The first two weeks back in the U.S. have been filled with awe and novelty, and a sense of deep dissatisfaction.   After enjoying Botswana and safari, we spent two full days of driving and flying to return to our home.  The airport was filled with so many people and once we finally stepped outside, my eyes could barely adjust to all of the shiny new cars.  How strange to see so many paved roads.  How strange we have a paved road all the way to our house.   We have a paved driveway.   A good friend picked us up at the airport and was surprised how intact we were.  I felt happy.  We live in a nice house with no termite mounds inside or outside.  It’s roomy and clean.  Our bedroom does not have a mosquito net and our bed is the most comfortable place either one of us has ever slept in a long time.

Past experiences have taught me that I need time to adjust to the western wastefulness, so I had 5 days off before having to return to work, to slowly rediscover stores, abundance, and the comparable self-entitlement of the general population.  My first day back at work seemed easy enough.  I only had seven patients.  After having a ward of 50+, then outpatients and then some additional patients on another ward (either ARV clinic or TB ward), I wondered how hard seeing seven (seven!) patients could possibly be.  My first patient was a very elderly lady; she had a significant memory deficit.   I was struck by how fragile she was.  The women of Zambia do the majority of the hard labor; their hands are heavily calloused to the wrist almost like leather.  Their skin is thick and shiny, even the extremely dilapidated are constantly oiled and cleaned by their sisters and daughters.  I was also struck that no family member was tucked under her bed to make sure she was OK.  This woman looked like she might disintegrate, covered with huge bruises from one day of transport by EMT and several attempts at placing IVs.  We discussed her food preferences for five minutes.  I found it difficult to act natural.  She called me “nurse” the entire conversation, regardless of my clarification that I am, in fact, a “doctor.”

The next patient is well known to the ward, she comes for admission to the hospital when her home life becomes difficult (under the pretext of “disease exacerbation”).  She has loud, public arguments with her husband on speaker phone.  As far as we’ve been able to tell, her actual disease process has been stable for years.  Her psychiatric state, however, is as predictable as New England weather.   She greeted me at the door of her room with a big open armed hug.  I thought about how uncomfortable that usually makes me, but being constantly around people took away the awkwardness.  This patient started off by giving me a thick coat of compliments.  She then explained that regular IVs fall out of her arms and she would need an invasive 30 centimeter IV to get intravenous pain medication.  Considering the dubiousness of her actual admission diagnosis, I refused to order the procedure.  She then proceeded to call me a bad and unsympathetic doctor, and yell at me at the top of her lungs while forcing tears out of her eyes about the myriad of her perceived hardships.  I called a psychiatry consult for her.

I then called Mark for me.   I asked Mark if I had chosen this work, if I was going to survive seeing another five patients, if I was an OK human being.  He was helpful.

Riled up by the experience, I proceeded to a particularly feared room among the staff, where a 20-year-old woman who had willingly injected herself (including a hearty dose of bacteria) was recovering from her infection.  She was angry that her visitation privileges were curtailed after she almost died from previously injecting herself – on purpose – while in the hospital.  She didn’t feel that she could be in the hospital for six weeks without the support of her “friends.”  I understood her well, but couldn’t take the risk of introducing more drugs with her visitors.  We talked for a full 30 minutes, arguing in circles.  She told me she would leave if she didn’t have visitors.  I had to call risk management.  A letter was written and after a short e-mail exchange, our security staff took on the responsibility to present behavioral contracts to the patient.  More tears shed, more names yelled, more virtual undressing of my character.  I watched her worn teeth gnashing at me while I explained the lethality of her condition; she explained that she would rather die than not see her friends for the next few weeks.   I breathed deep through this one.

I moved on to another patient.  The family insisted on calling me “Dear” and “Hun” with every sentence and informed me that “no one was running the show” and a big meeting of all the doctors was required immediately to sort things out.  I did my best to get in touch with their outpatient specialist.  The specialist came in the afternoon, ushered me into an unoccupied room and gave me a private, and personal, verbal beating for the terrible job I have been doing for the past week.   The defense of “I was in Africa” (i.e. not in the country and thus, not taking care of the patient) did nothing to thwart her anger since we have a very important patient on our hands and I really had better get my act together.

The rest of my patients were very old and very confused.  Their families didn’t want to take them home because they are a hardship around the house, yet the families demand chemotherapy for highly advanced cancers, request aggressive treatment for infections, and call for resuscitation of their major organs if those failed.  These unfortunate and unknowing seniors are facing the precipice of death, and the families don’t know what to do so they demand the works.  I felt sad after my day, leaving 11 hours after I came.  Instead of one doctor and one nurse for 30 to 50 patients, we have 3 doctors and 5 nurses to 20 patients and many seem completely dissatisfied with their care.

Two weeks passed, I worked every day and for the first time ever, I felt some bitterness of my job.  My knowledge and hard work arrive like waves on rocky shores, sometimes unwelcomed and rejected.  I turn to my backyard garden and running to clear the bitterness from my soul.   The nurses are surprised to see me riled by the patients; I usually take it all in stride.  I try to reset the clock by working in the urgent care clinic.  Patients are appreciative and I feel rewarded, happy.  Then towards the end of the day a man attempts to fake a prescription for a pain medication on a script I write him.

Macha and its mission hospital seem further away from here than just the two to three days of travel required to get there, but day by day "here" is feeling more like home.

Leaving Macha

Today is the day that we left Macha and departed for Livingstone, Zambia, for a visit to nearby Victoria Falls in the coming days.  We made arrangements to travel to Choma, some 70km away from Macha via the Malaria Research Institute’s vehicle on Wednesday morning at 6am.  Depending on how many people or how much equipment needs to be transported, they take a different vehicle.  Today, we would be taking the very large flat-bed truck to Choma.  Anna managed to get situated behind another few people inside the cab designed for three people.  I was in the back with another gentleman, both of us sitting on a crude wooden bench nestled up against the very front of the 4 meter-long truck bed.  Our other “bed mates” were car parts: wheels with suspension linkages still attached, a bumper, and other parts from what looked to be a Toyota pickup.  I was not looking forward to a particularly comfortable voyage, but it seems that this was the mode of long-distance motorized transport for the vast majority of Zambians (of course not counting the significant, 100km+ journeys regularly made via foot and bicycle of the hospital patients).


Anna contemplates taking the last seat in the cab or one in the flatbed

We started along the dirt road at a reasonable pace until we got to the edge of town.  Then my bench-mate informed me that the car parts were from the recent tragic accident in which four people from the Malaria Institute were killed, stunning the entire village.  The car parts were in transit to the insurance appraiser.  Once outside the village limits, our rate of travel increased to what I would consider “breakneck.”  Given the fact that there were the remnants of another fatal accident right in front of us, I was admittedly a little nervous for the voyage, especially since we were traveling at well over 100km/hour on loose, sandy roads.  In fact, I was imagining the various ways how things might end if we careened off the road or encountered a herd of cattle or goats around a blind corner.  The more immediate travel issue though was the constant jarring of the potholes and jumping of all of the car parts in the back of the truck.  We slowed for the most severe rough patches in the road, and I quickly learned to dread any time the driver applied the brake.  About 40km of “improved jeep trail” lent another air of hardiness to the locals, who regularly take this into Choma.  Dang, they are tough stock!


Flatbed contents: two humans, luggage and car parts

We did of course survive the journey, and it gave me a true appreciations for how remote Macha actually is.  We arrived after two flat tires under cover of darkness, but now the Zambian countryside was illuminated the entire way.  In short, Macha is “about an hour from the middle of nowhere.”  John did mention how Macha came to be way out in the bush, but there is no other town or large village for many kilometers in every direction.  There are simply small villages of three to five clay or brick huts with thatched roofs.  There is the occasional school and church alongside the road, with students pouring in for their morning lessons.  After several weeks with semi-regular electricity, mostly running water and a corrugated roofed brick duplex to stay in, I lost my appreciation for just where we were: a small village in the remote bush of Zambia.


After 30 minutes of driving, the remoteness of Macha really sets in


Not shown: white knuckles

About halfway towards Choma, the road incredibly turns to pavement, one of the few paved roads in Zambia.  While this meant ever increasing rate of travel, the road was smooth and we quickly zipped into Choma.  So many houses!  Look at the stores!  Where did all of these cars come from?  We were stopped at a police checkpoint for having too many people in the cab of the truck – but no mention of the people sitting on the edge of the flatbed – and were issued a ticket.  The irony was not lost on us as numerous other pickups and flatbeds zipped by with their beds overflowing with passengers.


Once in Choma, we are stopped by the poilce who promptly issue our vehicle a ticket

Dropped off at the bus stop, we purchased our tickets to Livingstone and could stretch our legs (and many other sore parts) after the first leg of our journey.  We had a little time before the coach bus came, so I took a stroll around town to pick up some provisions.  We found incredible bananas from a young street vendor and I found the Spar Supermarket.  By usual Western standards, this was a small market.  But the amount of choice just in the cracker section was mind boggling.  I did not heed the warnings that going home would require adjustments, and my reaction surprised me when faced with 12 different flavors, sizes and shapes of crackers: I couldn’t make a decision!  With some simple crackers and a candy bar (!) in hand, I returned to the bus stop.

We patiently waited for the coach bus to arrive and gawked at all of the hustle and bustle.  Choma is the largest town and trading center for quite a ways and this all plays out in front of you on the street.  People are often seen piloting enormous wheelbarrows with 200kg of corn meal, car parts, furniture, farm equipment or a combination of these.  Street vendors sell anything they can get their hands on from bananas to cell phones to hack saws to leather belts.  It felt like the Canal Street of Zambia.


We have exchanged the remoteness of Macha for the bustle of Choma

The large, full-size coach bus arrived and we hopped on board after putting our large packs underneath in the cargo hold.  There was a lot of activity putting in large sacks of cornmeal, tools, machinery and more, and thankfully our luggage successfully made it with us for the entire journey without getting stuck between oily engine parts.  We boarded the bus and it was incredibly comfortable.  We felt truly spoiled with our own comfortable seats, a nice view of the Zambian countryside, and only a couple of stops between Choma and Livingstone.  Once underway, we noticed the televisions on the bus were showing terrible kung-fu movies which we thoroughly enjoyed.  The time ticked by and soon we were approaching Livingstone on the potholed detour from the main road through Zambia.


Once on the comfortable coach bus, we are treated to kung-fu

We had to fight through a throng of cabbies all clamoring for our fare to meet our ride to the lodge where we stayed in Livingstone for the night before heading down for a brief safari in Botswana.  We kicked off our shoes, took a constantly-warm-temperature shower, put on our cleanest clothes and sat by the pool with a cold Mosi-Oa Tunya (“The Smoke that Thunders”, the national Zambian maize-based brew named after Victoria Falls) and couldn’t believe the extent we were pampering ourselves.

It was a busy week for both of us here in Macha.  Anna saw about 100 patients per day with a few very challenging cases and I was tied up with the pharmacy, although not in creating an inventory control system as I had hoped.  I turned into more of a computer helpdesk kind of guy as their computers were plagued with computer viruses, spyware and malware from months of people dropping in and using them for miscellaneous internet browsing.  Needless to say, I am now schooled up in unified threat management, although didn't make much progress towards automating the inventory tracking.

We did, however, make some headway towards our premeditated plans of creating a package of information to pass along to others who are considering a trip to Macha to ease the travel and preparedness factor.  Needless to say, there are some great opportunities to get involved with some groundbreaking work at the hospital.  There are opportunities for statistics people, computer folks, medical, nursing and more with some incredible opportunities coming up with HIV/AIDS research and treatment.

More posts are in the works but for now we'll leave you with some pictures.


Without a city for a few hundred km, the night sky here is like no other
410F1810lg.jpg (1.12 MB) - large version required to really appreciate it!



Fresh maize, okra and basil were conveniently growing behind our house


Porch interloper seeking a sympathy snack



Neighborhood alarm clock that rings at 6:00, 6:03, 6:05, 6:09...



Rainbow and cows, what more can you ask for?



A passing storm makes for a spectacular sunset

About to run off to the new ART Clinic building to do an assessment of their electrical and network systems for a future solar backup installation.  But for those wondering about our setup to work remotely, here is a brief rundown of what we carried halfway around the world:

Equipment of Note

• 1 Sony Vaio Laptop
• 1 Sony Vaio Laptop (old one, as a backup)
• Multiple power adapters (Europe, UK/Africa), though converters not necessary since power supplies are multi-voltage
• 2 Wireless USB adapters (in case our internal notebook wireless adapters weren't up to the task)
• 2 Wireless routers (MSI and Rosewill), each with 4-port hub built in to ease networking the two laptops
  
• Various network cables
• Trusty wireless mouse
  

Software of Note

• Standard development suite installed/configured on both machines
• RingCentral Voice-over-IP (VOIP) call controller
• Skype
• Subversion version control / file sharing client (to connect to svn repositories in our data center at home)
• Outlook (to connect/sync with Exchange server, and thus Blackberry, hosted by Rackspace)
• Variety of web browsers
• Cisco VPN client, which has held up well even on lossy connections

Things have been working reasonably well as far as connectivity and electricity.  The village has made a lot of progress in wireless coverage in the past two years when they first started to have internet connectivity via a microwave line-of-sight link.  And they have reliable GSM network coverage via the Zain network. Not bad!


Seating by Herman-Miller

The feeling of packing up before a trip to the known unknown is great exercise.  Weight and cubic inch restraints artificially limit the number of “needed items” one can have and thus is both less and more stressful.   The experience of my past visit to Macha helped to decrease the number of items to 3 skirts, 3 shirts, 2 different weight sweaters, one pair of earrings, and 2 pairs of shoes for the month.  The rest of my bag was stuffed with medications and supplies that didn’t fit into the box of medical supplies given to me by REMEDY and a couple very kind people.  Once finally packed, I paced through the house trying to clean in the minutes before the scheduled taxi arrived.   Dressed as if I were going for a photo-shoot for the LL Bean catalog, I dashed out of the house carrying my 40lb box of medical supplies, followed by a 40lb bag of my travelling gear and more medical supplies, an a 20lb carry-on bag with “just in case my actual bag gets lost” as the unsympathetic taxi driver watched.  Twenty minutes late and not particularly enthusiastic, my driver deposited me with 10 minutes to ponder the landscape along 101 overlooking Mill Valley.   Several women were dropped off by more exotic automobiles, well dressed and well cared for, eyeing our well-experienced moving box (this will be its fifth and final move) with fleeting curiosity as we awaited the bus.  The 1-hour bus ride to the airport was uneventful, as was the 2-hour wait in the airport, highlighted by a personal search prompted by my otoscope.  

The actual closing of the distance gap started with a prayer-inducing, very turbulent plane ride to Paris.  The highlight, in addition to my survival to landing, was watching a 3 hour movie about the life and death of Gandhi.  Very inspiring and motivational for me to both do great work and read more about Gandhi.   I once again was searched intensely for both explosives and other weapons, after which a nice bag x-ray operator emphatically pointed to the otoscope stashed in my bag, mildly disappointed to see the unimpressive instrument in real life.  After several hours spent reading David Sedaris, I was joined in Paris airport by Mark.  We boarded an almost empty plane to Johannesburg, grateful for several hours of sleep in 3 seats each.   In the Johannesburg airport, we perused stores, ate at a café, re-checked Mark’s luggage and took a bus to an airplane to Livingstone where our adventures would really start.

In Livingstone, the almost open-air airport was equipped to handle maybe 5 flights per day with 2 pleasant and very relaxed visa and passport workers at the counter and only 1 luggage conveyer belt.  With the proper visas and shockingly enough, all of our luggage in tow, we were stopped by a nice man who wanted to know what was in “the box” and our freakishly large travel bags.  I handed him a short list of medications and encouraged him to look into the box, only if he had tape.  Another nice woman worker came, they discussed the box, the list, looked over me and my invitation from Macha Mission hospital and agreed to not open the box since they didn’t have tape and Macha was really far away.  Next we were assailed by taxi driver representatives acting as professional middle-men who introduced us to several potential matches, instructed us how to take out money and told to wait for “our guy Frank.”  After almost an hour of trying to be as relaxed as the locals, we insisted on getting another guy and were quickly shuffled into a cab and whisked toward town.  


The van getting ready for another half-dozen passengers.

In Zambia, virtually every transaction is a team effort.  Almost nothing happens without someone knowing someone who knows someone.  We drove around town stopping by stores, street corners and visiting other people in search of a SIM card for our GSM phone. Finally we found someone who had a stash of SIM cards in his backpack, the official telecom shop being out of stock.  Then we drove around looking for a bus to take us up to Choma.  This was where our cabbie was extremely helpful and brought us by every transportation option on the market.  The coach bus had left and he warned us of the process of getting a shared van, so we went to check the trucks leaving for Lusaka.  Our cabby was pretty irritated when a potential driver of an empty truck asked to charge us 400,000 kwacha (about $80USD) for a trip that was on his way.  Instead, we paid a bargain 100,000 kwacha to stuff ourselves and our belongings in a mini-van bus along with 7 other people, waiting almost 2 hours to sufficiently fill the small van to overcapacity of 17 people, for the bumpiest 190 kilometers of our lives.   In addition to spending half the voyage on the wrong side of the road passing large trucks, the voyage was punctuated by additional stops at the roadside to fill the van with gas, pick up and discharge passengers, have local vendors offer their goods and other stops just to say hi to friends.  We arrived in Choma well cramped but thankful for making it at all.


Negotiating cab fare

The final leg of the voyage from Choma to Macha used to be the most broken down dirt road I have ever seen outside of a BMX dirt jumping course, but has recently been partially leveled and paved by a Chinese company.  We were surrounded and hustled into a taxi who agreed to take us for a “fair price.” Two nice gentlemen put our oversized luggage and a spare tire in the back and we were off to make better time than expected.   Unlike most cabbies in other parts of the world (including our van driver), the young man driving was slow and cautious.  To save fuel, he would frequently turn off the ignition and coast along any level or slight downhill. His driving companion entertained us and asked us many questions.  After a while, the car began to rumble and shake.  Could it have been a loose tie rod?  The answer came in the form of a gunshot sound and this was flat tire number one.  We proceeded at 20km/hr after this, but still flatted the replacement tire only minutes later after getting onto the portion of road that had not yet been paved which resembled a jeep trail.  By this point, the sun had set and we decided to try out our new Zambian phone.  The adventure finally ended when the medical director John and his wife Esther came to our rescue about 1 hour after we called.  Our taxi friends stayed behind to sleep with their downed vehicle, with friends coming from Choma with a spare tire in the morning.


Flat tire numero uno

We arrived in Macha at about 10:00pm very thankful that our journey had, at long last, come to an end.

Spent the weekend at Cyclocross Worlds in Tabor, Czech Republic.  Our Elite Men had some solid performances with Tim Johnson in 14th and Jamie Driscoll in 19th.  The staff and mechanics did a fantastic job all weekend and kept everything working like clockwork.  A special thanks to Ken, Els, Marc, Geoff, The Fox and the exceptional crew of mechanics: Davy, Stu, Troy, Mark, Dusty, Franky and Giacmo.


Els (USA Cycling Soigneur) prepares for the start of the Elite Women's race.



New England local Richard Fries was one of the announcers at Cyclocross Worlds, which was surreal.  It made it feel just like a 'cross race at home.  Richard definitely brought the excitement level up among the Czech and Belgian fans.

Tomorrow, We begin our journey to Macha, Zambia (via Cyclocross Worlds in Tabor, Czech Republic for Mark).


(Map courtesy Vayama.com)