Blogging from Bamako
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keywords: description: Blogging from BamakoRajiv Kumar, 2nd year student at Brown Medical School, was in Mali, West Africa this summer, working on behalf of Adopt A Doctor and the Global Alliance to Immunize Against AIDS (GAIA).
Thursday, October 12, 2006 Hope for Clean(er) Drinking Water? In Mali, as in other developing nations, the lack of clean drinking water leads to potentially deadly diseases like cholera and diarrhea – which is the second highest cause of death among infants. A shocking statistic: in Mali, 113 out of every 1000 infants die before their first birthday.This article from the New York Times suggests that there may be hope on the way:
Thursday, September 21, 2006 How we value a life – Doctors’ attitudes make a difference I took a break from this blog for a few weeks while I got settled back into Providence, Rhode Island and started up my second year at Brown Medical School. Now that a routine has finally set in, I plan to continue using this space to keep you up to date about the important work that we are undertaking in Mali and the impact your support is having in this West African nation.October 10, 2006
A $3 Water Purifier That Could Save Lives
By DONALD G. McNEIL Jr.
In very poor countries, the family that has to walk miles to fetch drinking water from a well or a stream may be the lucky one. In many villages, the water source is a filthy pond trod by animals and people, or a mud puddle out next to the yam field.
As a result, about 6,000 people a day — most of them children — die from water-borne diseases.
Vestergaard Frandsen, a Danish textile company that supplies water filters to the Carter Center guinea worm eradication program and mosquito-killing plastic tarps to refugee camps, has come up with a new invention meant to render dangerous water drinkable.
The invention is called Lifestraw, a plastic tube with seven filters: graduated meshes with holes as fine as 6 microns (a human hair is 50 to 100 microns), followed by resin impregnated with iodine and another of activated carbon. It can be worn around the neck and lasts a year.
Lifestraw isn’t perfect, but it filters out at least 99.99 percent of many parasites and bacteria, the demons in most fatal cases of diarrhea.
It is less effective against viruses, which are much smaller and cause diseases like polio and hepatitis, and it wouldn’t protect American backpackers against the parasite giardia.
Nor does it filter out metals like arsenic, and it has a slight iodine aftertaste (not necessarily a bad thing in the large stretches of the globe with iodine deficiency).
It can be manufactured for about $3, but it needs more field-testing. Only about 100,000 have been handed out, 70,000 to earthquake victims in Kashmir last
year.
Already in the works, however, is a Lifestraw toddler version — which will be squeezable.
Let's start this blog up again with an open letter from Dr. Annie DeGroot (far right, seated with two doctors funded through Adopt A Doctor) addressing health contrasts between the developed and the developing world.
How we value a life – Doctors’ attitudes make a difference – Annie De Groot MD
I have a dark space and a worn grey desk in my visual memory. That desk and its wooden chair from a clinic in
The memory of that clinic in West Africa and the despair that I felt when I heard she died is so far removed from the white laminate desk and black flat screen computer and wall-to-wall carpet that was in the front view of my vision. In fact, when the memory of
What is it about here – this place where we can open the door to a clean bright space that holds health care for all? Here, the great machinery that creates jobs and wealth and opportunity spins out health care for those that need it. Access is not denied - and although uneven, health care is available. Here, every physician knows that his and her responsibility is to smooth the path to life using any of the many high-techtools that are available. Hope for health is abundant, and the expectation of long life and wellbeing is, somehow, commonplace.
The ordinariness of health care that we experience in this country is so different from the healthcare that is available at that clinic in
I have much to say about why that happened, but more important, it is the contrast between hope and absence of hope that I would like to single out for attention here. Why did the physician who was charged with the care of that mother not act swiftly enough? Why, when we know that the fight against HIV can be won, person-by-person, with a handful of medications, was help not offered? There was a time when we did not have the hope for long life with HIV that we do have now. My memory is full of the shadows of patients that we were not able to save. But my recent experience of AIDS is one of health maintenance, and talk of children, or college, or businesses that are beginning – hope for the future.
That is here. That is now. But that is not now in
That different level of acceptance of death is ordinary in
What can we do to change this? What can we do? We can teach about hope. We can bring hope with us and travel there. We can send our brightest young trainees to
Dr. Annie De Groot is the founder and scientific advisor to GAIA Vaccine Foundation, an organization whose mission is to accelerate the development of a globally relevant and globally accessible HIV vaccine. GAIA Vaccine Foundation is preparing for HIV vaccine trials in
You can help Dr. De Groot bring hope to
Wednesday, July 26, 2006 Success for Adopt A Doctor in Mali! I have been living in chaotic Bamako, Mali for two weeks now, learning a great deal about how things function (and often don't function) here and working to do my part to improve the health situation on behalf of Adopt A Doctor.
I am excited to report that despite delays due to developing world bureaucracy, a slow pace of life, lack of technology, and poor infrastructure, I have now made real progress in improving access to lifesaving medical care by establishing a new, innovative HIV treatment program in the village of Sikoro.
Allow me to explain.
Providence-based non-profit GAIA Vaccine Foundation runs a medical clinic in the village of Sikoro, a semi-urban village that is part of Bamako, the capital city of Mali. The population of Sikoro is about 50,000 (population of Bamako is 1.2 million). Sikoro is one of the poorest villages in Bamako.
There are two doctors who treat patients at the clinic, Dr. Malick Kone and Dr. Adama Daou, both supported with funding from Adopt A Doctor. The clinic does mother-to-child HIV transmission prevention, delivers babies, and provides a host of other medical services for patients, including HIV-positive patients.
One service that the clinic has been unable to provide, however, is prescriptions for life-saving antiretrovirals (ARVs), the drugs used to treat HIV. Drugs for HIV patients are 100% free for everyone in Mali due to a $23 million grant from the Global Fund in April 2005. However, so few people here receive this free treatment, a result of a very poorly designed system. These medications are only prescribed at major health centers ("Centers of Reference"), of which only 4 exist. These centers are often too far and too expensive for many Malians to reach.
There is also great social stigma that comes along with going to one of these clinics, since that may mean a person has HIV. Additionally, HIV patients are required to pay for their clinical tests and for treatment for opportunistic infections.
Consequently, the majority of Malians in need go untreated. It is estimated that 2% of Malians (population 12 million) are HIV-positive, which means there are about 250,000 people who need ARV treatment. I just read a report at the UNAIDS office here that showed only 6,000 HIV patients are being treated in this country with ARVs!
As the GAIA website tells us, "experienced HIV providers are isolated in academic centers within Bamako, leaving large numbers of HIV infected individuals in the capital city and rural countryside without care. Furthermore, HIV care and risk reduction efforts are hampered by a severe lack of successful management models, vehicles for the exchange of expertise, defined standards of care, and effective treatment algorithms."
So the bottom line is that HIV care is free in Mali but not accessible to most people, and certainly not to the people in the village of Sikoro.
Inspired by Dr. Annie De Groot, I came here to Mali not to ask "why" but to ask "why not?"
So when I learned of this shocking situation, I asked Dr. Kone -- "Why can't we provide free HIV consultations, prescriptions, and treatment to the people of Sikoro?"
Together we set out to find the answer, and now a wonderful solution has materialized. With the blessing of Dr. Dao, the head of Infectious Disease at Pointe G (the largest and most respected hospital center in Mali), Adopt A Doctor will be establishing a new HIV treatment program at the Hope Center Clinic in Sikoro.
Funding from Adopt A Doctor will allow an experienced doctor to travel one day per week from Pointe G Hospital to see patients in the Sikoro clinic. This doctor will be able to see anyone with HIV, and because he will be affiliated with the major health center, he can prescribe ARVs for our patients.
In addition, Adopt A Doctor will be funding travel for all HIV-positive Sikoro patients to the central medical labs to have their bloodwork done, which is required every 6 months. The cost of travel would be too expensive for these people to bear on their own, so our funding is enabling them to receive life-saving treatment that they never could afford before.
With the establishment of this new HIV treatment program, Adopt A Doctor is proudly providing free and unparalleled access to HIV care to an entire village, one of the poorest villages in one of the poorest countries in the world. And hopefully this is the first step in pushing for a major overhaul to the current delivery systems for HIV care in Mali.
Dr. Annie De Groot has told us that “this is powerful medicine against the despair that comes with a diagnosis of AIDS in Mali.”
Adopt A Doctor's new HIV treatment program starts tomorrow morning. At 8AM a doctor will be arriving from Pointe G Hospital to see any HIV patient who comes to the clinic for care.
I am going to bed tonight with the hope of finding a long line of folks waiting when I get to the clinic in the morning. Hundreds of New Photos
I just posted hundreds of new photos, including ones from my recent trek south of Bamako with GeekCorps into the beautiful countryside villages of Mali, where they are setting up internet kiosks in villages that have no electricity and no running water. What they are doing is fascinating and groundbreaking, and I will blog about it later this week.
Click here to check out my pictures. Full Moon and the Maternity Ward This is a guest post from Maria Victoria Albina.
Disclaimer: this entry includes lots of sad and graphic medical details…
The full moon lit the courtyard at Clinique Sikoroni, flooding the airy space with beams of gorgeous, glowing light. Arriving after dinner, my colleague Megan and I were met at the Clinique's gates by Moustafa, the night guard, who told us to hurry to the Sal de Accouchement (Birth Room). Hurrying in, still wearing our backpacks, we met a grim faced Matron, hands firmly holding a laboring woman quietly pushing on the bed. Douga looked me in the eye and knew right away that this birth was not a happy occasion, and I quickly dropped my bag. Donning gloves from my purse I approached the table as the child began to crown. Slipping out quickly, the baby was placed at the foot of the table, and was covered in a piece of cloth. With the same quick quietness, the midwife delivered the necrotic placenta, and placed it next to the babe, for me to examine.
The child had been dead in the womb for some time. Just shy of completely formed, his head had collapsed in on itself, and was soft as tissue all around. His epidermis was sloughing off from its time in the acidic environ of the dead placenta. So sad to see this wee one, in such a sorry state, without a chance before he could start.
When the doctor came in, I asked him what had happened and he said that the mother must have had an infection, but he did not know of what sort, and that she didn’t have the money for the lab work to find out. There was also an air in the room that said The scientist within me couldn’t help but want to know what had happened.
With the young doctor translating my French to Bambara, I asked the woman if:she had a fever: yes, low grade, for two weeksshe had discharge: yes, lots.what color?: whitish gray, tinges of yellow, thin liquidand my heart started to sink…did the discharge smell?: umm, yes…oy vey.Did it smell like fish?: yes, poisson, lots of poisson.
heavy sigh.
While a lab test would be needed to know definitively, it seems like an obvious case of bacterial vaginosis, and thus, potential PID. A course of metronidazole or clindamycin would have saved this baby’s life, and saved this young mother much heartache.
It’s so difficult to know why treatment wasn’t sought out or provided, and it felt inappropriate to ask at such a difficult time, lest any implication of guilt be felt. I can guess several reasons why she did not seek treatment. She may have been embarrassed or not have known that her symptoms were indicators of a major problem, she may not have thought that treatment was available had she come to the clinic, and sadly, but obviously, she may not have been able to afford the 1000 Cefa or 2 Dollars for a clinical visit and medication. A sad case, but not an uncommon one…The child was wrapped in a piece of cloth and left on an empty exam table – rather disconcerting, frankly. It was so surreal how life just went on, how things always keep moving, how women kept coming, and having babies all night…
Understandibly numb, Megan and I went to bed, and got a good two hours sleep before a knock came on the door. Another woman had arrived. Already in active labor, she would stall out at 6 cm and take another four hours to have a normal, happy, healthy delivery. This was a bit of good luck, as soon after her arrival, Kadja arrived, every thin inch of her full with twin girls. As we helped her to the bed, checked her dilation and got her as comfortable as humanly possible, another woman came into the cramped room, and fell to her hands and knees on the floor, contracting hard and fast. The Matron looked at me and said and knelt to the woman on the floor. Kadja let out a low moan, and I looked over to see a small head begin to crown. Using my limited Bambara to tell her take a deep breath and push, I took the head in my hands and coaxed the first baby out, one shoulder and the next, and suddenly, a writhing pup of a babe in my arms, thick with vernix.
Laying her on the fresh cloth on the table at her mama’s feet, I suctioned her nose and mouth and heard a small gasp, and a cry. Excellent. One down, one to go. I showed Kadja her first child, and rubbed her belly down, giving her a moment to rest before the next delivery. Coaxing her again to push, I grasped the cord and gave a gentle pull, waiting for another crowning. Soon enough I saw another head full of hair, and took hold of it, preparing myself for the delivery. First the head and then a shoulder and then… and then… oh goodness. The shoulder was stuck. As Kadja moaned with pain and overexertion, I started talking to the babe in Spanish, hoping her memory of Babel still held, and that she would hear and understand me. And comprend she did, and as easily as her shoulder stuck, it came loose with a touch of my help, and I took firm held of her small and wriggling body. Laying her on her mother’s belly, I started to suction her nose and mouth. She would not cry or breath. I suctioned again, and again, and still, she would not take breath. With no suction tube in sight, I was at a loss. I got the matron’s attention, and she quickly evaluated the situation. Taking a corner of the cleanish cloth in hand, she placed it over the baby’s mouth and nose, and began to suction by mouth. Three strong draws, and the mucus plug was out of the baby’s throat, and in the cloth. Spitting the cloth away, the matron smiled and gave me a wink as she turned away. These women never cease to amaze me.
As twin number two (they are not named for a full week after birth) took her first breath, so too did I exhale. Babies delivered and in mama’s arms, I turned to help the matron with the next delivery, setting the pace for the rest of the night. Baby number eight was delivered just as the 5:30 am call to prayer rang out. Full to capacity, the new mamas and their new babies rested in the growing heat, while I set about helping the matron clean and bleach the birth room.Dawn came gorgeous and calm, the air crisp and inviting, with a gentle morning breeze. After a big glass of street-vendor café, filled half way up with sweetened condensed milk, we all took a seat outside to discuss our long and fruitful evening. Shaking hands and hugging, the matron and I had quite a moment. I feel so grateful to these amazing women who let me into their lives, and teach me so very much.
Exhausted, Megan and I finished some final chores around the clinic, and headed home to sleep before our respective afternoon shifts at other clinics, in other parts of town.And soon enough, to do it all again. To see more first breaths, first births, more pain, more joy. Till then… Friday, July 21, 2006 A Tribute to the Women of Mali From my observation over the past two weeks, the women here are the foundation and backbone of the Malian society, and most likely, the economy. This is probably the untold story around the world, but in Mali it is so glaringly obvious.
The streets are packed with strong Malian women, dressed impeccably in vibrant, patterned dresses and head wraps, doing the hard work in this place. It seems that almost every woman is carrying a child on her back--the Malian way--suspended in a cloth that they wrap around their torso and tie in a knot at their chest. The women walk for miles with these sleeping babies hanging from their backs, with no sign of complaint or fatigue. Despite the muddy, messy, trash-littered streets, somehow their brilliance never seems to tarnish.
The women also carry everything on their heads. From baskets of fruits and vegetables to giant tubs of water, mountains of fabric, and other goods to be sold in the market, the women carry these loads with unbelievable poise and balance. They hike up hills, dodge through treacherous traffic, and hop along open sewers without dropping their goods and rarely using their hands to help with balance. They squat in the dirt, vigorously washing clothes in striped plastic buckets, and they sweep the storefronts on their knees.
Women carry babies on their backs and tubs of water on their heads.
The women who are ill, or who have sick children, come alone to the clinic and wait silently for long hours on hot, metal benches to see a doctor, nurse, or midwife, if one is available. The men do not accompany the women to the clinic, nor do they look after the children. Even for childbirth, the women come alone in the middle of the night and deliver their babies in silence.
The young women of Mali are modern and savvy. They have cell phones and pagers. They ride their own motorbikes. They visit internet cafes and shop in the markets for the latest fashions. They wear jeans at night and go out to the clubs and movie theaters.
The women of Mali are strong and proud, and from my view, they are responsible for making this place work. Somehow they bear this burden with a smile, a joyous spirit, and an attitude that says "without us, this place would be in trouble."
Women wait all day at the clinic for medical treatment. Malians Heart George W. Bush
It is surreal to come from a country where President Bush has a 35% approval rating to one where, based on my anecdotal research of cab drivers, he is widely considered a hero. "I just love this man," one Malian cab driver told me. "I can't sleep at night until I have seen his face" said another. One cabbie even told me he keeps a poster of George Bush above his bed.
So what on earth is going on here in Mali to make George W. Bush such a popular figure? I posed the question to my partner on the AIDS project, Dr. Malick Kone. Malick told me that Bush is considered a "true warrior" fighting against terrorism all over the world. He says that Malians hate the terrorists and are very afraid that they will continue to attack. And even though Bush has done very little for Africa (they credit Clinton for doing the most), they are willing to give him a pass.
But surely Malians are not expecting terrorists to attack sub-Saharan Africa? No, but Malians are upset by any terror attack by Islamic fundamentalists, anywhere in the world. Perhaps it is because this is a "liberal" Muslim country, where religious extremism and Sharia law are considered evil.
Indeed, walking along the streets of Mali, it might take you a while to figure out that this is a 90% Muslim country. The only sign of Islam, as far as I can tell, are the mosques and madrassas scattered throughout the city, and the call to prayer that we hear a few times per day. Islamic symbolism is largely absent from Malian public life, and the city is plastered with advertisements for Castel and Flag Beer. Very few women wear veils. Song and dance pervade the Malian culture and sexuality is featured prominently in Malian artwork.
If you can imagine, Mali is a 90% Muslim country, one of the 20 poorest countries in the world, and the people here have a strong affinity for George W. Bush. This is truly a fascinating place. Wednesday, July 19, 2006 A Postcard from Bamako
Written July 6, 2006
by Annie De Groot, M.D.
Founder, GAIA Vaccine Foundation
I am sitting in Providence thinking about Mali - not just miles but centuries and distances more ethereal from Bamako. There are no donkeys waiting patiently for their burdens in the streets nor are the same streets full of impromptu lagoons or cars that are stripped to their bare bones having been marooned there for decades. There are no children playing with wire facsimiles of toys, wearing shreds of clothing. There are no dogs skulking at the fringes of the road, watching for flying stones, no beggars with twisted limbs creeping along the sidewalk on low carts with wheels nor are there whole families bedding down in front of shuttered stores for the night, with stones for pillows.
There are no sudden rushes of rain, nor the verdant splendor that comes afterwards nor red earth to contrast with the green nor the joy of being that is everywhere. That beauty is Mali. That joy of being that is everywhere in Bamako is uniquely Malian. That joy of being is abundant despite the lack of food, and clothing, education and certitude of health. Despite those deficits, in Mali, there is abundant joy to share.
But joy does not feed a child, nor is it enough to save a life. Perhaps that joy is one way of making it possible for people to accept the great disparities that are so obvious to those of us who come from outside. We can see but do not accept the great distance between health care systems and human welfare that we so easily transcend with planes and trains and bushels of dollar bills. We cannot accept this.
This is distance that dislocates the mind. This is distance that is built not out of asphalt but of disdain. And neglect. And willingness to forget. How can we accept the choices that are made every day in Mali- the choice of water that comes from polluted streams or clean water that is sold for prices that are beyond the reach of those that live at the fringe? Or, even worse, when resources are available in Mali (like bednets and antiretroviral medications and clean water) why are they not made available to those in need?
We do not accept this. We cannot accept this. We can see a different way of being. We must do what we can.
And so what is the problem have we come to address? We are in Bamako to stop AIDS. Eventually, we believe, we will have a vaccine that will stop this. Even though the vaccine is in development and making good progress, it is years away. What can we do in the meantime? Stop mother to child transmission. Teach about HIV prevention. Make treatment accessible. Bring Hope.
AIDS affects one in every 30 Malian women who are giving birth - and who can pass the virus along to their babies if their infection is not detected. Prevention is simple and almost 100% effective. So - while waiting for our vaccine to be developed - a long slow process that may take many more years, we wondered why not stop AIDS right now, if we can?
And so, in fact, last year we said why not stop AIDS in a tiny clinic in the village of Sikoroni, outside of Bamako, even though it had never been done before. There were no mother -to child-transmission programs in any of the villages in Mali. But we knew that there were women who had HIV in that village who would never get tested and would, if tested, never travel to the "center of reference" several miles away to deliver. We asked to help, our help was accepted, and so we set up a mother - to - child HIV transmission prevention program (Chez Rosalie).
Here are the results of our work - 1440 pregnant women in the village were evaluated for HIV infection at Chez Rosalie in the last year. 99% accepted the test so - - more than 1425 women were tested. 53 of these women were found to be HIV seropositive (3,7%). Of these 53, 19 women had delivered in the last 12 months - and 18 were provided Nevirapine (Triple therapy was not given at this time). Following delivery, three died. One from sepsis, one from AIDS, and one for reasons unknown. 40% of the women are providing artificial milk to their babies instead of breast milk.
I don't know if it's possible to describe how difficult it is to do this work in these most basic of circumstances. There are cell phones, yes, but often there is no running water. There are computers in the clinic (we brought them) but no patient records to speak of (until we came). There is a basic understanding of AIDS but no understanding of viruses and immune systems and how HIV is transmitted. The doctors and nurses are well meaning but overwhelmed with work - more than 100 births per in the clinic, day in, day out, without stop.
GAIA volunteer Victoria is catching babies at Chez Rosalie, our mother-to-child HIV transmission prevention program. She is catching babies in a room that is as old as the gesture itself. That room is dark, and hot, and smells like blood -there is nothing that remotely resembles the bright sterile field that she worked in before coming here. Victoria is catching babies and celebrating new lives - six bright new beings in just one day last Friday before I left to come home. Those babies were born while we were meeting just outside in the courtyard. I asked how this could be? We did not hear anything! Victoria told me that the women were bearing children without a even a cry - their only expression of pain was a single tear that rolled slowly down sweating faces in labor.
GAIA volunteer Maddie is teaming with a young woman living with AIDS called Ramatoullaye to track down and destroy ignorance about HIV. Armed with T shirts and a simple message, they started their work on Monday. Five fingers, five essential ideas: Treatment is Hope, Knowing is Power, Transmission can be Stopped, Families (ring finger) and Communities (hand) can fight AIDS together. This message will go to the elders, the women's groups, the men's groups, and to youth. Only 12% of girls in Mali know how HIV is transmitted. Maddie's program (Hêré Bolo, hand of hope) will change that.
Given these basic circumstances and the most basic of health care, we were amazed that the level of acceptance of HIV testing among the mothers at the clinic was so high - higher than reports from most front line clinics. We believe this is because they were given a clear choice - between health for their children or ill health. Given the choice, who would do differently?
But there is one problem that we discovered - even though we may have saved as many as 18 babies from HIV; none of their mothers were yet on treatment when we returned this summer, for their own HIV infection. And one of the mothers died -at least one from AIDS. We do not accept this.
When we asked why, the doctors said that treatment was not available in the clinic, even though it is free in Mali. The only place to get treated is in one of the "centers of excellence" where there are many patients, and too few doctors, and where our patients are afraid to go. And so we said, again, why not start an HIV clinic to take care of the women and their partners? GAIA donor Deb Norman made it possible to begin to think it possible, with her gift of $10,000 to start Hope Center clinic in Sikoroni, this Spring. While I was in Mali just now, we talked to the Chief of the village of Sikoroni, a gnarled man who welcomed us to his home high on the hill above Sikoroni, and his counselors about Hope Center Clinic.
We talked to the Mayor of Commune 1 and to Dr. Youssouf Sow, the local "director" of the many neighborhood clinics - while surprised by our request, they were pleased to give us their help. So we have their permission to build as soon as they confirm the site - the spot behind the clinic is still the best option, although we're going to have the city planners come take a look and see what they think.
And so, in answer to that question - what can we do, faced with the great disparities in care that exist between our own experience and Africa? We must do what we can, This is what we can do - shine a light, show the way, set up a pilot program, show that it can be better, raise expectations, ask not why, but why not. Indeed.
We can get the women in the village that need to be treated on treatment. We can test their partners. We can set up the electronic medical records that are needed to track them. We will work on getting HIV medication delivered to the clinic for them to take. We can put internet in the clinic. We can get solar power batteries to run the clinic's electricity from a local company that makes the batteries - AfriPower. We can get lab results wired to us from the clinical lab across town - the data will travel up to the satellites that are orbiting Africa, and then passed down through the ether to that village of mud and cement blocks and open sewers that is Sikoroni.
We can partner with the community to bring water to the far reaches of Sikoroni. We can help educate the elders about HIV and they will pass the information along to the younger ones who will listen. We will have a festival of music when this work is done. We will sing about HIV and dance about HIV and learn new words in Bambara like Yellé (Light) and Hêré (Hope). We will make change. We will ask Why. We will ask Why Not.
Why sit still when there is so much to do? Why not give each child, each woman, each man a chance to live a full life, and make it possible to choose health - and to stop AIDS in Africa so that every child, woman and man have a full repertoire of possibilities for the future. That is why we go to Bamako and Sikoroni, to live amongst the donkeys and the furtive dogs, amongst the joyful children and the beauty that is Mali. That is what we can do - and we continue to ask how else we can change the world while having two feet firmly planted on that red earth. I know we can do this. We can make it so. Tuesday, July 18, 2006 My Photo Album Every day I've been taking photos to graphically document my experience here. So far I've taken almost 400 pictures of life on the street, the medical clinics, local shops in the market, children playing in the dirt, the lush greenery, and more.
The sights of Mali are stunning, sometimes disgusting, and often beautiful.
Click here to browse through my online album.
Check back often, since I add new photos almost every day! The Children of AIDS Dr. Kone just showed up to bring me to the clinic. As I was waiting, I found this poignant article from Christiane Amanpour about AIDS orphans in Kenya. I thought I would share it with you all since it is highly relevant to our work here in Mali.
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World fails to save Africa's AIDS orphans
Africa's HIV-infected children also ignored
By Christiane Amanpour, CNN
Editor's note: CNN Chief International Correspondent Christiane Amanpour traveled to Kenya as part of a special documentary, "Where Have All the Parents Gone?," which looks at the millions of AIDS orphans now living on their own.
ISIOLA, Kenya (CNN) -- AIDS invaded our consciousness 25 years ago. A whole generation around the world has now grown up knowing only a world with AIDS.
We have watched the efforts to find a vaccine, to find drugs to control the disease, to educate people about preventive measures, and to end the stigma of AIDS.
There have been many successes in helping adults with the disease, but when it comes to the children, the world has failed dismally.
Millions and millions of AIDS orphans are the devastating legacy of this epidemic. Africans suffer the most.
According to the United Nations, there are 12 million AIDS orphans in sub-Saharan Africa alone, and in four short years that number will skyrocket to 18.4 million. That means AIDS orphans will make up 15 to 20 percent of the population in some African countries.
Traveling around the region, we met young children heading entire households, after losing one or both parents.
Because the adults are missing, entire economies are collapsing. There's no one left to plant crops, tend livestock or look after the young. And AIDS is killing the children as well.
According to the United Nations, HIV infection is more aggressive in children less than 18 months old than in adults. In the absence of any treatment up to 50 percent of HIV-infected children die by their second birthday.
In Africa, less than 5 percent of HIV-positive children who need treatment have access to it. And every day, another 1,800 children are infected with HIV, mostly at birth or from their mother's milk.
In Europe or America, this is almost unheard of because there is effective treatment to stop pregnant mothers from passing on the virus to their newborns. But in Africa, there is little access to this life-saving prenatal therapy. Furthermore, only 10 percent of pregnant women in Africa have access to basic treatment that could half the rate of transmission of HIV to their newborns.
"It's another grotesque double standard," said Stephen Lewis, the U.N. AIDS envoy to Africa.
'It's everybody's fault'
Ninety percent of all HIV-positive children under 15 are infected mainly through mother-to-child transmission, according to UNICEF's global figures. Special pediatric AIDS drugs have only been made for children in the last two years.
We asked Dr. Chris Ouma, UNICEF's AIDS specialist in Kenya, why children have gotten such a raw deal.
"I think it's everybody's fault really," he said. "We were slow on the science. We did not speak out for them. Companies did not see the incentive to invest in drugs for children as there's no one to pay. And all this has now resulted in an unacceptable death [rate]."
He added, "I think now as technology brings out superior drugs, things are starting to change. It's 10 years too late, but at least something is being done now."
Indeed Kenya is one of the countries that has made a significant dent in AIDS prevalence and treatment. But there still is much more to do. There are currently one million AIDS orphans in Kenya alone.
UNICEF reports that around the world, there are about 2.3 million children under 15 living with HIV. Two million of them live in sub-Saharan Africa, or 90 percent of the world's HIV-infected children.
Click here to read the rest of the article, which highlights some new solutions to the problem that are being implemented in Kenya. Mother to Child HIV Transmission Prevention I'm heading to the clinic in Sikoro today to begin our HIV testing of babies who were born to mothers who received medical therapy to prevent transmission of the disease at and after birth. This will be the first time that we will have any indication of the success of the program. I will post an update about my day at the clinic when I return this evening! Meanwhile, here is summary of the program from Dr. Anne De Groot.
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Chez Rosalie Mother to Child HIV transmission Project
As many of you already know, GAIA Vaccine Foundation already operates a mother to child HIV transmission prevention clinic in the village of Sikoroni within the borders of Bamako. Chez Rosalie is one of 12 such clinics in Mali, and the first in Sikoro. We knew that there were women who had HIV in the village we're working in who would never get tested and would, if tested, never travel to the "center of reference" several miles away to deliver. So we set up a mother to child transmission prevention clinic (Chez Rosalie) on site.
Chez Rosalie Update, July 2006 - Update by Annie De Groot
During my visit to Mali two weeks ago, I was presented with a summary of the first year of intervention by Dr. Malick Kone, and Dr. Adama Daou. Here is a brief synopsis of their results - 1440 pregnant women were evaluated for HIV infection at Chez Rosalie in the last year. 99% accepted the test, which means more than 1425 women were tested. 53 of these women were found to be HIV seropositive (3,7%). Of these 53, 19 women had delivered by the end of the 12 months - and 18 accepted Nevirapine treatment(Triple therapy was not given at this time).
This is amazing work and we celebrated it at the clinic - with the nurse midwives and the matrons who did most of the heavy lifting. We are amazed that the level of acceptance was so high - but there is one problem that we discovered - none of the mothers were yet on treatment and none had their CD4 T cell counts done to determine if they needed treatment. That is what we are trying to rectify with the Hope Center clinical project.
Meanwhile Victoria Albina is working on translating Dr. Adama Daou's "Memoire" about the year of work into English for publication, and she'll be adding her own insights about what it's like to implement Mother to Child Transmission prevention on the Front Lines as she is actively catching babies this summer at Chez Rosalie. Look for more information on MTCP and Chez Rosalie from Victoria next week.
Rajiv Kumar of Brown University, a medical student (who, coincidentally, helped found Adopt A Doctor and also campaigned to support GAIA with the Shape Up RI initiative this year) has traveled to Mali this week to help Dr. Malick Kone, GAIA Mali Director, and Dr. Ousmane Koita, our collaborator, to do HIV PCr and HIV testing on the babies that were born in the last year. We hope to be able to determine that the intervention that we put in place did in fact stop HIV transmission. We look forward to hearing from Malick and Rajiv about the HIV testing results. Monday, July 17, 2006 A Peer Education Pyramid
Maddie DiLorenzo, undergraduate at Brown University, is here in Mali undertaking quite an impressive and innovative peer education project to spread education about HIV/AIDS in this country where misinformation and misconceptions about the disease persist. I had the privilege of being a guest at one of her three-hour training sessions last week, and I truly believe that her program could and should become a model for HIV peer education across the entire African continent. Check it out and let me know what you think.
Here is her description of the program and an update on its recent implementation.
Projet "Hêré Bolo"
This summer, the GAIA Vaccine Foundation will pilot its first HIV peer education program, "Le Main de l'Espoir," at a clinic in Sikoro, Mali. "Le Main de l'Espoir" (which translates to "Hand of Hope" in English and "Here Bolo" in Bambera) will teach Malians about HIV prevention and treatment by using a mnemonic that is easy to remember and easy to teach.
The program will be five days long, and each day will correspond to one finger of the hand to emphasize a point about HIV - hope (the thumb), identity (index finger), transmission (middle finger), marriage, fidelity and family (ring finger) and the community (both hands together).
At the end of the five day program, all participants will have the necessary knowledge about HIV prevention and treatment to allow them to become peer educators and will receive a tee shirt that identifies them as HIV peer educators in the community. It will then be their responsibility to bring "Le Main de l'Espoir" to other Malians living in Bamako and Sikoro, and teach them the mnemonic so that more people can become peer educators. In this way, GAIA's program will put HIV prevention and treatment directly in the hands of the Malian people, and give them the power to carry out their own public health intervention.
July 17 Hêré Bolo Update
This week, Here Bolo kicked off its first week of peer education training. Due to the overwhelming interest in the program, the program was expanded to include 20 peer educators - 13 men and seven women, rather than ten. Training took place over three days from Tuesday to Thursday, and was conducted by Dr. Malick Kone, Ramatoulaye, and Maddie DiLorenzo.
Maddie administered a pre-assessment survey on Tuesday and a post-assessment evaluation on Thursday in order to assess the peer educators' knowledge of HIV prevention and treatment. While Maddie has yet to fully analyze the data, she has briefly scanned all of the surveys, and found that the majority of the participants have a pretty good basic knowledge of HIV prevention and treatment both before and after training.
However, Maddie did notice that pre-training, participants still held some common misconceptions about HIV - such that one could tell if a person was HIV-positive by looking at them or that one could catch HIV by kissing someone.
The sessions were also characterized by a great deal of debate as men described their reluctance to wear condoms and women described their reluctance to stop breastfeeding despite their knowledge of the benefits of these practices. Therefore, the peer educators' mission will be to not only educate others, but to address the gap between HIV knowledge and preventive practices in Sikoro.
Perhaps the best part of the program has been the peer educators' enthusiasm for their work - each day's session ran at least 45 minutes over time as the peer educators asked questions and began practicing for the upcoming Balonie de l'Espoir, which will take place in Sikoro on Saturday, July 29. The Balonie is a celebration dedicated to educating the Sikoro public about HIV prevention and treatment practices, and will feature all peer educators performing skits that illustrate the five points of the Here Bolo program: hope, identity, transmission, marriage and family, and community.
Dr. Malick Kone, Ramatoulaye and Maddie will dedicate the next two weeks to planning this event. Beginning on August 1, they will begin tracking each peer educator's progress as they begin to educate others in various parts of Sikoro.
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What an inspiring and entrepreneurial approach to public health! Children the nomadic areas of the Sahara and the Sahel and the agricultural region to the south. More than four fifths of the population live in rural areas. A combination of climate, migration, history, and culture has painted Mali with a mosaic of diverse peoples. To the north are nomadic groups of the Tuareg, of Berber origin, and Moors. To the south is a variety darker skinned peoples. The largest is the Bambara, who live along the Niger River. The Soninkle are descended from the founders of the Ghana empire and live in the western Sahelian zone. The Malinke, descendants of the Malian empire, live in the southwest, while the Songhay are settled in the Niger valley from Djenné to Ansongo. The Dogon live in the north-central plateau region around Bandiagara. The Voltaic group includes the Senufo, and the Mininianka; they occupy the east and southeast. The Fulani herders are found everywhere in Mali where large herds of cattle, sheep and goats can be grazed.
Islam is practised by nine-tenths of the population, animism by most of the rest and Christianity by a small number. Whilst French is one legacy from colonial times, few people speak it and the most common language is Bambara.
History
The Great empires
The area that Mali now occupies came to prominence in the thirteenth century when the first of a series of influential and wealthy empires, the Malinke empire, was established there. Commercial and cultural centrepieces of Africa, these empires dominated trade routes, exerted tremendous influence and became centres of learning. The wealth of the Malinke sultans was legendary. Some estimates reckon that two-thirds of the world’s gold of the time was in their hands. Indeed, when Sultan Kankan Musa, stopped in Cairo, during his pilgrimage to Mecca, in the fourteenth century, he distributed so much gold that its price fell for the next twelve years! Each year 12,000 camels would cross the desert between Mali and Cairo. Trade extended into present day Europe via Morocco and Moorish dominated Spain. This intensity of commercial and cultural interchange with the Arab world and Europe gave international prestige to the newly established and thriving University of Timbuktu. At its height the university catered to around 15,000 students. However, the Portuguese broke the Malinke virtual monopoly of the rich trans-Saharan gold trade, by diverting gold to the coast to exchange for European goods.
By the fifteenth century, in the face of attacks from surrounding groups and the loss of trade to the Portuguese, the Malinke empire gave way to the Songhay empire. Nevertheless, the empire continued to combine lucrative trade with a rich intellectual life. This period ended dramatically in 1594 when competition for the Saharan trade routes precipitated an invasion from Morocco. Timbuktu was pillaged and the university destroyed. The development of rival states contributed to the decline of the empire. The 'convert or die' jihad of El Hadj Omar Tall, leading an invasion from Guinea and Senegal in the mid 1800s, further weakened an already divided land which was unable to resist the final invasion; the occupation of the French.
A French colony
The French incorporated the area of Mali into the vast territory of French West Africa. Mali was to be the bread-basket for the area providing rice for the coastal French colonies and cotton for France. Colonisation heralded significant changes. Bamako was chosen as the site for the new capital. Trade, which had traditionally flowed north across the Sahara to the Mediterranean, was turned back to the Atlantic and Dakar. The Saharan trade routes dried up. To grow the rice for their colonies French engineers used forced labour to build ambitious irrigation projects, rivalling the Aswan Dam in scale. However the French never concentrated on Mali as they did in Côte d’Ivoire and Senegal; its importance lay mostly in its strategic position. No major infrastructure projects were attempted, other than the irrigation project on the Niger and the railroad from Dakar to Bamako.
The colonial legacy
Although life continued much as it had before for the majority of Malians during the French occupation, Malians may remember the French for four reasons.1. the French discouraged traditional customs such as the dina; a code of conduct by which disputes over land were resolved between pastoralists, cultivators and fishing communities.2. Malians were conscripted to fight in both World Wars.3. although only spoken by a tiny, educated minority, French is the official language.4. the French destabilised the nomadic communities of the Touareg by requisitioning their herds of camels for the first world war effort.
Independence
In the atmosphere of democracy that prevailed after the end of the second world war and amidst increasing calls for self-governance from Mali, the French embarked on a policy of gradual concessions, starting in 1945, that led to independence in 1960. Aware of their limitations Mali and Senegal joined in the federation of Mali but their differences of interest soon caused the alliance to collapse.
Socialism, drought and dictatorship
Led by Modibo Keïta, the same man who had steered Mali to independence, Mali broke its links with France, withdrew from the Franc Zone (a system governing foreign exchange, credit and monetary relations between France and 13 former French colonies) and became a socialist republic. However, the centrally managed economy was a disaster and Mali soon had to rejoin the Franc Zone. Foreign debts and plummeting agricultural production led to the overthrow of Mr Keïta in a military coup in 1968.
That coup heralded 23 dark years for Mali. The Military Committee for National Liberation (CMLN) led by Moussa Traoré, promised to fight corruption and straighten out the economy. The opposite was the case. The dictatorship evolved into a one-party system, the Union Democratique de Peuple Malien (UPDM), which held power until 1991. Mr Keïta died a mysterious death out in the desert, where he was held prisoner. Corruption became an institution; both as a form of government and as a way of life. The situation was aggravated by two extended droughts, in 1973-74 and again in 1984-85. Although the droughts opened up the country to international aid - the majority of the aid disappeared into the pockets of party officials.
Structural adjustment
The military-based government opted for a policy of internal structural adjustment which started in 1981. Adjustment was designed to reform the economy and allow Mali to pay its foreign creditors. The first structural adjustment programme, launched in 1982, was intended to streamline government bureaucracies, encourage investment and the private sector, reduce subsidies and match government spending with government revenues. Many of the economic reforms were necessary but little thought was given to the social costs of adjustment. Deep cuts in government spending on health and education provoked howls of outrage from the people. The weakening of education and health services hit the poor and the most vulnerable hardest.
Transition to democracy
From 1989 a broad-based coalition of social and political groups demanded a multiparty democracy, greater political freedom and full civil rights. Student protests were violently crushed. Meanwhile, the Touaregs were in open revolt in the north of the country and the government came under pressure from mass demonstrations in the cities. A series of bloody clashes between the people and the army culminated in the arrest of the president in 1991. Lieutenant-Colonel Amadou Toumani Touré installed a transitional committee. The transitional body included members of each of the organisations that had helped to bring about an end to the regime of Mr Traoré. They organised a national conference to draw up a new social contract and design a new constitution, held a referendum on the proposed constitution, put in place the rules for multi-party elections, oversaw municipal, legislative and presidential elections under the auspices of international observers and put Mr Traoré in jail. Then, after the democratic election of Alpha Oumar Konaré in 1992, they left office. Mr Konaré, a key figure in the ousting from office of Mr Traoré, has held power ever since.
Political stalemate
However, the economic and environmental crisis did not leave with Mr Traoré. Mr Konaré’s party, the Alliance for Democracy in Mali (Adema), tried with varying degrees of success and failure to tackle the war with the Touaregs in the north.
War in the North
Mr Konaré inherited a delicate and potentially explosive stand-off when he came to power. Rising discontent in the northern provinces had led to an armed revolt by the Touaregs. Since 1900, when their traditional trade in salt across the Sahara was destroyed by the French colonialists, the Touaregs had felt marginalised and threatened by the new world order. They rebelled during the First World War to try to prevent the loss of their camel herds to the war effort and again in 1963; both times the rebellions were violently repressed. In July 1990 an armed attack on government offices in the town of Menaka ignited a widespread Touareg uprising. Equipped by Libya, the Touareg units were mobile and well armed. They inflicted some heavy defeats on the Malian army. The first peace accords, signed in 1991, were soon eclipsed by the fall from power of Mr Traoré. The Touareg leaders grabbed the opportunity to maximise their gains and relaunched the attack. The cycle of violence resumed. Just before the elections in 1992 an uneasy compromise was reached, the Pact Nationale, which made significant concessions to the Touaregs, pledging investment and infrastructure support.
The Pact failed to resolve the situation for a variety of reasons. The break down of law and order, continuing problems with banditry, the issue of the internally and externally displaced refugees (250,000 were living in camps in Algeria, Burkina Faso and Mauritania), the perceived indecision of Mr Konaré and the disunity of the Touareg leaders raised the level of tension to breaking point. According to the terms of the Pacte Nationale the Touaregs were allotted jobs in the army and the civil service whilst other groups were suffering the pains of structural adjustment.
In 1994, the Songhay population decided to act, creating a militia, named the Ganda Koy. What followed amounted to a pogrom which polarised the country with retaliation and counter-retaliation between the sides. The army, rather than acting to resolve the conflict, took sides. When the Touaregs launched their largest offensive by attacking the military base of Gao, the military refused to defend the city or its inhabitants. Instead, once the attack was over, they killed over 200 civilians from a peaceful Touareg community on the outskirts of Gao.
On the brink of civil war, several courageous individuals managed to get the two communities to meet and a fragile peace was established. This culminated with the ceremonial burning of 3,000 weapons in Timbuktu in 1996. As a result of the instability many aid organisations pulled out of Northern Mali and aid projects practically halted for the duration of the unrest. Adopt A Doctor Doctors attitudes make a di... Success for Adopt A Doctor in Mali! Hundreds of New Photos Full Moon and the Maternity Ward A Tribute to the Women of Mali Malians Heart George W. Bush A Postcard from Bamako My Photo Album The Children of AIDS Archives July 2006 September 2006 October 2006
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