.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