Saturday, 07/12/14, 2:40 p.m.
I wake up every morning from nightmares.
My alarm goes off at 6:20 a.m., and rather than getting up grudgingly, I see it more as a merciful reprieve from the long series of very vivid anxiety dreams throughout the night. My morning run is more than just exercise, but also a way to dispel the chases, killings, and overall strange happenings from my churning mind. It wasn’t real, it wasn’t real, it wasn’t real accompanies the rhythmic cadence of my shoes on the dusty road. The dreams certainly are not a result of any kind of stress here--on the contrary, life is quite peaceful and work is easy. They’re actually the evil machinations of my daily anti-malarial pill, an antibiotic known as doxycycline. It’s a common one for malaria (and the cheapest), and is even used for things like Lyme disease and bad acne back home. This is my fourth time taking it on a trip, and, come to think of it, I’ve always had the crazy dreams, but chalked it up to the effects of travel until doing some Google browsing this week. I was surprised, because more-expensive mefloquine is the famous one for causing hallucinatory dreams! A good or bad side effect, depending on your disposition. I just don’t want to feel like I spent the whole night battling a Kraken (that happened) instead of happily inert.
Oh well, I suppose it’s not so bad (I haven’t experienced the other common side effects, like sensitivity to the sun--a good thing in an equatorial region), and I’m even safe in the event that someone mails me anthrax! I realize this necessitates actually acquiring a mailbox and an enemy, two things I have yet to accomplish, but you can never be too careful. Oh yeah, and that whole malaria prophylaxis thing is cool, too, I guess. There are big research projects here at IHI on malaria and mosquitos, and thus there are medical entomologists, so I have it from the best authorities that the particular mosquito species that lives in this area is the prime spreader of malaria. Everyone’s gotta be good at something. However, I was also told that, based on mathematical modeling for the Kilombero region, I’d need to be bitten 100 times in order to make one infectious bite likely.
I don’t think I’m quite up to 100 yet, although after last weekend it did feel that way. We also had a three-day weekend here, not for the Fourth of July on Friday, but rather a Tanzanian holiday called Saba Saba (Seven Seven: July 7th) on Monday. Rest assured that the few Americans here did force everyone else to humor us by playing baseball on Friday evening with Lisa’s cabbage ball and a locally-carved cricket bat, which rudely aborted the game when it decided to split in half. Saba Saba originally marked the creation of the first democratic political party in Tanzania, but now that there are multiple parties, it’s a day of celebration for businesses large and small. There are exhibitions, mostly in big cities like Dar es Salaam, and lots of sales. The only change in Ifakara was that we got Monday off work, so on Sunday afternoon, Lisa, her husband, Tom, Geofrey, a Ugandan Ph.D. student named Innocent, and I headed to the nearby Kilombero River to row out to a sandbar to camp for the night. We paid a fisherman to take us there in his wooden dugout canoe, and for him to stay with us overnight to take us back in the morning. As he pulled us along with a long stick he struck into the riverbed below, we fortunately/unfortunately did not see any hippos or crocodiles, which are apparently pretty common sights (and attackers) in the Kilombero. We made it safely to our idyllic little patch of sand and wandered around following animal tracks, looking at birds through Lisa’s binoculars, and playing Frisbee.
When the sun started on its quotidian descent, we set up tents (girls, boys, fisherman), played cards, and built a fire to start cooking Holy Sausages we brought from Ifakara. (Okay, I can’t confirm they’re actually holy, but a nun from the St. Francis Church makes them in her home, and if you knock on her door and say sausage she’ll sell them to you.) We had beer and homemade bread with honey as well, and the campfire conversation progressed delightfully into the night. At one point, I was urged to bring out my ukulele (because when, if not campfire-side, is a good time for a ridiculously tiny guitar?) and trusty three-chord songs like “You Are My Sunshine” and “I Walk the Line” accompanied the crackling fire and the more quiet murmurs of the river in front of us. Geofrey held a lantern up so that I could see my music, which immediately attracted every insect in a 20-mile radius, and soon I felt them all over my body. If you feel like you have bugs crawling all over your skin, in America, chances are you probably have a meth problem. In Tanzania, chances are you probably have bugs crawling all over your skin. I’m going to credit years of marching band for the discipline to just keep playing! However, almost a week later, I’m still shaking pressed bugs (ooh, scrapbooking!) out of my Daily Ukulele. We watched the fire die out, retired to our tents for the night, and returned home the next morning after bananas, some more bird-watching, and a rousing match of let’s-use-these-tiny-rocks-and-the-slingshot-to-hit-that-water-bottle-over-there.
But back to those mosquitos. Lisa said she heard one whining around our tent in the middle of the night, and I believe her, because I woke up with bites literally all over my hands. It was like Achilles and his pesky heel--I had applied bug spray the night before holding the can in my hands, and then had forgotten to give them a once-over afterwards. And see how well it worked out for Achilles! Rookie mistake. For most of last week my hands itched with a vengeance that no amount of After Bite could soothe. I’m going to say that’s why it’s been awhile since my last post, but no, I’m just plain lazy. In their brainless malice, though, mosquitos fascinate me. Worldwide, they kill more people each year than people do. I hope all the research efforts that are going on here and everywhere else will figure out a way to stop their rampant destruction. Tom, a medical entomologist on a grant from the Clinton Foundation who sports the DDT molecule tattooed on his arm, has invited me to spend a day at his lab’s field site, where they have a screen house that holds a mosquito colony they are studying. (There’s also a screen house on the IHI compound near my apartment, but I’d rather not know exactly what’s going on in there because it quite literally hits too close to home.) The way they feed the mosquitos is crazy--someone sticks their arm in twice a day for them to feed, and at night they bring in a cow for the same purpose. Every other day or so they switch people. How do you decide that? Draw straws? Not positive about the poor cow. Similarly, when studying mosquitos you often do something called a “human landing catch,” where you sit out at dusk to count (and smash?) how many mosquitos come looking for noms. Apparently these sado-masochists are ethically allowed to do this because there is treatment for malaria. You can’t, let’s say, do a human landing catch for Ebola virus particles (and thank you to those who have been concerned, but the Ebola outbreak has not made its way here from the West. Tanzania came out with a statement saying they will stop anyone who is infected at the borders, to which I say lol k good luck doodz). It’s really important research, though, and it would be something I could see myself being a part of later on. Just as long as someone else has to stick their arm in, of course.
Side note: malaria isn’t the only disease with which I’m grotesquely fascinated here. A good night’s entertainment comes from reading the “Rarities” section of my Lonely Planet Africa: Healthy Travel book that the Global Health Institute gave me during pre-departure orientation. I just can’t seem to stop reading about all the crazy parasites, or anything that could leave me with a bad case of the deads. Oh yeah, those really rare meter-long Guinea worms that burst from your skin--I could totally get one of those! And is this blister healing properly, or will I get sepsis? I don’t technically have enough doxy, so cerebral malaria is coming, like, tomorrow. My stomach rumbled, I DEFINITELY have giardia. I think this is akin to the hypochondria everyone seems to develop during medical school, since I’m learning rapidly about so many things that could possibly happen to me. In reality, I’m probably fine. I have the immune system of a veteran preschool teacher, and rarely get sick, even while traveling.
Meanwhile, at work, there’s not a lot of time to worry about invisible assaults. Alfa, the study supervisor who organizes the logistical side of things, is finally back from his two-week vacation, so I met him in person for the first time on Tuesday. Ever since I was stuck in Dar es Salaam my first week, the plan was to get permission for me to go into the labor ward of the St. Francis Hospital and collect HIV status data about the mothers who were initially enrolled in the Vitamin A study, and are now part of Saving Brains. We weren’t able to get permission from the hospital until this week with Alfa’s help. HIV status wasn’t a variable they initially accounted for, but there is now evidence to show that Vitamin A might actually be harmful to some infants because it sometimes increases the risk of mother-to-child-transmission of HIV. No one’s exactly sure how it works, but lipid-based Vitamin A might increase the number of a certain receptor (CCR5: holla at my LS1a peeps!) on the membranes of lymph cells, making it easier for the virus to attach itself. If we can confirm that this is happening in our cohort as well, the WHO would alter recommendations about neonatal Vitamin A supplementation. It would be a shame if this very inexpensive, nutrition-based potential intervention ended up being useless or even detrimental, but going back to the drawing board is better than risking an increase in MTCT.
On Thursday, Alfa and I went to visit the head of OB/GYN, Sister Natalia, who happened to do her medical internship with Alfa years ago. Connections! We were invited inside the labor ward theater, and as soon as the door opened, I was shocked to see a very-soon-to-be mother, her large, naked body lying on a bed, knees bent and apart, right in front of the door. I was embarrassed to be a stranger there at such a vulnerable time for her. I hurriedly followed Alfa the few steps over to the office, which was just the same room separated by a small wall that didn’t go all the way to the ceiling. While waiting for Sister Natalia to come see us, through a small window in the wall I saw latex gloves covered in blood, and I heard the mother groan, Aiiiiiiiii oh mama, mama, mama. I don’t think the baby was coming yet, but my heart started pounding uncontrollably and I was very uncomfortable. I didn’t want to bear witness to her pain, especially if something went wrong. Where was Sister Natalia? I wanted this to be over as soon as possible. I looked over at Alfa, who seemed as serene as a tree stump. Some lyrics started playing in my head, over and over.
I got no deeds to do, no promises to keep...
It seems that Ifakaran work philosophy is just about Feelin’ Groovy. I don’t know how groovy this woman over on the bed was feeling, but luckily Sister Natalia came in and was very impressed by my Swahili greetings. I gave her a letter from Dr. Masanja, OK’ed by the St. Francis medical director, and she said it was fine if I collected this data. This was a big relief for us, because originally the hospital was wary of a non-medical person having access to this very sensitive information. However, for whatever reason, Sister Natalia trusted me, and said that because the labor ward registers are so huge there wasn’t anywhere I could do this work in that office. Would I mind taking one book at a time back to the Saving Brains office to do this work? This, of course, was more than fine with me, as I don’t want to spend any more time than I have to in that labor ward theater. Geofrey told me his office for the Vitamin A study back in Dar was attached to the labor ward, and he would hear the doctors yelling at the mothers. And surprisingly, female doctors are the worst culprits! I remember being told by a woman from the School of Public Health in my Swahili class that there’s a similar problem in Kenya. She has transcripts of recordings of these perinatal harassments. You slut! I hope you liked it when he put that baby in you, because now it’s going to hurt a lot! I wish I had made that up, but my mind just doesn’t work that way. Really, truly horrific things that should never be said to anyone, but especially at a time when the woman is probably scared out of her mind already. Geofrey said you could bribe your way into better courtesy for as little as 2,000 Tanzanian shillings ($1.33). Remind me never to have a baby here? At any rate, I’ll only have to go in there to drop off one year of births and pick up the next, years 2010-2013, so hopefully I won’t personally witness any of that either. I’m a little nervous about going back in that room on Monday to get the first book, but I’m excited that after a month of waiting I can finally start on this data collection that could have some big implications at the international level.
As for Saving Brains itself, on Wednesday I sat in on an entire day of clinic visit assessments at the St. Francis clinic. Unfortunately, one of the nurses quit all of a sudden to pursue a more stable government job (IHI just works on contracts), so poor Nurse Neema saw five toddlers basically back-to-back all day long. Only one little girl was stunned into silence by the mzungu in the room, which I was thankful for, because while I want to observe the visits, I know my presence itself is distracting. The cognitive and motor skill tests involved lots of brightly colored blocks, rubber ducks, balls, and a big picture book with some more culturally-appropriate pictures taped on top of the original Bayley Scales ones. Kids here don’t really have toys at home, so most of them were very excited to play with Nurse Neema, and it was a joy to see when they figured out how to do some task or another.
Oh, and I did my own laundry this morning in a bucket. It makes you appreciate washing machines! I had a lady come and wash my clothes a couple weeks ago, thinking that while I have done it myself before I might as well support her, but my clothes came back not much cleaner than when I handed them over. I can’t get them completely clean either, but why should I pay someone to not do something I can’t do either? Reminds me of certain TFs of intro life science courses. A good benchmark of knowing you’ve scrubbed something enough is if the skin on your knuckles starts to peel, and by the end of a load you should have some charming stumps for hands. As I hung up my t-shirts on the line, I couldn’t decide whether it was better or worse than the mosquito bites of a few days before.
So it goes.
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