Monday, August 14, 2006

All Photos Uploaded

Click here for the gallery of the Ethiopia photos from this trip.

Click here for the Somalia photos.

posted by daviduri @ 9:47 PM 9 comments

Friday, August 11, 2006

Slinking back into the West

On Friday I left Hargeisa without a hitch (although the USD$30 exit fee was a surprise).
 
For all the hype, the Daallo flight was quite normal. Very old plane, all the seats were broken so they bounced back and forth to full recline and back, service was dodgy, the air-nozzles didn't work, etc. Par for the course, I think.
 
The only thing that made the flight bad was the heat. We sat on the runway, with no air moving, and everyone started to sweat. As people became more and more hot, the din of chatter gave way to silence puntuated only be the sound of the paper flopping back and forth as it fanned people. After 20 minutes, I could see beads of sweat forming on my forearms. The Somali man next to me was periodically dripping sweat from his chin.
 
My plan was to sit, unmoving, like a lizard sunning itself on a rock, and just stop producing my own heat. This seemed to work, at least somewhat, and I sweated much less than the people fanning themselves around me.
 
Halfway through the flight, I felt water hit my arm and looked up to see that water was beading all along the ceiling, thick enough to drip large droplets. It's gross, to think of 60 peoples sweat pooling and then dripping onto you, but it was so hot that nobody cared.
 
The Djibouti airport had AC and was lovely, but once on to the next leg, from Djibouti to Dubai, the new plane was equally hot. We sat on the runway there for the better part of an hour. The heat was too much and I pulled out the plastic 'safety instructions' card and fanned myself vigorously until my forearms cramped.
 
The second plane was more modern and once we got into the air, they had a cooling system. The stewardesses apologized profusely, but I can't imagine it's ever any different. Djibouti is one of the hottest corners of the planet and if you don't have a cooling system that'll work while you're on the ground, you just don't. They played it off as if it was a one-time hiccup.
 
-----
 
I had a day stopover in Dubai and while I had some vague interest in going bead shopping, I really didn't want to be there. In the airport, I ate some chicken tikka masala and then went to the Emirates desk and asked to be placed on standby for an earlier flights to NYC. There was one leaving in three hours and I made my way over to the gate. I ended up boarding, almost twenty minutes after the flight was supposed to have left, because there ended up being a few "off-loads" despite it being a full flight.
 
Some mess of hours later, I touched down at JFK in New York. At customs, nobody was waiting to question me. That might be because they have no interest, though that seems odd since Somaliland is technically Somalia and there's been all this hullaballoo in the news over terror plots in the UK. Or maybe it's because I skipped the first leg of my tickets (from Addis to Dubai), ended up on an earlier flight from Dubai to NYC, because I boarded at the last possible moment, because my name was misspelled when it was entered into the computer for the Dubai to NYC flight, etc. In any case, no gabbing with the FBI this time.
 
Now I'm in NYC. While Emirates moved me to standby for an earlier flight for free, American Airlines said they wouldn't do it, despite four daily flights from NYC to SF, without me paying a $150 "change fee." That was, they said, because the flight I wanted a standby on was on the 11th and my ticket was for a flight on the 12th -- nevermind that they're within 24 hours of each other, etc.
 
San Francisco has my bed and New York City has new haunts to explore, but they're otherwise a wash. I'm as happy to stay overnight in NYC as I would be to fly to SF. I'm at NYPL now, googling up a place to stay tonight. I desperately need a shower after losing probably half a gallon of sweat on the flights from Hargeisa to Dubai. Shower, scrub, food, wander Manhattan all afternoon and into the evening.
 
Tomorrow afternoon, I'll be back in San Francisco -- "Baghdad by the Bay."

posted by daviduri @ 9:30 AM 1 comments

Wednesday, August 09, 2006

"But you can never leave..."

Well, I'm still in Hargeisa. My plans to go to Ethiopia have been scuttled.
 
I went to the airport bright and early this morning. I arrived at 7a for my 8:30a flight and the airport was mostly deserted. I walked right through customs and immigration and out onto the runway. I took pictures of the planes.
 
Half an hour later, a guard asked me where I was going and then promptly informed me that the flight was cancelled. We called the Daallo office on his mobile and they said the next flight was on Sunday. That's a bit of problem as my international tickets -- Orbitz, non-refundable, et al -- start Friday evening on Addis. Addis to Dubai to NYC to San Francisco.
 
I hopped a ride to the Daallo office, composing in my head the best method for getting the situation rectified and, secondarily, getting Daallo to foot any expense. I put my angry and exasperated face on and was quickly bumped to a manager. He and I explored options -- there're no other flights to Addis today -- and then decided that I could fly from Hargeisa to Dubai, bypassing Ethiopia entirely, and that Daallo had a flight tomorrow. Although I had plans in Addis -- dinner with Selam, bead market, the Fistula hospital for which I had a personal letter of introduction from Edna that I was going to hand-deliver -- Dubai seemed to be the only solution.
 
Of course, he wanted me to pay for the difference in ticket prices. Hargeisa to Dubai is much more expensive than Hargeisa to Addis Ababa. After 20 minutes of arguing, with me laying out clear, cogent explanations of where culpability lay, he conceeded and gave me the new ticket for free.
 
So, that's that. I'm back at the hospital today. Tomorrow I'll leave in the afternoon and fly to Dubai via Djibouti. ("And Djibouti, I still like Djibouti, doin' squats...") The airport is Hargeisa is too short to support jets, so my flight from here to Djibouti will still be on a puddlejumper. The flight from Djibouti to Dubai will be on a much larger, more modern craft.
 
As an aside, during the Communist days, the Soviets built a huge fuck-off runway on the coast near Berbera -- one of the longest in the world. It's sat mostly fallow, although in the 80s the NASA leased it for many millions per year as an alternate site for landing the space shuttle. Neato.
 
-----
 
This afternoon, I met two Somali sisters and their half-Arab friend, all on holiday from London. They've just started volunteering at the hospital, doing admin and filing and sorting the library. We had a four-hour discussion earlier today about Somaliland, the Somali people, culture clashes, Islam (and whether or not Islam is compatible with democracy, in particular). It was a great conversation. I'm going to have dinner with them at the Ambassador Hotel tonight. Which means... pizza! Awful, sloppy, Somali pizza, but pizza none the less. Or maybe a cheese burger. My "beef burger" last time was fairly bad, but I enjoyed feeding my dinner roll to the kittens slinking around the bushes. Skin and bones, whiney, awfully cute save for the obvious ringworm infections, little kittens. I took pictures.
 
I hardly took any trip pictures, despite having lots of flash memory and a battery charger with me. I don't know why, really. I think I see National Geographic photos and I desperately want to take similar photos as a testament to me being here... but then everything is boring. Hargeisa is a dusty, East African town, notable for nothing. Most men dress in quasi-Western style. Most women dress in beautiful bright colors and patterns but won't let me photograph them. Modesty, etc.
 
A few days ago, I set out to wander the neighborhood and just shoot photos until my battery died. I didn't get 100 meters before kids swarmed me, demanding I take their pictures. Correction, boys. There were a few girls around, demure, floating near the edge of the crowd, but they wouldn't let me photograph them. Eventually, a woman emerged from the masses and talked to me in English. She was sure, with my beard and my "Salaam Alaiykum" greeting, that I was Muslim. They want to know where I was from, etc. When I asked her about taking photos, I got a very interesting answer. "We don't want you to take our photo because we know you will show the photo to people and say, 'These are refugees.'" Refugees, of course, are largely Ethiopian, ergo infindels, ergo (and this is the most important part, I think) infected with HIV.
 
A few days ago, I had a taxi ride with two men who had an interesting viewpoint. "We are not black! We are like you. We are white. It is only because of the sun for so long that was look like this." He pinched his skin for emphasis. "We are not like Nigerian! We are white. If you stay here for one year, you will look the same as us." Nigerians, of course, are liars and thieves and have no honor and no pride, etc. It was disappointing to hear.
 
Later, talking to Ayan, one of the Londoners I mentioned earlier, she said she'd heard the same sorts of things here and has also heard much talk about "genuine Africans." "We are genuine Africans!" The rest of the people here in Africa are... not. They're Others, somehow less.
 
I want to jot down an interesting conversation I had with a British doctor, but I'm running late for dinner. He's old British -- interested in culture and empire and bettering the world with "civilization" and infrastructure. We talked for 45 minutes about nation-building and Iraq and Afghanistan and the NWFP of Pakistan, etc. More on this later.

posted by daviduri @ 8:37 AM 0 comments

Final Days in Hargeisa

Everyone here naps from 1p-4p, but I'm not really tired then. Or at least not usually. When we have an emergency in the middle of the night, the nap the next day is nice. I'm not "on call," really, because I'm not one of the physicians, but I've asked all the doctors to send someone to wake me up if there're emergencies during the night. At 1am, or whatever, someone pounds on my door, "David! David! There is a c-section... you come quick!"
 
So life here for the past few days has been more of the same. More D&Cs, more c-sections. We got two stroke patients in the medical ward. There's so little we can do for them without a CT scanner. We treat the symptoms and tell the family to keep trying to talk to them and keep trying to get them to move those arms and legs.
 
I was back at Hargeisa Group Hospital again on Tuesday for surgery. We did the urethra repair that was bumped on Sunday, removed a bladder stone from a one year old (no shit -- but there it was), placed a three-way catheter in an old man with a hypertrophic prostate (he's too weak to have survived a full prostatectomy), and then removed a bullet from the leg of a man who was shot in Ethiopia.
 
The last was the most interesting to me simply because of boyish fantasies surrounding removing bullets from people. I wanted to keep the bullet, but of course the patient wanted it to show his friends. "...and then! Bam! Right into my leg! This is the actual bullet!" Add appropriate embellishments until the story attains heroic proportions.

posted by daviduri @ 8:14 AM 0 comments

Sunday, August 06, 2006

Surgery, Diana's NGO, and Daallo Airlines

I went to Group Hospital this morning and, after two previous strike-outs there, spent the better part of four hours in the operating theatre with the Chief of Surgery, Dr. Sulaimon. (My favorite Neil Diamond song too. Double trouble!)
 
Our first case of the day was a thyroid adenomectomy. We used local anesthesia (lidocaine) and spent an hour digging our way down, easing the gland up out of the fascia, and then cauterizing off the vast majority of it. Zzt, zzt. I quite like the electro-cautery pen. As we closed things up, we put in a tiny tube for drainage. I've written "we" here, but I was only observing on this case.
 
Dr. Sulaimon invited me to assist on the second case. It was a prostate gland removal -- open prostatectomy. We cut into his abdomen first, then slowly cut our way down to his bladder. There we aspirated fluid with a needle to make sure we were in the bladder, not the intestine. Everything looked good, so we cut into the bladder and then had another assistant insert a finger into the patients rectum and push the prostate up toward our incision. Once we were certain of the positioning, we cut into the floor of the bladder and Dr. Sulaimon used his fingers to excise the prostate. After that, it was catheters in, suturing, a drainage tube, yadda yadda. Today's procedure was fairly simple really. It's the follow-up, recovery, complications, etc, that're potentially difficult.
 
Our last case was the removal of dead tissue surrounding an ulcer on the bottom of the foot. Our patient was young, strong, not diabetic, and had the ulcer for 12 years. When we removed the bandages from around it, the room was filled with an intense smell of BBQ. The ulcer itself was approximately an inch and a half in diameter, and necrotic, rotting tissue puffed out a good half inch for the inner 85% of that diameter. Dr. Sulaimon used the cauterizer to cut the tissue off, leaving a large hole.
 
As he worked, smoke curled up from the wound, filling the room with the smell of burning flesh. I was thankful for this. It smelled bad, sure, but it was expected bad -- the "cost of doing business" as it were. The BBQ smell was bringing back memories of cooking on the patio at work, the delicious BBQ restaurant in Oakland, etc. I was consciously trying to prevent myself from making the associations but as I smelled the meat cooked for dinner tonight, it seemed to smell exactly like that man's foot.
 
Punch "foot ulcer" into Google Images to get an idea of what it looked like, if you're curious.
 
The hole will be packed with betadine-soaked sterile gauze for months, I think, as they hope the tissue granulates and starts healing. It's possible that it could heal and fully close and he'd be able to walk normally for the first time in over a decade. Judging from some of the slides shown at the "Advanced Wound Healing" presentation at this years AAPA conference, I'm not especially optimistic. They don't use silver nitrate here and they certainly don't use advanced techniques like applying vacuum pressure to the surface of the wound.
 
We had two more surgeries scheduled but they were both cancelled. The first, a hernia repair patient, had a terrible cough. The other scheduled surgery was for a man who fell off a wall, catching his crotch on the way down, who had "urethra damage." For whatever reason he ended up eating breakfast that morning so we couldn't operate.
 
I'll be returning to Group Hospital on Tuesday morning for more surgeries with Dr. Sulaimon. For those of you keeping score: I wasn't even a smidge queasy during any of the stuff.
 
-----
 
After lunch, I hopped a taxi over to Diana's office today. She works for EDC, the Education Development Center, on a project called SIRIP: Somali Interactive Radio Instruction Program. They're writing scripts and producing radio shows to help educate the populace. Teachers, even in rural areas, will be able to tune in and listen to the program and guide students through exercises, stories, etc. Diana is a school teacher from Houston.
 
A few days ago, her husband, who's a concrete contractor with KBR in Iraq, came in to town and I joined them both for dinner two nights ago. Diana made Louisiana gumbo and it was delicious. Afterward, we played Monopoly. I thoroughly trounced them, taking early risks that paid off big-time later, trying not to snicker as I mercilessly drove them into the ground. The Monopoly set they had was Houston-themed. Boardwalk was NASA, one of the orange properties was the Astrodome, etc. My player token was an armadillo.
 
Afterward, we talked about education in the country, the dangers of travelling, etc, and I mentioned my upcoming Daallo flight. Diana mentioned that one of EDC's staff members was recently ambushed on a road outside Mogadishu. She was robbed and her driver nearly died from gunshot wounds to his legs. In the last few years, she's worked on contract, usually for a year at a time, as a teacher in China, Abu Dhabi (UAE), etc.
 
When I went and saw her today, she'd printed out a funny joke one of her staff had found. I've copied it below.
 
One of her co-workers is a Somali who grew up in the US from age 12 on. He's in his early 40s now, with a PhD, and has returned to Somaliland to coordinate this project. His name is Said. He and I spent a few hours talking, covering everything from George Bush to female genital mutilation to chewing khat to promiscuous Somali girls (!) to raising quadralingual (or pentalingual?) kids. I'd met him at the "ex-pat party" previously (it was at his house), but hadn't spoken about anything of consequence. This afternoon, I greatly enjoyed his company.
 
-----
 
Diana's gift was a sheet of paper. She handed it to me with a big grin.
 
It read, "Welcome to Daallo Airlines! Good morning, ladies and gentlemen. This is Captain Sharmaarke welcoming both seated and standing passengers on board Daallo Airlines.
 
- We apologize for the four day delay in taking off. It was due to bad weather and some overtime I had to put in at the bakery.
 
- This is flight 126 to Hargeisa. Landing there is not guaranteed, but we will end up somewhere in Somalia. If luck is in our favor, we may even be landing on your village!
 
- Daallo Airlines has an excellent safety record. In fact, our safety standards are so high that even terrorists are afraid to fly with us!
 
- It is with pleasure that I announce that starting this year over 30% of our passengers have reached their destination!
 
- If our engines are too noisy for you, we can, on passenger request, arrange to turn them off.
 
- To make your free fall to earth pleasant and memorable, we have complimentary tea and laxoox!
 
- For our not-so-religious passengers, we are the only airline who can help you find out if there really is a god!
 
- We regret to inform you that today's in-flight movie will not be shown as we forgot to record it from the television. But, for our movie buffs, we will be flying right next to British Airways and their movie will be visible from the right side of the cabin.
 
- There is no smoking allowed in this airplane. Any smoke you see in the cabin is simply the early warning system on the engines telling us to slow down!
 
- In order to catch important landmarks, we try to fly as close as possible for the best view. If, however, we get a little too close, do let us know. Our enthusiastic co-pilot sometimes flies right through the landmark!
 
- Kindly be seated, keep your seat in an upright position for take-off, and fast your seatbelt. For those of you who can't find a seatbelt, kindly fasten your own belt to the arm of your seat. For those of you who can't find a seat, do not hesitate to get in touch with a stewardess who will be happy to explain how to fasten yourself to a suitcase."

posted by daviduri @ 12:27 PM 0 comments

Saturday, August 05, 2006

War Stories, Cultural Oddities, and

Every night, I see outpatients with Dr. Deeq. It's almost exclusively antenatal stuff and I've taken over the ultrasound. The first day or two, the ultrasound seemed like pure divination, reading tea leaves. Looking at the screen was like looking for a dove in a blizzard. Since then, I've become more skilled with it. While I still can't find femurs or penises for the life of me, I can now nail the head (BPD), fetal heart rate, and placenta. It's fun.
 
In between patients, Deeq and I talk about anything under the sun. He's enlightened me on the khat economy, fat women, stained teeth, different styles of FGM -- female genital mutilation, social factors around pregnancy, STD infection rates in Somaliland, etc. A few nights ago, we were talking about the social stigma around seeing women. Husbands don't want you to see the face of their wife, even while she's giving birth, but if you leave her veil on you're welcome to examine the baby, etc. So peculiar. This is all contrary to the traditional nomadic Somali woman -- a strong, bossy, decision maker, deciding when to move to a new grazing area, which goats to sell at the market, etc. Edna thinks the current changes are a result of people wandering off into the nearby Arab world an picking up terrible ideas and habits.
 
Anyway, while we were talking about this, Deeq mentioned that he used to work as a doctor in Yemen and that they were far more conservative than anything he's seen here. He related a story about a husband and wife who came in, the woman having a horrendous pain in one of her teeth. The woman sat, hunched over, crying softly but saying nothing. Her husband stood next to her, explaining all of her symptoms, the history, how she was feeling now, etc. He was wearing a dagger on the front of his robes (the sheath is curved, but the daggers themselves are straight), had a pistol strapped to his hip, an AK-47 slung over his shoulder, and a grenade on his belt. When Deeq asked the woman to lift her veil so he could look in her mouth, the husband stepped forward and loudly objected. They argued and the man and his wife left, with Dr. Deeq saying that if he wasn't allowed to examine her mouth, he couldn't treat her.
 
An hour and a half later, the man returned to the clinic. He was smiling this time. "I have a solution," he said, and he proceeded to draw his knife and carefully cut a small mouth-hole into his wife's veil for the doctor to peer through.
 
-----
 
We have emergency cases come into the hospital now and then -- 8th month, severe bleeding, immediate c-section required to save the baby and the mother. Husbands, who decide if their wives live or die, balk at the prospect of surgery, refusing the sign the consent forms. Edna tells me that twice in the past, with women literally bleeding away on the operating table and husbands steadfastly refusing the c-section, she's gone to the nearby police station and told the commanding officer there that her and herself were going to sign the consent forms, laws be damned, and if the police chief wouldn't sign, the woman's death would be on his hands. "Let them sue us tomorrow! Tonight we're going to save that woman's life!" Both times, the chief has signed, over the protests of the husbands. (I swell with enormous admiration for her when she tells me this but I say nothing.)
 
I'm absolutely incredulous at this. Is it that our head surgeon is male? Is is some part of Islam? It turns out that a big part of the reason husbands do this is because of the language. To describe slicing open a living being, we have the word "surgery." To describe slicing open a living being in the Somali language, there's only one word and it's not precise. "Slaughter." That's right -- the Somali word for "surgery" is the same word used for "and then we're going to the market and we're going to SLAUGHTER a goat." The nurses here have to devise clever, roundabout ways of describing the procedure to fretful husbands. "We're going to... open... your wife... and then we're going to lift the baby out..."
 
There're other reasons for refusing the surgery, but the language problem has gotta be a big one. You're a peasant from a rural area, living life as a nomad, absolutely zero education, almost no exposure to the modern world. Your wife is dying and you're in a huge metropolis, sights and sounds you've never seen, and someone in the hospital asks you to sign a consent form to slaughter your wife. Would you sign? :)
 
-----
 
A few days ago, at lunch, Edna described being a nurse here in Somaliland during the war with Ethiopia in 1977. "We were in Jijiga [present day Ethiopia, but ethnically Somali], loading up ambulances and driving back to Hargeisa. We could only drive at night and even then we had to keep the lights off, for fear the Ethiopia fighter planes would bomb us. We had patients loaded on top of patients; some were on the roof of the ambulance. The driver would go very slowly without lights and, when he couldn't see the path, he'd get out and walk ahead with a small flashlight, plotting our path for the next few hundred meters. Blood was leaking down the sides of the ambulance and I could hear hyenas howling in the darkness."
 
-----
 
I want to keep all three of my books for my personal library. They're that good. The plan was to give them away here, after I'd read them, gifting them out into the world. I could leave them in Edna's library, donate them to the absurdly expensive library in town, or give them to Diana -- the American NGO worker -- for dissemination into the NGO community. I'll probably do the latter, hoping for wide readership, and just buy more copies when I'm back in the States.
 
-----
 
My flight from Hargeisa to Addis on the 9th is on Daallo Airlines. The UN won't let their staff fly on Daallo because it's unsafe and now I keep hearing horror stories from expats. The gist of it seems to be this: Daallo planes are all small and old. Antonovs, I wonder? Some people have told me they're converted cargo puddlejumpers with benches against the walls. Everybody has said they have no seatbelts. This doesn't bother me since a seatbelt isn't much use when you're plummeting out of the sky in a metal tube. Still, the planes fly low and thus are buffeted by thermals. The turbulance can get so bad, I hear, that you can bounce off the benches/seats and slam your head into the ceiling. My flight is early in the morning, when it's still cool, so turbulance should be slightly reduced.
 
If I die in a plane crash in Somalia, I hope someone will gussy it up a bit and make the story more sexy. Not just a plane crash, but a traaaagic plane crash... not just in Africa, but a desolate corner of the Horn of Africa, a war zone maybe, where Westerners fear to tread!... not to be a volunteer doofus while on vacation from cushy San Francisco, but to comfort the weeping children! To "hold the line on AIDS!" A beacon of light in the heart of darkness!
 
That sounds pretty good. :)
 
In the afterlife, Edward Said will strangle me.

posted by daviduri @ 7:27 AM 0 comments

Friday, August 04, 2006

Somali Politics, Ex-Pat Party, and Books

I do my homework.

After I decide to visit a country, I start reading about the history, the culture, the political landscape. I delight in picking out small cultural cues, mentioned in passing. The customs, the mores, the folkways. Every day, I read the news -- BBC, CNN, a more local or regional source like Al Jazeera or, in the case of Somalia, Shabelle. Sometimes, I try to learn some of the local language.

I consider all of this to be pragmatic both for my own safety and for the depth of experience I'm able to have. In many of these places, I am the consummate outsider. It's unavoidable. As much as is possible, I want to get a real taste for a place. What do people want? What're they afraid of? What're simply "concerns" or causes of anxiety? What factors dominate the social or political landscape? I want to know and knowing requires talking.
 
In Afghanistan, I shied away from talking about politics, ostensibly for my own safety. Here, I haven't shied away at all. I've had long, meandering conversations with large handfuls of locals. We've discussed the history of Somaliland (Barre, et al), the "five zones" of the Somali people, the conflict between Ethiopia and Eritrea, the current situation in Somalia. Puntland, East Sool, Geddi's being forced out (which failed, but will probably succeed once there're no ministers left), the power of the government in Baidoa or lack there of (and why Ethiopian troops were the final nail in the coffin), the prior wars between Somalia and Ethiopia (Ogaden as a contested region, etc), how Mengitsu's mother was kidnapped and raped (no shit -- more on this later), the history between Abdullahi and Aweys, the real germinating force behind the nascent rise of the Islamic Courts Union (it's not who the Western media thinks), why the ICU will never fully control Somalia (they're purely Habr, among other things), which major African countries are supporting Somaliland (Ethiopia, Djibouti, South Africa), the tribulations of the Somaliland government as it has sorted itself out (15k population in Hargeisa in 1991 swelling to over a million today, ministries, pay raises for ministers, the "Al Qaeda-linked death squad" that was killing foreigners here for a few months), why Ethiopia will be ineffective in a cross-border war with southern Somalia (Somali rebels in Ogaden and opportunistic Oromo rebels -- and, counterpoint, why they'll be tremendously effective). The visits of US State Department officials to Somaliland (and how shitty the pizza is at the Ambassador Hotel compared to the local Italian restaurant -- Club Venizia?), why an American from a think tank linked to Project for the New American Century is poking around Hargeisa (and two reasons why he's not likely to come home with a complete picture), how and why a massive influx of aid money might fracture the Somaliland government, how and why international recognition might do the same.
 
It's all terribly interesting.
 
In the past three months, the situation in Somalia (not Somaliland, where I am) has changed almost daily.
 
Initially, I was watching it only with an eye to my safety in travelling to Mogadishu. The Islamic Courts Union, with popular support, wrested control of most of Mogadishu from the warlords who'd been controlling their little neighborhood fiefdoms. How does it bode for me? Good, in that things are now more stable, more uniform, etc, and bad in that things are now more ambiguous. It became unclear who could provide protection. What had appeared as utter chaos from the outside, with the warlords in power, was in fact very structured, albeit only on a "micro" level. The situation could be known, understood, and then gamed, with enough money, to provide relative safety and security. With the Islamic Courts Union having routed the warlords (or at least most of them -- at this point, there were still hold-outs in Mogadishu), a new issue comes up. The CIA was backing the warlords -- Americans with thick necks and briefcases had been wandering Mogadishu -- and an American male in Mogadishu will be assumed to be CIA -- very bad for me. A tentative peace deal was inked between the internationally backed government in Baidoa (the TFG -- Transitional Federal Government) and the ICU -- very good. Martin Adler, a Swedish cameraman with extensive experience in Africa, was gunned down at a rally in Mogadishu, seemingly simply because he was a foreigner -- very bad. The ICU condemns the killing and promises to provide protection to any journalist visiting Mogadishu -- good, if I can go in as a journalist. Sheikh Ahmed, a former school teacher who got into politics after a student of his was killed (aww!), is replaced as the head of the ICU by Sheikh Hassan Dahir Aweys and Aweys is on a US "known terrorist" list (linked to Al Qaeda, Africa embassy bombings, etc) -- potentially bad. Blah blah blah, on and on... Every day, BBC had an article or two. Al Jazeera had maybe five or six. Shabelle had more, but the commitment to quality in reporting might not've been there.
 
When I left San Francisco, Mogadishu appeared too dangerous to visit but I left it on the table as a possibility, figuring I'd be better able to sort things out on the ground. Things don't seem much (uh, any...) safer now, but it's a moot issue since I won't have time. I'm flying back to Addis on Wednesday the 9th before my flight(s) home on the 11th. I'm not sure what I'll do in Addis for a two days. I think I'll spend half a day visiting a hospital there that specializes in fistula repair and maybe visit the museum and see our great, great, great (ad infinitum) grandmother, Lucy.
 
And eat some food that is not goat meat. Every breakfast: Corn Flakes with powdered milk, french bread with peanut butter and chocolate sauce. Every lunch and dinner: oily rice, goat stew, and limp salad. Every few days, dinner will include goat liver and french fries, mixed. The liver is grey and clammy, like mutant elephant hide. Nothing is spiced or flavored. I've been drowning everything in hot sauce to make it more palatable. I'm used to eating Thai food on Monday, Indian on Tuesday, Mexican on Wednesday... I'm glad the food here hasn't made me sick, but damn, I'm desperate for variety.
 
Last night, I went to an "ex-pat party" full of out-of-shape UN and NGO workers drinking wine, smoking sheesha, and dancing to salsa music. I was happy to have a change of scenery, but I had a vague feeling that I was betraying my reasons for being here. The party seemed no different than any house party in the States except that you had to guess peoples nationalities. Italian, Armenian, Norwegian, the lone American resident. And then there was me. "Who're you with?" "Sorry?" "Who are you working for?" "Oh, I'm on vacation," I said. I got blank stares in return and then an, "Oh." I ended up spending half the night sitting outside, near the gate, talking politics with the guards and drivers. Redemption.
 
The most exciting part of the party, for me, was finding out that the Ambassador Hotel has "pizza" (of a sort) and that there's an Italian restaurant in town that's "really fabulous" -- no small compliment coming from an Italian.
 
-----
 
In other news, I finished "You Shall Know Our Velocity!" It was fantastic and had me laughing and giggling and reminded me so, so much of myself. The author, Dave Eggers, appears to be from San Francisco; he mentions 826 Valencia (my all-time favorite pirate supply store) in his acknowledgements section.
 
I also read Mark Bowden's "Black Hawk Down" a few days ago. Edna has it on her bookshelf. I'd seen the movie, of course, but had heard the book was much better. It had some good moments, with funny and insightful anecdotes about SFOD-D, but I didn't like the author's use of the soldiers own language in describing things. I imagine Bowden hoped readers would find it authentic, but I found it annoying. Chapters would talk about a soldier and describe his feelings, at whatever critical juncture, as (I'm embellishing here) "like two darn crawdads, fightin' in the Mississippi mud" -- it's got to be lifted from interviews, Bowden wouldn't write that -- or end a section with a line like, "It was fucking bad-ass."
 
Now I'm reading a medical terminology book and an embryology book. The library here is 99% medical but has a tiny "fiction" section that includes a collection of plays by Euripides and "A Prayer for Owen Meany." There's also a tiny library ("Gandi Public Library" -- not Gandhi) that's about a 25 minute walk from here. I skimmed their shelves and a book titled "The White Rabbit" looked interest, but when I asked about checking it out, they pointed me to their terms of service. Only members can check out books and the membership fee is USD$25 per year. Ha-fucking-ha. I'm not paying $25 to read a 180-page "wah wah torture" book about WWII. I'm leaving the country in five days. And I'm sure SFPL has it. And Euripides is probably better anyway.

posted by daviduri @ 2:47 AM 1 comments

Khat, Beauty, and the Public Hospital

The chat/khat (Amharic/Somali) economy is estimated at USD$700,000 per day. It primarily grown near Harar, so most of this money is flowing back into Ethiopia. Usage estimates among women in Somaliland are 10-20%. Usage estimates among men are 80-90%.
 
Khat can cause discoloration of the teeth, but it is NOT the cause of the dark brown staining that I keep seeing here. That, apparently, is from too much iodine in the water. It's a problem in the eastern regions of Somaliland in particular and may disproportionately affect women. (I'm not sure I buy that last part.) It's considered... sexy.
 
Also sexy: being fat. In the States, there's such a stigma for women around age and weight that they'll sometimes lie even to their healthcare providers. Here, women hem and haw and don't want to tell you their age, or they'll tell you a more optimistic age. But with weight, we always get the real answer (or a, forgive the pun, inflated answer?). Being fat means you're prosperous. Sexy.

Not surprisingly, the top two medical problems in this country are hypertension and diabetes. Infectious diseases are third.
 
It seems rather popular here to dip your finger tips in henna. You do this once this week, then again two weeks later, then again two weeks after that. Once the henna wears off your fingers, which're black to the first knuckle, you're left with a three-tone fingernail. The farthest portion, which has had three immersions, is very dark, followed by a band that's light, in the middle, and then a very light band near the cuticle. As the nail grows out, a "natural color" band is added. It's nailpolish, a French manicure, done henna-style.
 
When I gently pushed a Somali woman about it, she said pushed back. "In America, they put on the plastic and little drawings on them!" She's right. It's equally strange in America, except that at least this way you can still wash dishes and type.
 
-----
 
I spent this morning and yesterday morning at the Hargeisa Group Hospital near "downtown." It's a government run hospital and is wildly different than this one.
 
It's... big. It's a compound, with buildings spread all around. In between some buildings are barbed wire fences. Goats meander around, chewing grass between the maternity ward and the surgical ward. There're flies everywhere. The paint is peeling off the walls. Tile floors are in disrepair, stained by who knows what. Ceiling panels are falling apart.
 
In the operating theatre, there're things I can't even identify. I imagine one of the machines must be an ECG and one must be oxygen, but they look like they're from a 50s sci-fi thriller. Little metal switches everywhere; these are pre-button. There're boards lying around that look like spanking paddles for an over-the-top fraternity, but I figure they're probably old school traction splints. If you put rope in one end... yes, maybe. They have an x-ray. Non-portable, tiny, easily decades old. The nearest CT machines are in Addis Ababa, Ethiopia, and Nairobi, Kenya.
 
I want to take pictures but I'm worried it'd seem demeaning. They're doing the best they can. The wards are large. 25-30 beds each. Each is staffed, it seems, by a few nurses -- usually two. Doctors are "on call," not on site. I'm not sure what to make of this arrangement. I suppose it's fine if you have really crack, top-notch nurses. Nurses are the ones who really -run- a hospital, even when doctors are there.
 
Unfortunately, during my tour on the first day, it appeared that a lot of the patients weren't getting the attention they needed. In the middle of the tour, with me in my white lab coat from this hospital, a mother pushed her baby at me. Prolonged labor, became a c-section, infant is now about 5 hours old. It's wailing in a weird staccato in line with obviously (visually) labored breaths. Forearms are cold. I ask if there was meconium, if anyone has listened to breath sounds, etc. Nada. Where's the post-natal care?
 
Anyway, they do a lot more surgeries at Group Hospital than we do here, so I'm going to be going back on Sunday and on Tuesday, early in the morning, to observe surgeries all day. I met their head anesthetist and Edna has put me in contact with the chief of surgery there. It should be a good learning experience.
 

posted by daviduri @ 12:31 AM 0 comments

Tuesday, August 01, 2006

Craniotomy and Reflections on Reacting to Surgery

This morning, I went on maternity rounds with Dr. Qaws instead of the medical rounds I'd been doing with Dr. Derrick for the last week.

We examined a patient who was 8 months pregnant and had intrauterine death of the fetus four days ago. Since then, we tried to induce labor using an oxytocin analogue, Syntocinon, and had no success. Today, I put my fingers inside her and felt that the cervix was fully dilated, with the head of the fetus low, pressing against it, in something between a face and brow presentation. Dr. Qaws said that with this presentation, the space required in the birth canal is too great and the fetus cannot be delievered vaginally anyway. The presentation was missed on earlier examinations.

When I removed my fingers, a bit of the fetuses skin was stuck to my gloves. Four days was already really pushing it and the fetus had to be removed, pronto.

We were left with two choices. Either we perform a c-section and risk a likely infection, or we perform a craniotomy and risk rupture of the uterus. Since she's had no bleeding, and the risk of uterine rupture seems low, we opt for the latter.

A craniotomy is not a pretty procedure. The goal is vaginal removal of the fetus without labor. Labor would push the baby out; a craniotomy pulls it. The method is to cut into the skull of the fetus with very large, pointed scissors, remove some of the brain matter and fluid to reduce the size of the skull (for easier extrication), and then insert what amounts to a large pair of vise-grip pliers. The pliers grip a stable portion of the skull and then a tug-of-war ensues, doctor against uterus.

In our case, the whole procedure took almost half an hour. Dr. Qaws was trying to grip the back of the skull instead of the more readily available face -- a personal proclivity not medically indicated and one which lengthened the procedure.

With a strong heave, the fetus finally came out, skull split nearly in half, face badly misshapen, head like a deflated soccer ball forgotten under a porch. One eye bulged out of the socket. Brain matter littered the basin and table like so much pudding.

I started to imagine the psychological trauma that would result if a mother saw her baby in such a state. This patient was a calculating realist. When Dr. Qaws had explained the procedure to her before hand, she'd remarked, "My baby is already dead. If this (the destruction of the baby's body) is what you must do to save my body, so be it."

-----

Strangely, this procedure didn't phase me in the least. I found the first c-section and first D&C much more difficult to stomach.

I wonder, idly, if I'm over the hump in terms of having strong physical reactions to highly invasive procedures.

There's a big disconnect here between fantasy and reality. In my fantasy, it's a few years down the road and I'm alone in a war-torn country nobody could find on a map. I'm in a refugee camp, coldly calculating in triage, struggling to get a handle on an epidemic, performing surgery under abysmal conditions. I'm working 18+ hours per day and I'm positively masterful -- but it's still not enough. I'm stretched too thin despite giving my all. Every day is a struggle simply to keep my head above water, but I secretly love it. (To deal with the stress, I take up zazen instead of smoking, of course... haha!) I develop a "thousand yard stare" and later, in old age, I write a seminal book on philosophy informed by my experiences.

In reality, I'm sometimes a wet chick quaking in a cage, small in the world. (That overstates the case, but the idea is the same.) I've had two or three instances -- a bunch biopsy that became 15 minutes of digging with a scalpel, the elective c-section here in Somaliland -- that have left me woozy and flushed with sweat and needing to take a moment to breath and relax. Each time, it's struck me as painfully absurd, discordant with how I view myself. I've seen nasty traumas, gore, incredible messes, but these relatively minor, elective procedures have thrown me for a loop. I don't feel mentally or emotional distraught, but my body reacts: my temperature rises, I feel beads of sweat sliding down my legs, my forehead is wet.

I wonder if it's that they're elective? The punch biopsy was for a small, fatty nodule under the skin in the back. Invisible. He'd had one removed from the same place a few years previously and this time we used a scalpel to remove scar tissue. At first, I was fine, but the more my mind had a chance to wander... Perhaps an inability to turn empathy off completely? I can't make heads or tails of it.

In any case, I think, realistically, it's simply a matter of exposure. The first few times you compete in athletics, you're a mess of nerves and anxiety. Later, you realize that the "butterflies" are a positive sign, a symptom of excess energy raring to go, blood shunted away from the GI tract and into your biggest muscles, your body champing at the bit, ready for perform.

Perhaps surgery is the same. Either this stuff will simply stop happening or I'll learn to recognize the onset and channel it into something positive.

I also think I'm probably not alone in this. That it might be common for people coming into medicine. Besides, some people faint when they see, or even think about, blood, so getting woozy when liters of blood flood the floor and bodies are sliced upon is, at the very least, a step up from that. :)

posted by daviduri @ 5:28 AM 0 comments