Yesterday was a good reminder of the importance of the work that is being done here, as well as a testament to the people who continue to carry it out. I helped surgically debride (clean) the severe bed sores of a 15 year old boy who fell out of a mango tree and is now paralyzed below the waist. Think for a moment of an American teen boy in that situation - you can imagine the frustration, the anger, the energy in a now broken body…but in that situation every effort would be made to teach the boy and his family self care and independent skills. He would have special equipment, physical therapy, etc. Now think of a teenage boy not only facing a future of paralysis, but also of no mobility or independence at all. This boy came to Macha after being “cared for” in another hospital and then for a short time at home. His well-intentioned family does not know how to care for him and he had been laying in a bed in basically the same position since the accident. It was a sobering reminder that although I now get to go home to a life of great comfort, the need, and the mission, go on here. At Macha Mission Hospital this boy’s wounds will be tended, his family will be educated as much as possible. An effort will be made to provide him with a wheelchair…and his quality of life will improve. It was a good reminder.

And today was a good send-off. We had beautiful weather…and it was a good day at the hospital. There were lots of good wishes and friendly good-byes. I was so happy to have as one of my last patients a spry woman in her 70s who stands out as one of my favorite people I have seen in clinic. I saw her 1 month ago and today she returned for her monthly check-up and med refill. She has a great sense of humor and a great energy -talks a mile a minute and fills the room with her frequent laughter. When she saw me she called out, “My friend! Ah! My friend!” and came to sit at my station. I had several patients like that, just good patients to have on the last day.

But I think one of the Zambian docs summarized it best. He asked how my time here has been, overall. I answered, “it has been an amazing experience.” He replied with a smile, “but you are happy to go home. I know that feeling…something just  calls you home.”

Yes, indeed…an amazing experience…but I am also happy to be headed home!

I may post from Livingstone, but we will see how internet access issues pan out. In any case I will post when I am safely home, and after I get settled in I hope to upload some pictures to this blog. Thanks for being a part of this important experience in my life!

Today we had ward rounds and a nurse was helping me wash my hands between patients. You have to understand that the water that comes from the tap in most places of the hospital is unfiltered and therefore potentially contaminated with bacteria, parasites, etc from the water from the dam. For physicians to wash their hands between patients the nurses set up a little stand on wheels with a basin, soap, and a container of filtered water. To wash you dip out water and pour it over your hands into the basin which is hard to do on one’s own, so sometimes a nurse or someone will help by pouring the water. Anyway, the woman who was helping me was actually a nursing student, a younger woman probably in her early 20’s. I was complimenting her on the wisdom of having a day to honor all women (thinking that our version, Mother’s Day, is geared toward one category of women) when the young woman was interrupted in the midst of agreeing with me by the “in charge” nurse. This older woman, the “madam” as I hear her students calling her, told the girl, “what do you know of it? You are not a woman yet!” I had to laugh inside because here, as most places, the line between a being a “girl” versus a woman is very much in the eyes of the beholder :-).

Victory! The internet is still working this evening so I get a chance to tell you my story. I think it really highlights how the funny, beautiful, and sad aspects of life can be so rolled up together here…and it certainly illustrates the courtesy and generosity I have found so prevalent among the Zambian people.

Last month I examined a young man in clinic – he was thin but otherwise looked well and had a particularly friendly smile. He looked about 11 years old and was there with his taller sister who seemed more shy but greeted me politely in Tonga. When I put my stethoscope to his chest instead of the expected “lub dub” of a healthy boy’s heart I heard a dramatic whooshing sound and felt the palpable heave against his chest wall as his heart fought to move blood. This boy has rheumatic heart disease – because he did not get antibiotics during a case of strep throat during early childhood a valve in his heart was severely damaged. The heart is an amazingly adaptable pump, but it cannot withstand the mechanical strain of that injury for the span of a normal life. Although he is actually 17 years old, his frame is as slight as a boy much younger, and without surgical intervention that is not available in Zambia his heart will most likely fail at a young age. He comes every month for an injection of antibiotics that helps prevent bacteria from infecting his damaged heart valve. Despite this rough history and questionable future he and his sister were cheerful, friendly, and fun to interact with. I had some extra time to interact with them as one of the meds the young man needed for his heart was out of stock in the pharmacy and it took some work and some time to look for a small supply to send him home with. After awhile they went off for him to have his injection and the supply of medicine still hadn’t come. I asked them not to leave without it, but the sister (who spoke better English) explained that they had to ride TWO HOURS on bikes to get home and as it was already late in the afternoon, she didn’t know how long they could stay. So much for the sad part of the story.

Soon after they left to get the injection in another room I got ahold of the supply of medicine. Nervous that they had already left I quickly walked, then jogged, over to where I expected to find them. Appearing to hurry is not very dignified in this culture and people stared a bit at me trotting by in my skirt, but I was worried about the possible additional strain on his heart without this medicine. As I thought about this possibility I vaguely heard a girl crying, “Mom! Mother! I am here, over here!”. It made no impression on me as I just thought some girl was calling her mom, it didn’t even register that it was unusual for it to be in English. Suddenly I felt someone grab my arm and saw the sister, out of breath, at my side. She had run to catch me as she had seen me hurrying in the wrong direction. They had already finished with the injection and were walking a different way. Calling me “mother” was a very respectful address for any woman older than oneself…I have frequently been called “sister” here by men and women older or slightly older than myself (for example someone called out to me “good evening sister!” as I walked back to the dorm this evening). It was a little strange to me to be called “mother” by a 14 year old girl, but isn’t that a lovely and courteous tradition?

I gave the sister the medication and sent them on their way, not expecting to see them again. However, when I arrived at afternoon clinic earlier this week I was startled to have the translator tell me that someone had a gift for me. He said that she had approached him earlier to tell him that she would be on the look-out for my arrival and would bring it in when I came. Just then I saw the young sister in the doorway….and she was holding a large, brown and white, LIVE chicken in her arms!! In Tonga culture (as in many traditional cultures) it is extremely offensive to decline an offered gift, so with some confusion I stammered out my thank-you’s both in English and Tonga, and took the hefty bird in my arms. The girl explained that they felt I had worked hard to help them at their last month’s visit, and had brought this gift for me as a mark of gratitude. Talk about generosity. They certainly didn’t look as though they could spare a chicken and I longed to offer it back to them. I even pulled the translator a little aside after a moment and asked if there was any way I could politely return it, but he assured me that there was not. Then the question was of course what was I going to do with a live, breathing, clucking, pecking, feathers-still-wearing chicken while I saw patients in clinic? Fortunately the translator found a place to confine it (not in the rooms were patients were being seen of course!) until I was able to give it away to one of the Zambian hospital employees.

So, for the first time in my life, I was the owner (albeit temporarily) of a live chicken. There have been lots of “firsts” during this time in Africa, but that was one I wouldn’t have predicted :-).

The internet has been a little tempermental lately and I have not had access at all for several days…so sorry for the lack of communication. Things have been quite busy at the hospital this week and we have had a number of difficult cases. It has been challenging and very educational, both in a medical and personal sense.

I actually do have a wonderful story I want to tell, but I don’t have a chance at this moment as I have to get back for afternoon clinic. I will hopefully be able to post it soon, but wanted to take a moment while the internet was working to at least post a quick update.

Hope things are going well with you all! Love you!

- Mary

1) When do I come home: I will fly from Zambia on March 16th (yes fellow M4’s…the day we find out!) and will be in the US on March 17th. I will be back in Columbia March 19th for Match Day! Yay! (Match Day is when all fourth year medical students in the nation find out where they will spend their residency…the 16th is the day we find out if we matched at all, the 19th is when we find out where).

2) Are lab services automated: As I understand it, there is at least one machine that does the full blood count. I think we have another automated system that could theoretically do serum electrolytes, but the reagents are too expensive. That is a major factor…for example, even doing blood group typing, those reagents are expensive as well.

3) Is this area primarily a money or barter based economy: the Zambian currency (Kwacha) is used here and that is the primary method of exchange of goods and services between the people and “official” entities like the hospital. However, exchange of labor and barter are also important from person to person.

4) Do people pay for medical services: no, and that is awesome, because so few people could afford to pay anything. They do pay for a few things like 1000 kwacha for a small book that functions as their medical record (remember 1 dollar = 5000 kwacha). They pay for plaster of paris for casting, and a few other odds and ends - but hospitalization, outpatient clinic appointments, meals during hospitalization, meds inpatient or outpatient, surgical procedures, diagnostic tests, etc, are all free of charge. I am not entirely clear exactly how the financial responsibility breaks down, but the hospital is supported by the Zambian government, the BIC church, and various grants, charities, and aid organizations.

5) How do the people feed their cattle: the cattle basically wander across the landscape grazing from the rich vegetation. They are attended by groups of young village boys whose families own the cattle. There is no specified grazing land and in fact villages/towns put bars in the main paths leading into town to discourage cattle from wandering in. Average village families do not put up hay. Even in the dry season the cattle look for feed as best they can from the natural vegetation. Some larger farms do fence off grazing land and put up hay, but not the average villager who may own or share only 1-2 animals (they use them for plowing fields as well as for food).

6) What fruits and veggies are available: an abundance!! As I have mentioned most rural Zambian families have a garden, and MIAM and the hospital each have their own. Families with enough also sell fresh fruit/veggies at the market. There are bananas everywhere (a much smaller variety however), as well as guava, papaya, tomatos, and some lemons and oranges. I have actually really missed apples which don’t grow here. There are also onions, cabbage (lots and lots of cabbage), various “greens”, zucchini, some variety of squash, huge green avocados, beans, peanuts, and of course, lots of maize. With such fertile land it is a little hard to understand how there are such serious food shortages and starvation…and the answer to that question is multifactorial and not easily answered..but all of you with farming backgrounds will appreciate one big piece of the puzzle…much depends on the rains. In a simple view, Zambia has two seasons - wet and dry. If the rains are too early, too harsh, too late, too little…if the dry season is too intense, too long, etc…then the subsistence agriculture here is severely impaired.

7) Speaking of the rain, what is the weather like: well, it is beautiful. Seriously, most days are absolutely beautiful. It is on the cooler side in the evenings and mornings which warms toward mid day to the low 80’s. Sometimes in the afternoons the sun is intense and it is a little too hot, but in general it is pleasently warm with a blue sky, a few clouds, and a nice breeze keeping the air fresh. Probably about 4 days per week (although it is quite variable) there will be at least one period during the day where gray clouds roll in and drop rain for 10-30 minutes…and they roll out again. Sometimes there is a true “thunder storm” with crashing lightning and driving rains, but often it is just a steady, even curtain of rain that does its business and then moves on. Only a few days since I have been here as there been primarily overcast days with intermittent sprinkles and drizzle like Oregon.

A quick update on the week so far…so I got to have breakfast with a Nobel prize winning scientist who is here visiting MIAM…I also got to hear the lecture he gave to MIAM and the hospital community which was awesome. Such a strange reality to be here in rural Africa and meet this premier scientist and hear about the world-class research being done here by MIAM. I am on men’s ward right now doing one of my last stints in adult medicine for my entire medical career (pediatrics here I come! ).It has been very educational but I’m not tempted to change to internal medicine. And today I saw a chameleon walking across my path! How cool! I should have transplanted him to the dorm to see if he would help the geckos eat the bugs (and maybe some spiders too? We have enough )

Love you all! Thanks for the ongoing support!

The guide beached our boat on the white sands of a little inlet where we were met by another guide in a safari jeep. This guide has been working in the park for 18 years and his experience showed. As he maneuvered along the narrow sandy trails he was constantly scanning for animals and evidence of their locations: tracks along the edge of the path, broken branches, the warning cry of bird, etc. He took us on a short drive and showed us giraffes grazing peacefully among the acadia trees, a group of baboons running along the roadside, herds of kudu and impala, a family of warthogs…as well as deep, fresh tracks in the sand made by the massive paw of a lion. As the day grew hotter we were taken to our campsite in the bush - cluster of tents around a sheltered dining area and campfire. We were served a nice lunch that had been prepared over the fire and then we had some time to settle into camp and wait for the cooler evening hours. We enjoyed meeting our fellow travelers: a couple of other medical students from the UK as well as some university students from Norway.

At about 5pm we set out again - the park is amazingly beautiful. It covers a huge area and encompasses a variety of different terrains…I spent most of my time in the lush and fertile riverside area. The park rises to a plateau overlooking the shining ribbon of the Chobe river, there are relatively open grassy expanses alternating with more dense areas of acadia trees and bushes. Alongside the river a series of pools in a narrow grassy band alongside a forested area is a favorite haunt of herds of elephants.That was our first stop in the evening and it was surreal to be so close to a group of about 30 female elephants and their young as they drank from the pools and wallowed in the mud holes (yes, wallowed…I will never forget seeing an animal weighing several tons slowly lower itself to its side and wriggle about in the mud). Several baby elephants ran among their massive adult counterparts doing play charges, splashing in the water, and generally being adorable. When the jeep first drove up some of the females startled and wheeled around to face the threat, but they quickly settled and didn’t seem to mind our presence. Later in the drive we came around a corner and ran right into the middle of a smaller group of elephants grazing. The dominant female did not appreciate our presence. She spread her fan-like ears wide, lowered her tusks at us, and swung her head threateningly. She trumpeted briefly and bluff charged at us as the other females and lone baby escaped into the forest. It was frankly terrifying, but the guide has handled such situations before and everything turned out fine. After her short charge our direction she wheeled around and crashed into the trees after her family. In the evening the park is teeming with life and there were fascinating things to see at every turn…cape buffalo, a family of banded mongooses (mongeese? )…and countless birds darting jewel-like in front of our jeep, soaring above the bluffs, covering the branches of trees. Some say that the rainy season is not a great time to do a safari as the dense foliage makes animals harder to see, but I thought it was wonderful as it is the bird season, the park looks beautiful, and the animals all look healthy and many have their babies with them (the dry season makes animal populations more concentrated as they all cluster around the dwindling water holes, but it is also a rougher season for them).

Our guide had warned us early on that although there are both lions and leopards in Chobe National Park, few travelers see either of them. There are not that many for a park of such a great size, and the ones that are there can be shy and elusive. However, the tracks we saw earlier in the day had given him a clue as to the lions’ location. He has known the two male lions in the area (they are brothers) for a long time, and he knew that this one was with a single lioness - a breeding pair. He tracked them up to an area of dense foilage and we were creeping along in the jeep when we saw a bush move and a faint streak of gold in the grass…the lioness was sleeping among tall grasses and we could see nothing of her but her thin tufted tail. Far away we heard a chilling sound - the roar of the male lion. The pair was at that moment separated and unable to be visualized..we drove back to camp in the light of a blazing sunset with the promise of tracking the lions again in the morning.

After dinner we were sitting around the campfire talking when the guide quieted us. “Elephants”, he said, and flipped on a large flashlight. Passing only a few yards behind our tents a long line of elephants was slipping through the trees with surprisingly little noise. It was a remarkable sight to see their massive gray forms passing through the weak beam of a flashlight and then disappearing into the darkness.

At first light we were up again and in the jeep, stopping to take pictures of the glorious sunrise over the river with a huge group of baboons playing along the water’s edge.  We immediately began tracking the lions and as we came around a bush we saw a large golden form in the road ahead - the lioness. As the jeep advanced slowly past another bush there was a massive crashing sound - the lion had been startled by our arrival and lept into the bushes. The guide stopped the jeep and we waited, breathless, as his thick mane and heavy golden body slowly emerged from the branches into the road just behind the jeep. We were now between him and the lioness who had begun to trot down the road away from us. The guide put the jeep in gear and began to slowly drive away from the lion, edging the jeep over on the path so that the lion had a clear visual to the lioness ahead…but then the lion broke into a swift trot and the guide sped up the jeep, pulling it off the trail and behind a bush. He pulled the jeep around an area of dense foliage into an open space a little further along the road. We could see just a few yards behind us to where the lion had rejoined the lioness and the two were sitting in the road. The lioness suddenly lept at the lion, snarling, her sharp front claws grazing his shoulder. He backed away with a short roar and she subsided, suddenly deciding she needed to groom her front leg. The guide had explained earlier that during the mating season the dynamics between the male and female are quite dynamic and sometimes aggressive. It was surreal to watch them, wild apex predators just yards from our open jeep…I will never forget it.

Well this post is certainly long enough. I am sure it is clear that this was a remarkable experience :-). It was really refreshing and inspiring to spend some time where the natural environment is allowed to have its own way. After returning to Zambia we enjoyed the rest of our Saturday in Livingstone and traveled back to Macha today (Sunday).  I believe I will start on one of the adult wards tomorrow. Good luck in the week ahead! You will hopefully hear from me soon with the long promised Q and A