.in memory of Adam

                What does it mean to sacrifice?  The personal sacrifices are the hardest.  For a tribe, for a people, for a nation.  For someone who may never know your name.  For someone who may never remember you.  To sacrifice.  To give your health, your youth, your energy, your soul.  To give your children.  To give them back to the hard red earth.  For grass to grow over them.  To water the grass with your tears.  But for anyone else it’s just a dry piece of land.  Maybe it’s under a mango tree.  Maybe it’s in the front yard of a house you spent so many years living and loving in.  And your screams rise up to the hot pale unblinking sky and bounce back down your throat and threaten to crush you.

             And nobody knows but you what it took to take that next breath, that next step.  And nobody knows but you what it took to stay.   What it took to come back.  What it took to love another child. No one knows but the earth and the sky and the grass and your God.  And no one knows that some days you might not believe anymore.

             These are the heroes.  These are the people that give to strangers their last breath, their last chance, their last piece of soul.  These are the people that get up every day and give more.  These are the people no one will ever really understand. These are the people that seem hardened.  The people that gave their tenderness to a harsh and burning landscape.  These are the people who sacrifice the unthinkable, that which no one can ever fully appreciate.  These are the people that gave their own blood to the rivers of a parched country. To a people who will continue to die. These are the people who fight for life anyway. These are the people that still will believe in impossible things. These are the people that take the greatest of risks without the promise of earthly reward.  These are the people whose children speak in the wind.  These are the people that change the world.

             How far would you go for someone you didn’t know?  How far would you go for someone that is statistically going to die anyway?  How long would you breath for a child?  3 hours?  4?  How many children would you give to a country?  How many children have you saved in that country?   Sacrifice.  Most people have no comprehension of what that really means.  Most people do not care to ever know.  It is only God that can know the true depths of what you have given.  And it is only God who will sustain you.  And it is only God who can really understand what it means to sacrifice a son so that others might live. 

----- the 6 month old son of James and Sarah Appel passed away this morning from Malaria.  Please give them your prayers. 

.quinine

so let me tell you about quinine

bitter potent bells and locusts and swarms of stinging things ringing
and crashing and sawing in your ears. voices from the north and from
the south and oh yeah that was east and a person from the west just said
hi but i turn and wait they were in front of me

sounds are coming at you screaming through water,

imagine you are swimming in a deep green pool, you and your best
friend. and you are playing a game where you take a deep breath and
tread deep in the water and you scream secrets into each others ears.
and the sound is coming to you through a bell jar and you are in a bell jar

and you view the world, the world of distorted sound and the sounds and
the shapes merge and collide, crash and dissolve and you have
conversations that you don't completely understand and you wonder what
exactly you said but then you are too distracted by the ringing in your
ears to think about it for too long.

and let me tell you about swallowing quinine. it is cold and metallic
and bitter. and no amount of juice can wash the from your mouth and
even after you eat a brownie or a bowel of soup that fishy muddy talcum
taste lingers and scrapes the roof of your tongue and your count your
pills and oh thirty more to go

and the reason you are taking quinine.

malaria. the elusive enemy, the one that will strike you. silent. but
you know your turn is coming. i thought i could cheet it. i thought
that i could haphazardly take Fansidar and drink small sips of gallishly
bitter neem tea, a tea that barely even deserves the name. it is the
worst brew in the world. imagine the most outrageous root in the
universe, a root so deeply grounded in the Terra firma that only the metallic clang of a shovel can wrest it free. imagine stirring this sordid
green mess over a kettle and then forcing yourself to drink it. all in
the name of anti malaria.

but that didn't work either

i made it three months, one day.

and the the five days that the malaria was multiplying in my
bloodstream, disrupting the structure of my red blood cells, i choose
those exact days to begin a rigorous workout.

and the 4 days before i was sure, before i saw that dreaded 0.05%, those
days suddenly i couldn't eat any more. my favorite foods, i couldn't
put it in my mouth.

the 49 hours after i learned i had malaria were some of the worst in my
life. i still couldn't eat, i was trembling, forcing myself to drink
water and take quinine on an empty stomach, taking as much phenergan as
safely possible, and drifting in an out of a nightmarish sleep.

once i finally dragged myself out of my bug net 2 days later, walked the
mile to the hospital, and collapsed at the table for christmas dinner,
then i felt better. kind of magic i guess. the magic of an actual meal
not cooked over a tchadian fire.

but right now, its christmas eve, i'm feeling half way human again,
grateful for brownies and grateful for life.

merry christmas.

send me telepathic christmas love, not that i could hear it anyway.

.xmas

guess what I got for christmas?

malaria

have been here 3 months and 1 day.

the last one of the volunteers to go down

thankfully, the upside of being in Africa is that I can prescribe myself
phenergan

happy holidays all!!!

"I think he is just tired"

You can read studies, statistics, scholarly reviews, and opinion pieces on malaria problems endemic to parts of Africa.  You can read in the new york times about the possibility of a vaccine in the next like 7 years but is being debated because of "only" of 50% success rate in clinical studies.  You can know that statistically most of the deaths from malaria world-wide are children under the age of 5 living in Sub-Saharan Africa.  You can study economics and read about solutions to poverty and join the debate about the efficacy of indoor spraying of DDT........

but nothing can prepare you for the senselessness of it all.  Nothing can prepare you for the transition from data in a chart and theories on a page to a pediatric ward overflowing children, lines of mosquito-net covered beds, and quinine perfusions dripping into hands, feet, skulls. 

or when they come in too late...

...because they know they can't pay 

...because they don't want to pay

...because they live too far away

...because they went to the traditional healer first

...because they were hoping it would just get better

Poverty, lack of education, governmental corruption, poor public transportation, lack of roads, lack of clean water, malnutrition, traditional beliefs and cultural misconceptions, inequality, poor distribution of resources, poverty... a vicious cycle, although not necessarily in that order.   

Some people think they have the answer.

Some people, like Dr. Appel, want to eradicate malaria in Tchad.

Some people, like the rebels in the north of Tchad, want to eradicate president Deby.

Some people, like the nurses here, gather in small groups and talk about how they are going to find rice, about how the rains were short this year, came late, left early.

Some people, like my family, don't put the children in bug nets at dusk because everyone works far into the evening. 

Some people, like my patients, came to the hospital only as a last resort

or like today, came 20 minutes too late.

4 years old.

10 kg.

104 F temp, hot, dry

Resp - 60 bpm, rapid, shallow, hoarse, sever pulmonary edema

HR - 180

conjunctiva - pale - anemic

eyes rolled back, sunken

convulsions.  have you ever seen a child having convulsions from cerebral malaria?  how about 10?

.......

"how long has he been unconcious?"

3 days. 

"how long has it been since he has drank anything?"

3 days.

"how long has he been having convulsions?"

2 days. 

........


where is the tylenol?  the receipt says you bought it?  didn't the pharmacist give it to you?  the father...running to the pharmacy....running back.....with tylenol

tylenol won't reverse anything....but we want to try everything.

Diazepam - who mixed it?  unlabeled? we will guess. 

running to get dextrose....maybe if we correct possible hypoglycemia......

letting the quinine run in just a few drops faster.....won't reverse anything....but we want to try everything. 

the mother is already hiding her face

people don't really cry here.

the father, is holding his hand over his son's heart.

feeling it beating

feeling it slowing

is it still a statistic for you?  probably.

but how about when he asks, over and over

"he is just tired isn't he?  he is just tired."

he is just tired.

I'm pushing dextrose as fast as I can

and then he begins breathing slower

softer

calmer

and his father can't feel the heart anymore

and i can't auscultate the heart anymore

or palpate a pulse

you can see the whites of his eyes rolled back

his mother closes them with her hand 

and still she says

"he is just tired." 

and I am tired too.

I am tired of seeing this every day.  I am tired of the fact that we don't have any oxygen.  I am tired of the fact that there is no crash cart, that even if we called a code and anyone even responded, we couldn't maintain life. 

I am tired of a president that lives in luxury in the capitol, sitting on massive oil revenues, churning out misspelled public health propaganda that his population can't actually read.

I am tired of children dying because a mosquito bit them

I am tired of the kind of poverty that dissuades people from coming even to our seemingly dirt cheep hospital

I am tired of not being able to prescribe fluids because they cost 2 days salary, of deciding which of the three necessary medications is most important.

 I am tired of leaving the same dressing on a burned baby's arm for 3 days in a row because the mother can't pay the 25 cents necessary to change it.  of the fact that the OR is refusing to do the surgery to amputate said arm because the mother can't pay.  Of the attitude that an amputation is not "urgent" so we can't fill out a "fiche de urgence"  I am tired of the reality that here, i must pick my battles, and that i must save an argument about this for something more important.  something more important than a child that has a rotting and infected with only 2 fingers left and a mother with a bad attitude its impossible to call social services on.

I am tired of saying goodbye to a 7 year old with Burkit's lymphoma swelling the side of his face because 2 cycles of treatment later, his body having rejected the cyclophasamide and dexamathasone, covered with tunnelling, pus-filled absesses we finally have thrown every medication at our disposal at him and he is sicker than when we came

i am tired of non comprehension when i insist that a kid with meningitis should not necessarily sleep next to the kid 2 weeks out from chemotherapy. 

I am tired of a country in which parents genuinely don't know that children need water.  or vegetables.  or fruit.  of a country in which malnutrition is commonplace and famine is imminent. 

I am tired of working with nurses that don't give medications or take vital signs. 

And I am tired of death.

I am tired of 4 year olds dying with their father's hand on their heart.  4 year olds that were laughing and playing 4 days earlier. 

I am tired of watching tears stream down his face as he drapes a cloth over the child, lays him across the shoulder, and walks out to face a funeral far more expensive than the hospital would have been.

"I think he is just tired"

are you?

......


1 million people die each year of Malaria most of them African children. - Washington Post

300 million children contract malaria each year. - WHO

 Globally an estimated 3,000 children and infants die from malaria every day and 10,000 pregnant women die from malaria every year, 86% of these deaths are in Sub Saharan Africa. - WHO

 Malaria disproportionately affects poor people with almost 60 percent of malaria cases occurring among the poorest 20 percent of the world's population. - WHO

.rice

harvest season.

men are walking to the fields with scythes slung over their shoulders

ox-carts are rumbling by at all hours of the day and early morning,
loaded with hay from the rice fields, bundles of bean leaves, other
products.

there are vegetables in the market and chunks of fly swarmed meat.

there are peanuts and sacks of millet and baskets of dried fish.

it looks busy, happy, industrious.

but something isn't right

rice is hard to find.

almost every day, and absolutely every Friday and Saturday (big market
days) Bikaou, my tchadian mother, searches for rice.

its harvest season. and she searches for rice.

sometimes she comes back with a sack. sometimes 2.

planning ahead isn't a trait that is necessarily a trait that is
ingrained in the Tchadian culture.... but this year they have to plan
ahead.

this year is different.

the price of rice is rising every week. right now its 35,500 CFA.
Thats $72.00 US dollars. thats about how much the average Tchadian
makes per month.

how long does one sack last, I asked. there are about 10 people eating
in this family.

With millet, maybe a month. maybe.

She is looking for 12 sacks.

Why is it so hard to find? Why does she have to look for rice when we
are surrounded by rice fields.

because last year, this time of year, a sack of rice was 22,000 CFA.
$44.00. it has almost doubled.

next week it may be 40,000 CFA, $80.00.

they tell me, in a couple months, one sack of rice will cost 60,000
CFA. $120.00.

big trucks are coming in from N'Djamena. Buying up all the rice.
people are coming down in cars, on buses. They are calling their
relatives and sending money. Everyone is looking for rice. Everyone is
buying now.

she goes to the market at 6 am. trying to get there before everyone else.

we have 8 bags now. looking for 4 more. and 5 for her brother.

then, we will start doing the same with millet.

everyone is saying there is going to be a famine.

famine.

that's something that happens over in Africa.

Something thats always going on somewhere in this world.

not something my family should be worrying about.

not something that will affect my pediatrics patients.

not something that will strike my neighbors.

this year, it just didn't rain very much.

rain.

next time you want to curse the rain,

grab a cup of coffee and a good book instead.

because here,

rain is life.

**** the photo is Boule (no idea how to spell it) it is the staple food
of Tchad and made with rice, millet, or a mixture of both. it has a
thick consistency, like congealed gruel and to eat it you pinch it off
and dip it into various sauces. Most families here have this at least
once a day if not every meal.

.festival

Concoct with me the safest situation imaginable.

.every ER doctor's dream

a situation

in which

there is a huge dusty track circling the village square.

in which

heavily decorated horses wearing amulets, wooden jewelry, and headpieces
are racing each other

in which

the horses are drunk

the riders are drunk

riding bareback

and the crowd lining both sides of the track, are drunk.

in which

the dust so thick

you can barely see the horses

until they gallop right past you.

where the dancing

the real drinking

is in the middle of the circle

and the only way to get there

is to dart out in front of the horses

the whole village was there

enjoying

the safest situation imaginable

.sond nasogastric

sond nasogastric  (in french).  or NGT.  or lifeline.

 I never thought I'd be putting in infant feeding tubes but I guess all those harsh nights in the IMCU payed off in some way. 

this baby is Bria Suzanne. 

2 weeks old.

 the first cleft palate I've ever seen that isn't in a textbook.  Medically speaking, she has a unilateral cleft lip cleft palate.

dehydrated, malnourished.

 the parents keep a blanket over her face most of the time.

 she isn't able to breastfeed, not that most mothers breastfeed anyway here.

it is common practice not to feed the baby 3 or 4 days after birth and then give it water.  water from village wells.  water they bathe with.  water that isn't boiled. 

there is a cultural misconception that the colostrum will harm the baby.  Also that babies need water. 

Danae (the OBGYN) will talk until she is blue in the face, "ONLY breast milk. no water."  D'accord.  D'accord.  they will nod and click and cluck.  minutes later, the grandmother is giving it water. 

and round and round we go. 

there are also a startlingly high amount of umbilical hernias here.  One of the volunteers here, Tammy Parker, has actually witnessed a ritual that they do to many of the newborn babies.  The midwife or other will hold their hands in the fire until it is as hot as they can stand it.  Then, they will push as hard as they can all around the umbilicus.  they repeat this until they get the chord off.  no literature that I have seen supports it, but we all surmise here that is the reason that roughly 2 out of 3 children in the village of Bere have umbillican hernias. 

anyway

so.  we get this baby.  and none of the six nurses standing around know how to put in an NGT.  well, if there is one thing I know like the back of my hand, its that.  Finally, something I have done before. 

nurse:  Lay the baby down. 

me:  NO! sit the baby up.  like this (comme ca)

nurse:  no, lay the baby down.

me:  No! comme ca.


so then we establish that laying down is not the optimal position.  fabulous.

her mouth is dry and cracked, so I had the mother expess some milk and gave it little bits with the siringe.   She was swallowing it well so I told the other nurse to do the same while I put the tube down. 

nurse:  What are you doing?  don't do that.

me: NO!! give it milk like this

nurse:  no, we are supposed to give it through the tube.

me: YES! but this will help get the tube down.


and round and round we go.

and the same argument about measurements of the tube.

so finally the tube is in.  after an arguement about how to cut the tape.  i probably should have just given in on that one. 

so then, I explain how we need to listen to it in the stomach. 

I show then how to check for placement with a small air bolus and how we should hear it gurgling.  and how we need 2 other nurses to confirm as well. 

so, instead of doing it like i said, he puts the stethoscope to the abdomen and says "I hear it."  without the air bolus.  those are some great ears. 

and round and round we go. 

and then i wrote out this long thing in french about checking placement before each feeding.

then Marci Anderson, MPH and also a lactation specialist, came in and calculated exactly how much we should feed her.  and i left instructions on that too. 

every 2 hours.  20 ml. 

I hope they feed her.

how sad is it when you work in a hospital where you HOPE  the nurses will wake up to feed a baby. 

but, I actually have great hope for this baby.  She got fed all day today.  She looks better.  Her skin looks better.  She has a strong cry.  We started her on antibiotics for her fever.  Her mother has great milk production.  I think she is going to make it. 

.......

I actually am enjoying Pediatrics.  It challenges me the most.  It is also the most interesting.  and the saddest. 

but.  

bright spot:  I GOT MY FIRST BABY IV TODAY!!!!!  5 months old!!!  the countdown is on.  I'm so excited. 

and really, when else do you get  to see 2 cases of  Burkitt's Lymphoma, 3 cases of measles, meningitis, cerebral malaria, chronic anemia, periorbital cellulitis, and every other presentation of malaria all in one day?? 

.thanksgiving

Thanksgiving was lovely. I loved it. We had such a beautiful,
perfectly wonderful, eat until you throw up American thanksgiving.

there was real, glorious, whipped mashed potatoes. Rolls made with
actual white floor. there was pumpkin pie, lemon pie, pecan pie, white
chocolate chip cookies.

there was ice cold limeade and mango salsa, fresh pineapple, chicken and
gluten and corn and cornbread.

yesterday, i got to hold a real cup of coffee in my hands, and then i
got to drink it. it was that slightly steaming almost burn your tongue
but not quite kind of coffee, with real sugar, real creme.

yesterday, i ate cinnamon pancakes with peanut butter, orange sauce,
guava sauce, chocolate sauce.

basically, yesterday was a culinary miracle.

so I am supremely grateful to all the amazing people that whipped up
chicken out of cucumber seeds, pecan pie out of thin air, and so
graciously donated all their carefully hoarded American treasures.

......

also, I know this blog has been slightly dark and depressing, so here
are some things I am grateful for -

the fact that, in a months time, I will be proud owner and rider of
a tchadian horse

the amazing family I live with

antibiotics

green peppers

Gutenberg, Graham Bell, the Wright brothers

rat poison

friends who are nurses

kimmy

abbie

angie

jessi

mellissa

kelly

clean water

the absence of celery

snail mail

Alaska

mosquito nets

guavas

drinkable water

care packages

dark chocolate

dreams

health

lemon zest

and

life
life
life
life
life

every single second

that i get to live this

life.

.harvesting rice

.free

.wwwwwwwwwwwwwwwwaaaaaaaaaaaaaa

so you've heard about the U-curve, the rut, the end of the honeymoon
when you can't look at your wife without screaming phase.

the phase everyone said happens to people that sail off to Chad.

well, that phase of course wasn't going to apply to me. just like the
airline regulations and pretty much anything in general doesn't apply to me.

so, even though this is going to put a smile on the face of all the
haters, i may just be there.

I'm exhausted. I feel like I have no time. I feel like the 10 months
stretching in front of me are an eternity. I feel discouraged.

and most of all....i feel like i'm not making a difference.

but, of course, you tell me, you ARE making a difference. you touch
lives every day. blah blah blah. just a smile can change the world.

and yes, i do espouse that theory. I do believe one person can change
the world. I do believe in the one idea. the one stranger. the one
helping hand.

i do believe in the tiny rock that starts a ripple effect. and yes, I
do believe that the world can be changed one person at a time, on tiny
act at a time. I believe that

changing a life changes the world. I believe that one good deed can
make a life worth living.

If i didn't believe that i wouldn't be here.

if I didn't believe that I wouldn't have given up everything to be here.

If I didn't believe that I wouldn't stay here.

But for me, for the people that really believe that, for the people that
wander the earth hoping to change something for the better in their
wake, for them, for us, when we feel like we aren't accomplishing the
one idea we staked our life on, then well, you have the rut.

today is 2 months.

I spend my days arguing in broken french. i spend my days being laughed
at.

news flash.

suggesting that you should actually document when you give a medicine
isn't a comical joke.
suggesting that medications should be carefully explained before the
patients leave isn't a cause for mirth.
suggesting that a medication that is stopped, one that is ongoing and
one that is started should not be jammed up together in one box and
documented with a single X is not a roll your eyes moment.

so, every morning, I ask for the papers (each patient has one paper) and
I say I want to "learn" (which, i do) and then I go patient to patient.
I look at the medicines in their box. I look at what was actually
prescribed. I look at what was actually given. 9 times out of 10, they
don't match up. too much of one medication, none of the other, did they
not buy it? look at the receipt, no, they bought it, well, did you take
it, oh we took it yesterday, no one wrote anything, no one documented
it. If i find one time dose medications just hanging out, i'll give
those. if i find 3 medicines all jammed up together, i'll make a new
paper.

i feel like a spend all day arguing about documentation. or not
argueing, per say, but insisting that things be wrote differently, or etc.

and i also feel like thats not my place really, not the best way to make
friends and get respected, not the best way to make my debut. But i am
just doing my best to try to document medications. novel concept.

but then, they all got their meds before I got here. somehow. they all
were treated and went home and may or may not have been okay. is being
so nit picky actually helping the patients? or is it making me feel like
I am helping them? I don't know.

and I've been really sick, well, aggressive flu-like symptoms minus the
fever kind of sick and had this really aweful incredably itchy started
from nothing dark purple bright red skin thing spreading all over my
legs and feet and ankles. i threw every parasite med in the book at it
and today is my second day of doxy and i think its getting better, but
its still frightening.

i had myself developing osteomylitis, cellulitis, being airlifted back
to America. of course, now i feel foolish because today i'm better.
its easy to be cavalier about life until its our own.

and i was so weak on sunday I tried to do my laundry and i was just
sitting there with the bar of soap in my hand and started crying because
i felt like i literally didn't have the stregth to wash my clothes,
which is my favorite thing.

and its all glorious until you have to sleep with rats. or, rather,
until you have to be awake with rats because they scratching and
scuttering prevents sleep.

it was just a rough week i think.

and i keep telling myself, the measure of a man is not what he
does/thinks/says in times of ease and sunshine, but in times of
adversity. but repeating that to myself made me even more depressed
because I wasn't handling it in such a brave and noble manner.

is it selfish to want to make a difference? I think it may be. which
may be the reason i'm in a rut because I don't feel like I am.

i came here so i could be a better person, so it looks like I better
stay a while longer.

cheers!!!

you know you're in.......

you know your in chad when.....
   
      you thank God for big mosquito bites because its probably not Anopheles

when.....

    your family conveniently forgets to tell you they built a new latrine behind a garden of corn because the old one was broken.  you use the old one and fall in.

when.....
   
    being able to kill cockroaches unafraid is on your bucket list

when....

    you find out several kilometers too late that your moto taxi driver just may be functionally intoxicated and you just hold on and hope for the best the remaining 20 km.

when....

     every other child that shakes your hand has ringworm

when....

    you feel that spending 30 cents was really too much money and try to argue it down to 20 cents

when....

    the thanksgiving turkey is going to be a goat

when.....

    the headlights on your motorcycle is actually your headlamp

when....

    it's illegal to ride 3 persons on a motorcycle, but ten people crouched on the roof of a careening vehicle is perfectly acceptable.

when....

    you get sent back home because you were riding your horse without a passport.

when....

    the second you start congratulating yourself on that fact that your new chambre doesn't have cockroaches, you realize a rat lives there.

when....
 
    you have to get poison for said rat on the sly because too many people were poisoning each other, making it now illegal.

when....

    you wish you had malaria because at least then you would know what was wrong with you.

when.....

    you show the bizarre skin infection that appeared on your ankles and quickly spread to the only non OB doctor and he laughs and says "you should probably get that looked at."

when....

    you actually see a case of measles

when....

    7 pm is really getting past your bedtime

when...

    the 12 year old picks up something you can't carry and puts it on her head

when....

    1 try out of 10, you can actually get into your email

when....

    a box containing anything packaged, processed, colored, or otherwise genetically modified sends you into hysterical shrieks of happiness

when....

    the nurses are reprimanded during worship for drinking wine concealed in juice boxes during their shift.

when....

    everyone around you is eating crickets (I ate one!!! took me 10 minutes and a wide range of sound effects and facial contortions)

when....
    
    washing clothes by hand is cathartic

when....

    your sitting in the dirt writing this. 





   

.go

to dream
to challenge
to go
to journey
to face fear and wrap it around as a cloak
to walk with it and push through the gravel to wonder
to a wrinkled face to a stranger whose every dream is crinkled like a fan outside the eyelids
 to capture the dusty coat
 the one eye,
 the barefoot,
 the dog lover,
 the misty-eyed angel
 warriors of the road -
 forever immortal, infamous, inglorious, the forgotten -
yet who lived among a spirit
 a feeling
to have shared and been a player in that wanderlust that will forever endure
 to have been a part of that song
 part of that twang 
 to have left your light tread on the uncharted waters -
the footprint before a frothing wave
 to know and feel solidarity with those other souls who threaded the miles alone
 part of an age
 of a generation
of a  tribe that spans centuries
 to look at that same gypsy moon
to know that others danced and etched their blood on the walls of that cave to the glow of the spectral embers
to sit where others sat
  so insignificant, so unobtrusive, like a dancing feather or pondering ant
 like a small quiet pebble or the splash of a fish
 here one moment....no one remembers your name....
 the road, did it matter?
 but it did. it does.
 in that moment.
  it did to dream,
to know that other dreamers have left home with stars in their eyes and hunger as their lantern
 to see a canyon or stand on a rock in the dashing sea
pilgrim voyager gypsy charleton gravestone bleached pile of glorious bones hippie bohemian evangelist artist savant entrepreneur rubber tramp leather tramp road warrior motorcycle king tourist anthropologist archeologist seeker seeker wanderer tumble weed
 to belong to the pioneer
 to tumble into the void -
 to see and touch and wrap your heart around all things human.
 human
 human
 when your down and tired and fading light and crumpled bills and linty coins and laundromat and old magazine and dirty newspapers cling to tattood brick
 to see a face a smile a person
 to hear their story
 to marvel at a laugh
 to share a look a meal
 a sardonic wink
 to find that pair of eyes and you know at once the things they have seen because you have seen the too
 strangers and you know you know they know
  why your backpack is your soul
 to leave love
 to leave comfort
 to walk into the arms of terror
to rise to meet suffering
 to open your eyes unblinking to ugliness
 to love beauty
 to crave it to starve for it
 to seek it
to welcome questions
the fog
the corner
forever cursed
forever blessed
always to wander
always to wonder
to go
go,
 why does that word
 2 letters
 1 syllable
how has it  mercilessly held such corrosive  and creative power,
 how has it shaped kingdoms and colonies and fiefdoms
 how has it created heroes and villains
 how it is fodder and fire for every ballad and every dirge
 how has it broken homes and liberated captives.
 the urge
the dream
 the itch
 the need
the fire
 to explore
 to seek
 what up Columbus
 Sacajawea you were one tough chick -
Japhy Ryder and Jesse James
Jane Eyre and Elizabeth Bennet
 Eminem and Joan Jett-
 to change to challenge
 to see
 the bering sea
the english moors
the african plains
 to the one who sailed to see if the earth was round
 who died in a bus
 or froze in the artic
 to all who lived an idea
who layed realism and cultural and societal trappings on the line
 to all those who dared
to all those who climbed
when they could not see the mountain
 to Daniel to David Korn
 to Doom who went to Hawaii
 to the flamboyant tourist
to the photographer 
to the captain
to the motorcycle
 to the covered wagon
to the prospector
to the cowboy
to the missionary
to the pirate
 to all those who decided to march frantic and insane
to jump off cliffs
to dive in murky waters
to trade the substantial for the hoped for
to trade the answers for questions
to trade the walls for sky
to trade the roof for stars
to trade the routine for the challenge
to trade the buried dream for the final journey
for all those who listened
who heard
who answered
who followed
the pied piper
of the word called go.
 . 

ideas?

either this baby was born this way....

or he had peanut oil poured all over him....

or he was born this way and then had peanut oil poured all over him....

.....

he does not have eye lashes or eyebrows....
his eyes do not fully shut or fully blink....

(Abbie, this looks like the rare disease you presented in class....what
was it called??

welcome to Chad.

welcome to chad.
the place the world forgot.
the place that no one knows about and no one comes.
the place that no one writes about and few can read.
the place you go because you care.
the place that teaches you not to care anymore.
the place that makes men.
and then breaks them.
welcome to chad.
the place the world forgot
the place where BBC fact profile statistics are living, breathing,
dying people.
welcome to the world.
the place we are immune to statistics.
the place where haunting memoirs and photos entertain but do not move
us.
welcome to the world.
where everyone scrambles for solace and soul.
where others problems cannot be our own or we will go insane.
the place where prozac is nessesary to truly watch the news
the place its easier to forget.
welcome to chad
the place the world forgot
. the place without anything anyone wants.
the place where people make a $1.00 a day
the place where 500 ml of IVF is $2.00.
the place where there is no oxygen
welcome to Chad
the place the world forgot.

.who are you

here, you have nothing. Stripped down, facial nudity. No where to hide
and no where to break down.

here, there is no makeup to look out from. There is no media,
entertainment, or music to distract you from what you are and who you are.

here, there is no mirror to look in, yet here is the harshest of mirrors.

Who are you, when you are hungry?

Who are you, when hunger is all around you?

Who are you, when you are covered in bugbites and nondescript rashes and
are always caked in dirt no matter how many times you bath?

Who are you, when you feel your body breaking down? when you have fungus
between your toes and dirt in your eyes?

Who are you, when your chest and face are covered with oozing breaky
open fly bites?

Who are you, when with one hand you are eating and the other waving away
insects?

Who are you, when cockroaches are your co-inhabitants every night?

Who are you, when everyone asks you for your water bottle, your
headscarf, your headlamp.

Who are you, when you say no.

Who are you, when you see a boy covered with 3rd degree burns because
his mother poured boiling water all over him?

Who are you, when you shake that mother's hand.

Who are you, when you assess a child on rounds and he dies 5 minutes later.

Who are you, to think you should come here.

Who are you, to be in Chad?

Who are you, if you don't stay......

.Inshallah

The Christians here say it is up to God whether someone lives or dies.
In fact, almost everyone here does. Why did the baby die in the middle
of the night. Inshalla. Its God's will. They will shake a mother and
say sternly, "stop crying. it is God's will."

Why did the Arab man die after the prostectomy? It was God's will.
Why did 4 children and 2 babies die in one night? It was God's will.

Why, why why? it was God's will.

Is it God's will that you don't give your medicines?
Is it God's will that you don't assess you patients?
Is it God's will that you feel like sleeping and not taking vital signs?
Is it God's will that you don't check on your patients?

I don't think it's Gods will.
I think you didn't do your job.

Stop crying. Your baby died because it was God's will.

....

Nothing is an emergency here. One thing I value about American medicine
is that everything is an emergency. Anything that is either affecting
or endangering someone's life is an emergency. Although many times
futile and expensive, we aid, abet, prolong, and fight for life.

Who can put a value on life? Is it better to live for 10 minutes than
to never live at all? Is it better to open your eyes and blink them and
look at the world and feel your mother's skin and experience the
sensation of air filling your lungs, to see the colors and the faces, or
to never have opened and blinked and looked and felt and experienced and
seen at all?

Is it easier for a mother to lose her baby after 5 minutes or after 14
hours? Is it easier to have had that time, or is it harder?

Its easy to judge here. Its easy to think no one cares. Its easy to
say the nurses don't care. Its easy to say the families don't care.
Its hard to be culturally competent when this culture seems so incompetent.

You have to get people to give blood here. Even if their relative,
husband, child is dying. They still have to be begged, cajoled,
threatened. Even then, sometimes they don't. Its easy to think they
don't care.

Mother's often don't hold their babies here. After birth, they often
hand it to the grandmother, then turn and face the wall. Its easy to
think they don't care.

Someone may be brought in hemorrhaging, or may have been in labor 20
hours. Then, right after they get here, their families may take them
away. They will die if they leave, and they leave anyway. Its easy to
say they don't care.

The nurses don't assess their patients here. There is little energy
spent on those who are dying. Its easy to say they don't care.

and i know that they must care. I know they must cry. I know they must
love their babies. I know they must love their families. I know they
must want the best for their patients.

I will be the first to day I absolutely don't understand this culture.
I am not being impartial. I am being judgmental. Do I have a right to be?

.....

its not up to God and its not up to Allah.

Its up to me and its up to you.

its up to you to get oxygen in this hospital. Its up to you to get
better nurses. its up to me to be better. Its up to me to care even
when no one around me seems to. Its up to me to work harder. Its up to
you to work harder.

and maybe they would have died anyway. but why did they have to die
here, in t chad, with nobody to fight for them.

America, don't ever stop fighting for life.

.....(a few days ago, in the delivery room....waiting and breathing,
waiting and writing)

"This baby is dying right now. I've revived it 5 or 6 times. By
revival I mean CPR. Because I'm an expert in infant cpr.....It was born
4 1/2 hours ago. 2 months premature. 1.7 kg. She is so cute. Her
heart keeps stopping. I am doing CPR and someone is moving my operation
over, looking for a lost pen. A door slams, nurses walk in and out,
laughing, talking, watching. She came in 3 cm dilated already. By the
time the family bought the cefedipine (*** wrong spelling, desole, we
don't give Salbutamol here because the nurses can't be trusted to take
BP's), she was 4. She delivered 45 minutes later. She didn't make a
sound. No epidural. No nothing.

I should be breathing for it right now, but its against the skin and
they are laying down, the baby and the mother, facing each other, and I
think that's more important.

I don't want her to have 5 hours, i want her to have a lifetime. Its
not fair. Its not fair that this is her 4rth premature infant. Its not
fair that all the others died. Its not fair that she has never had a
baby except in utero. It is not fair there isn't a NICU team swarming
her right now. Its not fair that there isn't any oxygen. Its not fair
that if she was born almost anywhere other than here, she would have
made it.

There is a difference between seeing suffering and seeing preventable
suffering. Preventable suffering stabs a little more. Its the kind
that keeps you up at night and gets you up in the morning. The very
word preventable denotes personal involvement, responsibility. If
something is preventable, it can be prevented. If it can be prevented,
why isn't anyone preventing it? If no one is preventing it, why aren't you?

She is holding it skin to skin like I taught her. She loves it. I see
a tear on her cheek. I wonder how much babies know. I wonder how much
they see with their wise little eyes. I know its going to die, but I
keep hoping it will live. Maybe she just needs one more breath. What
if I stop before that one more? Maybe just one more round of CPR.
that's all. maybe. maybe. maybe. Live. LIve. LIve.

The infant mortality rate in Chad isn't just a number. It isn't just 1
in 8 births and 1 in 5 children. Its a real baby. with perfect blue
eyes that's try to cry. that's fighting for every single breath. its a
baby that would live anywhere else."

14 hours later, she died.

I wonder if the power to be incensed by injustice and suffering belongs
mostly to the young. To the ones who are freshly exposed to it. To
view horror for what it really is. Maybe we are the ones who should be
taken seriously after all. Age and sage and ad finem jade. That
doesn't change anything.

It is the tragedy of this life that vision is given to the young, but
power to the wise. Why can't the dreamers be 58 year old portly balding
hedge funders with more than enough money to buy the will of God.

Inshallah. I don't think so.

+++ Inshallah is my very poorly writ and most likely improperly spelled
version of the Arabic expression, If God wills it.

.boring but relevant

so i realized i haven't written anything too informative. so here
is some information.

I live in a small room on the end of a mud house. In Chad, most
families have compounds. Most compounds including mine contain a well,
hopefully a tree, clotheslines, a place to cook, a place to dump trash,
and maybe another house. The houses are mostly constructed out of mud
bricks. Most compounds also have a multitude of ducks, chickens, dogs,
and goats always scratching and running around.

My compound is about 15-20 minutes walk from the hospital. I walk down
a narrow packed earth path that winds through other compounds, corn
fields, cows, pigs, children, and trash. Once I enter my coumpound,
there is a lovely mango tree on the left. to the right is the 3 room
family's house (hut) with a metal roof and adjoining that at a 90 degree
angle is my room. I have a metal roof and metal doors and it is usually
15-20 degrees hotter inside and my glasses fog up when I enter. they
did however, give me the best room (i recently found this out) because
there's doesn't have cement floors and they have rats. (hence the
reason we are moving soon)) there is a kitchen outside in front of the
house opposite my room and there are woven mats held upright by sticks
that shelter the kitchen area.

there are these woven metal basket things that they fill with coal and
cook on. or 3 rocks placed at angles with sticks underneath and a pot
on top. I cooked soup once and it took me 2 hours and i was so
exhausted at the end. but they still magicaly always have hot food for
me no matter when i get home.

the family eats boule (spelling incorrect i'm sure) which is made of
rice and millet and it is like a thick cuttable pudding consistency.
when its fresh it is actually really good. they wash their hands and
just dip into it with the fingers of your right hand and then dip in
into a communal pot of sauce. the sauce is usually fish or goat meat or
chicken or tomoto or made of a green leaf called legume?? i actually
like boule but since i'm vegetarian they have decided to cook macaroni.
For almost every meal. the macaroni is exactly what you would imagine
macaroni to be and it is seasoned with tomatoe powder and copious
copious amounts of oil. I try to eat it but its getting difficult.

for breakfast...breakfast is my favorite. I usually get beans and rice
(beans = blackeyed peas) (also drenched in oil) or a starchy sweat
potato boiled and served with tomato sauce. Sometimes I get rice also
with scrambled eyes on top.

I am definately not starving but entirely grateful for the multivitamins
I brought. they also serve me heaping heaping portions of everything.
literally enough to feed a family of 4. so i usually eat for 2 and
leave 2 in the bowel. i try very hard. they said because i am big my
stomach is also so i need more food than everyone else. when i say our
stomach is the same size they laugh as if its the funniest thing they
have ever heard. so, so much for coming back from Chad skinny and
wonderful looking......

there are 6 kids in the family, ranging from 2 to 12, a 14 year old
niece that lives with us. 2 grandmothers, Bikaou, the mother, is a
midwife or "sage femme" in French. Teskrio works in
"urgence" the tchadian emergency room. they are lovely and intelligent
people and i am so glad to live with them. there is also the neighbor
that lives next to the grandmothers with 3 kids also.

i'm tired of writing about my surroundings but perhaps will add more
later.......

.beautiful things

.there are beautiful things here

like the way the wind moves over the rice fields and the shimmer of
the black and the green and the warm mud oozing between barefoot toes.

like the way the moon is brighter here. more luminous, milky,
ferocious. like the way the shadows move and the drums beat low in
your eardrums and how your headlamp illuminates a flash of pig and a
stalk of corn or the white eyes of strolling lovers. like the way the
mango leaves are dark and cut circles around the brightest stars i have
ever seen.

like the way the children dance. beneath the tiger moon. the way they
love reggae and we have mini raves on the woven mats after the work is
done. how we blink my light and wave it and dip and flash flash and
noodle arms and pounding feet and chanting "stop, can you hear the
sound...a little bit of riddim makes the world go round." (Michael
Franti and Spearhead - they LOVE it)

like the way they fall asleep on the mats. one by one, the littlest
first and then like falling dominoes, they all curl up and sleep until
we drag them inside. like the way there are 2 grandmere's and they tell
stories in the night and fan themselves topless under the naked moon.
and how we drinking steaming tea by moonscape and add heaping powdery
spoons of milk powder and how i have never tasted anything better in my
whole life.

like riding a moto and throwing your arms out like your flying and your
face cracks from the wind and from smiling and how they are laughing as
i pass but i don't care because i'm in Chad and i'm flying.

like sitting under the mango trees with Teskreo (my Chadian father)
having our language lessons. and how he can't stop laughing when i
speak really fast. or the look on his face when he understands what I
said. like the brightest whitest face crunching smile i have ever seen
when he says, "now that you are here, i can speak, i can learn to speak
the English." and how he carefully carries his "compact" (laptop) to
the hospital every day to charge it and how excited he is about learning
to hook up his external drive. like how he has shortened "how are you"
to "how." so i wake up in the morning, or I pass him in the hospital
and he says, "Janna, How?"

like how at breakfast he started singing, humming low, "the answer, my
friend, is blowing in the wind, the answer is blowing in the wind." and
how I almost teared up because it was Bob Dylan, because it was Africa,
because he knew it, because here, it could not to more relevant. and
how i ran and got my IPOD and we spent the rest of breakfast jamming to
Blowing in the Wind, Forever Young, Shelter from the storm. and how we
couldn't stop smiling and how he said, "Bob Dylan, he is my friend."
there is something so sacred about hearing music like that in a place
like this.

like how the 2 year old, Arnou, finally knows my name. and how he will
say, "Anna, I dive! Anna, I dive! (translation, Janna, High Five!) and
how all the kids are all high fiving now. and how we read french Dr.
Suess at night and the giving tree and how we all love to read.

and how the sky is grey and wild and the trees will whip and twist
before the rain and how you can feel the rain in your bones before it
dashes against your skin and how the chickens scatter and the leaves
slap your cheeks and how the bright colored clothes are snatched from
the line and the mats dragged in with the speed of light and how the
rain kisses the earth in giant splatters and how the air is cool and
fresh and breathable and alive. and how it sounds at night, on my tin
room, and how I love to just listen to the rain.

like how a baby is born, and it lives.

or someone gets better.

like how the spices are heaped up in huge wooden bowls and how they are
orange and brown and the black green of the tea and the red of the
millet and the white of the maize and the greens and yellow of the
pepper and the fresh gatos sizzling in shallow vats of oil and how the
fabric is everywhere, hanging and purples and pinks and sunset and
rainbow and garden of colors and how the fabric is on the head and on
the hips and on the racks and on the children and how the flies are
buzzing around the meat and the purple rods of sugarcane and buying a
fanta from the only frigerator in the market and tripping over sheep and
the stacks of candle colored soap squares and the peanuts, the heaps and
heaps of peanuts, (arachides) and the little plastic bags of peanut
butter and the coiled brown dried fish and the plastic flip flops and
strings of blue and red beads and the harsh and the sweet of the
languages bouncing off your eardrums and how the market........

like how there are beautiful things here.

. strictly nursing

Imagine a hospital in which......

there are no saline flushes

there is no tegaderm

there are no caps for the IV tubing.

there are no gloves to start IVs

the same tournaquit is used over and over

and it is a glove.

in which....

the medicines are in a box under the bed

the patients have to buy their own medicines

and the IV tubing

and each syringe for each medication

the IV pole is whatever you can find.

where medication administration is encouraged, but not enforced

and you have to look for your patient, to give them the medicine.

where if they have no IV, to spare expense, you inject it straight into
the vein

in which....

IVF, maintenance or otherwise, is not given unless in an emergency, or
the family can pay for it.....or they REALLY need it.

where there really aren't many emergencies

where people die during the night...and no one knows why

where night shift is 16-18 hours.

by headlamp

2 sets of vitals

double the patients

and double the meds.

in which.....

vitals are only taken Q12, if at all

where no initial assessments are performed

where report is a sentence or two

where no one knows a thorough baseline for their patient.

where there are no curtains

and little privacy

in which.....

everything is in French.

imagine you are a nurse at....Bere.

*** disclaimer**** this hospital does a vast amt. of good, i have only
observed for 3 weeks, prenatal care here is improving, many lives are
saved through surgery, the hospital itself is a blessing to the
community.....the doctors do an excellent job.....the nursing
however....is just....different.

.here!!....

so. not much time. sketch to no internet access.

chad.

today i saw a baby who fell in the fire. his arm and hand was twisted
and contracted and his fingers arched back.

last night I spent about an hour sitting rigid tense upright as i
watched a cockroach crawl all over my bug net tent and then slowly die
from the permethrin.

i keep a cockroach stick in my room, have everything sealed, and scream
regularly.

My family feeds me delicious beans and rice for breakfast and then
pasta every other meal. they are treating me special because no one
else gets pasta. I try to finish it.

when i am late coming home, my tchadian grandmere looks for me.

it is nice to nap under the mango trees.

i have finally learned the names of the kids in my family.

i taught them leapfrog.

and they now have a thing for Dr. seuss in french.

my feet have 4+ pitting edema most days.

I am priviledged to be here.

.stress

so, there is a distinct possibility I may be arrested when I return
to the US.

It turns out, that tags expire on cars every year. Who knew

and, you can receive a court date for that. who knew.

AND, that once given an October court date (although having spun my
whole, I won't be in the country in October lie),
the officer has 6 WEEKS to turn it in.

So, I am not in anyone's computer system. No court clerk can find my
court date, and therefore there is no way to dispute it before I leave.

Also, it turns out, that its a bad idea to lose your court date
slip.....because now I can't hire a lawyer to show up on that date......

so, i have just resigned myself to the fact that when I return from my
endeavors, the police may be waiting with open arms.........

.........
there is so much more involved to leaving the country than I ever imagined.

extra passport pictures, backing up files and pictures, buying unlocked
phones and converters,

figuring out how to take everything within luggage requirements,
figuring out how much money i need, getting that money into

crisp $100.00 bills, sorting and packing and giving things to the
goodwill, closing this account and that account, POA's and advance
directives,

and my first attempt at a will (consisting mostly of my funeral
playlist...i can't help it), getting that notarized, packing medical
supplies, saying goodbye to everyone, this is just a small list off the
top of my head that is literally just a sliver of all I have to do.

and I'm not complaining - I'm glad to go, this is just my first
immersion into the adult sphere of paperwork and red tape, and I wonder
why I wanted to grow up so fast.

........

I have also learned that there are high expectations pinned on my
arrival because I am their only volunteer with hospital experience.

this knowledge makes me so anxious and I can't stop thinking about what
I can do and how I can act so I don't let them down.

Sure, I have worked in a hospital for the last 2 years, but I have no
experience starting IV's, I do not know French, I know only minimal
information about pediatrics and OB, and tropical medicine.

I am suddenly wishing I had payed more attention in my classes, actually
learned the language, and oh possibly studied up on their common
diseases more.

and, i have received the impression that they want me to help increase
the standard of nursing care.

That terrifies me, considering my gameplan was to arrive with humility
and my objective was to learn.

but:

I am going to try to set measurable goals for my self.

like,

3 moths in - working knowledge of French and work on my own
6 months in - acheive competence at working on my own.
9 moths in - have researched and planned ways to improve standard of care
12 months in - have implemented several changes in the nursing
department that increases pt. care.

so, i'm sure all this worrying will be obsolete soon as the challenges
will be much different than I can imagine, but I am pretty much feeling
as unprepared as one could ever be.

.you will

this is a letter we received from the Md's that run the hospital.

"Mostly, I would like for you to tell them all the worst things about
life here:

You will see immense suffering that you can do nothing about here, which
would be easily treated in the states.

You will hold babies and adults while they draw their last breaths. You
will have fallen in love with many of them beforehand.

You will spend months in a sweltering hut, unable to escape the heat and
the sweat.

You will be hungry most days, fighting with a bunch of little kids twice
a day for scraps of unappetizing food.

You will work long hours.

You will be asked to do construction, maintenance, plumbing, childcare,
English teaching, computer work, filing, sorting, inventory, pharmacy
work, OR work, etc.... probably all in the same week. It will often be
menial and boring.

You will need to be flexible and roll with the punches.

You will need to be able to laugh at yourself.

You will need to be outgoing.

You will need to be independent.

You will need to understand that there are no hand holders here to get
you through hard times.

You will get sick as a dog...initially fearing for your life...then
fearing you'll survive.

You will vomit.

You will have pain, both physical and emotional.

pretty much, just be honest.

.risks

~ this is one of my favorite bits of prose, one of the things that gives me faith in the end of a rainbow. It became my favorite poem about 5 years ago when it was being read at the end of the very first video from the hospital founders asking for help and encouragement. At that second, at the end of that video, hearing this poem, I decided I had to go. not to just any place, but that I had to go there. to chad. since that moment i never wanted to start anywhere else.



RISKS

To laugh is to risk appearing the fool,
To weep is to risk being called sentimental.
To reach out to another is to risk involvement.
To expose feelings is to risk showing your true self.
To place your ideas and your dreams before the crowd is to risk being called naive.
To love is to risk not being loved in return,
To live is to risk dying,
To hope is to risk despair,
To try is to risk failure

But risks must be taken, because the greatest risk in life is to risk nothing.
The person who risks nothing, does nothing, has nothing, is nothing, and becomes nothing.
He may avoid suffering and sorrow, but he simply cannot learn, feel, change, grow or love.
Chained by his certitude, he is a slave; he has forfeited his freedom.
Only the person who risks is truly free.

Often attributed to the poet and thinker, Leo Buscaglia, the real author of this inspirational verse is Janet Rand.

.facts

Excerpt from BBC News: Chad country profile.

http://news.bbc.co.uk/2/hi/africa/country_profiles/1068700.stm#facts

• Full name:The Republic of Chad
• Population: 11.5 million (UN, 2010)
• Capital: N'Djamena
• Area: 1.28 million sq km (495,800 sq miles)
• Major languages: French, Arabic
• Major religions: Islam, Christianity
• Life expectancy: 49 years (men), 51 years (women) (UN)
• Monetary unit: 1 CFA (Communaute Financiere Africaine) franc = 100 centimes
• Main exports: Cotton, oil, livestock, textiles
• GNI per capita: US $610 (World Bank, 2009)
• Internet domain: .td
• International dialling code: +235

###

"Tchad by the Numbers"

~ Stolen directly from www.missionarydoctors.blogspot.com.

(does "citing" it thusly forgive me for the plagiarism? its just so interesting....)


0- Physicians per 1,000 people (2.2 per 100,000, compared to Washington DC with 752 per 100,000)

1- Ranking on Transparency International’s list of most corrupt countries in 2005.

1- Number of TV stations in the country (government-operated).

1- Number of movie theaters in the country.

2- Ranking on Fund for Peace’s list of most failed states in 2010. (We lost to Somalia. Again.)

2- Percent of pregnancies resulting in the death of the mother (compared to 0.001% in Ireland), most world-wide.
2- Number of flights/day to get out of the country (one to Paris, one to Addis Ababa).

5- Number of Internet hosts, 225th in the world.

8- Number of paved runways in the country (46 unpaved).

8- Percent of population with HIV (18th in the world).

9- Percent of women who die while pregnant or within six weeks of delivery (compared to 0.02% in Ireland).

10- Percent of population who read well enough to use it to earn a living.

11- Number of radio stations (2 AM, 4 FM, 5 short wave).

12.4- Percent of infants who die at childbirth (compared to 0.2% in Singapore) (190th out of 195).

21- Percent of children who die before the age of five (compared to 0.39% in Iceland).

40- Percent of children suffering from chronic malnutrition.

65- Percent of population living on less than $1/day.

80- Percent of population living below the poverty line.

80- Percent of population relying on livestock and subsistence farming for survival.

105- Degrees for an average high in April (76 is the average low).

120- Number of distinct languages in the country. Distinct means one village can’t understand the next.

171- Ranking (out of 177) on UN Human Development Index.

267- Kilometers of paved roads (33,400 unpaved).

13,000- Number of phone lines in the country, 199th in the world.

40,000,000,000- Dollars required to give basic health/education to the world without it.

1,200,000,000,000- Dollars allocated to the military by the US for 2011.