring and competent nurses. The story of one nurse in particular sticks with me. She was a well-trained nurse who had been placed two years ago in a new rural health center, by herself. The center had several rooms, was bright, airy and clean but lacked water or electricity. When she was placed there she was given just a desk, a chair, and a lamp. (The lamp strikes me as particularly useless, given the lack of electricity.) No beds, no supplies, no medications. (The large pharmacy room remains unstocked to this day.) For the first year she delivered babies on her desk, in the light of a bushlamp she purchased herself, with drugs and supplies she begged from other health centers, and having to run to the latrine 30 yards away to dispose of the waste, leaving the woman alone. Eventually she was given one rusty bed frame with a torn plastic mattress to use as her delivery bed. Now she goes door to door to check on the villagers since no one wants to come in to the clinic, and why would they? No one wants to deliver on a desk when they can deliver in the comfort of their bed at home, and no one wants to go to a nurse for a diagnosis when they have to go somewhere else to buy drugs. Frustratingly for this nurse, the clinic down the road, in the same health district, is overflowing with beds, supplies, and staff.

Here's another example of the misallocation of resources for you. A nurse at a small rural health center was seeing a lot of women who were experiencing complications during delivery and who needed to go to the district hospital for more advanced care. She applied for funds from an international aid agency to help alleviate the problem. They gave her a motorcycle, intending it to carry a full-term woman in labor and a nurse. And the nurse cant drive a motorcycle. Isn't development work hilarious?

On a less humorous and more frightening note, I must tell you about Dr. E, the single most insane person I met in Cameroon. Dr. E is in his late 30s and considered quite successful. He owns his own clinic, which has inpatient wards for men and women, a pharmacy, a lab, a delivery room, and a surgery theater, and employs ten nurses. But, like many incompetent and lazy doctors, he is scalpel-happy. He loves to do surgeries because they rake in money and he doesn't have to spend a great deal of time figuring out what's wrong with a patient. And Cameroonians believe in surgeries (if they believe in Western medicine) and are willing to pay for them so Dr. E markets himself as an efficient, inexpensive surgeon. He claims that while, yes, malaria is the most common illness he sees, appendicitis is the second most common. And herniated disks the third. Not a single other provider put either of those in their top ten most frequently seen illnesses. He charges 40,000CFA for each of those surgeries ($95), including post-op treatment and inpatient stay. Since the clinic opened in 2005, he has done 1,200 surgeries, sometimes as many as 10 a day, and seen 20,000 patients. (For those of you doing the math, that's surgery on 6% of his patients.) Dr. E is very proud of his surgeries, so proud in fact that he stores the organs/tumors/entrails of every surgical patient he's ever had. And he stores them in his surgery room (which has just one bed with a plastic mattress and a table of unsterilized equipment) in plastic buckets. They are crammed in together with just enough formaldehyde to keep them from reeking. And he will gladly, proudly pull them out to show you and explain the origin of each piece. So note, if you ever go to Mamfe, Cameroon do not under any circumstances, even if you actually have appendicitis, go to Dr. E. Your organs will end up in his buckets and you will contract a post-op infection, like most of his patients do.

But besides that complete psychopath, most of the providers I met were trying hard to provide the best care they could for their patients, while at the same time struggling to get by themselves. The system is highly inefficient and corrupt and the health problems Cameroon faces are enormous. But slowly progress is being made, and hopefully a new goverment will be able to improve the system, increasing access and quality of care for all its citizens.

For those of you who are interested (and apparently you are since you've read this far), I wrote rather long, detailed but interesting report on all of this. If you would like, I can email you a copy and you can subject yourselves to an even longer commentary on the Cameroonian health system as well as 17 health facilities. Just send me your email address and I will send it out when I finish it, which will be in the next week or so.