It sometimes seems surreal how quickly you can move from one place to another, from one culture to another, from one way of looking at life to another. I have been meaning to make several more entries on this blog about my experiences in Nigeria and about what I learned there. I also have over 500 pictures I've been meaning to sort through and post for you to see, both on previous entries and new ones. My goal is to work on that this week, so check back periodically.

I've been back at work in Massachusetts for a week already. The week before that took me from the Faith Alive clinic in Jos...

... to an 8-hour layover in Amsterdam and visits to the Van Gogh and Reichsmuseum...

... to hiking and camping at 12,000 feet in Medicine Bow National Forest, WY...

... time with family and a beautiful Colorado sunrise with purple mountains on the way to the airport...

... back to my apartment in Williamstown and its humid summer/fall weather...

... and my desk in the Overland office.
Talk about culture shock. It's been a much harder adjustment than I was expecting (although I don't know why this should surprise me, given how reluctant I was to leave Nigeria). Motivation in most areas of life is eluding me right now and making me feel frustrated. No small part of my discomfort with where I am is probably thanks to my rereading of this book:

If you haven't read it, do. As soon as possible. Every time I open it I feel like I am wasting my life because I am not headed to Haiti or Africa or India, or to Geneva, to WHO headquarters, armed with an MD and a resolve to save the lives of those who have no hope of saving themselves and very little hope from the outside world-- the outside world that can afford health care and medication, that takes sanitation and food for granted; the outside world that, in an era of historically unprecedented levels of wealth, tells poor people and those trying to provide medical services to them that they are working with "limited resources", that they can't expect first-world treatment in a third-world setting because local culture, beliefs and behaviors prevent effective cures, that health programs in the areas that have the most desperate need have to be "cost-effective" and "sustainable."


In a Developing Country

WARNING: some of these pictures are graphic.

You know how people are always saying that you wouldn't want to have to get surgery in a developing country? Well, now I understand. And you really wouldn't.

Dr. Mercy took me and Jen to JUTH (Jos University Teaching Hospital) on Tuesday morning to observe surgery. That in itself should tell you a little about the differences between the standards of medical care in a place like Jos, Nigeria and the standards in the U.S. We weren't watching from some kind of observation room or behind a window. We were in scrubs, wandering among surgeons, nurses and medical students, able to get alarmingly close to the action. Incredible doesn't even come close to describing the experience.

We started our morning with a couple of colonoscopies. The room where they were performed lead directly outside; the door wasn't closed, but rather a curtain hung over the entrance, through which the next patient would walk when his or her name was called. The patients would come in and situate themselves on the bed, with only vague directions from the distracted medical staff, kicking off their sandals and swinging their legs up onto the green sheet covering the table (not changed between patients). They were only mildly sedated before the procedures began, and the grimaces on their faces made it plain that they were in definite discomfort. I was shocked when I noticed the water source in the room: a large black barrel, similar to the one in our bathroom in the guest flat, only bigger. Keep in mind, this is a teaching hospital, badly overcrowded and understaffed, in a city that's been without running water for six months and only a few hours of electricity every day, if even that. The light in this room consisted of narrow windows up high near the ceiling and a single light bulb hanging from the middle. The scope itself was soaked briefly in some sort of bleach or spirit solution between patients. I asked Jen if she knew anything about their sterilization procedures, and she told me that she mostly just didn't want to think about them.

From there, we followed the residents to the operating room (called the "theatre" here), where we had been invited to watch Dr. Mike operate on a 26-year-old man. This theatre, however, adjoined with another one, and we were able to walk freely back and forth between them, so we got to watch three different operations. No one made us scrub in or sign in, no one asked for any sort of ID, no one questioned whether or not we were supposed to be there, no one seemed to think there was anything strange about having us in the operating rooms. Most of the observing med students were wearing flip flops, and almost no one was wearing gloves, except for those with direct contact with the patients during the surgeries.

The first operation we saw was so crazy that it took us a while to figure out what, exactly, we were looking at. Without getting too graphic, it will suffice to say that people here commonly don't seek medical treatment until the situation is dire because they are too poor to afford it, and by then, there is often little that can be done to save them. In this case, the patient will most likely survive, but he had lived with his condition (which was probably TB, a disease that affects not only the lungs, but causes a host of other problems and can lead to severe swelling of any body part) for a decade. The surgeons were partway through the procedure when we walked in, and when we asked one of the other doctors what was happening, he explained to us what they were doing, and pulled out his camera phone to show us what it had looked like before the drainage began. I think this is hilarious, and we saw it frequently: doctors would whip out their camera phones before or during operations whenever they thought something was especially interesting and snap pictures.

The next operation we saw was abdominal surgery. The young man had been waiting on a bench outside, and walked himself into the operating room and lay down on the table. As the nurses and doctors prepared, some liquid spilled onto the floor; it was mopped over to the side of the room, where a trough funneled it to a drain that appeared to lead outside the building. After the patient was put under, a nurse stood by his side throughout the process, pumping air into his lungs manually. After cleaning and disinfecting the young man's abdomen, his body was covered by sheets, leaving a square right above his bellybutton visible. Dr. Mike made an incision about six inches long and pulled back the layers of skin and muscle tissue. I was pretty much in awe at this point until the sight became even more incredible and I realized that he was pulling out the intestines- and not just a small section, but the entire length of the upper and lower intestine, bit by bit, feeling as he went. At one point, he removed a small piece of tissue and continued to examine the intestines. Once he finished with that and had replaced everything in the body cavity, he inserted his whole hand and wrist inside the upper abdomen and appeared to be feeling around. When he removed his hand, his assistants removed the props that were keeping the incision open and called for sutures.

If I hadn't been wearing a mask, about 25 people in that theatre would have seen my jaw hanging the entire time. At the end, Jen and I turned to each other with the same look: WHAT just happened?? We rushed over to find Dr. Mike, who answered all of our questions in a casual tone, as if this were everyday conversation, as if he was not holding his hands up, his gloves covered in blood from pawing through someone else's insides. The patient, apparently, had been complaining of symptoms that his doctors could find no cause for. They had told him as much, that they believed there was nothing wrong with him, but he insisted. He requested and insisted on having the surgery, even though the doctors tried to talk him out of it, since they had little reason to believe that they would find anything, but he would not be dissuaded. So Dr. Mike had cut him open, looked, and as suspected, had found nothing. He removed a lymph node to have it analyzed in the lab to see if that would reveal anything further. The whole surgery had been exploratory. Dr. Mike shook his head with the same half-depressed, half-bemused expression that I have seen so often here, as if to say: this would be funny if it wasn't so horrifying. There is no CT scan in Jos. There is no laparoscopic surgery. For some patients, it is simply cheaper and more feasible to pay for exploratory surgery than to make the trip to Lagos to get a CT scan. The diagnostic and other medical technology that we take for granted in the U.S. simply doesn't exist here, for the most part, because it's too expensive. (A lot of the instruments they do have here are old and used ones that have been donated from American clinics, such as Mayo.) At Overland this summer, we had a girl on one trip complaining of abdominal pain- her leaders took her to a clinic and the doctor ran a CT scan, just to be safe. It turned out to be constipation.

The JUTH campus itself looks like a mix of some sort of dilapidated high school and a refugee camp. Open-air corridors and walkways connect buildings with crumbling corners and peeling paint, while people camp and hang laundry in the open spaces between. The patients' families serve as care-givers while they are being treated, because there is not enough medical staff to cover everyone. Many have traveled long distances to get here, and once here, have no place to stay. So they set up tarps and blankets and pots and they make do. There are signs everywhere that say Cooking Prohibited Here; there is usually a woman stirring a pot over a small local stove less than ten feet away from the sign. An enormous hospital is being constructed here in Jos, and from the outside appears to be relatively modern and nice. It will be able to hold much larger numbers of patients than the current facilities combined and should ease the conditions like those found at JUTH, but there is no expected completion date, and it has been under construction for longer than I have been alive.

Patients are expected to pay up front, in cash, for medical services rendered, starting with 500 naira ($1 = 127 naira) for their hospital registration card and number, and they are charged per service. For example, one of the women we saw opted to have a colonoscopy because she could have just had a barium colonic, which would have revealed any potential problems on an x-ray, but if she had done that and they had found a problem, she would not have been able to afford both the colonic and the colonoscopy, which they would have needed to take a biopsy and make a diagnosis. (They didn't find the problem on the colonoscopy, either, so she remains undiagnosed.) Faith Alive is the only free clinic in Jos, and all of its services are free, including the patient registration card. It is obviously not exempt from the technology problem, however; it is in some ways even more tied by the lack of resources. They were donated an x-ray machine, but it has been held in port and prohibited for some reason by customs from entering the country since May of last year, so they have to send out for every x-ray they do, which takes about three days' turnaround and costs $10 per picture. Along those same lines, x-rays are the only tool they have to diagnose TB, because they lack the necessary lab equipment to analyze sputum samples. X-rays are very imprecise as a TB diagnostic test, but right now it's what they have to work with.

Aside from being the only clinic to offer free services to the poor, who would not otherwise be able to afford any care, Faith Alive has an arguably even greater benefit to offer its clients: a caring and committed staff, whose goal it is to provide holistic care to the community they serve. Doctors and counselors often offer to pray with their patients at the end of visits, and whether Muslim or Christian, every time I have witnessed this, the patient has accepted with a grateful look on his or her face; I've seen doctors and nurses dive into their own purses and pocketbooks to pull out cash for a patient who has no food or can't cover transportation costs to get to their appointments; the FANOL bank (Faith Alive Necessities of Life) offers food and clothing to those who need it; doctors and home-based care teams will go to people's homes to talk with families who have threatened to throw their children out because of their HIV status; the weekly support group meeting offers people not only a community who will not shun them, but a close-knit family and a place to sing and dance and celebrate, unbelievably. Imperfect and struggling though it may be at times, you don't have to be here long to grasp the truth that Faith Alive not only saves lives but changes them, as well.


Faith Alive Family

Tonight the four volunteers went out to dinner with Dr. Chris and his family, Biana, the amazing clinic administrator, and a few heads of departments from Faith Alive. During dinner, Biana asked me what has been surprising to me about my time here. I think that the biggest thing has been the friendships I have formed in such a short time. I really am surprised at how close I feel to some of the people here, and even more surprised at how sad I feel about leaving on Monday morning. It's been a while since I have felt this emotional about the end of a trip, and it's very bittersweet. I don't usually get sentimental about this kind of thing, and normally feel confident that I will return to a place and see people again- I don't really believe in goodbyes.

But this is different, for so many reasons. Life as usual will be that much harder to return to, having seen and been a small part of the community and the work here; already I can't wait to return. I have been surprised at how much I have loved Jos, and how many times throughout this trip I realized that there was absolutely no place else in the world I would rather be than where I was right at that moment. People I have met here have become precious to me, and the sadness I feel is because I regret not having had more time to know them, and the worry that they may not still be here when I come back next.


Sano! (Hello in Hausa)

Hello out there to anyone who may be reading this blog! Computer time and access is unfortunately short these days, as other people around here have more important work to be done on them, but hopefully I will be able to get in some good posts soon. In the meantime, I am trying to keep good notes as the days fly by (we leave on Monday and I am already too sad to think about it much... amazing how quickly I've grown to love this place and the people here.)

In the past couple of days, I have observed live surgeries, met with the founder of a women's initiative group that also started a microloan program, found some great Nigerian literature at a bookstore, spoke at the FAF staff meeting (beacuse they make everyone do that on their last week) and rode all over Jos on one of the ubiquitous motorbikes with Ezekiel, who does home-based care visits to patients too sick to come into the clinic. It was my favorite thing that I have done the entire time so far, and that is really saying a lot. I also got my hair done today (it took over two hours)- finally, after much prodding and teasing by all the women here, who keep asking me why I don't "look Nigerian" yet, and my clothes will be done by tomorrow so now I will be able to placate (and probably amuse) them. I will write at greater length about all of this and more when I get the chance... and feel free to prompt me if I don't. :) Love to you all!

With a mother and daughter who make batik tablecloths and wall hangings- I bought the red one the mother is holding- it has giraffes on it.Part of the Home-Based Care motor fleet.

Getting my hair "made".
Sunset in Jos.


Life at Faith Alive Foundation

There are so many amazing things going on here, so many amazing people doing incredible work... so much I've seen and experienced that I wish I could write adequately about and explain, but there are a few factors that make it challenging: one is that between spotty electricity and several people fighting for email access on a single laptop each evening, getting enough time to post is hard. We have also taken to watching the movie channel every night (the movies are great, horrendous, and everything in between; we watch them regardless), so even when I get my turn, it's sometimes tough to concentrate. At the moment, Jen and I are watching Alfie, using electricity from our generator (NEPA hasn't come on in two days) and keeping our fingers crossed that the satellite signal won't go out. However, I am going to attempt to tear my eyes off of Jude Law's face long enough to catch you up at least a little.

FAF Volunteers
Along with me and my Dad, there have been two other volunteers at Faith Alive during the time that we've been here, also staying in the same guest flat. Jen is a second-year pharmacy school school student from Baltimore. At first, I think, the two of us were not entirely sure about each other, but we soon bonded over our mutual love of all things edible. Together, we lead the late-night movie charge, giggle with the girls in Blessing's sewing shop, coo at the babies in the waiting room, and heartily enjoy everything set in front of us. Val is a big, middle aged woman with neon orange hair and a huge heart. She is the "anti-accountant" accountant, hailing from Fresno, and is here for six weeks to help train the FA accounting department on Quickbooks and get their records in line. It has been a huge undertaking, but she works incredibly hard and is rewarded with spending time with the all the kids from the clinic and surrounding neighborhood. Her Nigerian name is Mama G; Mama being a sign of respect, and G standing for generous.

Professor C. McDermott
Today I delivered a lecture to 4th-year medical students at the Juth Teaching Hosiptal, as a guest lecturer for Dr. Chris, who is also a professor of medicine there. (Wow, definitely never thought I would be writing those words!) Last week, when I told him I would like to go to Juth one day with him to see the hospital and see him teach, he asked me to assist him with his lecture. Friday, he handed me a flash drive and told me his power point presentation was on there for me to look at- and that I would be the one lecturing on Computer Applications in Clinical Medicine in his Monday class. I laughed, but he was completely serious; he assured me it would be no problem.

This morning, I met up with Dr. Chris at the clinic and asked if he wanted to go over anything with me, and he said, "No, it's fine! It will be nice for me to sit down! You can do the whole thing." We drove to the Juth campus to get set up before the class started (Dad and Jen came along for the show). Slowly the students began to trickle in, then faster and faster, still wearing their lab coats from the class they'd just come from- over 150 in all ended up packed in, barely squeezing into the lecture hall benches. I was feeling nervous and amused at the same time ("How does this kind of thing happen to me? I have absolutely no idea what I'm about to talk about... well, guess I'll do what I always do and just go for it...") I don't really have a problem with public speaking. I'm actually pretty comfortable with it; I just like to be prepared, I like to be familiar with my subject matter, and I like to be sure that I have something valuable and legitimate to contribute. Dr. Chris assured me that I really had nothing to worry about; that probably many of these students had never even seen a computer before.

Turned out it was their first lecture of the term with Dr. Chris; he introduced himself and talked a little about his classes and expectations. He is fantastic in front of a classroom, making the students laugh and challenging them at the same time. He set out clear and high expectations for them; he asked them why they had chosen to go into medicine. Someone said, "Because it's interesting." Another said, "To serve humanity"; another, "God's will". The last young woman he pointed to said, "it's a calling." Dr. Chris at this point stopped and said that there are many interesting things in this world. There are many ways to serve humanity and many ways to do God's will; they will not get you through medical school and are not good reasons to go into medicine. Medicine is truly a calling, and if anyone in the classroom doubted his calling, he should not be there.

I introduced myself and started the lecture; I had reviewed Dr. Chris' powerpoint several times and knew the basic information there, although all I had to go on were his bullet points about topics I have absolutely no experience with (online medical bibliographic references? automated lab equipment? electronic patient medical records and specialist telemedicine?). At the beginning, the projector wouldn't stay on, then we couldn't get the mouse to work correctly, and so I was on my own for a few minutes. I was to cover basic information about computer uses, the internet, and the many ways that computers are used in medical science. It was really hard- I asked how many people had ever used a computer before... no response. I asked them to raise their hands. I asked if they had all seen a computer before. I asked how many knew what the internet was, and if anyone had an email address. They didn't really respond, except for ripples of laughter. Even though Dr. Chris swore to me that many had never seen a computer, most had never been online, and the majority wouldn't have email, I was still terrified of the line I was walking. I didn't want to insult or condescend to them by explaining common and very basic concepts, but I also wanted to make sure that I covered the material so they understood. I tried to give a few examples, and hoped that it was not too painfully obvious that I am about the furthest thing from a medical student as you can possibly get (the last science class I took was my junior year of high school, if you think I'm being modest.) I stopped at a few points to ask if they could hear me, if they could understand me, if there were any questions. They were definitely not a silent crowd, but they didn't exactly respond to me, either.

As the lecture went on, I began sweating more and more and felt like I was rushing through the final slides- the more medical-technology-specific ones that I could barely pronounce, let alone explain. I let Dr. Chris handle the questions at the end; after a short silence, a few students began to raise their hands and ask really thoughtful questions. Dr. Chris told me I had done well and that questions are a really good sign- they were paying attention. He said that he really likes to use guest lecturers because they can help students remember a lecture more more effectively than the same professor they get all the time. A couple asked me for my email address afterwards; it will be interesting to see whether I actually hear from them. It was one of the scariest and most hilarious things I have ever done.

Before my med school lecture, I spent the morning with Jen in the pharmacy of the clinic, counting out pills to be dispensed to patients later in the day (Flagyl, 30 to a packet). Faith Alive relies on donations, both of cash and medications, for a lot of what they prescribe and dispense to patients. FA is the only free clinic in the entire city of Jos, which means that it is literally the only hope for many people. All the services are free, including office visits, tests, lab work and prescriptions. Jen has been helping to organize the pharmacy- in preparation for her visit, Drs Isichei and Biana, the admin, made sure that the new shelves would be here on time. Her major project this week (she leaves two days before we do) is to get all the drugs in the pharmacy alphabetized so that it is more professional and efficient. She has met with some resistance on the part of the staff, who tend to be somewhat change-averse: they have adapted to just getting by, which sometimes feels like is all you can ask of anyone under these circumstances, but Dr. Mercy and Dr. Chris are very serious about running the clinic as well as possible.


Sundays in Jos

Churches here are more ubiquitous than Starbucks in New York. At least half a dozen per block, with every other street sign bearing names far more creative than any church you've ever seen in the states: Christ Lives in Our Midst Church, Redeemed People of God, Living Word of our Lord Congregation... Some are huge and pack hundreds into their sanctuaries on Sunday mornings, with dozens more spilling out and listening from the parking lot. Some are small house churches, meeting in a living room or back room of a store.

This morning we went to Blessing's church with her, called Christ Embassy. It's a small satellite of a charismatic megachurch based in Lagos. The service lasted about two and a half hours, complete with loud music (which was great!), screaming, swooning and speaking in tongues. Quite an interesting experience. The main pastor of the megachurch is this guy named Pastor Chris, who dresses in all white (think P. Diddy) and believes he has the gift of healing. He holds giant "Atmosphere for Miracles" conference-type things, where he "cures" people of such ailments as TB, cancer, blindness and paralysis. He also preaches that anyone who has accepted the Holy Spirit will become impervious to any disease or infirmity.

One of the doctors on staff at Faith Alive told Dad that this is a big problem here- pastors and other religious figures telling people they are cured of their diseases, and causing HIV positive patients to stop taking their ARVs, which in turn builds resistance in their HIV strain and makes it even more difficult to treat, requiring the last resort seond-line drugs (that is, if they make it back to medical treatment on time).

My favorite part about the morning was the fashion show. Everyone comes dressed in these amazing outfits, brightest colors and wildest shapes. Women wear matching skirts, tops, and headwraps (and sometimes a wrap to carry a baby in). Gives a whole new meaning to "Sunday best".


Blessing's Shop

For some clients who come into the Faith Alive Foundation for HIV testing and test positive, FAF runs a sewing school, a knitting school, a computer school and a wood shop to give them the skills they need to support themselves. If they show that they are serious about earning a living and working hard, their doctors and counselors can recommend them to these schools, where they can attend classes for free, and upon successful graduation, they are set up with the necessities for starting their own businesses.

Blessing is a tall, beautiful woman with a huge smile and gleaming skin. She greets everyone who comes into her shop with sparking eyes and an enthusiastic hug, and is one of the sweetest, most genuine people I have ever met. Blessing is one of the graduates of the sewing school, and now owns her own shop a short way down the road from the FAF clinic. She received a sewing machine from the school- a manually operated Butterfly- and now has eight students of her own, who all staff her shop. She and her students make gorgeous clothes, custom tailored. She took me and Dad to the market a few days ago (an adventure in and of itself) to pick out fabric for our outfits, then took our measurements and requests. Val and Jen, the two other volunteers here who arrived a couple of weeks before we did, already each have several stunning Nigerian outfits- vibrant colors and patterns, no two skirts or dresses alike. Although I can't imagine a setting in the states where I could comfortably get away with the whole getup, I still can't wait to see how ours turn out and hopefully get to wear one here before we go.

Today I spent the morning helping with one of the HIV/AIDS clinic teams, seeing patients and filling ARV regiment prescriptions, which was both amazing and intense- and also, frankly, stunning, for reasons I will elaborate on later. After lunch at home with the others, I stopped by Blessing's on my way back to the clinic to say hi. She gave me a huge hug and told me to come in and sit down. It was raining, and the longer I stayed and talked with the girls, the harder it came down, so I decided just to stay until the rain stopped. Friends dropped in and out, bunches of children played outside and shouted "oyiba!" (white girl), laughing, when they spotted me inside. I was admiring a purple embroidered scrap on the floor and Blessing told me I could have it to use as a headband. It was still raining hard. Then her friend Mary decided that I should have my hair braided, so she plunked a chair down in the middle of the shop and proceeded to comb out my hair and give me two very tight and impressively straight braids. Blessing offered me some of her lunch, traditional Nigerian ache- a spicy couscous and vegetable stew- and later gave me a packet of cookies. She teased me that soon she would teach me to sew, and when I told her I knew how, she laughed and asked if I wanted to sew something. She found me another scrap and I sat at the empty machine. It took me forever to get a simple hem down one side of the strip I was working with and I never did quite get the hang of the manual machine. Blessing and her girls make it seem so easy, but it was actually really challenging and so much harder than it looks. I couldn't get the pedal pumping fluidly enough to keep the needle going in a forward direction, so it kept going forward a few stiches and then back a few stiches, veering off the fold. They laughed and laughed at me. Now I have even more respect and appreciation for the things they make, working quickly and expertly over complicated seams and zippers. A couple of people walked in and laughed to see me behind the machine. Blessing and Mary asked if I had a boyfriend and told me they could get a lineup of Nigerians to marry me if I was interested. Eventually it stopped raining, but I was having too much fun to leave, and before I knew it, it was 4:30. At one point the people hanging out in the shop pointed down the street and told me that there was another white person coming. A couple of minutes later, a Chinese girl walked in to pick up some dresses and have them fitted. She is actually French, in Jos for two months to work on a project at the university. Here, any non-black person is considered "white". Soon Jen, who is Indian, joined us on her way home from the clinic, and everyone kidded us about how the men would be stopping by to talk to the three white girls. They taught me some phrases in pidgin English, which is among the more than 250 languages spoken in Nigeria (pidgin English is just as indicipherable to me as any of the others).

I have loved getting to know some people here in just the short time we have been in Jos. Along with the work we are getting to witness and help with, this has made all the difference between Nigeria and Namibia for me. I feel like I am actually in Africa, and not just some American, closed-off compound in a city. I am getting the incredible opportunity to see and do things that are meaningful to me and vitally important to the community. Maybe this is an unfair generalization, but the people here seem so much friendlier and more open and outgoing than the people I met in Namibia- maybe this is a coincidence, maybe not. Maybe part of the difference has to do with the fact that I know I am only here for 16 days- so things like no running water, repetetive heavy meals, limited mobility, and missing family and friends have not bothered me, as opposed to living in a foreign place for months at a time. Whatever the difference, it has been huge.