Thursday, January 30, to Thursday, February 6 – A visit to Mali

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I had never visited West Africa, so when the opportunity presented itself to visit a close friend living there for the year arose, I decided it was the perfect opportunity to visit this incredibly historic and culturally rich country that I will have to admit I knew very little about beforehand. I did know that it was a land-locked nation in West Africa through which the great Niger River flowed and was also where Timbuktu was situated, a city that is often referred with little thought of its location other than that it must be someplace remote and exotic. There were many things that I didn’t know about the country, though, until I seriously began to entertain the thought of a visit. Such as, to where would I need to fly and what preparations were necessary for me to travel there. What I would learn was that Mali is a former French colony where only the local dialect of Bambara and French are spoken, which would be interesting considering that I don’t speak a word of French, let alone Bambara. Well, no need for that as I would have Hannah there to translate for me and, certainly, there must be some English spoken there. At least I was correct regarding the fact that Hannah could translate for me for, as I came to find, there is very little English spoke there and, even that, is a bit of an overstatement.

Eating our Ouidulja

The other thing I quickly learned is that Mali has been in a state of civil war, or factional fighting, since 2012 that has made it impossible to travel outside of the capital city of Bamako without the risk of kidnapping or death, neither of which I was truly contemplating as a viable option for this short and leisurely visit with a friend. When I looked at the State Department’s travel recommendations to this country, it essentially said, “do not consider unessential travel to Mali” for the reasons that I have noted. It went on to say that if you must travel to Mali there were certain suggestions that had, such as to have your will in order, to make arrangements with friends and family for your children and pets should you not return, and have a list of passwords and accounts made available to someone should similar circumstances occur. Seriously! My thought was that if Hannah was living there for the year as part of her HEAL Global Health Fellowship, it couldn’t be that dangerous or they wouldn’t have sent here there in the first place.

Thankfully, I was to discover that although the security flying into and out of Bamako was the most intense I had ever encountered (even more so than crossing into Hungary when it was still an Eastern bloc country with scores of Soviet troops everywhere), the capital city was still alive and thriving, and other than the constant reminders of additional security measures in most public places and the occasional security troops (French, American, Malian, and UN), there was little in the way of disruption to my visit. That is, unless you count the fact that we were, without question, completely barred from traveling outside of the city which meant that traveling to historic Timbuktu was off limits as was seeing any of the other wonderful cultural sites that existed in this country.

Our boat on the Niger

The flight to Bamako took me through Paris as Mali was, after all, a former French colony as were many other West African countries. I had left in the afternoon from Philadelphia and, after a short layover in Boston and Paris, arrived in Bamako the following afternoon which was about 18 hours of flying in addition to the six hour time difference. I immediately encountered the language barrier when I arrived to the immigration counter to find that the officer there spoke not a word of English and it was only with the aid of a fellow passenger that I was able to answer the rather simple questions I was being asked such as Hannah’s phone number and my occupation. Once through to the baggage carousel, I found my duffel and proceeded out of the airport into the bright sunlight and heat of the African day, but only after passing by a several US or French military who had come to greet fellow passengers on my flight. Thankfully, Hannah was waiting there for me as the language barrier had me rather disoriented and I have no doubt that I would have had significant difficultly had I been on my own trying to find transportation into the city.

Dicko, Anneïssoune and Madeleine on our cruise

Madeleine and Anneïssoune

I had met Hannah immediately after my move to Penn in 2013 when she was a medical student, and it was her unique background and my global health interests that had brought us together. She had been born in Botswana and grew up in Malawi and Nairobi as her father had worked on projects for USAID, keeping the family on the African continent. She had gone to Tufts University for her undergraduate education and then worked in Washington a few years before deciding to go to medical school and, hence, our introduction at Penn. She had decided to remain in Philadelphia for her internal medicine residency and given her interest in community medicine and international health, applied for the HEAL Fellowship, a two-year commitment that involves spending a year with the Indian Health Service practicing and a year in Africa working on a project. She had been in Fort Defiance, Arizona, last year, a lonely outpost, but a truly rewarding experience, so much so that she is considering continuing to work with the HIS there following her stint in Mali.

Casting a net on the Niger

In Mali, Hannah is working for Muso (the Bambara word for woman), a non-profit founded perhaps ten years ago by two physicians from San Francisco and several other African physicians that have worked with the Malian government to train a large group of community health workers in a district of Mali where they visit all of the residents and are trained to treat simple disorders such as dysentery and malaria, while also recognizing other disorders which they can refer to the government health center. Patients who participate and are referred in by the health workers pay a lower fee for their visit and medications, thus incentivizing those in the community to work with the project rather than using the center just as an urgent care center. It’s a brilliant project that has an amazing group of doctors from around the world working to make it run, in addition to the Malian physicians at the health center who are seeing the patients and performing on average ten deliveries a day. Empowering these community health workers to improve the quality of health in their community is what really drives the project. And, from what I saw during my brief visit to the health center and the Muso offices, they are a force to be reckoned with as they have a sure equation for success in this world of burgeoning populations with fewer and fewer resources to go around.

Before my visit to Mali, Hannah had put me in touch with the husband of one of her colleagues at Musa who had married a Malian and who just happened to be a neurology resident at Point G, the teaching hospital high on a hill overlooking all of Bamako. In corresponding with Dicko, I had offered to provide them with a talk and had given him a list of topics that I would happy to speak about. They chose to hear about our work at FAME, which of course I am always happy to share with others. So, that was it. I headed off to West Africa with very little in the way of expectations other than that I was really looking forward to visiting a country different than Tanzania where I could visit someone living there to show me around and was also excited to visit the medical school and the neurology program there. There are few African countries with neurology residencies to begin with, and knowing someone in advance who would be able to show me around would make all the difference in the world.

Dicko and I sharing Ouidulja

Bamako turned out to be a sprawling city of many, many districts and neighborhoods on the south side of the Niger while the city center with its many markets lay across the river to the north. There is heavy traffic coming and going from the city when one would expect it and there are three bridges that can be taken across. The center bridge, which is the old bridge, becomes one way during rush hour to ease the traffic woes, but the other two bridges remain two-way so that you’re never trapped on one side of the river or the other. Point G is the name of the hill that dominates the horizon when entering the city and where the medical school and hospital are, as well as the president’s home along with many of the government departments. I the center of the city is the massive city market place with its vendors selling everything one could ever imagine needing.

Making rounds on the ward with the residents

The drive through the medical school at Point G

As Hannah had an important day of work after I arrived, I was able to sleep in and wander around her neighborhood a bit that morning to find a breakfast croissant. It was quite hot by early morning, but the air was reasonable clear and it was incredibly dry making the heat quite tolerable. This time of year, there is a tremendous amount of dust in the air, but it didn’t seem to accumulate until midday so the morning remained a very nice time to walk and check out the environs. Madeleine, Hannah’s coworker and Dicko’s wife, would be picking me up around 1pm as I was to spend the afternoon at their home until Hannah returned from work. It was so relaxing to spend the time with Madeleine and Anneïssoune, their 8-month old boy, who amazingly wasn’t fully walking when I had begun my visit that day, but by the evening time was motoring his way across the living floor and seeming to gain confidence with nearly every step. Dicko came home during the afternoon, having been at work at the hospital in the morning and we ate some local cuisine, though the traditional bread, Ouiduija, that the family had been working on for me hadn’t turning out due to a bad batch of yeast. They were all distraught having wanted to share this delicacy from their home region with me, but thankfully the second batch they worked on turned out so that I was able to experience what was perhaps the most delicious bread I had ever tasted along with the sauce that we dipped it in. Hannah had arrived by this time and, even though the two of us had planned to head into town for dinner, the option of not sharing this dish with them never entered our minds for as good as the meal was, their joy in having prepared it for us was meant the world to me as did their smiles watching us enjoy it.

A view of Bamako from atop Point G with the Niger in the background

The Neurologie department

Resto Omega

Hannah had a specific restaurant in mind for dinner that was outdoors and they served chicken, chips and beer, along with often having live music. We were in luck this night, as there was a very good band playing some contemporary Malian music, but it was really the singer who came out a bit later that was just incredible and the band seemed to up their game in response to her singing and wonderful voice. She was playing an acoustic guitar and was barefoot while the band accompanied her through song after song. It was really a magical time, sitting at a small table, under the stars, enjoying the local beer and eating delicious grilled chicken that I couldn’t even see but tasted so good that it really didn’t matter what part I was eating. I recalled that we both were totally entranced with the lyrical sound of her voice and neither of had the urge to leave so we stayed much later than either of us had intended, but there was no worry as tomorrow was Sunday and we had no particular schedule.

Me and Christian, one of the doctors at Muso who spent a month at Penn last summer as a global scholar

Goat waiting for the bus along with us

Deciding not to take the bus

The following day, we both traveled to the Mali National Museum that sits in a very large city park with lots of gardens and the zoo nearby. Somehow, going to a zoo in Africa, or anywhere for that matter, has become far less interesting to me after spending the last ten years driving in the parks of Tanzania, where the wildlife roams free without borders. That’s not to say that I don’t see the necessity for zoos as they do serve a very specific purpose in the overall conservation and understanding of animal species, only that for me, it is now somewhat difficult to see the animals not in their natural habitat. The museum was wonderful even though all of the signage was in French. That didn’t affect my appreciation for all of the tribal art and the textiles, but did require Hannah to translate things for me on occasion if I needed more information about a specific carving. Most of the carvings are of Dogon origin, one of the larger tribes that further east of the city, a place previously well-traveled by tourists, but no longer given the political unrest here. It is so unfortunate as they live in very distinct homes in the cliffs that would have been amazing to see. Hopefully, over time, the unrest will ease and open up these regions to travel once again.

My talk at Point G

The audience for my talk

We had a wonderful lunch in a Lebanese restaurant nearby while our taxi was more than happy to wait for us so that he could take us later to the Dogon festival, an event that was taking place that weekend and was mainly a fair where there were plenty of kiosks selling the various carvings and bogolon weavings, or mudcloth, made by the Dogon. It reminded me much of the Maasai markets in Tanzania, where every merchant has much of the same items and buying anything requires an extensive amount of haggling, something that I am not the best at nor do I like. It was quite overwhelming for me and, in the end, I purchased only two inexpensive hats made of mudcloth for gifts, having decided that the carvings which I had very much intended to buy would have to wait for another day and rested nerves.

The neurology department at Point G

For my visit, Hannah had arranged for us to take a cruise on the Niger River at sunset and had invited a number of her friends and their friends to come along. The boat was typical of those that ply the river and had a deck on top where we could all sit and have virtually unobstructed views of the river banks as we headed east along the river for an hour or so until we reached the spot to turn around. Sunset was lovely and there were numerous fisherman on the river in their small canoes throwing nets to reign in their catch. The fisherman with the sunset behind were incredibly picturesque and the whole affair was about as relaxing as it gets in this world. Madeleine, Dicko and Anneïs had also joined us for the cruise and watching the little one walk back and forth with his new found abilities was a sight to behold and he was so very proud of himself.

Our group at Resto Omega after my talk

On Monday, I had arranged to go to work with Dicko up to Point G and visit the neurology department. Each department has their own building in which their inpatients also reside which is so very different than our large hospitals where each specialty has a separate floor, but all under the same roof. The top floor of the neurology building was for the offices of the faculty and the resident’s rooms and when we arrived, we went directly to the main room where all of the residents drop off their backpacks and get into their white coats. Watching and listening to them, it was much the same as what I remember from my residency and much the same as what I see today back home. What was so comforting to me was to see the very same level of interest and excitement for neurology as I see in the faces of our residents and the realization that there was no difference between them save for the circumstances of the facilities in which they work. Yes, there is an EMG lab and an EEG lab, but there is no operational CT scanner here nor is there anything close to an MRI scanner. For these tests, patients must be sent down into the city to the private scanners that are working where they must pay for the testing to be done in a similar fashion to how this occurs in Tanzania.

The central courtyard at the community health center

The community health center

They round here with one of the professors three times a week on the inpatients and today was the day they would be rounding with the head of the department. It was decided that I would round with the residents and their professor and add whatever clinical pearls I could along the way. Everything was in French, of course, necessitating that one of the residents who spoke fluent English stayed by my side during the entire five hours to translate the patient’s history and test results for me. Once I established that I can only hear out of my right ear (following an episode of probable viral labyrinthitis two years ago), she made sure that she positioned herself on the proper side so that I could hear her translation and things thereafter went smoothly. The rooms were often quite small and making space for the entire team was difficult at times, but we somehow managed and I felt like I was able to add to many of the cases. Once finished with rounds at around 2 pm, we went out for lunch just outside the grounds of the hospital, but still remaining on Point G. It was a lovely local restaurant, Resto Omega, where four of sat together and had delicious meals of rice and various bowls, mine being that of a small whole fish with vegetables. The entire meal for the four of us, including drinks, was less than $10, and despite my trying to pay, it was made quite clear to me that was not something that they would allow as I was their guest. It was late enough after lunch, that Dicko could head home with me, so the two of us took a bus down from the hill, still not allowing me to pay for anything, and then a taxi home, where Hannah met me and we walked back to her place for a dinner of a traditional dish of rice and peanut sauce that she had asked her housekeeper who lives upstairs to make for us.

Relaxing with lunch and my computer at Le Encampment

The following day I was to give my talk to the neurology department and Hannah had decided to come up with me, initially to meet with an infectious disease doctor there, but she was unable to reach him in the end, so decided to come hear my talk which was a good thing as I was clearly going to need a very good translator given the language barrier. The entire department including a number of medical students, perhaps thirty people, gathered in the large conference room and as the numbers continued to grow, they would bring in benches from outside to sit on as all of the chairs around the table had long been taken. The talk went incredibly well and after I introduced each slide with either data or a photo, Hannah would translate what I had said into French and it was clear that everyone was paying close attention as they were most interested to hear about the healthcare in another country of Africa and the history of FAME. I presented some of our recent data that had been so wonderfully organized by Leah Zuroff, the medical student who had accompanied us in September, and who had entered all of our patient data for us into our database. We had excellent results regarding the retention rate of our epilepsy patients and their adherence to medications clearly indicating that we were making a difference in their lives. When I was finished with my talk they went around the room making a list of everyone who had questions and then, one by one, they each asked their question, each of them excellent and though provoking. It was truly an amazing experience for me as there was a clear connection that we had made, easily bridging our different cultures and languages, and, for that moment making the world a much smaller place. Afterwards, it seemed that everyone wanted a photo with me, as well as numerous group photos and I was so incredibly honored to just be there and have had the opportunity to have shared something that I love and has become such a part of my life.

An epic free-form pool at Le Encampment

After lunch at the same restaurant we had eaten in the day before, again not allowing me to pay for anything, Hannah and I took the bus into town with tickets that Dicko had purchased for us. On our way, we stopped to do some shopping, where I purchased some carvings and bogolan without the stress of the market, and then made our way back to her place for dinner and later, a movie as I had brought an LCD projector with me for my talk that ended up not being necessary as they had one of their own in the conference room. I was leaving the following day which was sad as my trip had been so short, but we had packed in so much of Mali that I felt I now had a small taste of what it has to offer, which is tremendous, and I very much look forward to returning one day now that I have made such friends there.

The next morning, I went to work with Hannah so that I could see the community health center that Muso partners with as well as walk around the community a bit. Unfortunately, the family who she had lived with and wanted me to meet were not around when we stopped, but it was interesting to see the homes and streets of the district where Muso and their community health workers operate. We ended up at their offices so that I could meet some of her collaborators and she could work the afternoon, while I was to head to a small resort called Le Encampment, where I would spend the afternoon around their pools, have lunch and take a swim. Thankfully, Hannah was able to arrange for a taxi to take me there and wait for the four or so hours while I relaxed, then take me back to Muso where we head home with plans to have dinner with Madeleine and Dicko before heading to the airport for my flight which was not until 11:30 that night.

Dicko, the individual who really made my trip the success that it was

My visit had been such a success, mostly made possible by the hospitality of Hannah and my introduction to Madeleine and Dicko, both such incredibly lovely and welcoming individuals who made my stay in Mali so meaningful and rewarding. For Dicko, though, I was visiting his home and his pride was so evident and palpable to me that it set the tone for my entire time there. Equally so, was the entire neurology department that included all of the residents and professors, each of who allowed me to share a small piece of their daily lives and, though it was only for short time, it was clear how much my visit had meant to them and, hopefully, they it was clear to them just how incredibly impactful the experience had been for me. For that, I will be forever grateful and will always remember my visit to their amazingly wonderful country.