Senegal 6: The gift

A polite fellow, my age, comes in and declares he has had a sore crotch for about week. After some brief questioning, he drops his strides to reveal an ulcer the size of a 10-cent coin on the base of his goodybag. It's the first time I've ever seen such a thing outside of a textbook. I get some good advice that it's probably genital herpes, and look up the hospital's treatment manual: gentian de violet. It sounds like a dye we used in microbiology pracs in med school. He gets told to abstain and come back in a week.

He returns a week later, and his hands are dyed purple. I confess I hesitated to shake them when he came in. He states that no progress has been made except that all his undergarments are now similarly dyed purple. The examination confirms this sad state of affairs. He can tell I am at a bit of a loss. He reconfirms that there has been no fooling around on either partner's part, so it is mildly suspicious when he requests a test for syphilis. Surprisingly, he returns two days later with a positive result. The treatment for syphilis is fortunately very easy - a single injection, once a week for 3 weeks. He is sent to the salle d'observation for his first shot.

Another week passes. He comes back and he is a changed man. It is totally gone. The next week he bypasses the queue and comes straight to my room to tell me, happily, it has not returned. He is stoked. He asks me where I live and invites me over to dinner. This strikes me as potentially awkward and I politely decline. Undeterred, he returns the following week for his third and final shot, and presents the good doctor with a gift, pictured below, for his brilliant diagnostic skills.

And this is how the first ever present I received from a patient was inspired by a positive result from a test that the patient had to remind me to order.

Senegal 5: The football

Ben the medical student had been talking up the prospect of seeing Senegal play Burkina Faso in Dakar, the capital. It was a crucial match in the African Cup, with the winner advancing to the knockout round of the tournament. We had been assured that it was unlikely to be a sellout, as the stadium seated 80,000. It should be noted that these assurances were made after Ben failed to get tickets in the week leading up to the game.

After an eventful two-hour trip from Thies, we met up with Ben and his friend Jean-Claude, who had bought our tickets earlier that day, and casually made our way to the ground, arriving 30 minutes before kickoff.

The queue to get in was ridiculously long. It extended around the corner of the perimeter wall and beyond the limits of vision at both ends. Cars were gridlocked, attempting to get in. It was soon discovered that the queue was for people with tickets like ours. It was also not moving. As the cars began to inch forward, desperation provoked Jean-Claude to ask several drivers if we could be smuggled in. We also tried to walk up to the front of the queue, only to be confronted by a scary bug-eyed gendarme who threatened Vicky with his large tree branch before using it with excessive force on an unfortunate man’s face.

Moments before scheduled commencement.

We dejectedly commenced queueing ten minutes before kickoff. We had not moved ten metres when we heard the roar of the game beginning. Shortly thereafter the queue began to pick up speed, slowly, then at a walk, then dissolving as all ticketholders began to run towards the gates. Gendarmes furiously tried to rip everyone’s tickets. I was confronted by a gendarme demanding a bag search, and had to fling my borrowed umbrella (a potential weapon) into an ominous-looking pile.

Once inside, we realised it was already 1-0, 20 minutes in. We found seats (concrete steps) behind the Senegalese goal. The stadium was near full. Not long after our arrival, the underdogs Burkina equalised on a beautiful curving free kick. 80,000 Senegalese groaned simultaneously as a small band of Burkinabes danced and cheered.

Burkina equalises.

Senegal’s first half was dismal, passing poorly and fluffing several easy chances. The crowd grew restless, booing and shouting abuse. At the half-time whistle, the home team left to a chorus of jeers and shaking fists. Jean-Claude reminded us of the last Senegal international match he had attended, which ended in a riot and stadium lockdown for 6 hours for all spectators. We decided we would leave early.

Senegal were a changed team in the second half, playing with more class and attack. Finally they took the lead on a goalmouth scrap and the stadium erupted with joyous relief as strangers hugged and young men took off T-shirts and waved them. Five minutes later they scored again, prompting more mad celebrations, including stadium-wide beating of both drums and the odd Burkina fan.

The crowd goes wild/naked!

Ten minutes from the end we made our move. As we left via the main gate outside, a huge cheer signaled the fourth goal, and the first wave of like-minded spectators emerged from the gates, desperate to avoid what would be a massive traffic jam. We ran to the road leading into the stadium (miraculously collecting the umbrella on the way) and hailed a taxi that had illegally entered. As a gendarme approached, blowing his whistle, the five of us piled in (also illegally) and sped away.

The driver was listening to the game on the maximum volume his stereo would allow. Clearly the game meant a lot to him. As we hooned through the streets of Dakar, he would shout at passers-by: “4-1! 4-1!” and wave jubilantly. Moments later, Senegal posted their fifth, sending him into rapture and ever-increasing speed. He was now beeping the horn nearly continuously and flashing everyone in his path, overtaking all vehicles and flying over speed humps. We caught the excitement and began waving at all pedestrians and other cars. The game had ended and the news had clearly spread; everyone responded with victorious hoots and comical dancing, or reciprocal honking, or the now-ubiquitous cry of “5-1! 5-1!”

Senegal 4: Consultations

The language barrier here is multi-layered. Despite French being the official language, most patients cannot, or will not, speak it. Thus it is necessary that we use translators to convert the patient's complaints, in Wolof, into an unusual form of French that is best described as child-like medical lingo. With a set number of questions, learnt by repetition, one can usually come to a reasonable diagnosis.

• "What is the problem?"
• (Invariably, patient touches whole body and speaks unintelligibly with a sour expression, which is now instantly recognised as "all my body hurts".)
• "Is it that you have the fever?"
• "At night, do you tremble?" (Simultaneous mimicking of shivering.)
• "Do you vomit?"
• "Do you cough?"
• "Do you cough some things?" (Accompanied by hand actions demonstrating the expectoration of sputum.)
• "Do you have diarrhoea?"
• "The urine is normal?"
• "Does [body part] hurt?"

Following a very brief examination, usually conducted in the chair, one is ready to produce the fruits of his/her clinical wisdom: "Probably, you have [medical condition]. But, it's possible also that you have malaria. Therefore I write the medicines for all the problems."

"All my body hurts" is not the only manner of presentation. Other common ones include:

• The patient who walks in covered in scratch marks and sores/bites/boils. He or she has usually been prescribed anti-fungal medicine before their buttocks hit the chair.
• The patient who sits and immediately rolls up one trouser leg to reveal a hideous ulcer.
• The patient whose eyes are bloodshot and rests head down on the desk for the duration of the consultation. This patient usually needs to come into hospital for "fatigue" (ie. malaria).
• The patient who intercepts me in the hallway to discuss his/her planned surgery, mistaking me for Ted, the surgeon, who is at least 25 years older and has a moustache.
• The patient who has pertes blanches (white discharge) or boutonnes dans ta vagine (lit. genital buttons). Just as in Australia, they are usually referred with great relief to the midwife, with the explanation that "I cannot do the exam for the women" (indicates to groin).

Vicky generally sees children, as they are easier to diagnose (for her), and there is always the possibility that they will do something cute, like dance, behave extremely politely, or scream at the sight of the white ghost (Vicky). Conversely, I have been seeing adults, and particularly the elderly, which is generally an excuse to see charming old fuddy-duddies with diabetes or "pressure" (as in, high blood). The elderly are revered here, presumably because they have beaten the odds of infant mortality, car accidents and malnourishment. They are the most friendly of the patient population, and they love to crack jokes. In Wolof, of course.

One particular octagenarian hobbled in on his stick and whispered: "I cannot hear anything."

I replied: "But you can hear me now."

He thought this was hilarous and shook my hand in a congratulatory fashion. "In fact, I can hear the rain." Cryptic.

Although it was not presently raining, this did not strike me as a major problem.

He clarified: "I can hear the rain. In my ears. All the time."

There appeared to be nothing overtly wrong with his ears. With confidence, I declared: "This is a problem because you are 80 years old. This is a problem of the old."

He laughed and shook my hand repeatedly, then began to make grand circular movements with his arms.

"I have been to other hospitals - St-Jean, Regional. Barthimee is better. And you - you will be a great doctor of the world!" He left to collect some multivitamins.

Another 80-plus-year-old was brought in by her concerned daughter, who prattled on for a good two minutes in Wolof to the translator, concluding with "Explique!" (Explain!) and nodding in my direction sternly.

Translator: "She has headache, fever. All her body hurts. And, it feels like there is a man, walking inside her stomach."

Me: "... So she has pain in the abdomen?"

(Prattle prattle. Explique!)

"Yes. But, she wants you to know: there is a man walking in her stomach."

I faced the frail great-granny, who patted her stomach and smiled. I prescribed some medicine for worms, but wondered if they would be better left to thrive in the intestines to help battle the man in the stomach.

On a similar note, Vicky was seeing a young boy with his mother. The mother began her opening statement, but while speaking, extricated a Fanta bottle from her handbag. The Fanta bottle was about a third-full of murky grey water, in which about ten live, off-white worms were writhing about. This admittedly made the diagnostic process much easier.

Senegal 3: Our house

We live in Cite Malick Sy, a suburb about 1 km from the hospital. As evidenced by the relatively larger houses and cleaner roads, it is meant to be the rich end of Thies. Hence the need for a security guard and four locks. It is also mosquito Mecca, which means unlocking the four locks is usually done very rapidly while shaking all four limbs simultaneously. We are very fortunate that the previous tenants pretty much encased the house in mesh.

Our other front door.

It is a great blessing to have aircon in the bedroom. It is also the only unit in the house, which means we spend a lot of our time there, beneath the haven of the mosquito net (now replete with pieces of sticky tape covering all the large holes), eating and watching stuff on the laptop. It is also the only non-humid room, so all our laundry dries there. It's our sanctuary.

Everything one could need in life.

Conversely, the kitchen is the hottest and dirtiest part of the house. Its main failing is that there are dozens of cockroach-like insects that live in and behind the cupboards, which have a habit of regularly coming out between 6 and 10 pm to roam and forage for nutrients. Not even the fridge is off-limits. They are also seemingly impervious to local insecticides. Fortunately, we have a lady who comes twice a week to clean.

We cook every night. There is a relatively limited range of meat, vegies and spices available, but fortuitously the local supermarket has soy and oyster sauce for stirfry, and stuff to make decent pasta also. Instant noodles get trotted out on particularly tiring days. Lunch is usually bread (flamed), butter and sugar. There are also heaps of snacks: nuts, Pringles, Nestle Crunch, biscuits. Breakfast cereal is a bit of a luxury, being twice as expensive as back home. It’s not quite the healthy eating pyramid.

The scrubs help to absorb oil splatter.

Why, that burger is almost as big as her head!

The cable TV was utilised frequently once it was fixed, but has been declining in favour with time, mainly because of the unfavourable channel distribution. 400 channels, only about 5 English ones, of which one is Bloomberg and the rest are televangelical. The TV also suffers from being situated in front of the most uncomfortable couch in the author's experience, surpassing even all the ones in Bendigo doctor housing.

Still hard on buttocks despite modifications. Note stains.

Blackouts occur daily. If we are particularly cursed, they happen multiple times and/or at night, which takes away our climate control and entertainment. Usually they last less than an hour, but sometimes they can go for 4-6 hours. It is one of the worst things about being here, and there is no better feeling than seeing the lights come back on or hearing the humming of the fridge resume again. In fact we usually make sure all the switches are on during blackouts to maximise the joy of the power returning.

There has been a lot of craving and longing for the comfort, order and familiarity of Melbourne. Especially during blackouts. But all things considered, we're very lucky to be living where we are, to be able to wash our clothes in an automatic fashion, to have a non-squat toilet, a stove, drinking water, relative cleanliness, privacy, security, electricity, and 3-minute noodles.

Lifesavers.

Senegal 2: The hospital

We work at the Barthimee Centre Medico-Social, one of Thies' three hospitals. Despite the flies, the grasshoppers, the dirt and the dense body odour in the patient areas, Barthimee is considered a pretty nice hospital in Senegal.

Grasshopper!

It is actually owned by the mission organisation, and as such its role is supposed to be one of demonstrating the good virtues of Christians, through healthcare, to the Muslim community. It is apparently a widely-held belief amongst the Muslims of Senegal that Christians are immoral adulterous drunkards. This is derived from the observation that most Christians are white Americans, and white Americans are seen (at least on TV) to behave immorally, adulterously, and drunkardly.

The building is four storeys high, but the top two floors are mostly derelict, open-faced concrete construction sites. Most of the consultation rooms are on the ground floor, and usually in the morning the patients are crammed bum-to-bum in the waiting area. The tired ones lie down in the hallway or in the courtyard. The ward (24 beds) and theatres are on the first floor, as is the room Vicky usually consults in. The hospital is located on a very wide dirt road, which is either flooded or dusty, depending on season.

Dirt road. Width approximates that of Eastern Freeway.

Consultations

The patients start queueing at 7 am. The doors open at 8 am. There is a terrible bottleneck at reception, where one guy methodically churns through the registration of 100-180 patients per day. All services are paid for - there is no free health care in Senegal. A standard consult is 1000 CFA, which is 10 loaves of bread, or A$2.50. Consultations don’t start until 9.30 am; thus it is normal for patients to wait between 2-7 hours in the waiting area.

Waiting room.

After the ward round, we usually see consults from 9.30 am to about 2-3 pm. We are always paired up with people who can translate our mediocre French into native Wolof, usually nursing students, but also sometimes the cleaning lady. Nurses also consult, and they have the authority to diagnose and treat just like a doctor, sometimes resulting in some bizarre prescriptions.

Step into my office.

Services

There are two operating theatres, which are surprisingly well-stocked. There are operations at least once a week. This is when Ted is at his happiest (as evidenced by his singing and telling amusing stories during cases). Until the arrival of the gas machine, most cases are done under spinal. The spinal has a tendency to wear off, requiring rapid finishing skills on the surgeon’s part before the patient starts wriggling too much.

Power intermittently goes out, but water is a bigger concern. If someone forgets to operate the pump in the morning, there is no water (except in the “good toilet” in dentistry). On operating days, this means Ted has to collect several buckets of water from outside to go ahead with cases.

The X-ray machine is supposedly temporarily broken but after 4 weeks we had given up hope of its repair and now everyone is sent to the other hospitals for any X-rays. Interestingly, there is an incredibly high-tech little ultrasound machine in theatre (with no qualified operator).

The lab can only do: pregnancy tests, malaria tests, syphilis tests, urine tests (all of which are positive), blood sugar, full blood counts, and also sedimentation rate and rheumatoid factor, for some random reason. The electrolyte machine is usually out of parts. Other tests are referred out and usually cost an outrageous amount. For instance, thyroid function testing is 23 times the cost of a consult.

Hospitalisations

The inpatient system is unusual. If a patient needs to come in, they must pay upfront. Usually they are told to pay for three nights in hospital, plus drugs. Haggling usually follows. Once a deal is worked out, the patient and family go home to get the money, and return to be admitted. Sometimes they don’t return.

Ward round with Dr Adamson. Vicky performs lowly intern duties.

More than half the admissions are for malaria. They need a minimum of three days of intravenous quinine. Because of this, most patients stay three days irrespective of problem. If a patient is still unwell after three days (eg. still vomiting), they would much rather leave rather than pay for more nights. Conversely, if someone is almost completely well the next day, they will usually stay for three days and continue getting medicine they probably don’t need, because they’ve already paid for it.

Free beetle with every bottle of IV quinine.

The nursing of the inpatients is also unusual. The patients only have observations done once or twice a day. The nurses never wash patients. They only give the IV medications; the patients are expected to take the oral ones themselves (which they often forget). They don’t seem to follow the drug charts. They refuse to sign the drug charts because they don’t want to take responsibility for giving the drugs that they are actually giving. If it seems like easy street, it might be because there is usually only one nurse for 8-14 patients.

Another satisfied customer.

Senegal 1: First impressions

Tuesday

Arrived in Dakar late, almost midnight. First impressions of Senegal: Humid. Disorganised. Dirty. Everyone seemed to speak rapid, thickly-accented French. Interesting contrast of friendliness (airport staff helping us locate lost luggage) with dodginess (man at airport claiming to be the son of our driver, a common bag-snatching scam). There appeared to be only one sealed road during our hour-long drive to Thies, second-largest city in Senegal and our home for the next 9 weeks.

To minimise culture shock, we were to stay our first couple of nights with Dr Ted, a US surgeon of Japanese origin, and his wife Colleen, before moving into our own place. They helped us get used to the Thies way of life. Boil the water, then filter it. Bleach the vegetables. Flame the bread. Tuck the mosquito net under the mattress. We had our first bucket shower of the year.

Wednesday

We toured the hospital, our eventual workplace. First impressions of the hospital: Humid. Disorganised. Dirty. Everyone seemed to speak rapid, thickly-accented French. We met nurses, students, the cleaner, the lab guy, the pharmacist, all of whom looked the same. Ben, a British medical student, took us on a tour, the key points of which were the timing of lunch and the location of the good toilet and the drinks. This was followed by a vehicular tour of Thies, which was a disorienting maze of identical streets lined with ramshackle concrete houses, muddy puddles, and dusty Africans. Bucket shower number 2.

Streets of Thies.

Thursday

Moved into our designated house, recently vacated by a missionary family from Brazil. 3 bedrooms (A/C in the master), 2 bathrooms, front-loading washer, gigantic living room, intermittent cable TV. 20 year old security guard living in granny flat outside. Pros: Normal shower. Cons: House located in area of extremely high mosquito density. Killed 20 mosquitoes from 1 am to 3 am prior to sleeping under a somewhat hole-y mosquito net.

Spacious living area.

Friday

To reduce mosquito intrusion, spent morning using a spoon to push toilet paper into crevices around bedroom windows, prior to our orientation day at hospital. Got lost walking in and arrived 20 minutes late drenched in sweat. Introduced to the staff as les deux medicins honoraires d'Australie. I was designated as un specialist de medicin internale. Vicky was to shadow Dr Adamson, the Zambian anaesthetist/paediatrician, while I followed Ted, who saw a handful of consults before heading to theatre.

En route to work.

It had been 4 years since I had last been in theatre, so I was no longer sure if doing a circumcision under local anaesthetic was the done thing outside of Jewish circles. My job was to pass instruments and hold the 3 year old down. He was initially quite calm. Initially. Once the scissors made their first snip he became a screaming demon. He began to wriggle frantically and managed to escape his restraints (he was tied to the table). I recaptured his limbs and applied the bonds tighter but his writhing made aiming difficult for Ted. Difficult but not impossible. I fetched a third person to immobilise the pelvis. More local. More snipping. More howling. It seemed like hours. It probably was. At one point the child tearfully whimpered in Wolof: "They're destroying me ..." Finally, several tactfully-aimed sutures later, the destruction was complete.

Next, three gastroscopies. No sedation (the norm here). My role: to hold the mouthpiece in place, to ensure that the patient did not bite down on, and therefore destroy, the endoscope. Consequently I was also best-placed to wipe up the drool. Admirably each candidate managed to endure their procedure without asking Ted to stop more than thrice. Afterwards, was chuffed to discover Vicky and Ben had saved me some of the communal fishandrice, which was consumed rapidly despite the prior roosting of several flies.

Evening was considerably better. Invited to a friend's house for lasagne and ice-cream. Later at home, managed to somehow fix the cable TV, and discovered that the toilet paper had kept all the mosquitoes out.

Saturday

Woke up at 2 am. Chills, sweats. Vomited 5 times, breaking a 9 year streak. Spent the entire day resting and dealing with gastro. Luckily had cable TV. The wonderful therapeutic effect of Inspecteur Gadget in French cannot be underestimated. First home-cooked meal: instant noodles and "luncheon meat".

Sunday

Church. All in French, which made the sermon quite difficult to understand. May have been the dehydration. Lots of smiley faces and hand-shaking. Boiled our first pot of water for the filter, and discovered white calcific sediment on top, which explained the white calcific sediment in yesterday's noodles. I thought it was egg.

Just like a bath ring.

August 15-21: Paris

Actually, it rained about 80% of the time we were in Paris, many businesses were still closed for the “summer”, and we were staying in quite a dingy neighbourhood. Nonetheless, it is still Paris, romance capital of the world, and what says romance better than two people sharing 1.6 kg of mussels?

These mussels are from Brussels, in fact.

When it was dry, the delights of Paris were just as delightful the second time around, and slightly more satisfying than when we were miserly students. After two weeks driving around the provinces it was nice to walk through trendy areas like Marais and shop in iconic department stores, to the point of crippling fatigue.

Coffee in Marais. And one very large piece of bread.

For some culture we hung out in the Centre Pompidou, Paris’ modern art mecca, where we saw a variety of disturbing, weird and childish displays from all over the world. All very beautifully presented though.

Behind you!

Titled "White". For real.

Finally it’s worth mentioning that Paris is incredibly diverse, with a profusion of Africans, Arabs and Asians (both subcontinental and Oriental) residing in the city’s periphery and bringing their own cultural influence and commerce. Which meant that for the first time in two months we could eat Chinese food. Repeatedly.

August 12-14: Dunes & chateaux

France is home to Europe’s largest sand dune, the Dune du Pilat, which rises 120 m over the Atlantic shore. It is spectacular to climb, but possibly more fun to run down, as you can see.

The Malaysian fluffs the landing!

A slightly more restrained individual.

Our next stop was the Loire Valley, home to many lavish chateaux. We stayed in a semi-luxurious restored chateau with a nice lakeside location. We also cooked for the first time in 3 months, and the everlasting smell of fried pork will forever greet future residents of suite 23.

And here is the “after” photo.

The Loire’s most ornate chateau is Chambord, a huge, decadent palace which served as headquarters for the keen hunters in the French court. Its imposing walls and towers house several prize catches, most of which would traumatise animal lovers. Naturally, pictures are included below.

Chambord. Nice moat.

The Hall of Freaky Antelope Heads.

What animal is this? Suggestions welcome.

The owners often took advantage of monthly specials on printed fabrics.

At last, having seen a giant fortress, a giant church, a giant dune and a giant chateau, we were ready to complete our vehicular voyage through verdant France, and head to Paris!

August 9-11: Carcassonne & Lourdes

We left Nice in our new hire car (an upgrade) and refuelled with a quick brunch (KFC). How could things get any better?

Our first stop on our French road trip was Carcassonne, a town famous for its gigantic medieval fortress, complete with turrets, drawbridge, moat and daily jousting battles. Not so famous, but no less noteworthy, is the board game Carcassonne that we received as a wedding gift (thanks, Justin and Gina!). Surprisingly, it was not to be found in the fortress town.

Surprising, because clearly the people of Carcassonne see their purpose as the exploitation of all things medieval for the tourist dollar. Dozens of stores dedicated to swords, elves, magic crystals, knights, wizards, Harry Potter and Lord of the Rings. I wonder how many satisfied shoppers return home glad to have bought that crossbow or chain-mail suit.

Her worldwide search for a plastic mace now over.

A bargain at €2200, but difficult to fit into luggage.

Life-size replica of ye olde French students and idiotic tourist.

From there, we travelled to Lourdes, the site where 150 years ago, a young lass by the name of Maria happened to see Jesus Christ Himself. Subsequent miraculous healings further bolstered the town’s status as a place of pilgrimage for Catholics the world over.

Today Lourdes is home to a ridiculously large church, and plays host to a nightly procession of pilgrims who have travelled long distances, sometimes from the other side of the world, hoping to be healed in the presence of Maria of Lourdes (or at least her statue, which leads the parade).

The procession is both touching and macabre. The pilgrims walk in groups, and we saw a group of about 20 kids with cerebral palsy being pushed by volunteers, followed by a squadron of lederhosen-clad pilgrims from Bavaria, followed by a cohort of wheelchair-bound demented nursing home residents, followed by some Vietnamese guys in robes, and so on. Being bystanders felt a little voyeuristic but it was also moving to see them sing hymns and raise their candles as one. As darkness descended they all assembled beneath the silhouette of the massive church built on the site of the initial miracle, sang some more, and received some sort of benediction before dispersing into the night.

Below the church, pilgrims to queue up to touch/kiss/scrape off part of the wall of the grotto where Maria saw the vision of Christ. Adjacent to this is a series of taps where hundreds of people come daily to collect, in large bottles, what must be considered holy water. The streets approaching the church are lined with souvenir stores devoted to Catholic artefacts and trinkets. Faith is big business in Lourdes.

The grotto.

Holy water collection point.

Holy water in all shapes and sizes. Just don’t leave it in your hand-carry.