Running water

A good month. It started with Halloween - the insanity of such a frivolous, fabulous holiday magnified by the bewildered Malians as we stepped out of the Kita house dressed as super heros, millet stalks, Bush taxis and a vertitable cast of characters. Kristen and I went as two mut huts, complete with a broom shoved on our heads for our straw roofs. Costumes slowly stripped away as the night blazed with dancing, plastic bags of gin and hulahooping. There is such a luxury that comes with letting your strange Americaness float comfortably among other Westerners, flinging off the awkwardness that cloaks you in village as you fret to cover your knees and respect the cekorobas (old men). Speaking of which, I heard a fantastic Malian proverb the other day:

"You can jump over the old man's excrement, but you can't jump over his speech."

After Halloween a few of us jumped into Bamako for a few days. I had an HIV awareness meeting to attend, and we tried our best to soak in the Bamako goodness: ice cream, diet coke, chinese food. The post Halloween party was still roaring there, and we spent most of our time at our friends house, talking amongst the carved watermellon jackolanterns and the persuasive call of the Mosque next door at prayer time. Heading back we bumped into a fellow Kita friend and hopped on the night bus back to Kita, where the three of us squished into a two sear row as goats wrapped in sacks whined on the roof above us. When I came back I discovered that my computer had contracted a nasty virus - too many dirty flashdrives. Its out of commission until I get back to Bamako for training in December.

Despite my anticipation at returning to village - laughable Bambara, annoying children and ego challenges looming ahead - I reached the pink tipped millet fields and friendly straw roofs with a sigh of relief. The relief was short lived as I ran straight to the toilet, beginning my two weeks of contemplating the ingenuity of the Bambara word for diarrhea, konoboli (running stomach). Between bathroom trips though I was able to begin the incredibly uncomfortable experience of my Baseline Survey. My humility soared as I asked the chief of the village if he had heard of STIs and, not realizing I was talking to the Imam (Moslim priest), I asked, amid a cloud of 20 children, if he knew where to buy condoms. Still, I left each family with a sense of purpose, and I am ingraining my purpose into this village as I try to understand what my role is here. A representative for the Women's Association came up to me and asked if I could help them create a women's garden, which should be an interesting project. Thankfully my site mate is an environmental volunteer, so hopefully we can get that project started together.

The usual sadness still greets me at the health center though. A woman 8 months pregnant finally coming in for her first pre-natal consultation, so weak due to her severe anemia her husband finally gave her the money to come. As we put her on an IV a grandmother holds her one year old grandson convulsing with cerebral malaria, and she is screaming "Oh Allah!" over and over through glassed over eyes. We try to put an IV in the child's tiny hands and feet but can't find a vein with his extremities bloated with edema, the body's desperate attempt to keep hydrated depsite malnutrition.

As my language becomes more coherent, I have finally been able to make friends here, a task that is harder than it seems as many people either see me as a bumbling awkward outsider who can't understand a word or are trying to see how much they can get out of me. I think I might pull my hair out if I hear "Where is my present?" one more time. Still, I try to remind myself that manners is as cultural as anything else. And with real friends I am starting to have some real conversations about living here. As Soliba and I discussed the difference in families in our countries, I tried to explain why it was not only okay but even (fully aware of my Western ethnocentricity) better to have less children (7 is the average for Malian women). She was incredulous when I told her that americans have 2-3 children on
average, and asked me:

"But what if one of your children dies?"

From an isolated point of view this logic seems flawless - the more children you have the more they can work for the family. This is also one of the values that is written in the Koran. And since almost a quarter of children die before the age of 5, this loss must be accounted for. My limited Bambara tried to
explain that children in the US dont die as often because their
parents have fewer children, and can take better care of each one. But
who am I to tell them to reject their culture, and how do they grasp
that they can slowly get themselves out of poverty by having less
kids? (this is arguably the key cause of their poverty and the world's
food crisis).

Such a sad reminder of this vicious cycle of poverty and tradition.
Poverty perpetuated by tradition, naivety.
(Is this their leaders fault, or the population that doesn't ask for better?)
A need for stability through tradition perpetuated by poverty.
(Is this our fault?)
This shouldn't be something anyone should get used to.

After two weeks and many bathroom trips I headed back to Kita and discovered that I have a stomach parasite. Not really a shocker. We spent a few days with our tutor under the guava tree as I got through the intense anti-parasitic medicine which made my water taste like metal. Me and my friend jumped on the 1am bus to a big Thanksgiving gathering with tons of other PCVs. We made 20 pies, killed 5 turkeys and filled a bucket with fruit salad, another with stuffing and mashed potatos. The next day, despite our food and whisky hangovers, 12 of us decided to head to a nearby waterfall. All of us somehow squeezed into a sedan, and I spent the two hour trip with the clutch awkwardly in between my thighs. When we passed the Gendarme (police) stop a few people climbed onto the roof, ducking renegade tree branches as we bounced through the path as if on a dried up narrow river bed. We teetered on the narrow bridge made of a few bamboo branches stuck together and hiked, following the sound of the water. The waterfalls were incredible. We climbed up the rocks, hoisting ourselves up with vines, and jumped off the rainbow tinted waterfalls into the shimmering pool 20 feet below. Beautiful.

Trip to the Banana groves

 
 
 
 

Yesterday was another torrential rainstorm. Fanta grabbed me with words of "old woman" and "fever," and we went to see the old dying woman. We met up with Sangare, the doctor, who gave the unsuprising diagnosis - malaria - which is literally ravaging our village this time of year during the rainy season. We found her under bright purple sheets sown with green flowers, her shallow breaths contrasting with the feverent pumping rain. When it died down for a moment, she got up and walked, shakily gripping the walls as we sat shelling peanuts. As she reached the nyegen she looked back vacantly as the wind played games with her green headwrap. Her grip on the mud wall seemed to teeter between worlds, her stare exhausted and vacant. The next day I went out to the peanut fields with Fanta and a few other women. Our hands and heads and backs were filled with gourd bowls, radios, water jugs and little girls. We sat under a tree and pulled the peanuts from the roots as we exchanged warm but confused sentiments about farming and the village. Our picinic lunch of fresh sweet milk with millet and cut cucumber was refreshing, and I finally felt welome into this community of strong women, even though they make constantly make fun of my smooth uncalloused hands and lack of a husband. We left as again the black clouds rolled in, and ran the last half kilometer to the village as the rain slowly crept up on our heads.

I returned after the fields to give my blessings to the old woman, and then went to sit with Nasira as she cooked dinner - peanut sauce and to (ground millet patties) over a mud fire pit. The next morning the old woman had died. Fanta had no tears as she told me - she went on pounding millet. Of course, she had eleven children, another wife and a husband to feed.

10/13/09 ? I am losing track of the days...

Today I woke up after dreams of lying in Central Park listening to Belle and Sebastian with Gabby, a Starbucks white mocha frappaccino in hand. I was shocked to find myself under a mosquito net and a straw roof, listening to the donkeys morning wheeze. And there is no jarring sound like the donkeys first sounds in the morning - raggedly sucking in air in a tension filled shudder, and as soon as it seems like the poor malnourished beast's lungs have collapsed, it haws out a shrill choked exhale. Most of the day was spent in my usual way: mornings in the health center weighing babies, afternoon tea with the CSCOM staff, cooking lunch and studying Bambara as a crowd of aimless children stare at me, the evening tea and chat sessions followed by dinner with my host family. Still, I felt I was looking at my village through raw eyes, everything highlighted by the vibrant blue and yellow outlines that my anti-malaria medication fabricates. This is where I live? These are my neighbors, my friends, my co-workers? These straw huts with the swirling squash and cucumber vines - this is my home? What a strange, beautiful, simple world to be living in, so unlike the crisp, metallic New York! Even though the people asking me for money piss me off, the children laughing at my terrible Bambara is exasperating, and I haven't quite figured out how to successfully carry my water buckets on my head without getting soaking wet, its wonderful to live so intimately in this village. And despite the frequent loneliness that comes with being an outsider, and my (daily) efforts to get the children away who constantly swarm to my house (which is facing the school), I am amazed at how much I've integrated into the community in a month.

One thing I've been doing alot of is baby weighings at the CSCOM. During vaccination days on Mondays, women of the surrounding villages come, and I've tried to take this opportunity to weigh the 30+ babies there. In addition, almost daily children come to the CSCOM, for whatever reason, who are obviously malnourished. I've found that about 8 out of 10 children I've weighed are malnourished, either moderately or severely. Plumpy Nut, an ameliorated peanut butter distributed by UNICEF, has been a really helpful way to ensure that they are getting their daily protien and vitamin quota, which is so lacking in the typical Malian diet of rice and millet. But the French charts and guidelines are contradictory and confusing to me, and even more so to the other healthcare workers who seem to arbitrarily prescribe the peanut butter and make unconfident suggestions to the clueless parents. There is definitely something to the argument that literature and funding is great in terms of aid to developing countries, but taking the time to actually train the health workers in the rural villages is desperately needed, and inherently more sustainable than throwing money at a problem.

Where There is No Gynecologist

Preventing cervical cancer in low resource settings
By Dina Carlin

"Women are not dying because of diseases we cannot treat...they are dying because societies have yet to make the decision that their lives are worth saving."
-Dr. Mahmoud Fathalla, former president of the International Federation of Gynecology and Obstetrics

In a country where female reproductive health is barely on the agenda, cervical cancer is an example of how modern medicine has stopped short in Mali, largely due to the low availability of resources. Each year there are 500,000 new cases of cervical cancer worldwide, and more than 80% of these cases occur in developing countries (1). According to the World Health Organization, cervical cancer is the most frequent cancer developed in Malian women, with 1,336 new cases each year. Meanwhile, 1,076 cases of cervical cancer in Mali each year result in death. These figures are projected to double in the next 15 years (2). While these statistics are sobering, cervical cancer happens to be one of the most preventable cancers with even infrequent screening. A household condiment, it seems, may be the answer.
The development of cervical cancer, caused by certain strains of the sexually transmitted virus HPV (the Human Papiloma Virus), has been strongly linked to socio-economic status. The increased prevalence of HPV in developing countries, as compared to rates in developed nations, is linked to a comprehensive list of factors, including access to sexual education, age of first sexual intercourse (25% of Malian women have sex before the age of 15), and availability of medical resources. However, the high incidence of cervical cancer is in large due to the lack of access to preventative healthcare. It is estimated that 21.5% of women in West Africa are infected with HPV, and this number has been climbing. In developed countries with fluid, accessible medical technology, the 'Pap' smear, a standard part of a gynecological exam, followed by colposcopy (laboratory analysis of cervical tissue) are well established methods to screen for HPV and precancerous cells. In addition, a vaccine that prevents two strains of HPV most frequently associated with cervical cancer has recently become widely available, albeit expensive. These efforts have led to sharp decreases in cervical cancer worldwide, with the exception of Sub-Saharan Africa. The high cost of these procedures, untrained and inexperienced healthcare providers, and the need for follow-up treatment create obvious barriers for impoverished countries such as Mali.
New procedures for diagnosing cervical cancer have been founded on the need for inexpensive screening methods that require minimal training and single visits to the health center. Since cervical cancer generally develops slowly, screening every 3-5 years, sources say, can have a significant impact in reducing mortality (3). While not as effective as the Pap smear, and certainly not as empirical as cytology, VIA, or visual inspection of the cervix with acetic acid (also known as household vinegar) is a groundbreaking alternative for the developing world. An alternative is VILA, visual inspection with Lugol's iodine, which is a slightly more expensive alternative. It involves only spraying the vinegar or iodine on the cervix, where the precancerous cells turn white in the case of vinegar, or brown with iodine. The simplicity of this procedure involves almost no equipment other than vinegar (widely available in most butigis) or iodine, and can be administered by any health worker.
Treatment for cervical cancer is key, as 95% of cases become fatal within two years. While treatment options vary, one of the cheapest, easiest and quickest treatments for cervical cancer is cytology, which involves "freezing" the cervix using carbon dioxide or nitrogen dioxide, killing off the precancerous cells. Most of the materials are locally available, the training is minimal, and the 15 minute procedure can be carried out by non-clinicians such as Matrons. In addition, it has a very low rate of complications, with cure rates of 85-91% (1).
So what do we do now? Since sustainability is key, working towards training healthcare workers such as Matrones to screen and treat cancer would decrease the impact of this highly destructive cancer. Finally, education and screening initiatives, with the aid of NGOs such as Prevent International Cervical Cancer Now (www.pincc.org) or the Alliance for Cervical Cancer Prevention would help bring the issue of cervical cancer to the national spotlight. Turning to simple and accessible technologies such as VIA and cryotherapy can create the foundation for effective preventative care in reproductive medicine. With all the tools available here in Mali to fight cervical cancer, it is time to decide to take action.


1 Sanghvi H., Lacoste M and McCormick M (eds). (2006). Preventing Cercical Cancer in Low-Resources Settings: From Research to Practice. Report of a conference in Bangkok, Thialand, 4-7 December 2005. JHPIGO: Baltimore, Maryland.
2 WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). (2009). Human Papillomavirus and Related Cancers in Mali: Summary Report 2009. [Accessed October 2, 2009]. Available at www. who. int/ hpvcentre
3 Sankaranarayanan,R.,Budukh, A. M. and Rajkumar, R. (2001). Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bulletin of the World Health Organization. WHO.

En Brusse

Well, my first two weeks at my village have gone by, and I know this will be so much more challenging than I realized, and so full of beauty, friendship and rewards. I am already losing track of the days in this web of the Brusse. Sometimes it feels like I can turn my head in so many directions and still find myself plastered to the same spot; the same children with the same illnesses, the same sanitation deficiencies and the same lack of expectations. The language of simplicity though, while from an outside view is banal, creates such complex layers of relationships. They use charcoal fires in lieu of covalent ovens, and gather around the shaky radio broadcast in the pitch black. And yet they are, as a whole, one of the most vibrant and happiest people I have known. It is cliche, but they have nothing but each other to care about.

Back here in Kita, the 9 of us met up to celebrate getting through the first hump of living off the grid. It is a relief in a way to speak english and feel comfortable in my American skin. It is sometimes difficult, at site, to remember that you are in fact capable of normal social interactions. There is no challenge to the ego like your 12 year old host sister asking you, day after day, if you washed. I gulp down the cynical urge to ask her how often she cleans herself (or just her hands) with soap - and anyway, sarcasim is a concept unsupported in the language here. Instead, I manage an agitated/amused giggle at my sister's strange brand of hospitality, pointing to my wet hair. At this point, I wouldn't be suprised if she asked me about my bowel movements. Privacy, personal space, alone time - these concepts dont quite register with Malians. Enthralled with the novelty of having a white person so intimately joining their space, I have found that the one time I can acutally be alone is locked in my hut, drowning out their calls to me over my wood fence with my headphones. Each day, as hard as it is to leave the safety of my cool mud walls and wonderful english books, I push myself out to wander about - yalayala - through the snakelike paths around the fields and huts, stopping here and there to have tea with the breadmakers, joke with the boutigi owners about taking them back to America with me, or draw animals and portraits with the children. Right now, the feverent rainstorms has made my village overflow with vibrant green fields, and the plants literally sprout out overnight and have drowned the "path" to my cell phone service spot: a little worn down clearing in the middle of the cornfields.

The other day I saw my first natural birth. It seems that almost all deliveries here are made in the middle of the light, dramaticly lit by oil lamp. Of course it is because these women must wait till their husbands get home to get permission to go to the CSCOM, and the state of being 9 months pregnant does not excuse you from pounding millet, chopping wood and pulling water from the well. I remembered this girl from her pre-natal consultation last month. She had just turned 16. She looked petrified, her eyes as big as moons as she yalayala'd around the room, her amniotic fluid dripping down her leg. When she was dilated, the matrone jumped on a table behind her and began pushing down on her belly with all her might, as her mother and her sister, each with an infant strapped to their backs, held her legs open above a jagged plastic bedpan. She was completely silent through the hour long process, the only sign of her pain were her tears gathering in a puddle on the floor and one or two grunts. After my matrone pulled the baby out, she grabbed him by the feet and hit and shook him, yelling "Kuma!" (speak!), laying him down to clear his passageways and pump his chest. The baby was alive, but was almost as silent as his mother. She hardly seemed happy or suprised, as if this was all she had expected; and here it is. Today, talking about my experience with my friend Dave, he pointed out how distinct the difference is between their access to healthcare and ours. If any one of us PC volunteers have any medical issue that surpasses the normal gamlut of moderate bacterial and parasitic infections, we would be shipped straight to Washington, DC. Not even the best hospital in the whole country of Mali would be able to provide the adequate healthcare that we not only covet in the US but expect. Here, in brusse, this woman was lucky to have access to a health center where they clean their tools with bleach - most of the surrounding villages near me don't even have a maternity. The beauty of the 360 vision you gain from living in this village web is you can understand the problems here from so many levels, and try to find solutions that doesn't involve throwing money at them.

And more than anything, it is so incredibly challenging establishing my place in this village with this huge lanugage gap. Most of the people in the village speak a different minority lanugage than Bamabara, called Malinke, and it is frustrating having to be led around like a child. But, I have found that art is an amazing vehicle to teach, and out of my restlessness I painted a mural of the food groups at the CSCOM.

Overall it is great, and I am learning that Mali is a country of contradictions - happiness in simplicity and misery in deficiencies, love and happiness through family and community and imprisonment by it. And I am happy I am here to create even the smallest bit of moderation.

Swearing In

So as of Thursday I became an official Peace Corps Volunteer! After a greuling week of seminars at the training center and a very intimidating language exam (who knows how I passed...), we finally finished training. The swearing in ceremony was at the American Embassy, where we sat dripping in our Malian gear and pretended to understand the lovely French speech given by Madame Ambassador. The rest of the day was spent poolside at the American Club, where we got ready for our huge swearing in party. We all piled into a few clubs in Bamako (probably the most American thing about Mali), met up with tons of current PCVs, and were still roaring at 3am.
Right now I am in Kita, soaking up all the indoor plumbing, VHSs and market vegetables I can get before I plunge into my village. On Friday my sitemate Kristen and I will head to our nearby villages. While the thought of having to get by with my fractured Bamabara only with the only English speaker a few miles away is pretty frightening, I am so looking forward to finally making myself a home after living out of a suitcase for the past two months. Looking back on training, I am so struck by the unbelievable people I have met here -both PCVs and Malians - and am continually impressed by the immense value that volunteerism has in this country. Yes, it has been fun learning how to turn human urine into fertilizer, trekking to our boutigi for the occassional cold drink, and all crowding together to watch the occassional Flight of the Conchords off one of our laptops. But the dialouge I have had with so many volunteers and those who have worked with the Peace Corps had been one of such optimism. It is definitely energizing, and important to remember that even just sitting and having tea with my neighbors and comparing our cultures is progress. Dooni dooni (little by little...)!