Is Anyone Still Out There?

As I come to the end of my sejour in Africa, reflection inevitably follows the last days that I pass in Bamako. Most vividly, I recall my second night in the capital city after my first real day of Africa – the sights, the smells of open sewers and rotting fish markets mixed with toil and sweat and spices, the never-ending honking of taxis and motos, the sudden catch of music or drumming, the constant chaos only ever put to order by the regular daily calls to prayer that can be heard everywhere throughout the city. I found it fascinating, frightening, invigorating and bizarre. As I went to bed that night, I cannot deny that I had self-doubting thoughts about what I was doing here and if I would be able to last a year in this land.

Fortunately, these fears and worries came to pass as I threw myself into the rhythm of life that exists here – both simultaneously slow and frantic – and I came to discover the invisible undercurrents that guide people along in la vie quotidienne in this country. With this, I inevitably uncovered the aspects of life that greatly try my patience here – the necessity of having exact change even though small bills are perpetually in shortage, that people scream Toubab (white person) at me whenever I walk down the road, that taxis think nothing of making other stops while en route to your destination, that the police will want bribes from me if I am out after midnight. Parallel to this, I have also come to find Malian idiosyncrasies that I will never be able to explain – for example, why are there Mexican soap operas on the one television channel here? When there is miraculously toilet paper in a bathroom, why is it always colored? Why is Russian a required language in high school here? Why do the ex-pat restaurants put French fries inside your hamburger? Were they misinformed about the great American traditional cuisine?

However, in addition to things that annoy or perplex me, I should probably also consider the things that I have learned about myself. At times, I felt that I had lost myself only to discover that I was still there beneath a flummoxing surface. Before I left, everyone said this would change me for the rest of my life. As I recall one night in a bar in Washington, DC during Fogarty orientation, another fellow en route to Peru said to me, “You are really never going to be the same after Mali.” Because this was coming from a girl who was about to embark on theoretically the same type of fellowship as me except on a different continent, I felt both proud and frightened that others perceived my destination as one of the most untamed, adventurous, unknown. Yet, as I have gone through the flux of emotions, hardships, and triumphs that this year has brought, I realize I have changed but I have not decided if it is for the better. I am more patient, but I am less trusting. I am a better clinician, but I have hardened in these dismal conditions without resources. I speak more languages, but I say less and I spend more time alone. I have learned to adapt to cultures and lifestyles radically different than my own, but I am less confident about things that I thought I knew, less likely to assume that I know.

So will I be the same after Mali? Probably not. Am I still the same person? Of course. I hope that these moments of truth will reveal themselves as I continue to live my life, to wait and see how my African experience will inform and shape the moments to come. My experiences here in life and love and work and medicine have taken me to nadirs that I didn’t know existed and catapulted me to highs that I couldn’t imagine. While I reserve these details for myself, I can admit to you that living in such extremes is not personably sustainable. As I attempt to amalgamate these moments into one cohesive guiding principle for the rest of my life, I have come to one conclusion: that I will have to wait and see.

But I promise to keep writing.

La Blanche Qui Soigne Pour Les Cas Graves

It started out as a typical morning. I was in a back room at the clinic seeing one of my study subjects who was one week out from a malaria crisis and all cured – although unhappy that I was holding a needle to draw his blood. Suddenly, a nurse from the hospital popped into the room.

“Viens vite! J’ai un cas grave!” (Come quick! I have a severe case!)

Since my study enrolls all severe cases of malaria in children between 6 months and 5 years of age in Bandiagara, I dropped what I was doing and accompanied the nurse to another building where the cas grave was waiting.

Generally, severe cases of malaria present in coma, seizure, lethargy, or severe anemia with high fevers. We act quickly to stabilize them and then confirm a diagnosis of malaria (since it can often be meningitis or poisoning by traditional medicines). However, when I entered the room, I saw a father – most likely from a rural Dogon village based on his tattered clothing – and an older woman – most likely the grandmother. Between them was a small three-year old boy who was standing up in no apparent distress; in fact, he didn’t even appear to be engaged in his surroundings, just a listless stare into space. I felt his forehead. It was cool but I took my thermometer from my pocket to get a temperature. His inner eyelids were well-colored making severe anemia less likely (although all children here have anemia to some degree based on the poor diet). He didn’t have a fever. I was confused – what had led the nurse to believe this was a severe case of malaria?

Meanwhile, an explanation began in Dogon by the father and as the nurse hastily translated into French for me, I remarked that I did not think this was a case of malaria.

”But they traveled all the way from village 45km away yesterday and spent the night here so they could be here this morning when the clinic opened... They heard there was a white lady who cares for the severe cases”

La Blanche qui soigne pour les cas graves… C’est moi.

Wait, what? I said as I was trying to understand the nurse who was translating. Apparently, they said the infant had had malaria the year before and he hasn’t been right since.

No, I care for the infants with severe malaria right now, not in the past.

And, she continued, he hasn’t really talked much and sometimes he jerks. They traveled all the way here and passed the night to come here.

Okay, I say still not exactly understanding the story from the poor translation, Ce qu’on va faire – this is what we’re going to do – he can have a goutte epaisse and we can see if he has malaria right now and then I’ll figure out what we’ll do. I wrote out a lab request for the analysis and quickly returned to draw the blood from the other child in my study.

A little while later, I received the result – Negative, predictably. I found the family, brought them into a consultation room and asked my colleague, a PharmD who works in the lab with me, to properly translate. Based on the history, it appeared that the infant had been having generalized tonic-clonic seizures about three to five times a week for over a year. Looking at the infant who was about three years old, I could see that his affect appeared a little flat. He looked off into the distance, he never fixated his gaze on any objects or people, his tongue almost lolled slightly at the right side of his mouth, and he only walked when pulled along by his grandmother’s hand. Standing in the office, he urinated on the floor and did not move from his own puddle of urine. Was this the neurological damage the result of a year of untreated seizures? Was it due to sequelae from cerebral malaria? Or did he also simply have a seizure condition? Was he slow before the malaria? Before the seizures?

I had no way of knowing. But he did have seizures. I wrote for a prescription of Depakene (or Depakote) and told them to come back in two weeks. I explained that it was very important to remember to take the pills everyday and to immediately come back to the clinic with any new problems. In two weeks, we could adjust the dose accordingly if he was still seizing. In America, a prescription for Depakote would be accompanied by pharmokinetics tests to monitor the level in the blood. Too little and it is not effective. Too much and it is toxic. But you don’t have that here. You just... guess (based on weight).

The toll that malaria takes on the brain can be subtle or drastic – as in this case. One other severe case in my study developed right-sided paralysis three days into a malaria crisis. Four months later, it persisted but her mother insisted it was better. As I watched the girl refuse to walk for me, I had my doubts. I wonder about the subtle effects of malaria as all African children endure simple and severe episodes multiple times in their young lives – and even before this, in utero when their mothers suffer from malaria. How it does this affect their development? While we can study markers of intelligence, what about the more nuanced processes in the brain? What impact does this have on their abstract thinking? On their creativity?

The family seeking La Blanche qui Soigne pour Les Cas Graves never came back to the clinic. I understand that it is a long way to come. I understand they came with a lot of hope for a cure. I also know that the medications won’t reverse the neurological damage already done by an unchecked year of daily seizures. He may never speak much. He may never go to school or work. But I know that the meds can help prevent further damage if only this family had the access to care, if only they had the access to means, if only they had come sooner. If only.

Losing Cases 1: They Came Too Late

It was 9 o’clock at the hospital on Friday night and I had been working in Bandiagara less than two weeks. I was standing in the open air hallway when a moto sped up with a bundle of cloths thrown over the driver’s lap. He jumped off the bike yelling “Dogo toro” or doctor in the local language. Within the swaddle, he held a small 2-year old girl with ragged breaths and half-slits for eyes. We placed her in a bed in the grand salle and I immediately began assessing her for severe malaria, the most likely culprit causing her state. To do a thick smear diagnosis for malaria, we prick the finger and place a drop of blood on microscope slide. For my severe malaria study, I was equipped with a glucometer (to read blood sugar) and a Hemocue (to evaluate the hemoglobin level for anemia), two appliances that are typically not found at this hospital that I had brought with me to Bandiagara. This particular child was severely hypoglycemic (blood glucose 18mg/dl) and severely anemic (Hgb = 2.2g/ml). Even without my gadgets, it is never a good sign when you prick a child’s finger and it does not bleed. It is also not a good sign when the blood that you can squeeze out is the not the deep red of Saharan sunset, but a light, watered-down rose. I left to search for IV fluids, quinine and the like and by the time I returned, the mother had arrived and was sobbing uncontrollably at the bedside. I ask the nurse if anything had happened fearing that the child had died in my 3-minute absence. The nurse, T, gave a disapproving look at the emotional mother and said, “Elle pense que l’enfant va partir” or She thinks the child will leave (eg, die).

Some would say that a mother’s intuition is never wrong. Within minutes, before we could even get an IV started, we could not find a heartbeat and began CPR. The problem with CPR here is two-fold. First, no one really believes it is going to do any good so they do not execute it properly. Second, the deeply-ingrained belief that God, or Dieu, chooses the day that we die and there is nothing we can do prevents heroic life-saving efforts. Because even if you prevented imminent death at that moment, Dieu will surely take this child via another means on the same day. But listening to a heart slow when there is nothing to be done is one of the worst sounds in the world. Leaving the nurse, I went to find epinephrine in a resuscitation kit that I had seen left over from the first phase of the vaccine trials. Normally, I would have run in my own attempt to emulate Western medicine practices. However, because I needed a key to locked closet, I was accompanied by a Malian doctor who I least prodded to a brisk pace.

In the closet, I was amazed to find an entire resuscitation kit, the size of a small suitcase, with anything my heart desired to run a code. As I began to pull out vials, I looked at the expiration date. Absolutely everything in the kit had been expired for two years. Despondent, I returned to the hospital and we indulged in a few more rounds of CPR before pronouncing the tiny patient dead.

As I stood aside while the mother’s bawling escalated, T tells me what I heard many times during this malaria season. Ils sont venus trop tard (They came too late). I can understand that this is often true in our limited resource setting and that the staff are not just shifting the blame. But when this frame of mind pervades patient care, it may severely limit how much effort is actually expended by the staff. Yet, frustration with the system is not just the staff, but the behaviors of the parents who wait to bring their children. Sometimes I can better understand when parents arrive late in the disease process if they live 40km away with no access to healthcare and no transportation. But this child came from a village 3km away (less than 2 miles). Why did they wait? The child had been sick several days. These are not questions I ask guilt-ridden parents minutes after their child has died, but a parting word of condolence along with a reminder to bring the other children in as soon as they seem ill is often warranted.

I then watched as the mother picked up the small body and placed it on her back, wrapping it and securing it to her body with a large piece of fabric, as she done to everyday since the child was born. Then she left, dead baby in tow, back to the village where she had come. Do we need to do anything? I ask. At this hospital, the intern tells me that we only do death certificates for those over 16 years of age. No death certificates. No autopsy. No time for any of that. Given the climate here, it is important to bury the bodies as quickly as possible.

Rounds 3: La Malnutrition

As we continue rounds, we enter one dimly-lit room in La Maternité that is designated for children with severe malnutrition. PlumpyNUT® protein supplement wrappers and plastic cups with crusted remnants of high-calorie milk solutions are scattered on the floor. A yellowing chart posted on the wall describes the appropriate weight-to-height ratios for normal children and then those for children with mild, moderate or severe malnutrition. While most children in Bandiagara seem to have some degree of malnutrition to my untrained American eye, only those with severe malnutrition are admitted into La Malnutrition. As we enter, we are greeted by protruding ribs and big heads often covered with roux, the reddish-brown fuzz that represents hair in children who have severe protein malnutrition, that occupy the two beds in this room.

One Monday morning, a beautiful young Peulh woman with large, wide-set eyes held a small, lethargic girl in her lap that had been admitted over the weekend. The mother’s ears were pierced from top to bottom culminating in a cascade of intricate dangling gold earring that would have delighted any child to swat. I wondered if this 2-year old child who weighed less than 10 pounds ever had enough energy to grab for them. She was sitting up but slumped against her mother’s arms and foam drooled from her mouth. In her fist, she held a small piece of beignet, or fried dough. While the children here are supposed to be on a strict, high-energy, high-protein diet to combat their poor nutrition, the chef began to ask what she had. He then spied the small bag of beignets that the mother was trying to conceal with her skirt. Grabbing the contraband, he proceeded to scold the mother for feeding the enfant the Malian equivalent of “junk food.” The mother said nothing, looked up with the blank, timid look that I see on so many parents’ faces because they simply do not understand or cannot appropriately care for their children. When we returned to the room the next day during rounds, another underweight, swollen-bellied child sat in the bed with her mother. All too often, children are admitted too late to La Malnutrition to be re-nourished before their small bodies give up. The small girl had passed away overnight and the striking young mother had gone home. Given the previous day’s events, I asked myself if it were really one too many beignets or not enough?

Malnutrition is a complicated phenomenon that continues to evade me. It is so rampant and wide-spread but so simple to prevent and to treat if not advanced. Lack of basic education and family planning appear to be the greatest barriers. For one severe malaria case in my study, a major obstacle to his recovery was going to be proper nutrition. As I tried to explain this to the parents, the father simply shrugged and said there was just not enough food for his six children. Compounding matters, his wife was pregnant again after just delivering twins 11 months before. I sent him home with some PlumpyNUT® bars and hoped it would help.

However, one of the more interesting cases of malnutrition manifested in a 6-month old girl whose mother had died shortly after childbirth. The grandmother was taking care of her and her brother as is often the case when parents are absent. By some twist of nature, the grandmother had begun lactating after the death of the mother and the child continued to breast feed. Despite this fortuitous biological transformation, the child was still severely underfed and was admitted to La Malnutrition by another doctor on the team.

Another similar severe malaria case of a child with only a grandmother and no parents presented the same problem. The child remained severely anemic and listless for four days after appropriate treatment. The child did not begin to improve until I directly handed the equivalent of $4 to the grandmother and told her to go buy some fish and meat to feed the child instead of the diet of bouille, the ever-ubiquitous liquid meal of boiled millet that all these children are given by well-intentioned but impoverished parents. To no one’s great surprise, the child was ravenously hungry and we were able to discharge her two days later after a few good meals.

Rounds 2: The Land of Broken Tummies and Tired Breasts

Once we leave the main hospital, the team marches across a dusty field littered with grasshoppers the size of a man’s hand to a collection of three run-down buildings with peeling green paint. Two broken-down ambulances sit to the right of the entrance of the first building, La Maternite, where women give birth side-by-side in a back room. Immediately to the right is the middle building or Le Bloc, a petit operating room where a limited number of surgeries are performed (eg, inguinal hernia, appendectomy, and C-sections). The third small building is where patients are kept after receiving these surgeries with a small room of two beds dedicated to children with La Malnutrition.

Here, at La Maternite, a group of sage-femmes, or mid-wives, await our arrival on the front stoop. They are always dressed in their brightly colored, tailored outfits with perfectly matching head scarves and equally non-matching heels that click on the cheap linoleum. There is a cackling chorus of greetings and laughter as we approach and reciprocate the greetings. La garde, the sage-femme wearing the white coat that day, takes us to the first room and begins with her presentation.

The women in this building have all given birth naturally. Our typical patient often had carried between 5 and 9 pregnancies with slightly lower numbers reflecting her live births and perhaps an even lower number signifying how many children were still living. However, there were the young teenage girls who had just given birth to their first child. Even if their still taut breasts were covered, the fear projected in their faces gave away their new motherhood status. Perhaps this is the universal face of first-time mothers, but here the fear is compounded by lack of education, scarce resources, and one of the world’s highest child-mortality rates (6th highest rate at 238 per 1000 children dying by the age of 5). Nearly 1 child out of every 4 children will die before his 5th birthday in Mali. The already-mothers are calmer as evidenced by their tired, hanging, scarred breasts that have been feeding children without respite for years, possibly decades.

As we go from room to room observing the mothers and newborns, it is all too often that a mother lies alone in the bed. No newborn is waddled up next to her. There are no words of condolences and she is examined as usual and we move on. It is a fact of life, of everyday life here in fact. Although everyone simply accepts life is hard, the staff is not without complete remorse and the medicin-chef scolded a sage-femme for putting a mom and her newborn in the same room as a woman who was not as lucky. I can only imagine the long night she spent watching the other mother feed her little one as her own breasts painfully ached for a lost child.

The same routine occurs in the other building where the women are kept after C-sections. Often, they have babies nestled next to them and often not. Except these women are forced to stay longer as their wounds heal.

In adjacent post-op rooms, elderly men in long boubous (traditional Malian robes which effectively double as hospital gowns in a hospital where there are none) lie still after inguinal hernia repairs. Only after the medicin-chef, the male nurses, the intern and I, the only female, enter the room and lift up the boubou to expose the surgical site do I realize that our gaggle of sage-femmes remained at the door. If they must enter for a point of wound care instruction from the doctor, they avert their eyes from the inguinal hernia repairs that they are obliged to clean.

Rounds 1: Meet the Players

“Girls just wanna…they just wanna…”

The medicin-chef leads the rounds, ou “la visite”, each morning at 8am and then I often don’t see him again until the following morning at 8am. He is responsible for the entire Cerc (or district) has a commanding but gentle sense of authority but mumbles his French as though someone paralyzed his lips. At 8am he comes to the Salle de Garde (Room of the Guard), an 8’x8’ room with a sagging bed and termite-ridden desk that serves as a point of entry for all patients, a cafeteria, an examining room, a call room for sleeping, a consultation room for all general visits, and of course, a tea-making venue.

“Girls just wanna…they just wanna…Girls just wanna…wanna have fun…”

The medicin-chef begins fumbling in his pocket for his cell phone. Little does he know that his ring tone is a song most often associated with dancing pre-teen girls and a classic 1980s movie. After four months of rounds, I became accustomed to hearing this light-hearted jingle multiple times interrupt the grave-faced chef discussing it was too bad that we couldn’t do anything more for this or that patient. On peut rien faire.

Once our motley crew assembles, and after our traditional salutations regarding our families, how well we slept and how well we ate for breakfast, we proceed first to the three rooms that serve as the “adult wards”. Four beds in each room, but not necessarily mattresses as well. Typically, the chef, nurse or intern pokes his head in the room and yells something in Bambara, Dogon, or Peulh telling all the family members to vacate the room. Mothers, sisters, brothers, cousins and neighbors shuffle out after quickly picking up the mats and pots and pans and plates that now litter the floor. Meanwhile, the team shakes their heads disappointingly and complains about the flies in the ward that doubles as a family dining room. By this time, T, the nurse, has finally reluctantly thrown out his cigarette before we walk in to the room. Picking up the a piece of wood with the Fiche de Traitement crudely tacked on it, the person who admitted the patient gives a presentation that includes name, age, ethnicity or tribe, and neighborhood. A brief history of illness follows then the exam findings and lastly, the list of medical hypotheses that invariably includes paludisme, or malaria.

A brief description of the team is likely warranted here. As I mentioned, the main and often only nurse, T, is a tall, dark-skinned Malian in his 40s who has 3 wives, 14 children and 1 mistress and is yet always at the hospital. Given his constant smoking habit – which is not always extinguished for patient care (as I have seen a sick child in his arms and a cigarette in his mouth as he places an admitted child on a bed in the grand salle), his voice is gravelly and when coupled with his deeply chiseled, angular face and yellow eyes, he could easily pass for a Disney caricature villain. This image is further reinforced when one enters the Salle de Garde and plumes of smoke surround T’s visage as he makes his tea in the small, stuffy room. Hushed voices at the clinic later told me that he sometimes charges the patients for the medications that we provide free of charge for the study. However, quick with a smile and ever-ready to help with an IV when I really needed it, T positively contributed to my experience in his own special way. (See photo of us to right)

The only other permanent fixture on the team was the 28-year old intern aspiring to be an obstetrician-gynecologist. Often it would only the three of us – T, the intern, and me – although one other nurse, B, was sometimes present and had some training in anesthesiology. He and the intern would disappear each time a C-section was warranted.

After three rooms of adults and teenagers, we typically see malaria, typhoid, cobra or viper bites, burns, strokes, hyperthyroidism, or poorly defined heart conditions in patients as young as 20 years generically labeled “cardiac insuffisance” for which digitalis is considered a panacea. We then move on to the “grand salle” which is the pediatrics ward with ten beds AND ten mattresses (it was recently refurbished with biomedical research money from the US). A nurse’s station sits in the corner with a thick layer of dusk having never been used. Mosquito nets hang from each bed more as decoration since I never actually saw anyone using them. During malaria season, each bed also held a small dark sweating body that refused to eat or refused to wake.

We follow the same procedure by yelling at the medley of families gathered in the grande salle to leave although one parent is allowed to stay with the child. This requires another chorus of yelling at any parent who is sitting on the bed and then a shuffling of chairs so that there is one chair per bed with an obedient mother perched next to her child. We move from bed to bed discussing how much quinine each child has received for their malaria crisis, assessing their alertness, and turning to the parent only to ask if the child is eating or drinking. For every child with fever, we tell the parents to wrap them in a cold cloth or l’enveloppement humide especially if the parents cannot afford to buy medicine for fever, something simple like aspirin or Tylenol.

Generally, by the time we have finished in the main hospital building and effectively shooed families helter-skelter, the medicin-chef has also frequently berated T for one clinical misdemeanor or another. As the power struggles begin, I cannot help but wonder if our energies could be better directed in a hospital that has trash cans overflowing with used needles and cupboards completely devoid of gloves, sterilizing alcohol, and often even paper on which to write treatment regimens for patients.

Tales from a Hospital in the SaHEL

The next several installments of this blog will depict an array of stories and events from my experiences while living and working at the hospital in Bandiagara from September to December 2008.

Essakane or Bust

November 15, 2008

The Embassy of the United States of America in Bamako, Mali, would like to renew its caution to U.S. citizens regarding travel to the town of Timbuktu and areas north of Timbuktu. This includes Essakane, site of the Festival of the Desert…

I recently returned from an amazing adventure to the Sahara Desert with eight friends, other Americans hailing from various parts of Africa plus two amis from Sweden and the UK. Our destination was Essakane, a desert oasis 70km north of Timbuktu, where the world’s most remote music festival, Festival au Desert, brings West Africa’s best musicians to jam for three unforgettable days in a celebration of Tuareg music and culture. (Tuaregs are the last true nomads on earth wandering with their animals across the Sahara Desert, mainly in West Africa but parts of North Africa as well). Equally spectacular as the music was our intimate interaction and peaceful immersion with the Tuaregs whom we encountered there and now call friends.

Securing airline tickets on inter-African airways and arranging visitor visas for other friends who are likewise coming from countries like Uganda, Zambia and Nigeria, is a challenge that would make the even the most-coiffed and cool travel agent sweat. In addition to the international logistics, I began working with a tour guide in September to begin to long process of hammering out details and prices of how we would travel from Bamako to Essakane via 4x4 trucks, pinasse (similar to a large pirogue or canoe), and camel. In retrospect, the most reliable means of transport was the camel considering that both our pinasse and our 4x4 broke down at one point or another.

New to my trip-planning skills, I also had to account for the small snag of receiving warden messages like this from the US Embassy in my email box three weeks before our voyage.

December 10, 2008

Due to recent armed conflicts, kidnappings, armed robberies, and the continued presence of Al-Qaeda in the Land of the Islamic Maghreb (AQIM), the Department of State recommends that U.S. citizens avoid all travel to northern Mali. AQIM has been designated as a terrorist organization by the United States. The presence of AQIM and Tuareg rebel groups in northern Mali presents serious potential dangers to travelers.



Areas of particular concern include the Mali-Niger and Mali-Algeria borders, the Kidal region, and areas north of Timbuktu. This includes Essakane, site of Timbuktu’s Festival in the Desert scheduled for January 8-10, 2009. American citizens who must travel to any of these areas despite this Travel Alert should remain vigilant at all times, exercise extreme caution, and avoid large gatherings.



How does one avoid large gatherings when our goal was in fact to BE at a large gathering, eg the concert? As far the other advice, I could be vigilant and practice caution but this is difficult in a setting where you are surrounded by Tuaregs in turbans and covered faces.

Any form of racial profiling that has been gleaned from watching CNN or Fox News broadcasts about Al-Qaeda would cause you to think that everyone at Essakane was a terrorist. Even a fanatical follower of ‘24’ would be hard-pressed to discern warning signs in this Saharan setting.

So clearly I have now lived in Mali long enough that I did what any good Malian tour guide would do (and this is in fact what our guide did the entirety of the trip even when our boat completely broke down in the most dangerous, deepest part of the Niger). I ignored the warning and when my friends asked me about security concerns in Mali, I told them “Pas de probleme.” On and off, there has been long-standing warnings against going to areas north of Timbuktu for the past couple of years so I wrote this off to American government paranoia.

My friends were due to arrive on the 31st of December to ring in the New Year Bamakoise-style before we set off on the big adventure. Prior to their arrival during the month of December, the Warden released another 4 messages warning people against traveling to the Festival au Desert.

December 30, 2008

On December 20, 2008, Tuareg rebels attacked the Malian military base in Nampala, the northernmost town in the central region of Segou… Given the rapidly evolving security situation, U.S. citizens traveling to areas … despite the Embassy's warnings,… please exercise vigilance and avoid large gatherings.

December 31, 2008

This Warden Message is being released to urge American citizens against travel to the January 8-10, 2009, Festival in the Desert situated in the town of Essakane northwest of Timbuktu. The U.S. Embassy in Bamako, Mali, has received information regarding threats against westerners attending this festival.

What else was there to do? My friends had arrived (after some harrowing flight incidents), at least half of them were able to secure visas (that was another administrative nightmare unto itself and so we prayed the police would not ask for passports for the other half of the group), and we had already forked out the money for the 4x4s, pinasse, camels, etc. We were going. Pas de probleme. Essakane or bust.

For a detailed day-by-day account of our amazing 10-day adventure, please go to www.healingnumenor.wordpress.com where my friend Justin eloquently and descriptively recounts our exploits while also providing historical background and ethnographical observations. As I read his rendition of our voyage to Northern Mali, I realize that I have already become habituated to some of the interesting and unique aspects of Mali culture and lifestyle that inspire his comments. For these reasons, I implore you to read his well-written account of our journey through the eyes of a Mali-naïve traveler.

Post-script: While writing this blog entry, I received an email regarding the kidnapping of 4 European tourists on Saturday, January 24, 2009, after leaving the Tuareg cultural festival at Anderamboukane. Tuaregs with automatic rifles gunned down the 3-car convoy although one car was able to escape. None of the four hostages were injured in the assault. No group has claimed responsibility. In a separate incident on Thursday, Mali militia claims to have killed 31 Tuareg guerillas in Kidal.(http://www.guardian.co.uk/world/2009/jan/24/mali-niger-hostages) Perhaps the US government is not paranoid after all…

Let It Be

While it had been challenging to follow the 2008 election from a distance – compounded by no access to cable coverage and limited internet access in the field – I nevertheless experienced a swell of pride upon hearing the winning candidate of the 44th president of the United States of America after a 4am phone call to my parents. In the weeks leading up to the election, it was all that my Malian colleagues could ask me – “Qui va gagner?” Sheltered from slandering political ads, detailed commentaries on candidates’ stances on the war in Iraq and the economy, swaying polls and endless endorsements, my pride may have been uninformed and naïve… but I was nonetheless proud to be an American.

A few hours after the 4am phone call as I rode my bike through the sleepy, early morning streets of Bandiagara, I drew cheers as fellow residents, most likely unable to read or write, yelled, “OBAMA!” in my dusty wake. While I had felt momentary sadness at not being in America for such a magnanimous event, I could not help but feel that those Americans in Africa were able to celebrate in a unique and special way. We have front-row seats to the unfettered display of hope that Obama represents to the rest of the world. This vantage point is bittersweet because we know, likely better than our cheering African counterparts, that current domestic realities may indeed hinder his international efforts. While I worry that Africa may be disappointed, I know that only time will tell.

Because I missed all the election coverage living in the field, I was determined to watch the Presidential Inauguration now that I live in the city of Bamako with plenty of access to cable. I went alone to a hotel bar after work today and arrived just in time to see the pre-ceremony mulling-about. I, along with four Malian bartenders, a Ghanian hotel guest, a Kenyan and a French woman, remained glued to the screen for the hour of festivities. While I could easily think that I lent authenticity to the group as an American citizen, I realized that the new Presidency transcends nationalities like never before in history. Yes, I was likely the only one with teary eyes during Aretha Franklin’s rendition of “My Country ‘Tis of Thee” but when our new President gave his Inaugural speech (complemented by a overlaid nasal French translation courtesy of EuroNews), the section directed to “the poor countries of the world” did not fall on deaf ears in my mixed African company.

Today, hopes soared not only in America, referred to in the President’s speech as “the most powerful and prosperous country on earth”, but also here in a poor, oft-forgotten West African country. Tonight, in villages across Mali, when villagers gather to watch the one local Malian channel on the sole rabbit-eared television that is shared by the entire village and powered by an old car battery, they will see a one-minute news clip of the son of an African immigrant taking the most powerful office in the world. This will be repeated in innumerable villages across the African continent and hope will be boundlessly magnified that life is going to improve. Let it be. Oh, let it be.

Epilogue

After sharing such a traumatic event hours after it happened when I had so few details, I thought it only appropriate to provide you with the follow-up to this sad, tragique story.

The entrepreneur, as they are called here, had negotiated the contract to build the water tower as part of an ecotourism project funded by USAID. In an effort to cut corners and keep the extra money, the entrepreneur did not build to code using more sand as filler, and presumably less concrete, during the construction of the water tower. He also purportedly did not use iron supports when building the chateau d’eau. Therefore in his attempt to pocket US government funds for personal benefit, he constructed a shoddy water tower that collapsed on my two friends when its basin was filled with water.

When the tower collapsed, likely around 10am, the villagers proceeded to remove the large pieces of concrete and stone that had fallen on my friends. The entrepreneur decided that my one girlfriend was already dead and moved her body into a room in his house. They then loaded my other friend, who was still conscious, crying and very much awake, on the camion and brought her to Bandiagara Hospital. After the fact, when asked repeatedly why they did not bring BOTH girls, the answers are weak.

Il n’y avait d’éspace pour les deux. (There was not enough space for two.)

L’autre etait déjà décédé. (The other was already dead.)

The mounting frustration with answers such as these is hard to ignore, hard to repress. I feel the same frustration when parents do not bring their children to the clinic when they are sick with fever or vomiting, but rather they wait until they are in a coma from the malaria that is ravaging their brain. As with this, it is indefensibly wrong to me that a random villager with no medical training is able to decide if someone is dead, to deny her access to care, to tuck her away in a room in a house until the medicin-chef arrives a few hours later to snap a few pictures for his report and declare head trauma.

After my other friend arrived at the hospital and fluids were started, the intern loaded her into the one working ambulance to transport her to Mopti for further care for her open femoral fracture. She said upon arrival that our other friend was still in the village and was more severe, yet it still took a minimum of 2-3 hours before anyone could get to this village 15km (only 10 miles) away from Bandiagara. Why? Why can’t we use the other two ambulances to go to the village?

Ils sont en panne. They’re broken down.

Why did the medicin-chef take so long to get there? I tried my best to gingerly ask him these questions afterwards. If we knew at 11am, why did we not go until 2pm?

L’information ne passe pas, I hear. The information is not passing.

While I am familiar with the pace of life here and would not be surprised if he decided to have lunch first, the main excuse I seemed to have heard for the delay was that she was already dead. As proclaimed by a villager with no medical training, I reply trying to be respectful, repressing my anger at the deplorability of the situation. Surprisingly, he agrees with me and commiserates. For him, this is how things are. He is the sole doctor in the National Health System for a huge territory in poor rural Africa and he knows no other system for delivery of timely and efficient medical care. It does not exist.

When reconstructing this very nebulous timeline, I still never quite understood exactly when my friend’s body was finally removed from the village and brought to Mopti but I know that it did not arrive at the morgue in Mopti until closer to 6pm. Mopti is one hour from Bandiagara. In a country where appointments are unheard of because people do not own watches, a rendez-vous is simply scheduled based on matin (morning) or soir (afternoon-evening). Hence it is difficult to answer these questions. There are gaping holes in this timeline. I apologize. I asked questions, perhaps more than I should. Apparently, I even made my quasi-boss, the medicin-chef, nervous because he asked me if the “FBI” would be involved – which is the only investigative American bureau that he knows thanks to the fact that the TV series 24 airs on Friday nights at 11:30pm here. I assured him that they would not be involved, particularly given they are a domestic bureau and we are in Africa.

My other friend arrived in Mopti in the early afternoon. She did not have her purse, wallet or information with her and securing medications was a problem. In Mali, you are given a prescription at the hospital and someone must go to a pharmacy and get the medications for you. Fortunately, the intern from Bandiagara had accompanied her and helped smooth the process as best he could until others arrived. The surgeon operated in late afternoon and stabilized and closed her leg. She spent the night in the Mopti Hospital with Peace Corps and other friends in the area. She was taken to the airport at 6am the following morning because no one knew exactly when the medical evacuation jet would arrive from Togo. My friends who were present who outraged by the fact that she waited without medications in an un-air-conditioned ambulance on the side of the tarmac until the plane showed up at 11am.

Upon arrival in Paris, she was admitted to the ICU and received several surgeries for her leg. While she had been fairly clear and lucid in Mopti in order to make decisions and converse, her state of consciousness dissolved as a likely combination of heavy pain medication and a drop in adrenaline as the seriousness of her injuries took hold of her body. When she would waken, she would cry as though she would remember fresh the accident. She developed a serious infection in her leg amongst her other injuries and the French doctors debated whether she would be able to make the trip to America where she needed to receive another urgent, life-saving operation within 24 hours. Finally, she was sent via air-ambulance to the East Coast. Unfortunately, the infection was too serious and the American doctors amputated her leg this week. She remains in critical condition and has not yet awakened to learn of her losses. We fervently hope for her rapid recovery and rehabilitation while anxiously awaiting what the future will bring.

However, the sad finality of my other girlfriend’s fate is unchangeable – in spite of constructing timelines, interrogating others or asking hypothetical questions of “What if…” Her body was expatriated and she was buried in El Salvador the following week with her family and fiancé present. As a testament to her contribution in Mali, two separate services were held – first in Bamako and then in Bandiagara – people arriving with food and t-shirts to fill a church, her office, a director’s house. Between the two ceremonies, testimonies to her character were given in a number of Dogon dialects, English, French and Bambara, but the tears shed universally communicated the loss of a friend. While her life was cut short brutalement, her future endures as it continues to exist in the legacy she has created in this sandy, dusty, oft-forgotten corner of the world. At both memorials, the temoinage was extensive as person after person stood up to bear witness to her greatness, to provide their memories, to share their grief, or simply - to rejoice in her soul.