Haba (standing), the author, Tanti, baby Terry at two months, and Hatouma. I have fantasized about moving my practice to Mali.
Underneath my name on the shingle that hangs outside of my office's front door are the words "Berkeley International Health." Until we sold our practice nine months ago. That was what my partner and I called our family practice. For two weeks in February, I took my practice to West Africa.
Dtenne guide Yelfa and his sister. Djenne mosque in background.
I had been to Mali, a boot-shaped country just south of Algeria and the Sahara Desert, once before to visit Terry, an elementary school teacher from Maine who served there in the Peace Corps for two years beginning in April 1993. After finishing my residency in 1992, I left Maine for Berkeley to start my practice, ending my two-year relationship with Terry, but I told her I would visit her while she was in the Peace Corps. The first weekend of December 1994, I went to Mali for what was supposed to be a vacation.
Friday, the day of my departure, my travel agent called. Air France had canceled my flight from San Francisco to Paris, so I had to fly first to Los Angeles to catch a later flight to Paris from LAX. I was to spend the next night in Paris anyway, so the four-hour delay did not make much difference. After arriving at L’Aeroport Charles De Gaulle late Saturday afternoon, I left my bags at the Ibis, France’s equivalent of Motel 6, took the RER (Paris’s rapid-transit subway) into town, and strolled along the Seine and the Champs Elysee until I reached the Arc de Triomphe. White lights lined the tree branches along the entire length of the Champs perhaps as much to celebrate the season’s absence of tourists as the upcoming holidays. Many pairs of young lovers had chosen this crisp, clear fall evening to wander the illuminated trail to the Arc’s base and flaunt their passion before my eyes. I’d have to return when my luck had changed.
Terry met me at Bamako’s Senou Airport the following afternoon, and within moments I could not help but notice Mali’s influence on her. Sporting a shorter shoulder-length haircut, a brown West African cloth dress, and flip-flops, she guided me through the omnipresent porters—who tried to carry my bags so I would be obligated to tip them — out of baggage claim to the taxis in the front parking lot. She bartered in Bambara, the native language, to get a reasonable rate and ushered me into a typical third-world taxi, complete with several broken windows, doors that didn’t open from the outside, holes in the floor, and rags that had replaced the original upholstery. As the descending sun glowed orange through the dust overhead, we rolled toward the Niger River, passing men on mopeds and elegant women clad in bright African cloth dresses and scarves who balanced baskets and water jugs on their heads as they strode along the roadside. We turned off the main road just before the river and proceeded taking dirt roads to the house of Terry’s friends, three teachers at the American school in Bamako. We would spend the next two days with them. After dinner and a party on the roof of their house, eight hours into my vacation and in a moment of utter clarity, I proposed. Fortunately, Terry accepted.
Now, two years later, we were returning to Mali as husband and wife. Terry wanted to see her host family again, especially the child they had named after her. Kira, 29, a fifth-grade school teacher colleague of Terry’s who had never traveled to
Africa, accompanied us. As my heels touched the hot black tarmac of Senou Airport’s only runway and my eyes squinted to see through the dust clouds, I surprised myself by almost bursting into tears. This, my third trip to Africa, felt like a homecoming.
I had lived in Africa for ten weeks in the winter of 1989. A fourth-year medical student, I had come to Nairobi, Kenya, to do clinical research on the spread of sexually transmitted diseases within a group of prostitutes. Tanzania’s Muhaya tribe sent their women to the slums in east Nairobi to earn money by doing as many as 14 “jobs” a day, at about a nickel each. Eighty-eight percent of those who came to our clinic for care had tested positive for HIV, so our education program and free condoms had arrived too late to have a great impact.
Away from work, I lived at the YMCA, where many other young people from Western countries had come to stay while doing long-term projects in Kenya. There I befriended Phoebe, a Kenyan postal service secretary in her mid-20s who took me out of the Westernized urban city to west Kenya to meet her relatives. She showed me a more representative example of life in her country and in the more remote regions of Africa.
Whether one is visiting the Luo tribe in west Kenya or the village of Konobougou in southern Mali, your hosts will give you their most comfortable bed and prepare the heartiest meal they can afford. Because they never possess much more than the barest essentials of life, they put their highest priority on spiritual and human relationships.
When Terry, Kira, and I arrived in Konobougou, where Terry had lived for two years, the village knew we were coming and had arranged a warm welcome. The favors started that afternoon in Bamako and caused us some uncomfortable moments. Baba, Terry’s Malian father, had ordered one driver, who made daily runs from Bamako to Konobougou, to pick us up. We hadn’t seen him that morning, so we signed up with another van. When we returned to the crowded, dusty downtown market area, the assigned driver recognized Terry and greeted her in the customary Malian manner, which means exchanging a series of rapid-fire questions about everyone the other knows. He then escorted us to his van, infuriating the other driver. After a loud but brief argument, our driver prevailed.
Two hours later, Baba, Jen (Konobougou’s current Peace Corps volunteer), and two other Peace Corps volunteers (PCVs) from nearby villages led the small mob welcoming Terry back. Jen, a kind, confident, and cynical recent graduate of James Madison University who wore her long, straight blond hair tied in a pony tail, led us to her cement house, which had a couple of extra rooms for the three of us. Jen explained why she had mixed feelings about this event.
“Did you really build the school with your own two hands?” she asked Terry with jovial skepticism. An education volunteer, Terry had helped create a library for the village school and improve its instructors’ teaching skills, but she hadn’t lifted a brick. If they like you, Malians will embellish your accomplishments in your absence, so most new PCVs go through a period where everything they do is compared unfavorably to their predecessors.
In fact, Malians do not, as a rule, make it their business to build others’ self-esteem. Much of their humor is derived from insults. It starts in childhood. Parents almost never praise their children, frequently tell them they are ugly or stupid, and do not eat with them. Relationships between different families reflect this as well. Every family has another family of "joking cousins.” Whenever joking cousins meet, they exchange insults, such as "You eat beans” “You’re ugly,” or the more serious “You eat donkeys.”
The emotion surrounding Terry’s return broke this tradition. Two years of living in the U.S. had not withered her skill with the Bambara language, so the same Malians who had for two years told her over and over again, “Your Bambara is terrible,“ now praised her speech at every opportunity, often with reverential undertones.
We had not expected such warmth. Terry had returned home once during her Peace Corps stint, and upon her return she had been met with requests for gifts, and those she brought never seemed quite enough. We expected to be inundated with such demands during our visit, but instead our hosts were overwhelmed that we, “who have so much,” would come back to visit them, “who have so little.” Tanti, Baba’s wife, who in typical Malian fashion did or supervised all the household chores, told us there wasn’t anything they could do to express the immense gratitude she and the family felt. As she told Jen, “This must mean Fatouma (Terry’s Malian name) really loves me."
So the next day they killed and cooked a sheep for us, which is perhaps the highest tribute a Malian can pay. Gaussou, a thir-tyish, balding butcher from nearby Barouelli, who is one of Terry’s favorite Malians because of his uncustomary' respect for women, performed the ritual killing before us in the traditional fashion. Neither Terry nor I could bear to watch the death-defining moment as it played itself out in the yard outside Baba’s house. Amy, the PCV from Diawarala (another small village in the region), watched through the windows of Baba’s car, as though that would insulate her from the violent, gory act. After tying the sheep’s legs together, (iamsou sliced through the thin white neck of the floppy-eared black-and-white victim, whose blood unfurled a red carpet over the dusty desert earth.
The scene reminded Terry of an incident from several years ago. Malian families often select one son to send to faraway villages to study the Koran during adolescence. These garibous beg to survive, and in Konobougou, while Terry was living there, they lived with their Koranic teachers in a house behind Terry’s. The teachers did not allow them to live inside the house, even during the rainy season, so Terry permitted a group of them to stay in two sheds behind her house. Somehow they procured a sheep, which they raised for several months. This sheep had a unique and charming habit: if you held your hand out to it, it would gently butt your hand. No matter how endearing, sheep in Mali are raised for one purpose, and the garibous shared the delicacy with the local PCVs. During that dinner, one of Terry’s colleagues, in a final respectful gesture, took a piece of meat between his fingers and with it nudged his other hand, eliciting bittersweet laughter from the garibous.
Tanti made several dishes from our honorary victim, all of which dripped with as much grease as a double cheeseburger, and she treated us to multiple-course meals, which are almost unheard of in Mali. The staple food in Mali is millet, a terrific nutritional source that does not easily take palatable forms. Malians most often serve millet as to (pronounced toh), a thick, dull green, Play-Doh-like paste lacking any discernible taste. The accompanying sauce determines the flavor. Unfortunately for Terry, Baba has intestinal problems, which prevent Tanti from adding much spice to her sauce, so for the 18 months that Terry ate Tanti’s cooking, she forced down a lot of bland to.
From millet, one can also make bashi, which looks like and has the texture of soft sand. It absorbs the sauce better than to and most people prefer it, but it takes more work to prepare it. My favorite millet preparations are moni (MOAN-ee) and siri, which are porridges that have a smooth, sweet taste I prefer to any hot cereal I’ve ever had. One can also make a richer form of siri from rice, which is Tanti’s piece de resistance; we know we’re special because she treated us to rice siri twice.
We all ate like kings in one of the poorest countries in the world. All of us, that is, except Mama, Tanti’s second grandchild, who was eight months old at the time of our visit.
Until about four weeks prior to our arrival. Mama had been a round, happy infant, but a month of vomiting, diarrhea, and fever had turned her into a limp, listless lump of misery. When awake, she cried incessantly, expressing herself in a nonstop series of whimpering, sheeplike sounds that ruined everybody’s mood. Soon after I first met her, her bowels burst like a volcano, erupting a liquid stool of a deep green hue more impressive than any I had ever witnessed. The green color of secreted fluids, such as nasal mucus, bronchial sputum, or stool, comes from neutrophils and eosinophils, cells that attack invading germs. Mama's stool thus revealed a war between her bowels’ immune system and an invading organism, perhaps an Esdhena coli, Salmonella, Shigella, or amoeba. Baha and Tanti asked me to look at her, and I was eager to do so.
Her “appointment” was the next morning after breakfast. Batouma, Tanti’s oldest child and Mama’s mother, brought her to me, papoosed as usual on her mother’s back. There, she always remained silent, but the moment she left Batouma's back, the pitiful braying began. On my lap, she could not hold her head up or sit up alone, things almost all healthy eight-month-olds can do. Her deep black skin had lost much of its elasticity. Her heart raced at a rate of 160 beats per minute, about 40 beats faster than normal. It was obvious to me that Mama’s resources for fighting this battle were running out.
About a week earlier, Batouma had taken her to the village doctor, who had given her two prescriptions. The first was amoxicillin, the pink bubbie-gum-flavored antibiotic elixir that remains the treatment of choice for ear infections. Many bacteria that infect the guts are resistant to amoxicillin, so it is not often used in developed countries to treat bacterial gastroenteritis (infectious diarrhea), but in Konobougou, it’s the only choice they have. The second medicine was metronidazole (sold as Flagyl in the U.S.), which kills giarrdhia and other parasites; Batouma had not used this yet.
We didn’t have a lab, so I had to decide on clinical grounds whether Mama had a bacterium or a parasite, and I needed to be right. Because her illness had started suddenly, not gradually, with fever and diarrhea, I went with bacteria. I had brought some Septra (two sulfonamide antibiotics combined in one medication) to use in case we contracted severe gastroenteritis. Septra is also the preferred drug for children’s bacterial gastroenteritis. Baba brought me a pestle and a metal pan, which I used to crush two and a half Septra double-strength tablets
I had calculated this would be enough for 20 doses, or one dose twice daily for ten days. Baba also gave me a shot glass, on which I drew a red mark just above the bottom. I filled the glass to the mark 20 times with water and added it to the powder, making a chalky slurry, because the Septra did not dissolve. I made sure Baba knew how to measure and give the medicine twice daily, and so Mama’s treatment began.
Tanti also had a medical problem. That afternoon, she summoned me to her house to evaluate her stomach troubles. As I stooped to lower my head through the curtained entrance to her shadowy room, I felt a bit ill-at-ease: A white man, just getting to know this family, in a Muslim woman’s bedroom ready to discuss details of her bodily functions and to touch her body. She would be exposed in a way that her religion does not allow. We would speak French, the second language for both of us, which I thought might impair our communication.
I need not have worried. From the moment she sat on the edge of the bare single mattress that rested in the middle of the deep gray cement floor, she adopted that familiar tone of a patient describing her troubles to a trusted doctor, and her French turned out to be more than adequate to give me the detailed symptom accounts I needed. Even when she prepared for my examination by removing all her wraps from above the waist, something I rarely see at the Berkeley clinic because I leave the room when patients change into their paper gowns, it seemed appropriate in our simple surroundings.
Tanti’s abdominal pains had troubled her occasionally for years but had become much more frequent over the past several months. The more she talked, the more I realized that if she weren’t speaking French with a Malian accent in a sub-Saharan African village house, she could have been any middle-aged mother of four with a critically ill granddaughter coming to my office with these complaints. The deep discomfort just below her sternum that often woke her at night and diminished when she ate told me that her many worries had given her an ulcer.
Not having to contend with a waiting room full of patients, I had time to explain the relationship between lifestyle and excess stomach acid. Tanti, like most Malian women, toils all day long in scorching heat preparing food, washing clothes, caring for her children and grandchildren, while her retired husband ponders political and social issues with his other aging friends (“The Men’s Club,” as Terry used to call them). Her youngest daughter, Ata, is losing most of her early adolescence and many school days to heavy labor; Tanti can’t do all the work herself, and the family cannot afford to hire outside help. I couldn’t change the situation, so I taught Tanti some simple meditation techniques to help her detach her emotions from things she cannot control. The next day, we went to Segou, where we found a pharmacy that carried cimetidine (Tagamet, at one time the largest-selling prescription medication in the U.S.) and bought Tanti a six-week supply for about $16.
Buying medicine for Tanti was not the reason we traveled to Segou, Mali’s second largest city. Thouwa (pronounced TOO-ah), Tanti’s second daughter, goes to high school there, because Segou has the only high school in the region. Her future had become our project. Nineteen years old and first in her class since elementary school, Thouwa is a senior this year and has the audacity to dream of becoming a gynecologist. “She’s not very smart, but she works hard,” explained Mr. Cisse (pronounced SEA-say), her former English teacher, giving another example of how difficult it is to earn praise from a Malian. There aren’t any female gynecologists in Mali; in fact, there aren’t any gynecologists at all in Konobougou. There is a Malian-trained doctor there, but Malian doctors get only a few years of training directly out of high school. Thouwa wants to go to medical school in the United States.
Which is, of course, impossible fora Malian woman. Unless the mother of one of the PCVs (Amy) in your village’s region happens to be the president of a college in the U.S. and awards you a full scholarship. Thouwa’s infectious charm, relentless study habits, and good fortune have won her a three-year scholarship at Barat College in Lake Forest, Illinois, beginning in January 1998.
This will necessitate a bit of an adjustment. A teenage African who speaks minimal English, Thouwa comes from a small (about 3000 people) village in one of the world’s poorest countries and wears layers when the daytime temperature plunges into the high 80s during the cold season. She will be attending a small liberal arts college in Chicago’s wealthiest suburb on the western shore of Lake Michigan in the dead of winter. The wind-chill factor will fall to almost 200 degrees below that to which she has grown accustomed.
Terry and I didn’t know about any of this before we arrived in Konobougou, where Jen told us. We would need to take care of some logistical details, both during our travels in Mali and after our return to the States. Thouwa had not yet sent in her application to Barat College, which required, among other things, transcripts, a personal statement, and letters of recommendation.
Terry and Thouwa had become close during Terry’s Peace Corps days, but I had never met Thouwa. Wearing arresting bright red Malian wraps, she welcomed us like a warm fire, first engulfing her American sister with her arms and then grabbing Terry’s breasts, a behavior we hope she will unlearn when she moves to the United States. She then engaged us in a conversation in French, a language she spoke with shyness two years ago but now with the ease of a well-educated high school student. After buying Tanti’s medicine at a pharmacy in town, we spent most of the evening running errands to get Thouwa’s papers together and visiting members of their family. Terry thus landed in the middle of an intense family dispute.
About a month before our visit, the students at the high school had gone on strike. This is not an unusual occurrence in Mali, where the government pays the students to go to high school. Usually, the students strike for more money, but this time they had a different agenda. High school students can fail up to two years and still stay in school, but if they fail a third time, they are not allowed to continue. The students went on strike to gain the right to fail three years and still go to school and earn the government stipend. The students lost, and while my sympathies almost always go to laborers, I was glad.
Thouwa’s younger brother Mohammed, also a high school student, participated in the strike demonstration. We were told he threw books out of a classroom window, but Malian classrooms are bare and do not often contain books, so we’re not sure that was his transgression. In any case, the police arrested him, and he spent a day in jail.
He was not going to tell Baba, but Thouwa did. Mohammed’s refusal to speak to his sister since then had upset Tanti so much that Tanti begged Terry to try to bring the two siblings together that evening. Terry succeeded in getting Mohammed to shake Thouwa’s hand, but he then left before saying the necessary Muslim blessing that confirms the resolution of a dispute, and so it was not finished.
We left the next morning to begin the tourist phase of our trip. Our destination was the Dogon country, about 270 miles east of Segou. In Bamako, at a bed and breakfast where we spent the night and the bedbugs feasted on our faces, we met an artist from New York. A seasoned traveler, she had just finished a month of sightseeing in the Dogon region. “I cannot recommend it to most people,” she told us. “It’s too much work.”
We soon saw her point. Because of the high expense of renting private vehicles, most travelers ride baches (“BAH-shay”), which are covered pickup trucks or vans that provide public transportation. Each day we stuffed ourselves into an over-loaded, dilapidated, barely functioning bache to accumulate grime and sweat during hours of travel through the Malian desert. Thanks to a driver who left us when our guide brought us back an hour and 15 minutes late from a day-long hike, we spent one night in the Dogon village of Djiguibombo sleeping on bare beds made of millet branches. Every hour, I woke up hurting so much on the side on which I was sleeping that I could barely turn over to subject another body part to the same punishment. The next morning we took a four-hour, 12-mile, relatively comfortable donkey-cart ride back to the hotel in Bandiagara where we had left our belongings.
Two days later, we and 30 other travelers (all Malians, if I recall correctly) boarded a bache headed about 180 miles west to Segou, where showers (without hot water, but still a luxury) and beds would await us after our anticipated seven-hour trip. Thirty-three people crammed into a vehicle the size of a full-size van. Malians put extra seats in the center aisle, sacrificing access to the rear exit to allow more passengers to ride. We left Djenne at 4:15 p.m., ferried across the river without any problems, and turned onto the main highway. About 30 miles from Djenne, we made an unscheduled stop in Tene. The news of our flat tire eventually reached those of us in the back, so we got off, freeing those seated in front of us to alight as well. Whenever a bache stops in a Malian village, local vendors swarm in to sell food and drinks to the passengers. Because we were hungry, Terry bought us some cou (koo), a relative of the potato that tastes like a fluffy white cloud of salt. While we ate, I noticed on the bache's roof a tire standing tall amongst the enormous load of cargo and wondered if it might be a spare tire and, if so, why we weren’t putting it to use.
Malians do not approach this type of situation the way we do. Malians, like most Africans, do not care much about schedules and therefore are never in a hurry. Most Africans do not understand the concept of being in a hurry. Those who do will often make fun of Westerners by pointing to the wrist and saying, “Time is money, time is money.” So when one travels in Africa, trying to rush is a recipe for complete frustration. They are much more concerned about getting the maximum use out of their scarce resources, such as tires. And they take care of their basic needs: the driver took extra time to eat dinner while waiting for the tire repair. Ninety minutes later, we re-boarded the vehicle and resumed our trip.
We had driven slightly more than a kilometer when we all heard a loud psssssss from the vehicle’s left rear. Under a cover of darkness, we once again disembarked to join the cobras, scorpions, and whatever other creatures might be ready to accompany us in our roadside vigil in remote West Africa. As one of the Malians sprinted back toward Tene, rolling the useless rubber tube ahead of him, I glanced toward the top of the truck, where the unused tire stared back at me like a big black eye. Must be for another vehicle, I assumed, and planted my butt on the tarmac next to my companions and wished for the appearance of an empty bus that would whisk us to Segou. Five days of Malian-style travel had used up my patience. I considered taking a nap, but the road was narrow enough that each passing truck looked as though it might hit us before roaring past, thus ruining any thought of resting.
It took us an hour and 15 minutes to get going again. With each mile of eventless progress, I allowed myself a bit more hope that our worthless piece of crap of a bache might stay on the road awhile.
Thirty-five minutes later, we pulled off the road again and stumbled out of the truck. Even the Malians, who are accustomed to this kind of travel, began muttering to themselves and whoever else would listen. To my surprise, someone mounted the truck and pulled down the tire that would have spared us so many hours. We didn’t have any more blowouts. And the delays were getting shorter; this one lasted only 45 minutes.
But three minutes later, the bache coughed and wheezed to another halt. During three and a half hours of delays, no one had thought to make sure we had enough gas. Malians never put more gas in the tank than they need to complete a trip, and almost as often as not, they don’t have enough. This time, though, one could argue that they hadn’t planned this trip with much thought, since we were still less than a quarter of I he way to our destination.
Too tired to protest and, at least in my case, astounded beyond words at the stupidity of the situation, we all watched the designated runner take off again, this time in pursuit of a willing gasoline donor. We had come to the outskirts of another village, so he returned within the hour with enough gas to get us to San, where we all would alight again while several men put their heads together to figure out what to do with the bachL From what I could tell, all they came up with was rotating the tires, which they did.
We sat on outdoor wooden tables, much like picnic tables one would find in our parks, at times putting our heads down to rest or mumbling tired witticisms about the futility of our adventure. It was almost 1:00 a.m.; it had taken us just under nine hours to complete the first quarter of our trip, which meant a 4:00 a.m. arrival tomorrow in Segou unless we picked up the pace.
Which we did. We didn’t stop again until we reached Segou three and a half hours later.
The nightmare trip was over, but another unpleasant discovery awaited us the next day. The three of us took a taxi to the lycee, where Mr. Cisse informed us that Thouwa was ill, which Terry later told me is a common occurrence. In fact, whenever Thouwa gets a fever, she and tier family assume she has malaria and treat her for it, which means her body has seen a lot of quinine. She did look drained when we arrived at the classroom where she was resting, but her runny nose clued us three Americans in to the cause of her misery: a cold.
So this was not a big deal, and by the time we finished lunch Thouwa felt well enough to bundle herself in a sweater to ward off the chilling 90-degree temperature and take us for a walk along the Niger River. That Mr. Cisse accompanied us did not seem odd at this point, but when we needed to find a picture of Thouwa to enclose with her application, and Mr. Cisse volunteered that he had a few at his house, yellow lights began dashing in my head.
Upon our return to the Segou Stage House, where the PCVs from the Segou region stay when they come to the city and where we had spent the previous night, Mr. Cisse seated himself on the reception room couch next to Thouwa. Her feet brushed his lap. My inner lights dashed red. Words weren’t necessary, I knew my wife had noticed. In this predominantly Muslim region, this seemed the equivalent of a passionate, lip-locked embrace. Often in Mali, teachers abuse the prestige and power of their position to take sexual advantage of their students, and although we have not proven Mr. Cisse guilty of this, his behavior seemed too obvious to ignore. He accompanied us in all of that day’s activities, which did not seem appropriate and further fueled our suspicions.
We returned to Konobougou that evening and reported these events to Jen. “I want to vomit,” she said, putting into words what we had felt all day. Thouwa had not, of course, told Jen anything about this situation, and approaching the subject would be difficult. Three years earlier, a young man from Ghana had come to Konobougou to tutor Thouwa in French, and some people, including the PCVs, erroneously suspected her of sleeping with the tutor, which had made her angry. So Jen will be navigating an emotional minefield, but we are also sure Thouwa realizes one of the few things that could derail her plans to study in the United States would be a pregnancy. Six months later, we have yet to receive any updates from Jen on this situation.
Jen and Baba did give us progress reports on Mama and Tanti. Mama’s vomiting stopped several days after starting her medicine, and her multiple bright-green bowel eruptions gave way to a single daily yellow stool In our five-day absence, she had almost completed her metamorphosis back into a happy, normal infant. During breakfast the next morning, Tanti praised my doctoring skills, contained, in this case, in those two and a half Septra double-strength tablets. Tanti’s stomach had improved, and she too was grateful.
Ah, family medicine; what other specialty is so portable? More than a few times since my return I have fantasized about moving my practice to Mali, away from managed (or “mangled,” as my associate prefers to call it) care and lawyers, where people appreciate everything and anything you can do to help.