August 28
August 29th, 2008 Posted in Uncategorized | No Comments »28 August 2008
FAQs
I depart Cameroon on September 1st and arrive in Kigali, Rwanda on September 2nd. Shyira clinic is a 3-4 hour drive from Kigali, outside of Ruhengeri. They tell me the only internet access is on top of a hill and unreliable at best, so this may be the last blog for a while.
I thought I’d close my time in Cameroon by answering a few questions my future-dentist-brother (hi Philip!) sent me at the beginning of my trip:
Q. So where are you and Mbong (and how do you say a silent “mmmm” sound?) staying now?
A. In the hostel/rest house. Along with having a few rooms dedicated full-time to the optometry students, this the main housing for visiting medical students, doctors, researchers (there is a very successful Burkitt’s lymphoma treatment program), and some missionaries. The walls are thin, and my first week here I kept thinking people talking outside were right here in the room with me. The floors are concrete, and all in all it’s a bit drab, but Mbong and I had some fun decorating by making collages with the airplane magazines. Definetely better than the 20 year old calender-pictures that were encrusted to the wall!
Q. How are the toilet and laundry facilities?
A. Didn’t have hot water for the first few weeks. Toilet is fine. Laundry means hand-wash and line-dry outside. When the weather has been thunder-stormy (as happens here often in the rainy season), we had clothes strewn all over our room for a few days to dry. I enjoy the line-drying-thing, although I had to get used to my clothes smelling like all the hospital linens (same soap, yuck!). After one particular load with a certain orange-skirt (ahem, Mbong) we both had quite a few “newly” peach/orange colored socks etc.
Q.How do you get around most of the time? Bus? Car? Bike?
A. Most of the time I don’t, since I live right next to the hospital – very similar to a college dorm. When I go into Bamenda, the nearest biggish city that is a 30-45minute drive, I catch a ride with a hospital vehicle or cram into a taxi (see photo album for answer to the question “How many people can fit into a taxi?”)
Q. What’s the typical diet?
A. Fu-fu and N’jama-jama are eaten with the thumb and first three fingers of your dominant hand. Fu-fu is made from ground-up corn, and N’jama-jama is a dark-green leafy vegetable (full of vitamin K and why, incidently, the surgeons here have to use crazy amount of anticoagulant before their surgeries). Bananas and plantanes are abundant, and peanuts are the snack-food-of-choice that every child carries around on their head in a large tray to sell for the equivalent of 5cents per bag. Fried fish with onions and pepe (a VERY hot spice) is another meal option that I love. And of course there is abundant pineapple, guava, popo (like mango but in the rainy season), and other fruits I haven’t yet learned to identify. Sounds exotic to write it, but really it’s everyday life for the people here. They laugh at my “fruit excitement.”
Q. Have you met any biting insects yet?
A. Nothing exciting. Just a few mosquitos. Yay for malaria-prophylaxis (although I’ve been told that Mbingo is at an altitude that does not get many mosquitoes).
Q.What’s the frequency of diseases seen compared to the US?
A. All I have is personal anecdotes from my two months here, which is hardly a randomized-controlled-trial or statistical-report, but according to the WHO there’s a lot of malaria, TB, and HIV/AIDS. Mortality is still due mostly to diarrheal diseases among other things.
Q. Do you get a lot of the typical US problems like diabetes or HTN?
A. Yes and yes. Mbingo JUST last week got the machine to determine Hemoglobin-A1C, without which it is almost impossible to track diabetes. (Dr.Palmer says that trying to follow diabetes without an A1C is like following HIV without a CD4 count.) As for high blood pressure, I have switched quite a few patients off of their calcium-channel-blocker (Nifedipine) to the current recommendations of HCTZ and an ACE-I, both cheap here. As far as inpatient HTN is concerned, many times the nurse will call me over to report a BP of 160/90 as being vitally concerning. I have watched Dr.Palmer explain numerous times that HTN is a chronic disease 99% of the time and an isolated high blood pressure does not constitute an emergency. But they still call me over.
Q. Do you see more protozoal-type diseases?
A. Umm…I can’t say. E.histolytica comes back from many of the stool-exams I send to the lab (Flagyl (Metronidazole) for 10 days), but I really can’t comment on anything else. Although there may be a patient in female ward right now with Elephantiasis…but that’s a bit different.
Q. How’s the paperwork, comparatively?
A. WONDERFUL! Surgery notes are about the same length as in the US (vitals stable, afebrile, good urine output, abdoment soft, incision clean.). My medicine notes are the longest of anyone’s, and they really don’t go beyond a few paragraphs. Everything I write down is mostly for communication with other doctors. As far as charts are concerned, there are none. The patient carries around a little book that all the doctors write down complaints and meds (and occasionally a diagnosis or lab result, if I’m lucky). Many patients will have a different book for each clinic or hospital they’ve visited, and they’ll only bring the one book to each appointment, making it very difficult to track past medical history. Occasionally (like with Lilian, my pt with schizophrenia) I have written a “physician’s discharge note” in their book to increase the likelihood of good followup; oftentimes I’ll recommend what the doctor at the next visit will do. For instance, if Lilian develops extrapyramidal side-effects of Haldol, will the next doctor be able to recognize them, much less know how to treat them?
Q. What’s the most common language there? (Your e-mail suggested language wasn’t much of a barrier to communication.)
A. Cameroon has ten provinces, 8 are French speaking and Mbingo is in one of the two English-speaking provinces. Most people speak “Pidgin English.” Evidently at some universities or schools, there are “no Pidgin allowed” signs but I haven’t seen any yet. It’s amazing how I can take a fairly comprehensive patient history with just a few phrases. When Cameroonians ask me if I’ve learned pidgin yet, I share with them my few hospital-phrases (see previous blog) and they all start to nod and laugh and altogether seem to find it quite humerous.
Posted by Mary at 5:13 PM 0 comments 
24 August 2008
The phrasing’s the thing
Some people here call me “white-man.” For example, in the market: “hello white man,” “white man come look at this,” or “white-man come marry me.” My response, if I’m not ignoring them, is to turn and say “White-WOman, white-WOman” which will inevitably bring some rousing laughter and leave them laughingly discussing it while I have slipped away.
Mbong was frequently referred to as “black-white-man-girl,” since she looks like the people here but talks like someone from the U.S.
Descriptions took a bit of adjusting to at first, as well. People are not afraid to call someone “Fat here,” but unlike in the U.S. it’s not usually meant as a derogatory term. Rather, like “white-man,” it is a descriptor. For instance, they might refer to “that fat woman over there” or that “fat-fat-man in B ward.” Many people here actually see being “Fat” as desirable. Although when they talk about some of the Americans they have seen on T.V. that are ‘fat-fat,’ I do detect an element of humor in their voices.
Once I saw the wife and daughterof one of the surgery-residents walking by. As I knew both of them, I said “good evening, cherie cocoas, two beautiful women together!” They both laughed but the mother quickly said, “no just one” as she pointed to her daughter. I know that she attends the aerobics class and “is not reducing” (according to her husband who rounds with me in female ward), and was disturbed by her response a bit because it reminded me of the way so many women (myself included) respond to comments about beauty and weight back home. I hope that Cameroon will be able to encourage a more healthy perspective on these things, but am afraid that this commonly-struggled-with-issue is present in some forms, even here.
Posted by Mary at 6:48 AM 1 comments
For anyone interested in the physical therapy side of things here, check out Mbong’s blog at Mbong.easyjournal.com. Here’s an excerpt (unrelated to PT, but amusing):
“…As mentioned previously, language is extremely important to the people here and now that I have ‘mastered’ the basic greetings in a few different dialects shows them I care. The ‘name calling’ is all in good fun, Africans can be very blunt at times, particularly the ones in the more rural areas, so if you are fat they’ll let you know or if you are white they’ll be sure to remind you.
Earlier this week I mentioned to a coworker that I would like to learn the Kom dialect. “You know what would be the best way for you to learn to language?” my coworker asked. When I suggested that maybe reading the bible translated in Kom would be helpful, he responded with a very serious and emphatic: “no. You need to marry a Kom man.” No pressure. Right…”
Mbong had many propositions while she was here, which we had quite a few laughs over (not that she would be propositioned, but the way they would do it). I had a couple market encounters myself: “Kate, come and marry me” or “Kate let me give you this ring so I can marry you.” (Someone told me that some men call all white women Kate here, anyone know why?). I decided to take my friend Bree’s advice and answer sarcastically. so far the response that gets the most laughs is “I have nine husbands already, but would you like to be #10?” Thanks, Bree!
Posted by Mary at 6:43 AM 2 comments
“We are not alone…”
On a hike a few weeks ago, we stumbled upon some unexpected visitors and Mbong commented rather omminisely: “We are not alone…”
She wasn’t talking about the waterfall, either… (I decided NOT to capture on film the various sized brown-clumps littering the entire hillside). She then proceeded to teach me the difference between cow-pies, horse-poop, and goat droppings. Begs the question - where did SHE learn all this? I still don’t know…
After treking for a few minutes, we found some of “the culprits”…
Posted by Mary at 6:29 AM 0 comments
Lilian (discovering mental illness in Cameroon)
“Eeeeeiiioooeeeeee!” Wailing reached my ears just as I turned to walk out of the outpatient department. The source, a young woman bending over to hold her left leg as she shuffled to a seat, looked to be in much pain. As a new arrival, she had a long wait ahead of her in the clinic’s first-come-first-served no-appointment policy. Her wailing continued and, as I turned to watch, the man accompanying her tried half-heartedly to quiet her. There was little effect and he soon quit trying altogether.
Curiously concerned, I continued to watch. In the middle of a bout of hysterical sobbing, the woman suddenly burst into loud laughter, causing the few remaining heads not looking in her direction to turn and blatantly stare. Soon the laughter subsided and she began to mutter a few phrases over-and-over: “Have mercy on my soul, have mercy on my soul…” Eyes welling with tears, she then began again to cry, this time silently.
Deciding to take advantage of her temporary stillness, I sat down next to her companion and began to get her story. Her name was Lilian, and the man who had accompanied her here to the hospital was her junior brother, Roland. How long has her foot been paining her? “For one week.” What happened? “It just started swelling one day…” I sped through the usual questions and then finally asked the question I’d been yearning to ask – have you noticed her behaving differently or oddly? “Umm, yes yes,” Roland responded, eagerly and hesitatingly at the same time. “She acts very strangely. Sometimes she walks around the house, touching things and talking.” Does she ever talk to people who aren’t there? “Yes, yes!” he answered emphatically, “she talks to people that we don’t see. It is very strange…”
Just then, Lilian jumped up, wailing hysterically, and ran out of the waiting area. Roland and I followed and found her out by the front of the hospital. Lifting up her dress, she was pointing to her groin and saying “Wound! Wound! I have a wound!” Her brother, looking embarrassed, told her very sternly to “put your dress down and be quiet.” After a few minutes I was able to convince Lilian to come with me into an examination room, where I got more of her history from her and her brother.
She had been “acting strangely” for the past month. Although the family was very embarrassed by her behavior, if it hadn’t been for her foot swelling up they would not have brought her to the hospital. She had acted like this about four months before. After being at a different hospital for three days, however, her mother (who is separated from her father) came and took her out of the hospital against medical advice. Lilian herself wanted me to know she had HIV. Roland then told me that although she had tested negative a few years ago, she had lately begun expressing her desire to have the deadly and stigmatized virus. Lilian’s father, also present, wanted me to know that “it’s her wickedness, doctor, her wickedness that is causing this. She talks of old things, terrible things, and is wicked.”
That was a long story, I know, but I wanted to “show” instead of “tell” how the experience of identifying mental illness is more similar to that in the U.S. than I expected. Of course there are cultural differences in the ways it manifests and the “screening” questions to use. I won’t get into the discussion about the difference between “mental illness” and “spiritual illness” (though I’ve enjoyed having such discussions with various chaplains here) except to say that Lilian fits the clinical presentation, diagnostic criteria, and age-group for the onset of schizophrenia. After two weeks on Haldol (one of the two antipsychotic drugs available here), she stopped hearing voices, her emotional lability resolved, she stopped accusing her father and brother of being “demons,” and she began talking and smiling “normally.” It is amazing what adjusting the dopamine levels in someone’s brain can do! Too little dopamine equals Parkinson’s disease; too much, and people tend, like Lilian, to begin showing signs of psychosis (hallucinations, delusions, bizarre behavior, emotional lability, etc.).
In addition to watching her slowly improve and getting to know her (as opposed to her illness), one of the highlights of Lilian’s two-week stay in female ward was meeting Reverend Ndongnde. My first week here, a few people told me I ought to go and talk to him about his interest in mental illness. I never did, however, getting caught up in the everyday hustle-and-bustle of the busy wards. Now that Lilian arrived, however, I began seeing his daily notes on the chart: “stopped by, patient asleep, reviewed chart and recommend psychotherapy and possible family meeting in the future,” or “Patient seen and denying auditory hallucinations at this time, family meeting scheduled for Monday…” One day I caught him in the act: “So YOU’re the one who’s been writing these wonderful notes!” I said exhurberantly. “Doctor, doctor” he said, shaking my hand vigourously, “at last we meet, I am glad to work with you…I was hoping you would come to the family meeting, as you are the expert…” I couldn’t help but notice how he reminded me of my psychiatrist-father, that is if my father was a mildly plumpish African man of medium-height dressed in a suit and tie (Cameroonians like to dress up). I answered that I would love to come to the family meeting, but that I was sure he is more of an expert than I and in either case he could explain things to them in their own language which is more important than anything else I would do.
Walking into his office with the family, my eyes were immediately drawn to the large and small versions of the DSM-IV lying on his coffee-table (the manual of psychiatric diagnoses according to the American Psychiatric Association) along-side a book entitled “Schizophrenia: what a family needs to know.” His slightly cluttered bookshelves were filled with volumes on everything from psychotherapeutic techniques to “family counseling from a Christian perspective,” “how to teach counseling,” and “Boundaries” by Cloud and Townsend. For the next hour, I sat trying to hide my delight at the entire situation (as the topic under discussion was, for the family, an understandably sober matter). Rev. Ndongnde described, in Pidgin, the four different types of Schizophrenia (disorganized, atypical, catatonic, paranoid). The family began nodding in agreement as he described people with the “paranoid” subtype : “they di get suspicious plenty plenty of everybody, for example they go for say that their chop (“food”) it be poison, or they di say that people they bi following them…” etc etc. The family all agreed that Lilian sounded most like the paranoid type. The father and step-mother speculated that perhaps her biological mother had some paranoid behaviors as well (i.e. pulling her out of the hospital, or jumping from country-doctor to country-doctor), giving us a perfect opportunity to explain how commonly schizophrenia runs in families. Rev Ndongnde emphasized that, although some people have speculated in the past that schizophrenia was made worse by unstable family situations, people do not think that very much anymore and that they should not think that this is Lilian’s, her mother’s, or any of their own faults. The relief on their faces were evident. Her father shared how he appreciated learning about the disease (in general people are good at giving positive feedback, when sincere, here) and that it wasn’t anyone’s fault or the family’s fault that she is this way.
Rev. Ndongnde has quite a few patients come to his office on a monthly basis for what he calls “psychotherapy” or “psychoeducation.” He occasionally will have a psychology student from the US or UK come to spend a month with him, and he is enthusiastic about having visiting psychiatrists come and teach. All in all, this is one of the most exciting discoveries I have made here in Cameroon – an inroad into the subset of people who are interested in and intrinsically motivated to take care of the mentally ilil. Of course this is no easy-matter, especially when even in the U.S. the mentally ill are still frequently a marginalized community. At the same time, it would be interesting to see how, in this “culture of hospitality” where taking care of family is one of the greatest moral values, the communities may react to the possibility of effectively carrying for these people.
(As a sidenote, from these two months in Cameroon I am now 99% certain and committed to a combined residency in Family Medicine & Psychiatry. Were I to practice soley in the U.S. I would be completely content to be a practicing psychiatrist. However, because I would like to practice possibly full-time in the developing world, I see the benefits of encouraging development of a mental health treatment program from within an already established primary-care infrastructure. That and I am finding how much I enjoy treating diabetes, hypertension, snake bites, and HIV all in one day.)
Postscript: Before leaving, I am hoping to spend a few hours with a psychiatrist in Bamenda, yet another connection thanks to the wonderful Ngong family (Mbong’s relatives that have adopted me as their own). I also hope to visit a psychiatric hospital in the capital city of Yaounde.
Posted by Mary at 5:54 AM 0 comments
Stubborn Courage
After-dark taxi rides in Cameroon are uncomfortable at best, terrifying at worst. Even when I trust the driver, he knows the road well and both headlights are fully functioning, I still find myself praying the entire time, analyzing why-after-all life is so important to me, and with every passing vehicle reaffirming my own complete readiness to die at any moment. My first such trip occurred two weeks ago, when I found myself transferring taxis at a smaller town (“Bambouy”) on the way back to Mbingo. It was light when I arrived, but as the driver wanted to wait until the car was full before taking off, it was more than an hour and finishing-twilight by the time we took off. The driver seemed to be looking everywhere BUT at the road with visibly growing distraction and frustration at one of the passengers who was continuously yelling at him for making him late. When I expressed my concern aloud, one of the women crammed into the backseat agreed with me said “Ashiah driver, look to the front please, Ashiah.” Earlier her and I had looked after eachothers belongings while waiting to take off, and now we struck up a conversation…
As it turns out, she is a special-education teacher who trained who Nigeria for two years before coming back to her home-country of Cameroon to start a school for disabled children. She has been working and teaching there more than 10 years now, has fifteen disabled children under her care, and runs a school for 71-kids integrating the deaf and blind children with non-disabled children (part of her educational philosophy). “You see in our culture,” she explained, “if a parent cannot care for their children then another relative can be counted on to take them in and raise them on their own. Sometimes when a child is disabled, however, the parents and family abandon them… you see I’m a Christian, and I believe all people are valuable. I went to Nigeria to learn about why and how people get to be this way, and how they can be helped…by integrating the disabled with the non-disabled, it allows those with disabilites to come-to-terms with it at an early-age while still feeling valued, while teaching the non-disabled about these things so they can then grow up and make good laws.”
Many people after talking to me for only five minutes ask me for my phone number or email, and I have developed various ways of declining. In this case, however, I asked the woman (“Susan”) for hers. As the man in the front seat continued to yell at the still-nervous driver, she wrote her name and email on the paper and said “Oh doctor, I would love for you to come visit me and see the school. You would be very welcome…” The only day available for me to go ended up being two days later on Sunday afternoon. I took a young friend with me (because she is always bored and I told her there would be free lunch – free food is a universally effective bribe I am coming to suspect) and we trekked two hours to Belo.
Walking into her house, I immediately felt at home. The walls were covered with pictures of children, family, and a large map of Africa. In particular my eyes were drawn to two large paintings of children with tears coming out of their eyes, one a boy and one a girl. When I asked her if there was any special meaning, she said: “Oh yes. My first daughter, when she was five, saw this picture in a shop one day and, when she heard about how children in Ethiopia were starving, said “Mommy, we should cook them some fu-fu and visit them tomorrow!” Laughing, Susan told me how she had to explain that, even if they were to leave tomorrow, the food would be spoiled by the time they reached Ethiopia. She bought the picture for her daughter, however, as a reminder and ever since that day her daughter decided to dedicate her life to helping these poor children. A few years after her son was born, he asked where his picture was – and so the second picture of the crying little boy was purchased.
That was the beginning of her story, she said. It was later that she began learning about the deaf children in Camaroon and went to study in Nigeria for two years to learn about disabilities and special education.
By the time she returned to Cameroon, she already knew a few children that were disabled. When no church would help support her school, she started teaching the children on her front porch. One day a woman walked by and wanted to know what she was doing. Upon hearing, she asked “do you know where you would build a school if you could?” Susan already had a piece of land in mind. The woman, who had some connections, went to the government and a few years later the school was built!
In addition to knowing brail and sign-language and becoming an expert on special education, Susan also, with her husband, has taught classes on church-planting and mission strategies. Anyone who has ever experienced this will know what I mean when I say that she is one of those people who I have to know for only thirty-minutes before discovering that we are “kindred spirits” and good friends.
We visited the grounds of the school, with Susan moving from room to room excitedly pointing out the floor-to-ceiling piles of brail-Bibles and books that had been donated, the bulletin boards covered in chalk drawings depicting various math formulas or ASL sign-meanings, and the cluster of bananas the children had accidently left in the corner. Those of you who know sign-language can interpret her “signs” in the pictures below. I didn’t get to meet many of the children as most of them were on holiday (those whose families had abandoned them staying with volunteer families), but back at her house we had watched a video of the fifth graduating class as they recited poems, verses, and stories. At this school even the hearing-children learn sign-language (ASL) so they can communicate with those who are deaf. One older boy I did meet, I don’t remember his name but he was 20 years old, wore dark-sunglasses, and when he heard Susan’s voice he darted out of the store-hut he was keeping guard in to greet her and me. I was amazed at how good his right-hand-shake aim was and admit it took me a few minutes to realize he was blind. “One of my first students,” Susan said as we walked away.
Susan has all sorts of plans: “Over here,” she said, gesturing to an open-space of land, “is where I want the hospital to be someday. Or a treatment center for mental illness” she said, winking at me. 
“Mostly what we need now are people to come and help teach the children sign-language or brail as well as bring supplies.” Earlier she had showed me a brail typewriter and expressed how she would like every blind child to have one. For the moment what she needs most are supplies, and people to come and help her and her fellow teachers teach. “We love short-termers, especially if they know ALS or brail, but anyone who wants to come is welcome.” When I asked how she had gotten this far already, she said, “God. And God-given stubborn-courage.”
Postscript:
If anyone has any connections to brail-typewriters – let me know! I will be keeping in touch with Susan and am curious to see what God will do with this connection.
