Rapid Malaria testing in Yamalé

[This post is being published out of order; the story is from mid-August 2014]

On August 13th, I accompanied three medical staff and a driver for a mobile clinic in Yamalé, a village on the road that leads from Bambari to Bakala in Ouaka préfecture, Central African Republic (CAR). Yamalé had, until very recently, been deserted; the population spent months living in the bush. We had already visited the village the previous day – August 12th – to resupply the “point palu”, which translates as “malaria point” – basically, MSF trains a small number of people in the local community and equips them to carry out rapid diagnostic tests for malaria, the leading cause of death in the region. We also supply medicine so they can hand out treatment to those who test positive, free of charge. In addition to resupplying the point palu, our visit would allow us to announce the mobile clinic we had planned for the following morning, asking the villagers to clean the school and cut the tall grass for us to use.

Only thirty-odd kilometres northwest of Bambari by road, you might expect the drive, in good weather and remarkably light traffic, to take about half an hour. The condition of the dirt road, however, lengthens the journey to nearly two hours, and that’s before accounting for the trees. While it’s beautiful driving through the dense green forests in CAR, the logs lying horizontally across the road are moderately annoying. Luckily we only encountered two such obstacles. The first tree took over twenty minutes to hack apart, while the second one was cleared within less than ten.

Guy and Eric bushwhacking in Ouaka, Central African Republic

Fallen trees block the road in Ouaka, Central African Republic

Clearing the road was a useful exercise, which would save a lot of time the next morning. Once we arrived in Yamalé, Eric and Gladys discussed medical stuff with the local point palu guys, restocked their metal trunk with malaria medicine, and then we turned around and headed back to Bambari.

Eric and Gladys speaking with Yamalé malaria point staff

We arrived shortly before 8am and over the next seven hours I drew droplets of blood from over two hundred people – mostly screaming children – to screen for malaria. Among the children, almost every single one tested positive for the mosquito-borne parasites, and a huge number of the adults tested positive as well.

One of hundreds of fingers I pricked to test for Malaria in Yamalé, Central African Republic

The other person striking fear into the hearts of the children of Yamalé was Brice, our driver. Together, we tested between four and five hundred people for malaria, most of whom continued on to the next rooms for consultations.

Brice testing locals for Malaria in Yamalé

As we sat in front of the village school stabbing people’s middle fingers, Anti-Balakas loitered around the centre of Yamalé, standing and sitting beside the main road less than a hundred metres in front of us. With long rifles slung over their shoulders, machetes in multi-coloured sheaths strapped to their backs or hanging from their hips, magical charms and amulets strung round their necks and taped to the foreheads of some, the Anti-Balakas are strikingly special in their outward appearance to those of us who doubt the protection offered by their magical machetes. Having been boiled in a very special herbal mixture, the machete’s flimsy steel blade is capable of stopping bullets. I wonder, however, if these boys took the time read the small print in the instruction manual: only stops bullets thrown by hand.

We considered the mobile clinic a great success. Each person was screened for malaria, and most of them also saw one of our medical staff for a consultation. Each person diagnosed with malaria received the appropriate medicine (a highly effective combination of artemether and lumefantrine) from an MSF medic. For these and other medicines prescribed, MSF staff supervised first doses on-site, explaining how much and how frequently to take them.

Our midwife held thirty consultations for expecting mothers, and the two nurses altogether consulted 375 patients. Among the more common health complaints compounding the impact of malaria, the nurses diagnosed many cases of worms, amoebic dysentery, various skin infections, upper respiratory tract infections, and bilharzia. While these conditions are all endemic in CAR, the rates seen in our mobile clinics are higher than we would expect if the people were not forced to live in the bush for months at a time, unable to protect themselves against the mosquitoes’ nightly feasts, forced to drink from murky waterways because they’re too afraid to return to their village wells, unable to reach a health post to access treatment because they feared being attacked en route. Those who aren’t afraid often cannot return home because their mud brick homes are roofless: armed groups routinely lighted the highly combustible archetypal thatched roofs on fire as a means of terrifying the population.

Roofs of homes burned by armed groups in Central African Republic

Large-scale arson seems to have stopped (to put it differently, the fire has ceased) in the area, though nobody can say with any certainty that it will not reignite again in the near future. Regardless, until the rains give way to the dry season toward the end of October, it’s too time-consuming to gather enough dry grass for new roofing, a circumstance motivating many villagers to remain in the bush for the time being.

At the end of the day, it was clear to me that the villagers urgently needed the medical care we were able to provide in the Yamalé mobile clinic, and they were demonstrably appreciative of our efforts, thanking us over and over for coming to help them. However, as I finished off a piece of stale bread and a handful of roasted peanuts on the three-hour drive back to Bambari, drifting in and jolting out of sleep, I wondered: will this kind of short-term medical activity have any lasting impact?

Before I could work out an answer, my eyelids dragged my chin down toward my chest, and my dirt track nap nodding began anew.

Yabada Siguigi

[This post is being published out of order; the story is from late August 2014]

Yabada Siguigi village signpost

Many years ago, French colonists arrived in a village in what is now the Central African Republic. The chief, whose name was Yabada, and all his people fled into the bush, terrified of the strange white people. Eventually the foreigners convinced the people to return to their homes, and under the colonial bureaucracy the village registered their name, Yabada Siguigui, which means “Yabada left”.

* * *

We drove the DAF truck four times to the laterite quarry on Friday, loaded the DAF four times, and unloaded those four truckloads of laterite at our compound to reduce the severity of the frequently experienced inundations that followed any rains.

Daily workers digging laterite soil outside Grimari, Central African Republic

Unloading laterite at the MSF compound in Grimari

Then, we went searching for stones.

***

5km along the track leading to Possel, we stopped in the quaint little hamlet of Yabada Siguigui.

The village chief came to greet the four of us in our Land Cruiser, his two front teeth set at just the right angle to give the impression he was goofing around, regardless of what he was really saying. We told him we had heard of flat stones sold nearby, and he directed us to drive a kilometre further south, where we could find them. As we drove, trees gave way to brush and tall grasses, the landscape transforming quickly from densely forested jungle to a sort of savannah permeated by outcroppings of bedrock along which the defining lines of the area’s geological history tilted upwards, rebelling against the horizontal inclination of the stony surroundings. Having agreed that the area’s stones would suit our needs, we pulled a U-turn.

Back in Yabada Siguigui, from the driver side window, we exchanged a few words with the grinning chief. He assured us that he had stones prepared, so we arranged to return the following morning with a truck to load up.

***

Saturday morning Sunday morning, according to schedule, I climbed up into the cab of our big transport truck, an old DAF paradoxically equipped with four-wheel drive but road tires. Six daily workers loaded ten boards measuring four metres each, then hopped up and over the walls into the open-air truck bed. When we came to a bridge, we pulled out the boards and reinforced the bridge deck to avoid taking a morning dip in the water. Having had relatively little rain over the past two days, the dirt road was hardened, and our truck rolled along with barely a care in the world.

Yvon driving the DAF truck

Following a few minor jostles and jolts, our merry band arrived in Yabada Siguigui. The chief and an impressive entourage of local youths joined us in driving south to the area. After parking the truck, the chief led a column marching eastward, single file, down a footpath toward the stones. 15 minutes later, the village chief resignedly admitted that he no longer recalled where the piles of stones lay. Boys with machetes fanned out through the grass to search, and they eventually succeeded.

The mound of stones was about 50 metres north of the footpath, in the middle of nothing. Discussions began in earnest as each of the village’s self-declared civil engineering experts (i.e., everybody) trumpeted his opinion on the ideal route for the truck to make its way to the site. I asked if our daily workers and the villagers couldn’t slash a path through the plant growth with their machetes. I blinked and they had already cleared the first few metres. As the boys hacked away, I sat with the chief to negotiate a price.

In negotiating a fair price, we reminded the village chief that MSF provides medical care, free of charge, encouraging him to give us a good price as a favour for a charity working to help his people. As carefully chosen words rolled off of tongues and into ears, the chief took hold of the hem of his shirt and in a smooth motion slid it up and over him. There were three main scars on his back: two on the right side, one on the left. He told us that the streaks, angled upwards away from the spine, were the marks of his time held prisoner by one of the armed groups active in the area, who accused him of being a leader of the other armed group.

Scars still visible from lashes across the back

Our discussion turned to other subjects, and a few minutes later the boys returned to tell us that a channel had been cut for the DAF truck to make its way through the grass.

A path hacked through the tall grass for the truck

Yvon, the driver, rumbled into position; in half an hour, as children sat staring at the strange white man making funny faces, the truck was loaded.

Children watch as we drive away

We started back toward the village at a slow pace, cognizant of the cargo’s tremendous weight. All was going well until, just as we began turning from the cleared track onto the well-worn path, we all heard the sound every bush driver dreads: the rapid rush of air escaping from its rubber prison cell. One of the village boys had cut a small tree but left a pointed stump about two hands high, hidden from view by the cut grass.

Flat DAF tire

Out came the red bottle jack, elbows dropped to the ground, and then… nothing. The jack wouldn’t lift. No problem, we thought to ourselves, we’ll just use the other jack, a navy blue one. Just our luck: the second one did jack squat. I was surprised when Yvon brought out a third bottle jack, this one black. Astonishingly, three of three jacks failed us. I phoned back to our base in Grimari, asked another driver, Zacharie, to bring more jacks. The day had been incredibly hot and muggy, flies harassed us as most of us sought shade from the overbearing sun, but gradually a refreshing but worrying wind picked up from the west, a telltale sign of an impending storm.

An hour into our ordeal, after much tinkering, Yvon got the red jack working. The next obstacle was removing the enormous truck tire. Normally, this would take a few minutes, but we had the joy of pulling off washers that had cracked in multiple places, effectively transforming them into lock-washers. As we struggled to free the wheel, the cool wind brought towering clouds overhead. Lightning crashed and thunder boomed to the west of us. And then, a particularly harsh and ill-timed deluge of water roared deafeningly downward, drenching us in seconds. The rain refused to weaken, remaining steady for over half an hour. Just as Zacharie arrived in a Land Cruiser, the sun began to shine, and a few minutes later the rain ceased. Yvon managed to remove the wheel, and Zach helped mount the spare. Finally, after over two hours, we again moved forward.

Our joy was short-lived: in fewer than a hundred metres, the truck got stuck in the mud. A brand new tow strap and shackles linked the rear of the Land Cruiser to the front of the DAF truck, and in seconds our pitiful convoy was freed to continue.

This time we made it the full kilometre back to the village, Yabada Siguigui. I pulled two purple notes from my wad of cash and slid them into an easily accessed pocket, ready to pay the village chief for the stones. But then we got stuck in the mud again.

This same road had been a piece of cake a few hours prior, but had severely deteriorated during the day’s downpour. Five minutes of digging and the Land Cruiser was able to tow the truck out. Not more than twenty metres further on, the truck’s tires were once again spinning uselessly in the mud. Shifting the truck into reverse, the Land Cruiser towed it from the other end, and again succeeded to free the beast. We decided to try for a different route, but this time the truck got so deeply stuck that it took over an hour and a half to move it, using every imaginable strategy. By this time we had offloaded all the rocks. We ran a metal cable around a magnificent mango tree and began using our brand new manual winch, but a brass pin sheared off in two places as we pulled the lever back and forth, rendering the winch completely useless.

Trying the ratchet hand winch

Broken winch pin

I showed the drivers how to use a Hi-Lift jack horizontally as a makeshift winch, but we didn’t have enough chain or rope to set it up that way. We put metal mud boards down but, designed for Land Cruisers, they were too stubby and did nothing to increase the heavy truck’s traction. By 16:30, the truck finally lurched backwards, out of the deep ruts it had dug, and up onto more solid ground. Again we made a quick assessment and chose a new route to get through the village, crossing fingers that we could manage without further incident. After just fifteen metres, the passenger-side rear wheel slurped into what may as well have been quicksand. Thirty minutes spent digging the wheel out, placing rocks, and multiple failed attempts at towing, eventually led the truck back onto stable ground. It was nearly 17:00, so we set off to try and make it back to Grimari before our 18:00 curfew.

We returned empty-handed to our base, arriving at 17:58, just in time. A few minutes later, just for good measure, it rained some more.

A Sunday drive in the Central African Republic (August 2014)

[This post is being published out of order; the story is from 17 August 2014]

Butterflies, clustered by the hundreds on the red laterite road, fluttered up into the densely hot air like rebellious snowflakes as we rolled, bounced, and jolted west toward Grimari in a convoy of two Land Cruisers. White, with easily distinguishable red Médecins Sans Frontières (MSF) logos plastered on every surface, our vehicles are easily recognised by the local population; women smile and sing “merci!” in perfect unison as I wave from the passenger seat. Here in the Central African Republic (CAR), those who don’t speak French use the word “merci” to say “hello”. Hundreds of people raise both hands high, palms facing forward, to tell us we are welcome here.

Butterflies clustered on the forest floor in the Central African Republic

Usually, my jaw hurts from all the grinning I do during road movements like these, but today I have a more serious look on my face. I still wave, still make eye contact and nod my head or raise my eyebrows to greet people we pass, but it would be inappropriate to smile from ear to ear while a young man sits behind me, watching over the body of his dead brother.

Shortly before 10:00 that Sunday morning I was sitting in the MSF office in Bambari, my stomach still feeling a little fragile after an uncomfortable Saturday spent making an above average number of visits to the latrine, when our project coordinator called on the satellite phone. The other logistician handed me a pen and I scribbled a message on a square yellow piece of paper: 27-year-old man; stab wound, left side; internal haemorrhaging; ETA Bambari hospital 13:00. One of our nurses went to the hospital, not far from our office, to give them the news so they could prepare to operate immediately on arrival. We loaded a stretcher and extra medical gear into a Land Cruiser and left Bambari with two vehicles. Our plan was to meet a Grimari vehicle halfway, what we call a “kiss” movement, move the patient into a Bambari vehicle, and send him onwards. Two vehicles would continue to Grimari, where I would be based for the coming two months.

A stretcher and medical kit loaded in the back of a Land Cruiser in Ouaka, Central African Republic

The distance from Bambari to Grimari by road is about 80km. Our project coordinator, travelling east to meet us, called over the radio as we passed the 40km mark and spoke to me in English. “Chris, we are losing the patient. We are trying to resuscitate him, so we will stop in the next village. We’ll see you there.” Sliding the radio handset back into the shiny metal clip on the grey plastic dashboard, I translated the message to my driver and gave him permission to exceed the speed limits set by MSF in this country, within reason. Twisting around to look over my left shoulder at the two Centrafrican nurses who would be caring for the patient until he could reach the operating theatre, I asked whether the increased speed would bother them. “Of course not,” they replied in French. One elaborated: “We heard the explanation; we’re here for the patient.”

An MSF Land Cruiser driving from Bambari to Grimari in Ouaka, Central African Republic

Soon enough, the other Land Cruiser came into view. It was parked on the road, opposite the small mud-brick Catholic church in a small village called Kongue. We pulled up alongside to make it easier to transfer the patient, but as I climbed down out of the vehicle, my eyes met those of our project coordinator, and I saw that it was too late. I asked, to be certain, and she confirmed that the patient had died a minute earlier.

Villagers began to gather, and we asked them to leave some space so that a young man could grieve in peace. One teenaged boy in particular stood out from the crowd; the white string tied with a knot under his chin led up the sides of his face to a gaudy piece of fashion engineering: a tortoise shell – inadequately sized for his head – perched precariously on top of his cranium. Above the shell were layered a piece of aluminium foil and a handful of baubles. A string of evenly spaced magical charms sewn into small leather pouches formed his protective necklace. These accoutrements revealed his affiliation with the Anti-Balakas, the village self-defence militias found in many parts of CAR. He milled about like the other locals, concerned or curious – or perhaps both – by the three white faces standing on the middle of the road and the dark-skinned feet sticking out from under a sheet in the back of our Land Cruiser.

I offered to be lead passenger in the vehicle carrying the deceased back to Grimari so that Mark, the American nurse who’d worked so hard to save the patient, could have some breathing room. An hour or so later, we stopped for a few minutes in Grimari, picked up two more family members, then began the drive to the deceased’s village. It took us an hour and a half to reach Ngbékota, a village 31km from Grimari on the road that leads to Sibut. Pulling off to the side of the road, we reversed slowly under the shade of towering mango trees, and parked the Land Cruiser.
The wailing began before the engine stopped, a chorus of women crying and screaming.

While the family and friends mourned, someone approached the two MSF nurses. There’s a badly wounded infant, they said, can you have a look? We went together to meet the baby’s mother. As she unwrapped the cloth that covered her daughter’s wound, we were saddened to see what was underneath: an abscess covered the entire left buttock and more. It was a seeping, puss-filled, disgusting wound, covered and worsened by a brown mess of fibrous plant matter, the local treatment for open wounds.

We wouldn’t be able to treat her adequately in Grimari, so we all agreed she should go immediately to Sibut, where the large hospital would be equipped to care for her. We asked to see the village chief, and when he arrived the two nurses spoke with him at length about cleaning wounds with soap and water and sending patients to a health centre before their condition worsens. I gave 22,000 francs CFA (about 33 Euros) to a local motorcycle taxi driver to carry the mother and infant to Sibut immediately, and gave 10,000 more to the mother to feed herself during her stay there. We drove off, hoping the child would not need to have her leg amputated.

The only reason we found her was that her father was the young man who’d kept watch over his brother all day in the back of our Land Cruiser.

A third of the way back to Grimari, we came across a pair of French military vehicles. A soldier weighed down by weapons, ammunition, gear, and protective equipment motioned us to stop. “We’ve found a body,” he told me – in French, but with a strong accent like most of his Foreign Legion companions – “are you able to take it?” I had known since morning that a body had been found 17km from Grimari, but the soldier said the victim was from Ngbékota, the village we’d just visited. We couldn’t return the body, I explained, as that would keep us out on the road past our curfew. “Nobody wants to take the body,” said the soldier. “He’s not from here and we don’t even know his name.” “Well,” I said, “if you’re not able to find someone to take possession of the body, and you can’t take the body back to Ngbékota, your best bet is to dig a hole somewhere nearby and bury him before the stench of his decomposing body becomes unbearable.” The legionnaire said he understood, and we drove on.

Panhard VBL of the French Foreign Legion in Ouaka, Central African Republic

Within minutes we again found ourselves idling next to an armoured vehicle. For some reason, the French flag is always at half-mast on their vehicles in CAR. I jumped down from the Land Cruiser. The soldiers asked the same questions, got the same answers. One of them showed us the body, straddling a green bamboo pole passed through the wrists and ankles, which were bound together by vines. His eyes had been gouged out and his throat slit wide open, exposing marbled red and pink flesh and muscle, streaks of white ligaments, and yellow subcutaneous fat curds. The soldier dropped the small scrap of vinyl sheeting back over the body to keep the flies off.

As we prepared to leave, repeating the advice to bury the body nearby, one of the young grunts came up to my passenger-side window and told me they couldn’t dig a hole because they hadn’t any tools. “You’re soldiers, but you don’t have shovels?” I asked, my eyebrows furrowing incredulously. “We broke them all back at camp,” came the reply. The putrid stench of his pitifully defeatist tone of voice, wafting toward me on a wind of inability and ignorance, was nauseating. I asked the driver to remove a shovel from the roof of the Land Cruiser, and gave it to the French soldiers to dig an unmarked grave. They promised to return it to our office in Grimari later that night. Visibly dejected, they thanked us as we drove off.

The sun disappeared minutes after we arrived home; the Milky Way streaked through the darkness directly overhead; the rumbling of the town sputtered and died; the frogs and cicadas took up their instruments and began to play a symphony rehearsed every night but never perfectly performed. After a dinner of plain white rice, onions that smelled of fermenting tomatoes, and chicken as chewy as my steel-toed Australian leather boots, I took a cold bucket shower, lay my head down, and sweated myself to sleep. That was Sunday, the only official non-working day of my week.

What did the nut say to his buddies as he left the cocktail bar?

Realising that I was slouching on my stool, I made an effort to straighten my spine. A minute later, I spotted my reflection in the mirror, his posture once again failing as he leaned with his right elbow on the bar table, which was bolted to the floor. The tabletop was a slice of a tree trunk with a jagged split that had been filled with translucent resin. Red LEDs glowed through from below.

Mirror reflection at the Keefer Bar in Chinatown, Vancouver

Sitting in this atmospheric cocktail bar in Vancouver’s Chinatown during my first ever “online date”, I had no idea that my mind was about to be blown. My date pulled out her iPhone. Swipes, scrolls, and taps followed in quick succession, and before I knew it the screen was facing me and I gripped my chin in pain from my jaw having dropped so hard.

What, you may wonder, could be so amazing?

Cashews, that’s what.

She showed me a series of photos of cashews from a trip she’d made to Brazil. In all these years of eating cashews, I never knew that they grow out of the bottom of cashew apples. Wrapped in a green protective casing, a single cashew nut clings tightly to the bottom of each cashew apple.

48 days later, I was sitting in the passenger seat of a Land Cruiser pickup somewhere between Kissidougou and Kankan, in northeastern Guinea. Red dust shot out and upward from the tires; billowing clouds lost their definition almost as soon as they formed, leaving a thick, rusty fog in our wake. A small orchard of unfamiliar trees on the left hand side of the road caught my attention, but it was out of sight as soon as I’d noticed it. No more than five minutes had passed when more of these trees came into sight, lining both sides of the road for hundreds of metres. This time, it was impossible not to notice the yellow fruit on the trees: cashew apples!

Two nights later, I paid 40 cents Canadian (about 32 cents US that day) for eleven cashew apples, and 45 cents Canadian for four mangoes.

11 cashew apples and 4 mangoes in Kankan, Haute Guinée, Guinea

I downed five cashew apples and a mango in one sitting, even though I was stuffed from a large dinner.

Biting into my first ever cashew apple, in Guinea

Next, to gain a little perspective on cashew nuts, I spent half an hour fumbling with my Leatherman to get them out of their protective casings.

Cross-section of a cashew nut in its casing

This bunch of eight cashew apples:

8 cashew apples, with cashews still clinging on

…gave me this set of cashews:

8 cashews, unopened

…which in turn held this little set of cashew nuts:

8 cashew nuts

In case you ever find yourself face to face with a real live cashew apple, here’s a protip: don’t consume any milk products before or afterwards. I haven’t yet verified whether this is a legitimate problem, but when he was in the Gambia, my friend Zack (who insists his name is not spelled with a “k”) was told that combining dairy with cashew apples is a recipe for a gastric disaster. My Guinean colleagues told me the same thing, without any prompting. I’d be interested to hear from anyone who might be able to shed some light on whether such a reaction really results from mixing milk and cashew apples, or if it’s perhaps a folk tale serving another purpose.

“Cashew later!”

Picking a cashew apple right from the tree, somewhere between Kankan and Kouroussa, Guinea