Transformations

En route home from the market we stopped at the workshop en plein air of one of Nouhoun’s uncles, a numó, so he could fix my knife. Bambara men carry a long sheath knife with a wooden handle. Nouhoun had given me one that had belonged to his grandfather and back during Tabaski the edge had been damaged by a young man using it to chop ram bones. Nouhoun assured me it could be repaired

Out in the open, under a brush-covered arbor was the blacksmith’s workshop. There were scrap pieces of heavy iron and steel to use as anvils. The forge, a depression in the ground, was served by a bellows made of two large, fired clay pots. The pots were half- buried in the earth, with open tops. At the bottom of each, buried in the earth, was an opening attached to a tube leading to the forge. As we watched the smith attached a leather bag to the top of each of these jars and bound them tightly to the pot with a cord. A younger man was summoned who sat himself on the ground behind the bellows. By pulling up on one leather bag while pushing down on the other, a stream of air was blown into the forge.[1] A fire was started and the smith gently heated the knife blade. He then carefully hammered the metal to stretch it back into the nicked area. It took perhaps twenty minutes from start to finish and the job was done. It was impossible to tell where the nicks had been.

The numó gently heats the knife blade while his assistant pumps the bellows. A skilled blacksmith can create extremely complex rhythms with the bellows.

Back in the village, I was gifted with a rooster by Nouhoun’s

father and a hen by someone else. Later in my stay the imam and the village chief each sent me a rooster. Big honors!

People here are so eager to share their culture, especially their language. They teach constantly. Adama, Nouhoun and Braima spent two hours this morning coaching me in Bambara. I’m actually retaining some!

There are no mosquitoes at this time of year. They can’t stand the flies.

Later. Swallows wheel their evening paseo in the indigo sky. Three-quarters of a moon and a hundred villagers celebrate a wedding. Last night there was drumming and two balafons (marimbas) amplified by a PA system hooked to car batteries. The PA horns persistently screeched feedback but no one took steps to eliminate it. Perhaps they consider it a natural characteristic of PA systems; like ants at a picnic. Maybe they don’t know how to fix it. I’m not clear on why they consider they need a PA. Perhaps it makes things fancy and modern and upscale, a machine that makes one more powerful. Drums and balafons aren’t instruments that need a lot of amplification. After all, how long have folks been celebrating and done just fine without?

The music was at the groom’s house. At one point everyone went to another house in the village where the bride was. She was brought out, face covered with a shawl. She got on the back of a motorcycle and was whisked off to another house where she would spend the night. Today she will be brought to the groom’s house.

Women perfom a line dance at the wedding. A drummer is at right.

At the night-time music a horde of pre-teen boys danced frantically to the balafons. It was comical; all these dusty, skinny legs sticking out of baggy short pants. They kept moving in, encroaching on the musicians and kicking up such a cloud of dust they had to be repeatedly scolded and driven away by the grownups. Finally, a few men cut long switches from some nearby bushes and kept the madly jigging 10-year-olds at a reasonable distance by swatting at their bare feet. None of the blows connected.

Eventually some of the young men came out to show their best steps. These guys could really move and Michael Flatley from Riverdance will be in for some competition if these boys ever make it out of Mali!

This morning Nouhoun’s motorcycle got a makeover. The mechanic, Adama, from another village, installed new piston rings in less than an hour, then repaired the horn, horn switch, brake lights, turn signals and headlight in another two. All done under a shade tree and without multimeter, ratchet, end- wrenches, etc.

We went to another market; a smaller one. For the first time I saw someone drunk. We’d gone to a shop stall on the edge of the village where some sort of local beer was made. The drunk was sitting and unsuccessfully trying to play a bintan bolon.[2] When he saw me he reached up to shake hands. Then, to my shock, he threw himself at my feet with his face in the dirt and groveled! For a moment I thought he was making fun of me, but Africans aren’t big on irony and it became acutely embarrassing. I motioned to Nouhoun for us to get out of there and we did, but the man followed, singing and playing, stumbling and falling down. When we got back to our motorcycles at the market he fell again and this time he stayed down. An old man happened by carrying an axe. Suddenly the drunk lunged and tackled him. He pulled the man to the ground and started punching him, not with any great effect, though. Women screamed, people shouted, and the old man gave the drunk a few good whacks with the blunt side of the axe but it didn’t faze the drunk a bit. The crowd closed round them to intervene and we left.

Tonight Nouhoun took me for a walk to a small hill outside the village. Ex-archaeology student that I am I could tell the place was an old habitation site. The vegetation was different and there were potsherds everywhere, thicker than I’ve ever seen at any ruin. Thousands upon thousands. Plain, incised, stamped, painted, basket-impressed. Nouhoun said it was inhabited by the ancestors of the villagers but they were driven away by a great war, no one knows how long ago. Gradually the people filtered back and established the 3 villages that are now here, no one knows how long ago. One man stated with great conviction “280 years”. An old man said more than 400 years. The site of the old village is considered sacred.

There is actually a third town inhabited by Serahule tribesmen. Serahule are known as great traders. Many of the Serahule in The Gambia are extremely rich, even by Western standards. I only visited their village once and, at least superficially, it looked like the Bambara villages.

When we returned we found a small watermelon Mama, one of the chief carvers, had brought for me. It was the best watermelon I’ve ever eaten: pink and delicately crisp with a scent of earth-sweetness it had drawn into itself.

Binna and Mama Koumare. Master carvers of the village. Mama carries a trapezoidal hunter's bag of heavy leather with a wooden-handled iron knife attached. This is typical of Bamana men in the villages.

Morning brings a quiet, concerted busyness to the compound. Animal sounds fill the cool, golden light. Cocks crow. There is already the ubiquitous thonk-thonk of mortar and pestle. A bala-bala bleats hoarsely, monotonously, reminding everyone that sheep need breakfast.

Children ready themselves for school and head out with their satchels. Little girls take care of the babies. Hens shepherd their chicks scratching up small dust storms. Greetings are exchanged:

An sogoma? How is the morning?

M’ba sogoma! A good morning!

Ereh sira? Did you sleep well?

Ereh! Very well!

Ereh sira? Did you sleep well?

Ereh! Very well!

Men ready tools for work -- hoes, axes, adzes – testing edges, checking hafts.

The compound’s bad-tempered little green-and-yellow parrot, his wings clipped, goose-steps past, a self-important minor functionary, the only animal here that isn’t required to earn its keep. His step is a trifle wary though. I’ve seen the occasional hen give him a whack in passing, letting him know he is really just a very small bird and useless, to boot.

Nana, Nouhoun’s wife in Sina (his other wife, Hawa, lives in Bamako) brings a bowl of plump millet pancakes and a thermos of hot water for our morning Nescafe. We dip the pancakes in a bowl of wild honeycombs seeping honey, deep brown, pungent and complex.

Nouhoun's wife, Nana, walks past the family granaries where millet is stored.

Visiting the village school made me reflect on the enchantment of this place. It is easy for a visitor to romanticize, but at the bottom of the page of the Book of Sina is poverty. There is richness of culture, richness of society, of family, but there are also those child graves outside the village, likely as not a reflection of the complete absence of medical facilities. (The nearest is a tiny dispensary manned by a nurse, 35 kilometers away over rough tracks.) There is the poor soil. There is the fact that, each year, to draw water from the wells requires a longer rope. They survive on the edge. I expect a few of them know about global warming and it is bound to affect them. If desertification continues and the Sahara moves further south the Sina people will decamp or die. Sina will become another “habitation site”, not a village. There are no alternatives. Everything depends on forces beyond them. If there is a dry(er) year there is hunger. If there is a political twitch in West Africa and the flow of tourists dries up there is no market for their masks and chiwarras and there is hunger. Life on the edge.

Schoolroom, Sina Bamana.

Watermelon transformations.

And there is watermelon. Mama brought another last night. And I marvel at how something so dripping and succulent could emerge from the Malian dust. How such a miraculous transformation could take place.

That’s the wonder of transformations. Tribal people accept them for the mystery and miracle that they are, for the change of inanimate to animate and back again, insensate to sensate, inchoate to known, ordinary to miraculous. Their rituals, masks, dances, celebrate transformation. We in the West seek to quantify such processes and some, in doing so, believe that they truly freeze –objectify – describe the truth of such miracles. Some believe such quantification sucks the life out. Some believe that is a good thing. Einstein understood that such quantification no more mummifies the described than writing down the notes of a song can rob the emotion from music. The description simply accomplishes yet another miracle of transformation.

I heard a balafon playing and went to investigate. The young man motioned for me to bring another balafon that was leaning against the wall of a house nearby. When I’d brought it and set it down he handed me a pair of sticks and showed me a simple pattern. Et viola! I was instantly 2^nd balafon in the the Sina-Bamana Balafon Duo!

The Sina Philharmonic.

As always, it quickly drew a crowd of kids who started dancing their skinny little legs off and raising a cloud of dust. Balafons are right down there on the ground and a little bit of dust goes a long way. It made me think. Tendonitis is common among professional musicians but I’d never realized silicosis must be an industrial hazard for balafon players!

One of the old women came to the compound and scolded Nouhoun for hitting one of the children. I’ve seen children scolded, and not much of that, but never hit. If a child survives the health problems this must be a wonderful place to grow up. Infants are always with their mothers or another woman. When they are hungry the breast is always available. There are other children to play with. Gaggles of kids chase around the village unattended well after dark. They are loved and doted on and raised by the whole village.

Toys: motorcycle and auto tires and bicycle rims without the spokes are rolled around like 19^th Century American kids in knickers used to roll hoops. There isn’t nearly the intensity of football play I’ve seen in the city and less remote villages. Older boys have catapults (slingshots) with which they hunt birds.

Saturday, 3 Feb.

The village chief sent a gift of a chicken to us this morning and a bit later a man went around the village blowing an antelope horn to announce a festival to be held in my honor. They will dance the chiwarras I was gifted as well as other masks.

Village herald sounding his antelope horn.

Meanwhile, I was called to attend un malade. Nouhoun had explained to the man and his family that I had no equipment, not even a stethoscope, but they wanted me to consult anyway. It turned out to be a “gimme” diagnosis. He had a huge goiter, had obviously lost weight and had a fast rest-pulse and a tremor. Thyrotoxicosis. Goiter seems to be common here. I saw two people at one of the markets with large goiters. Perhaps there is no dietary source of iodine. Anyway, the man is supposed to go to Bamako with us on Monday and we’ll try to get him hooked up with a doctor there.

Last night Musa Coulibally came by with a mask for Binta and a carved catapult for me. I’d bought two very lovely chiwarras from him and I guess he appreciates the business.

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[1] Throughout the Mande world (Bamana, Dogon, Bozo, Mandinka, et al.) numó pump the bellows in incredibly complex rhythmical patterns. So complex, in fact, that drummers say they learn their rhythms from the blacksmiths.

[2] A stringed instrument made from a calabash, one of the predecessors of the kora.

Wins, losses.

Tuesday, May 09, 2006

Up until 3 last night. The moon is waxing and the natives are getting restless. My first clue was coming back to the hospital late in the evening and noticing a blood trail from A&E leading toward the major theatre. I was off-duty but figured I’d see if they needed some help.

There were three patients. bleeding One man had been attacked with a machete (they call it a cutlass here). He had one gash in his head and another, a defensive wound, in the undersurface of his forearm that severed tendons, the radial artery and key nerves. Lucky for him the bleeding had been controlled.[1] All was laid open to view. A good anatomy lesson. The Cuban orthopedist on call got that one.

The other two were another victim and his assailant. The victim had been at a mini-mart, keying some numbers on his mobile phone when a short, drunk man he didn’t know attacked him with a broken beer bottle. The attacker’s handiwork included a small, deep gash across one knuckle, a foot-long superficial cut to the victim’s left upper arm, and a deep, triangular excavation to the underside of the man’s right forearm. The victim was a well-dressed man with thick, muscular arms. A huge flap of skin lay contracted over what looked like chunks of stew meat simmering in blood.

For an hour and a half, Lamin, the “theatre” (operating room) nurse, and I stitched the guy back together with a fluorescent desk lamp for light, tucking in pieces of meat here and there, and inserting a drain to keep blood and other fluids from accumulating. In the middle of the process the hospital lights went out. A bystander unfolded his mobile phone for the light the screen provided. I directed him to fish my LED penlight out of my t-shirt. We continued the operation by electric torch. Twenty minutes later the generator kicked in (it turns out the generator man was sleeping) and the lights came back on.

Shortly, we heard a commotion in the hall outside. The still-drunk assailant had been brought in by the police to have his cut ear fixed and he’d started an argument with the victim’s friends who were waiting in the hall for me to finish my suturing. The cops had been told to keep the assailant outside so an altercation with the victim’s supporters would be avoided, but these cops were not the brightest bulbs in the marquee. They brought him in anyway.

The voices grew louder and soon we heard thumping noises. I went out into the hallway, bloody rubber gloves and all. Mr. Drunk Assailant was grappling with one of my patient’s buddies. The police were standing around looking interested but doing nothing. I waded in and separated the two men, telling the constable to do his “f…ing” job and keep the peace. He asked me what he was supposed to do. Meanwhile, Mr. Assailant, still drunk, was trying to fight everyone else there. I grabbed him and told him this was a hospital not a street brawl and he had to leave. He spat at me and said they didn’t need any white bastards telling Gambians what to do. When he started to go after me the police finally stepped in and escorted him out. Then I went back to finish the suturing.

By the time all was stitched and glued, seams straight, bandages on, etc. I looked up and it was 2AM. We had to get some antibiotics into my patient but the hospital pharmacy was closed. I went off to one of the wards where a friend had been admitted that day, borrowed two of her amoxicillin, and fed them to my patient. God knows, he’ll need it. There’s no way to maintain a sterile field with the setup at this place. Aside from any bugs introduced in the initial stabbing we certainly added plenty with our operating technique.

Christ! These people are tough! They have to be to stay alive!.....and to survive what WE do to them!

Wednesday, May 10, 2006

So I get to work this morning and before I get a chance to get oriented one of the docs notices that a woman on the second exam table is seizing (convulsing) and has bitten her tongue badly. She’s choking on her own blood and secretions and there’s blood coming out her nose and mouth. I get her over on her side and run for a suction machine but the one I find doesn’t have a plug on the end of the cord. So the nurse heads off looking for the other suction machine and somebody else shows up with an endotracheal tube and laryngoscope and this lady’s inhaling her blood like there’s no tomorrow. We can hear it gurgling and when she coughs it blows out her nose in a spray all over the place. It spatters us and the floor and walls and the nearby patients. I’ve given her IV Valium but I can’t get a laryngoscope in because her jaws are too tight from the seizures. So Dr. Conde, the wonderful Cuban head of A&E, finally gets a tube in her nose and into her trachea but then it gets pulled out while Dr. Conde is putting in a central line and we have to try to get it in her all over again except this time it won’t go in so we give her more Valium and get her mouth open enough to do an oral intubation. And I’m sure she’s inhaled so much junk her lungs will never recover. And eventually she’s wheeled off to the ICU and I never did find out what she was here for.

And for the rest of the day I’m treating people with malaria and with anemia, and a stroke, and with malaria AND anemia. And it’s not even malaria season yet. And there’s the guy who was asleep under a truck and someone drove the truck away and it ran over his leg. The leg is broken and the skin over his calf muscle has been stripped off neatly so the whole gastrocnemius muscle lies there, neatly covered in its intact fascia, pulsing and twitching like a computer-animated photo from an anatomy text. Meanwhile, the owner of the anatomy lesson lies on the gurney conscious, showing no emotion whatever.

The fruit are ripening and daily children are brought in who have fallen from mango trees. It is a yearly ritual. Mango trees grow big and full; deep green and magnificent. But the limbs are fragile. So we have a 13-year-old girl who has fallen from a mango tree. She is unresponsive, pupils fixed and dilated. We assume her neck is broken or perhaps a head injury. There is nothing to do for her. The treatments available back home are unavailable here. She will die.

And in the midst of it all a hospital courier comes in with a letter for me from the administration telling me that the lease on the house I am about to move to expires at the end of August and at that time I will be responsible for my own accommodations. I think I may have to have a discussion with the administrators. They’re getting an OK deal so far: an American doctor at the price of a room they haven’t had to pay for.

My sewing project from last night did show up this morning. He looked good and told me he really didn’t have any pain. I can’t figure that out. That forearm wound looked like hell before we got it stitched up and I figured the man would be in agony. There aren’t any pain-killers available here stronger than a weak Tylenol/codeine combination but he said he didn’t even need them. Tough people!

I’m off to Marong Kunda for food.

Thursday, May 11, 2006

Shitty day! No details. The young soldier from yesterday is dead. The woman who spattered me with gore yesterday is dead. The young man who came in vomiting blood continued doing it until he died.

I wasted my kora teacher, Alhaji’s, time and pissed him off. And other petty annoyances.

Dinner with Allen and Margaret. Their trip to Senegal was lovely. We ate huge prawns and drank gin-tonics and lousy white wine and laughed a lot. Capped off the dinner with the last of their Talisker Single-Malt.

I drive them to the airport on Tuesday, and then move into their house. I hate to see them go and have reservations about moving into the house. I’ll be trading connection to my family and the Banjul aliveness for (relative) luxury and isolation. I’ll try it for awhile and see if it is worth the exchange.

I returned to Banjul in the dark to the sound of drums and singing. I followed the sound and found a crowd in one of the side streets. Darkness, drums, and people doing a slow, counter-clockwise, circular dance. I stood for a long time listening and watching. No one paid me any attention. Eventually a young man appeared from one of the houses with a tray of some sort of drink in plastic mugs. When he reached me I asked what the program was. “We are praising Allah”, he told me. The beverage was tart and complex and savory, not overly sweet like most things I’ve had here.

Perhaps the words were Arabic and Muslim but the music was pure African. Whatever the name of the god that was being praised the form and practice came from Black roots, not anything bred of Arabian sands.[2]

En route back to the hospital a small, long-haired dog decided to play with me. The dog didn’t look Gambian at all. The usual critter here is a short-haired, nondescript cur with fly-blown ears and a belly so full of worms that play is out of the question.

The hospital dogs in action.

At the main gate the security guys asked me to sit with them and wanted to know about America. What was the biggest city? What was Colorado like? Georgia? Dallas? Did they drink ataya in America? Is it cold there? It was a cool evening, but I was sitting in my Hawaiian shirt in comfort while the guards were putting on coats.

To bed. I’ve got to kill more patients in the morning. I’m out of my depth and we’ve got nothing to work with here!

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[1] As clinical instructors like to say, somewhat cynically, “All bleeding stops eventually.”

[2] These celebrants are Mourides, or followers of the Sufi saint, Sheikh Amadou Bambá Mbakke, who died in 1927. The Brotherhood is centered in the Senegalese city of Touba, which the Saint founded, and the annual pilgrimage to the holy city attracts 2 million people yearly!

Music, the kora, ceremony, trash and breasts.

Saturday, March 18, 2006

“Toubab! Toubab!” Wherever I walk little children shout it gleefully. There is no onus to being a white man. It is simply what I am; like “old guy” or “baldy”. And the children are fascinated. I will frequently be surrounded by a gaggle of 9-year-olds wanting to shake hands and try out their English, or 3, 4, and 5-year-olds who come up and take my hand, or stroke the hair on my arm, or even hold my hand to their cheek and kiss it. Nothing fawning about it. Just a pure, sweet kiss. Sometimes I’ll have three or four children holding each hand as I walk, until I am far enough from their home compound, then they peel off and run home, waving goodbye. If there is time some of them will take a little pinch of skin and rub it. I am told they are checking to see if the color will come off.

A few days ago I was sitting in front of a music shop listening to some CDs they were demo-ing for me when a little girl of about ten walked over and stopped a couple of yards away. She stared at me interestedly. I put out my hand and said, “Hello. How are you?” Her face opened up in a delighted smile, eyes twinkling. She stepped up, shook my hand and said very, very precisely “I-am-fine. How-are-you?”

“I am fine. Thank you.” I replied.

She turned and as I watched her walk away I saw her throw her arms up in the air and do a little dance of pure joy. What a pleasure to make a child’s day just by being. I met a very interesting American today. His name is Grey Parrot. He comes from Maine near Bar Harbor. He plays the cora, and has been coming to The Gambia since 1990. Grey makes arrangements for people to come here and stay with families while they study music or dance, or art, or what-have-you and his wife does import/export, mainly fabric and dolls. He knows a lot about African music and culture and I learned a great deal listening to him. We met at a very lavish naming ceremony in one of the subdivisions of Serekunda. I’d gone for a cora lesson. When I got there, Alhaji said he needed to go perform at a naming ceremony and then we’d return to his place and do my lesson.

Alhaji Kuyate: have cora, will travel.

So, off we went through the deep-sandy streets with the sun shining and a nice breeze coming off the ocean. We’d stop often so Alhaji could chat and introduce me. (I think there’s a certain cachet to having a toubab doctor as one’s pupil. I also think I “show well” as I’m getting reasonably adept with the greetings in Mandinka.)

At length, we made it to the compound where the naming was being held. A large sheep was being led off to be slaughtered. Two tall towers of speakers were set up in the dust of the street with African music blaring. A crowd of jelis and jelimusos were gathered outside the gate and soon the jelimusos, all dressed in the same color green-and-white traditional outfits, started to sing and all danced into the compound. Plastic lawn chairs were stacked up by the scores and by the time things got rocking there were several hundred people. Huge cauldrons of rice, cous-cous, and the mixtures of sauce and vegetables collectively referred to as “soup” were being stirred up with spatulas the size of a little league baseball diamond. There were drummers and cora players and electric bass and jelimusos clapping bamboo sticks together and lots of singing. Big energy and smiles galore and the colors were brilliant. One of the women pulled me into the circle to do a bit of buck-and-wing. Children were everywhere. A babe-in-arms would start to snuffle and mom would flop out a breast and suckle the little one. Dogs slept in the dust and half-fledged chicks and hens dodged feet and scurried for dropped scraps. Overhead, the ever-present vultures circled or perched on nearby palms and walls, awaiting their turn and the ever-present African sun baked it all.

We did eventually get back to Alhaji’s house. He seems to be very pleased at my progress and is pressing me hard to come and “train” more often than I am really willing. We’ve already settled what I’ll be paying him weekly for my lessons, so his insistence surprises me. Maybe he really thinks I have some promise as a cora player.

The whole musician-thing here is interesting. In Mandinka culture only jelis make music. No one else played an instrument or sang. I’m not clear yet on whether it was a right reserved to them or whether others were prohibited. From Essa I understand there is a class division of “those who praise” and “those who are praised”. Aristocrats would not bow to play music; they are the ones for whom music is played. After all, Queen Elizabeth attends concerts, she doesn’t perform in them. In fact, Essa tells me it would be very bad luck for him to even touch a musical instrument. But what about the rest of society? I guess music was not something one did to entertain oneself. I have a feeling some of this division is gradually breaking down. Interesting.

Friday, Essa, Mussekebah, Essa’s brother, Ebraima and I are going up-country to his village in the Badibu District. Each year there is a village reunion to feast and pray for all the families in the village that they will have a good year. The event (or “program”, as they call it here) is Saturday. Essa tells me the family will slaughter a bull to eat and he wants to take me to see a baobab tree that looks like a pregnant woman. He’s quite emphatic about the tree.

Sunday, March 19, 2006

Trash.
It is everywhere. Everyone litters. Plastic bags, orange peels, banana peels, aluminum pop cans, plastic motor oil bottles, all sorts of wrappers, solitary, worn out flip-flops,solitary, intact flip-flops, rags, bits of paper, foil and metal, unidentifiable organic somethings, more plastic bags ! especially plastic bags. As in Latin America and the Caribbean my first impulse was a self-righteous, “Why don’t these people take a little pride in their environment and keep it clean?” Until I began to think a bit. To avoid litter you have to have infrastructure to centralize and dispose of the litter. Trash cans, trash pickup, a place to put it, processes to do something with it once it’s there, etc. To do this requires money; resources.

Litter-strewn streets in Guinea.

Each year, the Third World experiences a net loss of gross domestic product. Raw materials are taken out by the First World nations, refined or turned into manufactured goods, and sold back to the Third World. A net loss to the so-called “Developing Nations”. So, the resources are not available to create the infrastructure. Let’s face it. How many of us would carry the piece of paper our sandwich was wrapped in all day until we got home and had a chance to throw it out? How many of us would do it, or would we seek a spot to surreptitiously ditch the greasy wrapper?

Then, there’s the organic vs. non-biodegradable problem. Not too long ago everything these people made, used, kept or discarded was biodegradable. The banana peel will be eaten by something pretty quickly. The plastic will not. And who is it that floods the Third World with plastic? There are no plastic factories in The Gambia, or the Bahamas, or Panama.

On the last Saturday of each month there is a government mandate that all businesses close from 9AM to 1PM for National Clean-Up. No one is even permitted to drive a vehicle without a special permit. Teams of students pick up litter from the roads. Businesses clean the street in front of them. Trucks come around to pick up the trash. Could you imagine the uproar in the US if business closed down for half a day each month?

Women and Walking
African women have this sultry, languid walk. Part of it is that few people hurry. I remember an episode from Cannery Row where Doc’s girlfriend discovers that the secret to appearing elegant is to do things slowly. The women here don’t walk fast and it is both sensuous and elegant.

I discovered part of the reason, however, when I bought a pair of flip-flops. You can’t walk fast in footwear without a heel-strap. Try to rush and you’ll immediately lose a flip; or a flop. So that’s where some of that elegance comes from. The sultry hip-swinging, though, is pure style.

Breasts
They are not considered sexy here. Lots of women go bra-less under clingy or even transparent tops. Babies are nursed openly and ubiquitously, as should be. And there are a lot of babies.

(My mother would have plotzed. There was nothing in the world she loved more than babies, especially brown ones with huge eyes.) But I digress. I asked Essa what African men find attractive in women; physically speaking. First of all, he told me, they like big, fat women. He doesn’t understand why toubabs like skinny women. Fat women are strong and healthy. Secondly, he said, “The back is more important to us. We like a woman with big butt-tocks, especially when they are well organized.”

Harmattan

Friday, March 10, 2006

The town and countryside have been searing in a haze of tan dust for more than 5 days. The annual harmattan wind brings fine sand particles from the Sahara, hundreds of miles away and suspends them in the atmosphere, turning the sky a featureless dun in which the sun hangs, an anemic disc. The eyes turn gritty and everything coats with dust. Shadows lose their definition and the muezzin’s voices sound hoarse as they call the faithful to prayer.

Mid-day in Banjul. Dust from the harmattan obscures the sun.

People with lung disease have problems when this sort of weather hangs about. They pile into A&E coughing and wheezing. Those with marginal respiratory function are sometimes tipped over the edge and our resources are slim.

Today on the street, returning from the Albert Market and man called to me from across Independence Drive. I didn’t recognize him. He ran across to me. He is ebony-skinned, with high cheekbones and fine, chiseled features. As we shake hands I touch a shoulder hard as granite. “Remember, you took care of my father in the A&E?” he asks. Then I do remember. The father was a tall, dignified, calm man of 84, in a caftan and fez, struggling for breath. He had been left on a gurney in the waiting room for quite some time. No one had thought to triage him in to the doctors. No one thought he might need oxygen. So, he was simply put with all the non-emergent cases. Eventually, a family member came in and asked me to see him. He was in obvious distress. It took a bit of goading but I had him moved into what passes for a procedure room. No oxygen. It took some time to locate an oxygen cylinder, tubing, and a mask. (In the used car business the mask and tubing would have been referred to as “pre-owned”.) Two men carried the big H-tank, tall as a man, into the room. Then it took a while to get him hooked up on a cardiac monitor. An IV was started. A nebulizer treatment. I asked if a 12-lead electrocardiogram (ECG) could be done. Tomorrow, I was told. No, I say. We need one now. Arterial blood gasses? No such thing here. Pulse oxygenation meter? Same. How soon can we get lab results? Tomorrow.
Eventually, someone finds an ECG machine. Eventually they discover the electrodes. Is there conductant gel? A withered tube of gel is found. We get the patient hooked up to the machine. I read the ECG. He is having a heart attack.
Did I cause it by ordering the nebulizer treatment before the ECG? I won’t ever know. I really had no choice. His breathing improves somewhat and we ship him to a medical ward. The next day I look for him but can’t find him. There is no central admitting here where you can locate a patient.
Today, the son thanks me for taking care of his father and tells me the old man passed away. With a sense of futility I try not to show, I shake his hand and tell him it was my honor to take care of his father; that he was a lovely man. I don’t mention my misgivings about the (in-)adequacy of my treatment.
I have devolved (evolved?) into working permanently in A&E. Dr. Azmi, one of the Egyptian surgeons told me they needed help there and would I come work. I don’t feel competent to do emergency medicine but they do need the help.

The big news this morning is that someone in the hospital “misplaced” 41,000 Euros donated by a Rotary Club in Holland for the psychiatric unit. An investigation is in progress.

Tonight, I took my laptop to Essa’s compound and showed the family the photos Essa and I have taken around the compound, in the streets, and on our trip to Fort Bullen. The show was a great hit. Ebraima brought out a Boyz II Men CD he hadn’t played yet and we put that on for awhile. Then we played some Ali Farka Toure, Afro-Cuban All-Stars, Supremes, Coasters, and The Rail Band, from Mali. Lasers in the jungle. What a priviledge! To sit on ramshackle chairs by the light of a single candle, under the rusty, corrugated metal shade, and share music from places imaginable and unimaginable on a machine that cost three times what the average Gambian makes in a year, with people whose richness of culture and family beggar the sterility of our technology. The grandmothers exude such a pure, unaffected, joyous love and warmth. And they thank ME! How strange.
Today, being Friday, I wore my caftan in the afternoon. Friday is the Muslim Sabbath and most people dress up in their go-to-meetin’ duds; the men in caftan and “alhaji” hats, the women in their brightest finery. Even the children all duded up, scampering about. I am accosted by men who want to know if I am “alhaji” (converted to Islam) or just wearing the clothes. The clothes seem to some Africans to indicate being Muslim but others tell me it is simply African. A few of the accosters are quite persistent that I must look into converting. Despite the insistence that there are no fundamentalists there are certainly some very, very evangelical Muslims about.
Essa and I had a long talk today about his statement (a repetition of a national advertising slogan) that there is “Zero Crime” in The Gambia. The discussion began when we left the hospital by the A&E entrance to see a body, tightly wrapped in faded, patterned cloth, being loaded into the back of an ambulance. Essa said it was a young man who had been stabbed in the chest by another young man. I asked him how he could make the statement that there was no crime in The Gambia. He explained that No Crime meant “compared to other places”. I pointed out that Zero means Zero and that one loses one’s credibility if one makes such statements and they prove to be untrue. That even if crime is very low it still exists. He answered that they didn’t consider it crime when it is just a bunch of no-good young men who get drunk and smoke cannabis and hurt each other. It is only crime when it involves “other people”.

First Day at RVTH

Wednesday, March 1st

First day at RVTH.
I worked in the female medical ward this morning. Cuban attending physicians, Gambian med students, Gambian and Nigerian nurses. Nothing happens fast. Little seems to have a system or plan. When you ask a nurse a question she doesn’t pick it up and run with it.
Example: “I need a pair of sterile gloves.”
I get a blank stare. A shrug. “I don’t know where they are.” No attempt to find them, find out where they are, if any are to be had. Nothing.
“Would you please find some.”
“I don’t think there are any.”
It takes several more requests before someone goes up to the “theatres” (surgery) to find some. Meanwhile, I have a patient in severe respiratory distress who needs immediate care. Perhaps they are so used to disease and death that they are lackadaisical about it. I took care of a woman crashing with AIDS and diarrhea; another with a gangrenous diabetic foot that looked like a blackened charcoal stump.



Another patient was a very sweet lady part of whose diabetic foot had simply fallen off (autoamputation), then gone septic. It is healing slowly but still smells awful.
And not a single complaint. They suffer in silence, with a patience and acceptance that is both extraordinary and heartbreaking.
For a real shock work ER in this place! They call it A&E, Accidents and Emergencies. The paint peels. The lights are dim. There’s no privacy. There’s little in the way of equipment.
To get oxygen for an 84-year-old man with a suspected heart attack it takes two men to carry a 5-foot-tall tank from an adjoining room. The oxygen cannula is crusty with use but there is nothing available to clean it. We use it anyway. At least there is oxygen! Patients are accompanied by family members and these “attendants” crowd around as we examine and discuss. They are respectful and don’t interfere but will come forward with questions or requests for the patient. With our lack of staff they are valuable for helping provide care and we enlist them to help move patients and equipment.
A young boy is carried in by relatives. He fell from his bicycle and fractured his right ankle. As they carry him in the bone pokes through the skin and the unsplinted ankle flops about, dripping blood all over the floor. He grimaces in pain but doesn’t cry out.
A 20-year-old woman with pelvic pain and seizures lies at the other end of the room, convulsing.
Along the wall are three beds: a man with a liver the size of New Jersey, one man with a urinary catheter filling a bag with frank blood, and a young woman delirious with cerebral malaria. Two scarred desks line one wall; two more along another; all in a 15 by 20 foot room.
The staff is me, Dr. Rene Rodriguez, a small, handsome, wiry, 35-year-old from Camaguey, Cuba, and 5 or 6 medical students. The students are earnest, intelligent, and hungry to learn. They are terrific.

West Africa? Who cares?

There I was, running the Accident and Emergency Department in the "flagship" hospital in the The Gambia, Africa's smallest country. I'd never thought I'd end up doing emergency medicine when I left my home in western Washington State. It was a roller-coaster ride from the get-go. I kept a log and emailed it to a list of about 85 friends in the US, Canada, Mexico and the UK but had never thought of publishing them as a book.
Several friends -- some of them published authors -- suggested (Actual Quote: "If you don't publish these I'll kick your ass!", Paul Raczka, author of "Winter Count, A History of the Blackfoot People" and numerous articles) so I've been working on doing just that.
Following are excerpts from what will soon be published.