A Quick Note to All

We're sorry it's been a few days since our last post. We've been busy and our internet access has been limited. Go figure. Our time here in Maputo is closing and we're heading north to Inhambane tomorrow for a little change of scenery. We will send along a few more posts as we get more time to think about what we've been doing for the past 4 weeks.

Happy birthday to Paul Mann. We'll be ready to celebrate upon our return.

On our next post...
How a simple 24 hour adventure to South Africa can turn into an odyssey of oddities. Wildlife and exotic animals were abundant - and that was in a Nelspruit pub!

Enjoy a couple of photos of us doing stuff.

Indian Dinner

Last night, Erin and I were invited to eat copious amounts of amazing Indian food. It was completely vegetarian and, yes, it was all lovely. CC, be aware that I will bring back recipes for a couple of the relish items that were force fed on the side. One of the attending physicians at the Heart Institute, Dinesh, invited us to dine at his parents home in Maputo. So we said yes. upon arrival we were introduced to his mother, father, sister-in-law, brother (who had just walked in the door), and his nephew - all of seven years old and capable of quoting every current and archaic American catch phrase completely out of context. Cool, Dude, Know what I mean, Jump High.

We were offered a glass of whisky because that's what American drink. I accepted, so as not to be rude to our hosts. This is when the strangeness began. Dinesh started searching through the TV cabinet for the "open" bottle of Chivas Regal. After looking through roughly 6 unopened bottles of Chivas, it was finally accepted that there was no open bottle and a new bottle would need to be opened. This was all quite humorous because no one in the family drinks alcohol.

We then were privvy to the family photo album and viewed the photos of Dinesh's brother, who lives in Texas, at their sister's wedding here in Maputo. Got it? Good. The wedding photos were great and Dinesh's brother looks to be a nice man. Hard to say, but we were encouraged to call him when we return to the states. The family, including Dinesh, seems to be very proud of Dinesh's brother (maybe even more proud they than they are to have a doctor in the family.) because he lives in America. Priya, maybe we can find you a nice husband, eh?

At any rate, Dinesh, Erin, and I sat down to eat and were promptly shown the spread. There was way too much food for the three of us and we kept waiting for mom, dad, sister-in-law, kids - anyone - to join us to eat.

Long story short, I overate, Erin filled up (remember, all veg), and we had a great time. We were invited back, so, good one for us.

Today is hot again and we are getting geared up for our holiday up north. We'll keep you posted.

Comfort Zone?! Erin's Post.

Yes indeed, despite all of our posts about sightseeing and playing with the kids, we have in fact been working…and I would like to take this post to describe what I have been up to from a medical perspective.

I think you all know that I spent some time in Ghana as a 4th year medical student, and it has been since then that I have been dying to come back to Africa, this time equipped with actual skills I could use. In planning for this trip, I tried to avoid working in large University-type hospitals or with Pediatric Cardiologists because I truly wanted to have a new experience, to be able to contribute tangibly rather than just observe. When we finally chose to come to Mozambique, we thought I would be working in a newly established rural HIV/AIDS clinic, me serving as the only actual pediatrician—perfecto! When that project was delayed, Jeff and I both had to quickly find other ways to be useful here; indeed, as you know if you’ve been following the blog, with literally one week left before departure, we were still only had a vague idea of what we would be doing, where we would be staying, etc. So, unlike Mike (one of two very dear friends of ours who are currently being pediatricians extraordinaire at a mission hospital in Kenya), I had NO assumptions going into this trip—in fact, the only thing I was sure of was that my comfort zone would likely not make the overseas flight…and boy was I right.

So what am I actually doing, you ask??? Well, as I have mentioned, I am spending Tuesdays and Thursdays working at the Maputo Instituto do Coracao (or Maputo Heart Institue) by the gracious invitation of the program’s director, Dr. Beatriz Ferriera. It is a private NGO funded primarily by donations as well as by “working relationships” with some of the areas larger companies, meaning that the institute provides medical care for employees of these companies for a significant discount. The facility is on the site of a military hospital (one of those working relationships I was talking about), and it is quite well-equipped. There are 4 Enferiemas (or wards) which are basically big rooms, each housing 3-5 inpatient beds. One of these is the Pediatric ward where I spend the mornings seeing patients and helping to write notes or orders (that is, if I can understand what the hell they said on rounds which take place solely in Portuguese—if you think learning another language is hard, try talking about complex heart disease...). There is also an intermediate care unit which can be converted to an ICU if mechanical ventilation is needed, but for the most part, they try their best to manage patients in the general wards because of nursing and cost issues. There are 3 outpatient consultation rooms, a few pretty nice ECHO machines, and even a cath lab. The diseases I have seen here are a little different than back home, but the pathology is very interesting with great physical exam findings—lots of Rheumatic Heart disease, HIV related cardiomyopathy, and interestingly, Mozambique has the world’s highest incidence of Endomyocardial Fibrosis. The physicians are very well trained, particularly in the area of physical exam, and they really challenge me to listen and explain what I am hearing. Then, we go get the ECHO machine and see if we were right. Yesterday, I even did an ECHO myself!!! The Doc who was helping me printed a picture so I could show my dad and put it in my scrapbook. Pretty cool. Next week I am going to the cath lab…☺
Unfortunately, despite my best efforts, the language barrier has admittedly limited my ability to help here, and I do feel very much like a medical student again, very far from my comfort zone of knowing what to do, who to ask, or at least how to ask it. But, boy am I learning. And perhaps one of the most important lessons I have learned at the Institute is how to deal with the problem of knowing what to do and not having the means to do it. Last week we saw a 12mo with Down Syndrome and a PDA who will never be operated on because he has Down Syndrome—he will die early. Several children go without operation because their problem is not recognized until it is too late. Others would do fine except they cannot afford their medicines. On the other hand, there is a little boy who will stay an inpatient until March when the next Cardiac Surgery Mission Team comes from New York to fix him; he is stable now but he is from the far North of the country and they fear if they let him go they will never see him again. So we do what we can.

Which brings us to the other half of my week where I am acting physician for Kutwanana Home Based Care project. This project is headed by Pastor Patrick’s wife, Grace, who has about 3 weeks of medical training, and who organizes a collection of about 20 volunteer ladies from the church who have absolutely none. On most Mondays and Wednesdays, we go deep into the village to visit the homes of the patients who are deemed most needy. As you can imagine, not all of these are children (comfort zone, where are you???) and many of them are bedridden with musculoskeletal problems, malnutrition, you name it. A significant number of them have HIV/AIDS. The first day I went out, I just kept thinking “what am I supposed do with these people…they are already dying???” And then I remembered a story my dad told me, of which the moral is that sometimes the most important thing you can do as a doctor is to prepare the family for the patient’s impending death, to be honest, to provide comfort, to allow them to ask questions and make plans. So that is what we do when we need to, something I don’t think has been done much before.
When we are not making home visits, I see patients out of Grace’s office at the church, our own little makeshift clinic. Again, I see both children and adults here, and have diagnosed things like tinea, eczema, ear infections, cellulites, acid reflux, and zoster. We do what we can at the church, and if I think a medicine is warranted, then Grace and I go later that afternoon to the pharmacy and see what they have that might work. Talk about knowing what to do and not having the means! Last week I saw a 21yo young lady with an abscess the size of a golf ball on her cheek, a LARGE golf ball. It soooo needed to be drained but all I had was my pocket knife and a pair of tweezers, so I told her to go to the hospital as quickly as possible…she said OK, but I haven’t seen her again and I am very worried that she did not go. But again, we do only what we can.
Perhaps the most lasting difference I will make is during the short teaching sessions I have with the volunteers on Fridays. The first day we talked just about HIV/AIDS. I hope to offer some tips on treating basic kid stuff before I go, because as my time here comes so quickly toward an end, I think teaching is the only way to offer any sustainability for what we have done so far.

Indeed, as Jeff and I are both finding out, there is only so much we can do in a limited about of time with limited resources, in a place where problems are so deeply embedded into the culture that they are not even recognized as problems. All we can do is provide new information, offer a new perspective, teach an alternative way of doing things…and hope they remember. As for our actual time here…the hours we have spent working, thinking, trying, playing…we are the ones forever changed.

Thank you all for your continued prayers for wisdom, patience, safety, etc.
And Paul, thanks for taking care of Joaquim. We’re glad you like him.

Some photos of our work

I have taken refuge today in one of Maputo's ultra fancy, rich people's hotels. It's one of those places that locals have heard about in stories as children. You know the kind - "up on the hill, overlooking the ocean, there is a palace. In that palace there lives a mysterious people. Their skin is the colour of alabaster concrete and they only leave the palace to fly in giant, noisy birds."

At any rate, it's pretty sweet and they have free wireless internet. This is also pretty sweet, as I continually get cut out of the phone system when trying to dial up in other places.

Erin mentioned in the last post the temperatures (49 degrees Celcius is wicked hot) and our time at work or church. I'd like to say that we'd been going to church daily for spiritual guidance, but in reality, "church" is the term we use for the Kutwanana orphan and home-based care program - conservation of words is a must in this heat - because that's where it's held. As for work - we're living in a country whose citizens have no history with proper health care and it's children are growing up where there is no emphasis on the future. So, our work, when we look through American eyes, is very frustrating. When we look at the big picture though, our presence might be a whole lot more than these people ever get or expect. It's challenging and overwhelming and it's probably a good thing that there are no bars near. Because this could lead one to drink (more than...you know what we mean.!)
Just clarifying for you what we're doing.

On Maputo, Concrete, and Technology

**Please note that due to technical difficulties, this post was written yesterday (Monday) but is being posted today (Tuesday)**

We awoke as we do most mornings here, at 0530 (at least here it is because the sun is coming through the window and not because I have to be in the ICU in 30 minutes), each peeling ourselves from our respective sheet, thankful we at least have a fan to circulate the oppressively hot and heavy air throughout our little cement room (imagine a brick oven that you might use to bake things—or people—with). After a cold shower (which is likely the only 10 minutes of the day we might not be sweating), we share breakfast with our front door open as to try and let in some of the cooler morning air. The view from our front door is not all that breathtaking as it is comprised mostly of the cement wall that surrounds the grounds of the Dutch Reform Church where we are staying. Every once in a while, we hear a rooster crow or a Muslim call to prayer in the distance, or someone on their way to the church wanders to the water spigot that is located in our “front yard”. Not uncommonly, we hear voices outside the wall and notice women walking by as marked by their basket of wares which bob just above the surface of the wall. We often make bets about what’s in the bag—today it was a baby bobbing along, either hitching a ride on someone’s neck or a really tall baby!

Anyway, after breakfast, we typically are off to work or church, but today, we took an extended weekend as the Mulenga family was traveling to South Africa to see their youngest daughter off to boarding school for the term (and any work we would have done today would have fallen on non-English speaking ears). So we walked to the center of Machava to catch a chapa into Maputo for further exploration. I think we have mentioned before that a chapa is a taxi here, much like the tro-tro’s of Ghana and the combi’s of Botswana. We’ll talk more about them later, but suffice it to say if we weren’t quite sweaty yet, a 20min ride standing between dozens of sweaty people made it so.

On arrival to town, we squeezed out of the chapa and began to navigate the city once again, taking in all of the sights and smells (some not so pleasant!) and trying to explore some of the nooks and crannies we missed the first time around. Today, after much hard work and determination, we managed to purchase a really cool Mozambique T-shirt for Jeff, a new pair of sunglasses for Erin (as hers are now laid to rest at the bottom of the Indian Ocean, a casualty of wave jumping), and a collection of postcards for loved ones that cost us no less than $30 (that is more than we paid for bus tickets to ride half-way up the country!!). At one point, we had the pleasure of meeting with Felipe Berho, one of the very important members of Vanderbilt’s team, working here in Maputo to get the clinics in Zambesia up and running. He is a very gracious man, offering to help us out in any way; we made plans to see him again over dinner and live music some night before we leave!

After our meeting with Felipe, we found an Internet Café, with “AirCon” and all, just asking us to take a break from the heat to catch up with you all! Turns out, not 10min after we logged on, the server went down. So lets take a moment to think about the irony in that situation—for almost 30min we sat in an Internet Café called "African Communications", waiting for none other than internet access, all the while Michael Bolton singing to us that all we needed was “time, love, and tenderness”. When a parrot from the pet store down the way walked into the café and squaked, we took it as our cue to head out. Unfortunately, as we would discover about 20 minutes (and several blocks) later, we had left our little digital photo storage device at the café, so we made a bee-line back, hoping it would still be there. It was, and we successfully retrieved it just in time to enjoy a much needed cold beer before our chapa ride back into town.

This ride was a doozy. Now, chapas are not known for their luxury accommodations or flawless ride, but riding at rush hour is a different experience altogether. Imagine a can of vienna sausages, except they are people and they smell worse. Truly, after barely squeezing onto the bus, I (Erin) found myself precariously positioned with all of my weight balanced between one leg (which may have actually twisted off with any wrong move) and the other arm (which was holding on for dear life to the handrail above). I would like to think that the utter strength of that arm in its buffest flexed position was keeping me upright, but the truth is I couldn't have fallen over if I had tried being that I was propped up on all sides by people. From where I was standing, I could see the young man in the window seat who had his nose covered with a rag, looking like he might lose his lunch out the window at any minute--I felt sorry for him and at that point realized you really couldn't live here if you were claustrophobic or were routinely carsick. As I watched this guy choke back his junk, I struggled to keep mine in its own place, because if I would have lost it, it would have gone straight onto the head of the beautiful baby who was staring up at me over her mother's shoulder, bare breast in her mouth just chillin' out. I entertained myself making faces at the baby who happily smiled back, just hoping that it was Jeff's arm around my waist. At each stop, we prayed for someone to get off, but no such luck, just more people on! Thankfully, our driver was skilled and the potholes were not too unbearable, but we gladly got off a few stops early to begin our last small trek, arms numb and knees aching, back to our little oven, thanking God again for our safety, our health, and our fan.

The Road from Machava to Maputo

First, close your eyes. They closed? Good. Now picture what you think Mozambique (or any southern African nation that you can think of or spell) looks like. What do you see? Well, what we see here may or may not be like anything you’re picturing. Sally Struthers showed the sad parts – babies taking care of babies, neither of whom have enough food to feed themselves much less their extended infant tribes. The Lion King illustrated the majesty of the bush – as it exists inside the better game reserves in South Africa and Botswana. The collision of cultures, traditions, and technology is humorously portrayed in The Gods Must be Crazy. And Tsotsi (if you haven’t seen it, rent it – PLEASE) demonstrated the brutality of poverty on the youth of Africa and the innate human capacity for compassion in spite of condition.

Our picture of Africa is some and none of that.

Perhaps the best illustration we can give you of our Africa is to try and describe the road from Machava into Maputo city proper. We make the trip several times weekly now (in going to and from the Heart Institute, running errands, for a night out, etc.), and it still never ceases to amaze. It is it’s own microcosm – that road is a “developing nation”. The road itself is fairly nice (by African standards), paved and frequently traveled. If you have to be somewhere, be sure to allow extra time for “rush hour” at the expected times. Note however, that the back-up that occurs seems less related to sheer volume – which is admittedly increased at these time as folks from the outlying neighborhoods jam themselves and their wares into chapas to travel to and from work – but more a factor of the scattered massive and many potholes which simply refuse to accommodate even a modest increase in commuter traffic. These lesions infect the lowest lying parts of the road and are most likely the remains of the floods of 2000, which have still not been adequately repaired. Mind you, as you go you might run into a few young men who spend their days filling the potholes with sand, rocks, debris…and then asking passing drivers for money. Wonder if the TDOT would approve of such a method of road renewal?? Anyway, as Jeff navigates the potholes (driving like a true local…forcing Erin to carry an extra pair of underwear with her on each journey), we both peer out the windows in awe.

Out of Jeff’s window (to the right, here!) we see what looks like great strides toward recovery from years of war and natural disaster – a big fancy BP gas station with an immaculately kept lawn, a huge shiny building that is one of a few local breweries (Mac-Mahon, pronounced here “doyz-em” or 2M…and yes, if we find out they give tours, we are totally going), and rows of cement homes and apartments. From this window, there are a few modern high rises in various states of construction – most appearing to be in a period of slumber. This view is sparse and leaves us wondering what’s next

Out of Erin’s window however, we see a totally different picture – a picture screaming of poverty. On that side, the section of road farther from town, boasts a fairly wide expanse of farmland, which is divided into small gardens tended by townspeople. At any given time, we will see dozens of men and women out watering their plots with watering cans, bending over to pull weeds or harvest their goods, silently acquiescing to the blazing sun. As we approach town, the road is lined by a row of shabby bars and “quiosques” with tin roofs and walls of plastic sheets, which flap in the breeze, selling anything from a roll of toilet paper to a cold Fanta to a cell phone card. Behind these bustling businesses, we see crowded neighborhoods comprised of tiny square huts made of straw – literally. At this point, these neighborhoods are perched above the road, which is running parallel to a concrete-tiled drainage canal. The sloping walls of the canal drop 20 feet to the bottom. Sometimes the canal has some water in it and we have, more than once, seen little kids filling their water jugs with that water a few feet downstream from someone else who had been using it as a latrine. That concrete slope is always littered with trash...lots of trash…enough trash to require mouth-breathing.

Looking from one window to the other, we wonder which is the view of the Mozambique to come. It’s hard to imagine our Africa any different than this. There is a simplicity that is both comforting and concerning. Comforting because it lacks any pretension and it is what it is – people moving and working to stay simple. Concerning because it is that simplicity that struggles to support the apparent need to keep up with the rest of the world. We kind of hope for a little of both.

Happy Birthday to nossos Irmaos (our brothers)

Also, happy birthday's to John and Dan.
We thought for your respective birthdays that we'd come to Mozambique and buy you each a postcard.
Cool, no?!
Chau
Jeff and Erin

Proof of our locale

I thought I'd take this opportunity to post while E was out in the village being "a Doctora Erin." The quotes necessary to inform of the Portuguese title "a Doctora".

At any rate, she's wandering around the village going house to house to heal folks in need of healing and I am sitting on my can recovering from yesterday's heat and work. I spent the day working with the orphanage's teachers. Language is no barrier, especially when you've got someone there to translate for you (thanks Shula.)

Erin had her first full day at the Maputo Heart Institute and loved it. While communicating was rough, she's an adventurer and a scrapper. I'm sure that she will have much more to say about her first day there, so I'll leave that.

Enjoy the photos. Some are work; some are play. You make the determination yourselves.


In case you were wondering where we were.


Mama's at Kutwanana with a new baby.


Jeff, Erin, and Shula enjoying umas bebidas in Maputo

Sunday Off

Folks, this post will be brief.
Sunday saw us at our first Mozambique-an church service delivered in Shangaan, Portuguese, and some English. Hot and a hoot. Beautiful voices, beautiful children, and a welcoming congregation.
Abbreviated notes:
1. Driving is not too hard here, but one must be aware of where the sun is relative to your arm hanging out of the windows. Erin's left arm and my right arm are thoroughly paired. Mike, we feel your pain.
2. We taught Shula how to drive her own car. Drove way out to the farm (to be defined in a later post) and gave her the wheel. No place to learn like the African bush. If we accomplish nothing else...
3. Children are almost always beautiful and willing to have staring contests.
4. Priya - It is most definitely "brown hot!" Farm work for tomorrow has been cancelled on account of the "Brown Hot" Advisory.
Chau for now.
We miss you all
J And E

It's Africa Hot

As is traditional in Africa, things will happen - but in their own time. We woke early this morning only because the sun was up and our eyelids were the only things not stuck to the sheets. Our first task of the day was to get to the Maputo Heart Institute for a meeting (o reuniao) with Dr. Ferreira, the institute's director. We have been given the keys to one of the Mulenga's cars (a Toyota Something-or-other) and free reign of the streets. CC can attest to the fact that I am skilled at the right-side drive automobile, but am challenged with the turn signal switch v. the windshield wiper switch. Left turns can really obscure one's vision if the windscreen is 'buggy.' Erin is the essential navigator as the roads are potholed (read: craters of the moon) and the avenues are infrequently signed.

At any rate, we made it to the institute where we were warmly greeted by Dr. Ferreira. She gave us the skinny on the history of the Instituto do Coracao (ICOR), toured us through the center, and invited Erin to spend as much time there as she'd like. This little organization is quite amazing considering the governmental restrictions on non-governmental organizations (NGOs). ICOR, in it's 5th year, has done over 500 corrective heart surgeries, many on indigent children for free. The equipment, save a cardiac cath machine from funds donated from a French company, is all used and donated. The clinical staff are all well trained in Portugal, France, Sweden, and the UK, as well as right here in Maputo. Recently, though, technical and administrative staff have been developed locally. Young adults who have demonstrated academic competency have been given jobs as orderlies and trained during their service. This is a great service the institute provides to the local economy (with 30-40% unemployment in the skilled and professional sector) and it helps with program sustainability. I'm sure Erin will like to tell everyone more about it as she will be working there as part of the Team.
Then, Jeff tried to buy a t-shirt off of the back of some guy. Unfortunately, it was the wrong size. But, after a couple of phone calls and a day's wait, the shirt (new and sized) was purchased.
Then we went to a birthday for a little girl living in the village. We were greated with kisses and hugs from the WHOLE FAMILY - including grandma and grandpa. This family spoke, primarily, Shangaan, so we had no idea what they were saying. But, as the little girl, Paulina, was opening her gift, they all clapped and whistled. The older sister, Mizinha, was even crying from happiness for her little sister. It was good sport.
We look forward to more ventures into the community as our work begins more formally next week. We'll keep you posted!

Lost luggage and no room - the long story

Upon arrival in Johannesburg, we were told that there would be no accommodations contrary to our conversations with South African Airlines for the two months prior to departure. Oh well, we thought. We'll make do. So we went to claim our bags and found that one (the one with all the medical supplies and games for the orphan program) was missing. Ugh. No room; no supplies. This is the perfect beginning to an African adventure. BUT, like I always say, there is always someone else having it much worse. While I was dealing with the luggage mishap (next to a guy who had lost ALL of his luggage on the way), E took a minute to talk to a lady at S. African Air who actually knew the scoop on who to talk to in order to get taken care of.
So, within one hour, we were sitting in the lobby of the Southern Sun Hotel, drinking a complimentary glass of South African Shiraz and being informed that our "lost bag" would be joining us on our flight the following day and arrive in Maputo. After an elegant dinner, a great night's sleep, a filling breakfast - all courtesy of South African Air - we packed up and caught our last plane to Maputo.
It was evident from the air that Maputo is a huge city, still trying to recover from years of civil war and, more recently, catastrophic floods that drowned the city and killed the slowly growing tourist economy. But, it was encouraging to know that the country's motto - "Land of Smiles" - wasn't unfamiliar to the locals. Indeed, after we collected our bags (ALL THREE of them...YAY!) and quickly passed through customs, we were met by smiles and hugs from our new family, the Mulenga's.
Pastor Patrick, mom Grace, and our guide and friend, Shula, drove us around the north side of Maputo to their home in the town of Machava, just on the outskirts of Maputo proper. We were treated to a lovely dinner and were then taken to our lodgings for the month, just down the street at the site of the Dutch Reformed Church. Here, there are several rooms that are usually used by missionaries as they move between South Africa and Northern rural Mozambique; but since they are all on summer break, we've got the run of the joint. True, for mere pennies a day, we have been blessed with a bed, a kitchen area (with fridge and cooking options), a flushing toilet and a shower (with hot water nonetheless). Better yet, it is just a short walk from Pastor Patrick's church and the Kutwanana program run by Shula and her mother with whom we will be working for the month.
With only a few days under our belt and already more than we could have imagined, we can hardly wait to see what is in store for us for the rest of the month. We'll keep you posted! Casa da Mulenga - The Mulenga's house in Machava.