the amazon! - manaus

everything is bigger in the amazon. the scale of the river is unbelievable - it is up to 50 km wide, has water level variations of 60 feet based on the season, and discharges more water volume than the next 7 largest rivers in the world combined. manaus is the largest city in the amazon basin, with about 2 million people. it feels like an outpost fighting back the rainforest. huge plants break through the asphalt. i got the feeling that the fauna would take over in days if the people gave up and let it.

manaus is a working class, spread out city of concrete, famous for its rubber. the rubber wealth allowed the construction of its iconic opera house, ornately constructed with materials from all over the amazon. sadly, tours were shut down for a private event when i went to visit. i decided to take a public ferry across the amazon river, which crossed the "meeting of the waters" - after the black, more acidic rio negro and muddy, more basic amazon rivers meet, their respective waters continue to flow side by side for some kilometers before beginning to mix. the ferry passes over this meeting of the waters and it was definitely worth the 3 hour excursion! manaus also has the largest urban park in the world, measuring over 100 square kilometers. i went for a hike through the rainforest there, and climbed a wobbly viewtower which afforded spectacular views over the forest. even from the city, the amazon is awe-inspiring!

the amazon! - adventures in tres fronteras

my foray into the amazon took me to two fascinating locales: the tres fronteras region of colombia, peru and brazil, and then to manaus, brazil, the largest city in the amazon. i flew from bogota to leticia, colombia, in the far southeastern corner of the country. it is amazing how large colombia is; leticia is almost 2000 km from the caribbean coast, and deep in the rainforest - 700 km from the nearest colombian road. at the airport they seemed to have instituted a new $10 "tourist tax" - not much choice on that one. i walked the sweaty 1 km or so into town, to the anaconda hotel. the town is famous for its central square, where thousands of chirping birds congregate nightly at sunset. i was able to climb the steeple of the town church to watch this, which was amazing, then eat an amazonian fish for dinner! leticia is an impressively bustling town for being so geographically isolated; half of the town lives on homes on stilts over the amazonian marsh.

the tres fronteras region is composed of the towns of leticia, tabatinga, brazil, and the island town of santa rosa, peru. one can travel freely between the towns, but must clear immigration before moving further into any of these countries. i arrived on a friday night, and when i told the staff at the anaconda hotel that i planned to fly out of the tabatinga airport the next afternoon, they had some stressful and unexpected news - apparently the immigration offices were all closed for the weekend. if i couldn't stamp into brazil then i couldn't catch my flight to manaus, and i couldn't get back to work on time, and it was going to cost a ton to backtrack. i didn't get much sleep, and before even eating breakfast in the morning i jumped on a motorcycle taxi across the border into brazil to try to figure it out for myself. sure enough, the brazilian immigration office was closed, with a sign in portuguese telling me to come back at 9am monday morning. i asked around and tried to google solutions to no avail, and was feeling quite despondent. then somehow, by the grace of God, i chanced upon a nearby police station, and amazingly, one of the officers was able to stamp me into brazil! next time, don't try to do this on a weekend, he told me.

after that scare, i had a few hours to breathe, so i went back to leticia and took a boat taxi across the amazon river to peru! the private motorized wood longboat ride cost $1, and took about 20 minutes. crossing the amazon was surreal; the widest, muddiest river imaginable. i walked around the sleepy one-road town of santa rosa, peru, before heading back on another ferry. from santa rosa, one could also take a ferry in the other direction to iquitos, which takes about a day. i was a bit confused as to whether tabatinga was in the brazilian or colombian timezone, so playing it safe ended up arriving at the sleepy tabatinga airport way early. at least i had my stamp!

on illegal ubers in bogota

after medellin, i had a layover in bogota for about 24 hours on my way to the amazon, and i'd like to think i made the most of it! bogota is a sprawling city of 10 million people pretty high up in the andean foothills. when i was there it was overcast and chilly, which was rather refreshing. i learned as i went that uber is available in bogota, but illegal. so the meetups have to happen under the radar. my drivers kept calling me and trying to explain things in espanol, and then cancelling when they found out i couldn't communicate. finally found out they were calling to a arrange a clandestine meetup point in a parking lot or somewhere else than the curbside. when a nice driver who spoke english finally explained this to me, things got a lot easier, lol. she said the police impound the car on the spot if they find out someone is ubering. if we were to be pulled over, i am a friend, not a customer. for this reason they insist you sit in the front seat too. i'm cool with being a friend!

i stayed in a nice area called usaquen, which used to be its own town but has been swallowed up in the bogota sprawl. there were cobblestoned streets along which i got a nice dinner and walked around. in the morning i headed downtown, which took over an hour in the very slow-moving traffic. i went to the main central bolivar square, which is surrounded by government buildings, and is famous as the site of a siege of the colombian government by m-19 guerilla tanks in the 1980s. nearby is the most famous museum in colombia, the museo de oro, which is all about pre-colonial gold and metallurgy, a topic which inspired the mythical city of el dorado. the museum only cost $1 to visit and was actually very impressive - one could easily spend a few hours there. bogota is in a valley overlooked by a mountain viewpoint called monserrat which can be reached by a cable car which i tried to take up, but ran out of time.

the whole reason i was trying to stick with uber is that taxis in bogota sadly have a terrible reputation. in the past they have been some of the most dangerous taxis in the world, with famous "million dollar rides" around to atms at gunpoint, and druggings of passengers for amnesia. at minimum, one could expect to be ripped off. even today, the taxi fare is not metered, but the meter has a number which corresponds arbitrarily with the rate the driver wants to charge, which may or may not be on a laminated piece of paper in the back seat, which the driver may have just switched out for you when he saw you weren't a local. apparently the taxi cartels have lynched uber drivers to protect their turf, and of course they are the lobby behind uber being illegal. anyway, i got in a taxi out of necessity to make it to the airport on time, and it went all right. whew!

solid day in bogota!

city of eternal spring: medellin!

i got to go on a great little trip for one week to south america - first to medellin and bogota in colombia, and then into the amazon! of note, colombia was the 100th country i have visited!

i started with 2.5 days in medellin, which was very relaxing. this city in the andean foothills is called the city of eternal spring due to its constant spring-like perfect weather. it is also famous for being the home of the world's most famous drug boss pablo escobar and his medellin cartel, which controlled the streets of the city until the mid-90s, and gave it the highest murder rate in the world through the 1980s. pablo developed an estimated net worth of over 30 billion us dollars smuggling cocaine to america before he was gunned down and buried in medellin, and the sites of his demise and burial have now, perhaps questionably on an ethical basis, become tourist pilgrimage sites. i did start watching the tv series narcos on the plane ride down, which is a great show if you haven't seen it. the city, along with others in colombia, is also now home to many people displaced by the colombian civil war over the past half century, between the leftist revolutionary farc and eln and the government and other paramilitary groups. the war killed over 200,000 people and displaced over 5 million people. thankfully now a peace agreement has been agreed to by the involved parties, and members of the farc are being integrated back into society peacefully. obviously, the drug wars and the civil war were horrible for regular people in colombia, and they are trying to put this violent history behind them, and generally doing an amazing job of it. now, medellin is known as a city where expats love to live and start tech companies, as there are all the amenities one could want, it is safe, has perfect weather, and very friendly people.

i stayed where all the tourists stay, in an upscale neighborhood along a hillside called el poblado. really nice hotel for excellent value - about 25% of what one would pay for a similar room in the usa. there are multiple huge, very nice malls, which of course made me happy! the most glamorous is called el tesoro, and is perched on the side of the hill with amazing views over the city in the valley below. one very cool thing about medellin these days is that the city is doing tremendous work to provide top-notch transportation, libraries, and other services to the socioeconomically disadvantaged people who live in the hillside suburbs. in addition to its very impressive metro system (the only one in colombia and a great source of pride), the city has built cable cars to various suburbs to make commuting easier for the locals, which cost a very small amount to ride. i took 2 of them up the surrounding hillsides for excellent views. there is also a famous series of outdoor escalators which has been built in a once very rough neighborhood called communa 13. now the city has sanctioned a lot of colorful graffiti in the area, and built free escalators. definitely a cool place to check out.

downtown there is a nice museum called the museo de antioquia, which contains many sculptures by medellin's most famous artist botero. he had a unique style of sculpting globular, almost spherical people and animals. i also visited a museum devoted to the memory of those lost to the colombian civil war, which, while heartfelt in its intention, was a bit of a disappointment from the tourist/education perspective. i at ea ton of street food, most notably numerous empanadas and cups of freshly cut mango slices covered in lime juice and spicy salt. overall a really great time in medellin!

cancun pit stop

this fall my sister had a baby up in alberta, canada where they live, so we obviously needed to go visit! turned out it was actually cheapest to fly to cancun for a day and then to alberta, so why not!

my flight was significantly delayed, so arrived at about 2 am. of course, i had neglected to arrange transport from the airport to the city in advance, which it turns out is not ideal in cancun if you arrive in the middle of the night, as they recently banned uber. after fighting back the rabid taxi drivers, i finally found a guy driving a resort van going in the other direction that could drop me off at his friend's house, who could then drive me into the city. whew!

the first night i stayed in a really cheap hotel downtown, but the second night fully availed of the amenities at a brand-new sheraton four-points, also downtown, booked with (not too many) hotel points. it had a nice pool on the roof and a steamroom. between steam sessions, i walked around the hotel zone, which in cancun is along a long, thin peninsula jutting out into the caribbean. it was nice, but i was wearing a boot on my foot as i had recently broken my toe, so wasn't able to get out into the water. it was a great place for a day, but if you are not at an all-inclusive on the beach, cancun is just a regular mexican city, only much more expensive. i had some fun exploring the downtown malls. glad i went!

morocco!

we spent about 4 days in the amazing desert city of marrakech, in the shadow of the snow-capped high atlas mountain range! we were able to stay in a super-nice hotel in the new city using hotel points compliments of a credit card sign up bonus (get at me if you want to get in on the game!). most cities in morocco have a new city where moroccans generally prefer to live and is more modern, and another ancient, walled, car-free part of the city called the medina, where most of the excitement for a tourist is. marrakech is a great place. there is a huge square in the medina called jmaa al fna, the largest and most exciting in morocco. it is filled with stalls selling amazing and cheap fresh-squeezing orange and pomegranate juice, and snake charmers. at night, there are bands playing traditional music, arabic storyellers, and cross-dressing bellydancers, as well as many food stalls with extremely aggressive salespeople. never a dull moment! a moroccan comfort food in the market in marrakech is snail soup, which you can get a bowl of for under one dollar. there are miles of narrow medina passageways surrounding the square, where one can wander for days. that is exactly what we did and it was excellent. highlights included two hammam experiences on successive days. the first i went to was at a very traditional male-only one called mouassine hammam which is most frequented by the local men of the city for their regular baths. you enter a large, communal, moist room and bath yourself with buckets of water and black olive soap, perhaps helping an old man wash his back if you can understand what he is trying to ask you. i then hired the staff there to give me a rub down with a glove of steel wool, and amazing, aggressive 30 minute massage during which a very large man vigorously and systematically attacked every pressure point in my body, including the groin ones and the ones behind the knees. it was very intense but also very relaxing once it was all over. the next day ann and i went to a luxury underground hammam experience at a riad called medina elisa, which was excellent. it was a lot more private and gentle, but again involved another steel wool scrub down, which i would not recommend 2 days in a row, as my skin was quite pink by that point. there they had a serene pool which we reclined by and then there was a foot massage which was very luxurious. going to a hammam of some variety is definitely the thing to do in marrakech!

we then drove out the 7 hours or so out to the edge of the sahara desert! first, we had to cross the atlas mountain range, which are snow covered year round! there is even a ski resort near marrakech. over the atlas range, we stopped at a famous deserted town called ait ben haddou, which has been abandoned by locals for over a century but has recently been a movie set for many films including the jesus movie and gladiator. it is composed of mud-built houses built on a hill, and is a very fun place to explore for an hour or so.

our destination on the edge of the sahara was a small town called merzouga, which sits beside an area of massive sand dunes. contrary to what i had thought, much of the sahara desert, at least the northwest part of it, is more rocks and mountains than sand, but there are areas of sand that develop where the wind blows right. we stayed at a desert hotel called ksar bicha, which while being rustic was actually really nice and great value. after one night there, we headed out into the dunes on camels for a night in the desert! definitely the highlight of the trip. it was about an hour-long camel ride to a desert camp they had set up, and we had a berber guide and were with one other couple from germany. once we got to the camp, we hiked up the largest dune (which took about 45 minutes), and watched the sunset. amazing. then the guide made us dinner and played some traditional berber songs on the drums while i danced, and the rest of the group watched, lol! it was fun. we then played some cards games which didn't require any verbal communication before sleeping in some little tents and riding the camels back to the hotel in the morning. an amazing experience in the sahara!

our last stop in morocco was a few days in fes, which is another walled, ancient city in the northern part of the country. here we splashed out for a room in a really nice riad (called lune el soliel) - riads are the traditional living spaces in the medinas - a large home with many rooms surrounding a central courtyard. there we got amazing breakfasts on the roof overlooking the medina. the medina in fes is the largest car-free urban area in the world, and takes days to fully explore! fes is famous for its traditional tanneries, where the animal skins are cured and colored in different pools of liquid, all of which can be seen from elevated viewpoints over the area. one of the days in fes i drove out to another nearby but notably less touristed walled city called meknes, where there is a massive city gate of historical importance, some underground storage reserviors, and another medina to explore. nearby, i stopped at an ancient roman ruin called voluvulis, which is a remarkably well-preserved city which was one of the largest in the roman empire in its day.

overall it was really a wonderful 12 days or so in morocco! we thought of it as our honeymoon, and it didn't disappoint!

a pilgrimage to feed the british monkeys

we had almost 2 weeks of vacation in morocco! we rented a tiny car, which was amazing, i really wanted to make it to gibraltar and ann needed to get some work done, so upon arriving, she took the train to marrakesh and i drove north to take the ferry to europe! morocco has a pretty impressive toll expressway system, so it didn't actually take too long to drive to the northern tip of morocco, to a town called fnideq. after spending the night there and finding a place to safely park the car, i made my way to the border of an enclave of spain in north africa called ceuta! it occupies a tiny peninsula of north africa, and is one of a few remaining enclaves of spain on the continent. spanish sovereignty over these areas is contested by morocco, so it remains a sore spot between the two countries. the other major enclave a few hundred kilometers to the east is called melilla, and interestingly there is also a third small enclave between melilla and ceuta that is just one small island a few hundred meters square, which is permanently staffed by a contingent of the spanish military to protect it. that one can't be visited by the likes of me. the short border between morocco and ceuta is very heavily fortified with a huge wall, as many migrants have attempted to make it into the european union this way, often by rushing the border en masse. at the time of my crossing, there were thousands lined up on the moroccan side - i was told they were headed to europe for work. the city of ceuta is an interesting fusion of spanish and moroccan culture, and is pretty substantial with about 80,000 people. from there, i jumped on one of the frequent one hour long ferries to algericas, spain. for whatever reason, i love ferries! once in algericas, one walks to the downtown bus station and takes a 45 minute bus ride to la linea, which is one the border with gibraltar. by this time it was about noon.

approaching gibraltar is fascinating. spain gives way to british accents and very british things such as many posters advertising the territory's upcoming open snooker tournament. gibraltar is perhaps even more proud of its british heritage than is the typical town in england, because it is so isolated and has a rich history - indeed it has been british longer than america has been american. immediately upon crossing the border, one finds themselves walking on winston churchill avenue across the centre of the single runway of the peninsula's international airport! signs advise to "walk fast" and watch out for landing aircraft, of which there are just a couple each day.

it takes about half an hour to walk into the pedestrianized centre, where i got a huge fried british breakfast of blood pudding and mashers and 10 other fried things. i then took a cable car to the top of the rock. the view was spectacular, and there are famous barbary macaque monkeys up there! they are very tame and numerous. they were brought from africa at some point, and when they started to dwindle following world war II more were brought from africa to replenish their population. today they are not having any trouble with all the tourists feeding them. despite being basically just a huge rock with forest on one side and a cliff on the other, the rock of gibraltar has a fascinating amount of history. there is a massive cave of st. michael that is seemingly endless, and in which there is evidence of neolithic human habitation. there are massive stalagmites and stalactites which are quite impressive. there are also many kilometers of man-made tunnels, built for strategic protection of the rock in the 1700s and during world war II, many of which can be explored. the tunnels from the 1700s open out of numerous holes in the cliff face, where cannons were fired from. there was enough space in the tunnels to house and provide for up to 1600 men for one year. very fun to explore.

after exploring the rock, i headed back the way i had come - back across the runway, the border, bus to algericas, ferry to ceuta, border crossing to morocco, into the rented car which had survived the day, and then as far as a terrible hotel in kenitra just north of rabat that night. an excellent day!

togo excursions

i was volunteering in togo through an ngo called world medical mission. while generally they are a great organization, they were super paranoid about not letting their volunteers use public transportation or even taxis, which is outrageous - as a result i am probably going to avoid volunteering with them again. on top of this, the hospital is in a very rural area without many nearby towns, so i didn't get out as much as i would have liked to. oh well.

i was able to go on a few daytrips on the weekends. on one saturday a group of us visited visited a nearby boarding school for blind children, run by the same mission agency as the hospital. it is very cool - they provide great education for the children (and even adults), who are mostly blind due to trachomatis flies, the most common etiology of blindness in africa. they are taught braille at the school, and there are textured posters on the walls of the school for teaching various things like topography on maps and different organ systems of the body. they are also taught how to weave furniture which they can continue to do once they leave to provide a service to their communities. there are some new missionaries running the center who are really doing some great work there. they also have an aquaponics farm they showed us, where they grow tilapia fish and use the waste to grow plants such as lettuce and strawberries. we then went to a french restaurant in kpalime called chez fanny, which was pretty good.

one sunday myself and some medical students climbed one hour up a nearby mountain to attend a church up there. we were soaked with sweat upon arrival so needed to change. despite being at the top of a mountain without electricity, each of the approximately 20 people who showed up were wearing their sunday best. they were very welcoming.  speaking of, its been nice having the medical students around - there have been 3 of them at any given time. one is going into pediatrics so i have been able to do some teaching and he has been very helpful around the hospital.

on our last weekend, we took a long drive and then a long hike to a very high waterfall right on the border with ghana. so despite my previous successful endeavor to visit ghana, got to step across the border again! we went swimming beneath the waterfall and the water falling hundreds of feet created a crazy wind tunnel of mist. it was great. 

there has been a lot of fomenting unrest in togo while we've been here, with widespread protests against the autocratic leader, faure gnassingbe. between him and his father, the family has been ruling togo since the 60s, and people are starting to get tired of it. compared to its immediate neighbors, togo is relatively poor - the reasons for this are of course multifactorial, but it is at least partially due to government mismanagement. there are weekly protests including in the nearby city of kpalime, which are generally very peaceful, but during some of which people have been killed by government security forces. this is part of a wider trend across africa right now, dubbed the "african spring."  my amazing wife ann is actually writing about this while here, so has been traveling around the region while i've been at the hospital.

lassa scare

about a week after arriving in togo, i examined a six year old girl who presented with about one week of fever, diarrhea, emesis, and diffuse abdominal pain. i didn't think much of it, and didn't use gloves, because they aren't really readily available in the clinic unless you go looking for them. i have been using them since. we did some blood work, and admitted her to the hospital. she tested negative for malaria and typhoid fever, the two most common etiologies of fever here. she also had significant pancytopenia (low white blood cells, red blood cells, and platelets), which is strange. we started her on the empiric antibiotic treatment for typhoid fever, but after two days she continued to have persistently high fevers, and her three year old sister also started developing the same symptoms. her sister was found to have the same lab results, and both also had very high transaminase (liver enzymes) levels as well. all these symptoms are consistent with viral hemorrhagic fever, specifically a terrible disease called lassa fever. to top it off, the younger girl started having profuse blood in her stool.

lassa fever is an arenavirus endemic to certain parts of west africa, spread by the aerosolized urine of a certain species of rat, which come into people's homes during the dry seasons. it can also be spread between people via any body fluids. it was first described in the 1970s, and was named after a city in northeastern nigeria where there was a major outbreak. it is a viral hemorrhagic fever similar to ebola and marburg virus, as in addition to the nonspecific symptoms of fever, abdominal pain, diarrhea, emesis, and throat pain, etc, it can also cause bleeding from mucosal membranes and hypovolemic shock and end organ failure. so pretty scary. it has even been cited as a potential agent for bioterrorism. about 80% of people who get it actually don't get sick enough to be hospitalized, but the mortality rate is about 50% for those who need hospitalization. even more scary, well over 50% of nosocomial infections (person-to-person in a healthcare setting) are fatal.

there had never been a positive case of lassa fever in this part of togo before, making it less likely. however, antibody studies have been done suggesting that the majority of togolese have been exposed to the virus at some point, meaning it exists and just hasn't been isolated, likely simply due to lack of testing. the first person confirmed to have died from lassa fever in the recent past who contracted it in togo was an american physician assistant who was working in a mission hospital in northern togo and fell ill last year. he continued to deteriorate, and was evacuated to germany, where he sadly died. they then discovered he had lassa fever. he didn't have any known exposures, so no one really knows how he contracted it.

after the girls had been sick for a while and after much discussion among the hospital staff, it was decided to send a blood sample to the central lab of the government in lome to test for lassa fever. it became apparent that it is quite the process. the local authorities have to sign off on the test being done after a meeting, and a medical provider has to escort the blood sample all the way to lome as it is considered biohazardous. this all took the better part of a week to arrange. once the blood finally made it there the confirmatory test by pcr was relatively quick. i read everything on the internet about lassa fever. interestingly, a number of studies about transmission in exposed, unprotected individuals came out of germany last year after the missionary from togo was evacuated to there with a yet unknown illness. there is an antidote of sorts, but it doesn't really work very well, and isn't exactly available on short notice to a rural hospital in togo.

thankfully, the test came back negative! i must admit though, in the intervening days i was quite scared that i might get it (and if i did, more likely than not, die an agonizing death). because the disease starts with nonspecific symptoms like sore throat, diarrhea and fever, i was constantly thinking that i might be coming down with it. i prayed more frequently and fervently than i normally do. it was an important reminder for me of the fragility of my life, and that they can end before we want them to, a reality that isn't as apparent in the west as it is in africa. i really needed to trust in God, and be reminded that my faith in Him is all i really have that matters, and all i really need. there are so many frivolous concerns in our lives that just don't really matter when you think you might die soon. thank you to my amazing wife who comforted me when i was really on edge. we still don't know what the girls had, but it was almost certainly something viral and nasty. thankfully they started to do better and we were able to send them home.

ghana or bust!

one saturday during my rotation in togo i decided to go visit ghana. i had obtained a visa in advance and wanted to make sure i at least used it. jumped on the back of a motorcycle from the hospital to the main road, then took a shared taxi to the main town, kpalime. there, i found my way to the taxi park, where dozens of taxi drivers compete for your attention. i procured one with limited effective communication to drive me to the ghana border, which was supposed to be about 20 minutes south of kpalime. from there i was hoping to find another taxi to go the ghanaian city of ho, which should have been about another hour or so to the south.

once in the taxi, however, we started going in the opposite direction, up a mountain to the northwest of kpalime. the taxi driver was insistent that he was taking me on the most direct route to ho, and i eventually stopped asking and just sat back, as i admittedly didn't really know if he was wrong. we went through a town called klouto on the crest of a mountain, which apparently is a worldwide destination for butterfly enthusiasts. the togo border police had a gate set up there, through which they let us pass. we then continued on an ever-narrower dirt path for a number of miles, with no other cars or even pedestrians for miles. at this point i had no idea where this guy was taking me. eventually after about an hour, we arrived at a border post though! the guards sprang into action, breaking out their collection of passport stamps and ceremonially carrying out a huge ledger book. i saw that the most recent entry of someone who had used a passport to make the crossing was 3 weeks earlier. they asked where i was going, but this really intensified on the ghanaian side. i told them that i just had always really wanted to visit ghana, which is true, and they thought that was hilarious. through long deliberations in the local tribal language ewe with my taxi driver, the taxi driver and the ghanaian border guard decided i would visit the nearby border town before returning to the border post and kpalime. it also became clear that the taxi driver was going to charge me much more than we had initially agreed upon. sadly i lacked the leverage of using another taxi at this point, as there wasn't one for miles, the nearest city was now > 2 hours away, and getting back to the hospital after dark or the next day wasn't an option.

we continued to the nearest town in ghana, dafar. i took a walk around the dusty market area and witnessed a funeral procession. the taxi then made a few stops so the driver could pick up some things for his friends, including a large, 2 foot long object concealed within a garbage bag, for which money was exchanged. when i was asked what it was, he said it was "soup." it was again exchanged for money with the togolese border guard on the way back. the border formalities on the trip back were faster now that they knew me, and were complicated only by the togolese border guard's insistence on a bribe "for beer." when he refused to give my passport back for a few minutes i finally caved and gave him the money with the insistence that he use it only for beer. i then asked if i could take a picture of a spray painted sign that said "welcome to togo." he told me no, it was against regulations. i then asked him of collecting bribes was also against regulations, and he gave me my money back. cool! that was my couple hours in ghana, and i made it back to the hospital is tsiko before dark!

first weeks in togo

as an elective during my third year of residency, i am able to do a month of global health! i arranged to come to togo, west africa. i am spending one month at the karolyn kempton memorial christian hospital, also called hospital baptiste biblique (hbb). it is the second largest hospital in the country, and is a missionary-run hospital in tsiko, near adeta, togo, a rural area about 3 hours north of the capital lome. on arrival in lome, the hospital had arranged a redundant "welcomer" to meet us prior to customs. she directed us to the wrong line, and then when customs guards asked for a bribe for one of our suitcases, advised us to pay it. we refused, and they eventually let us through without it.

in togo, good medical care is very hard to come by, so the services hbb provides are much appreciated. people in togo must generally pay up front for any hospital services, including emergent ones, such that motor vehicle accident victims, even if obviously wealthy, are not resuscitated in emergency rooms until the medical providers are paid, leading to countless preventable deaths. widespread frustration over these practices are one of many drivers of recent protests against the autocratic government. hbb is unique in that they treat any presenting emergent patients first, then ask for payment later. they also supply medicines and supplies for inpatients, which contrasts with most hospitals in the country which require patients or their families to provide supplies and medicines, which they need to buy at markets outside the hospital. all the physicians at hbb are western missionaries (which makes it a good place to learn for a resident such as myself), though there are a staff of togolese physician assistants who see many of the patients in clinic and are the first call overnight. physicians, including myself while i am here, act more as consultants overnight, and do rounds on inpatients and see clinic patients during the day. everyone in the area are subsistence farmers, such that even just the meager salaries of the physician assistants and nurses have essentially created a middle class in the area. most of the locals are people belonging to the ewe tribe, which stretches across the west african countries of benin, togo, ghana and others. there are other tribes as well though, such as the fulani, who are more nomadic cattle herders and have their own language. they often come by the hospital, are told how much something like a small surgery will cost, leave, and come back a week or two later with the money, which is often a lot for this part of the world. we had one little fulani feeder-grower premature baby who had been there for weeks, requiring a special high-calorie formula and an incubator. every day it was someone's job to explain to the grandmother why the baby needed to stay until they reached a certain weight, because they wouldn't survive life on the road at their size.

i have seen some very interesting medical cases thus far. by far the most common diagnosis is malaria, which often causes severe anemia requiring blood transfusion and extreme splenomegaly. this is the diagnosis for well over half of the admissions. many children also get cerebral malaria which can cause confusion, seizures and coma/death. one of my patients died recently from this, likely a brain herniation. typhoid fever is also very common. one child had an intestinal perforation secondary to typhoid, which is not uncommon. intestinal amoebiasis is also very common, as are hookworms which are often visible just beneath the skin. impressively, the hospital has developed treatment guidelines for many of these prevalent conditions, so diagnosing and treating them as a tropical medicine novice has not been as challenging as i might have expected before arriving here. there are also a large number of developmentally challenged children who present to the clinic, some already many months old, who have never been diagnosed and have never seen a medical provider before. many have traveled long distances, often even from neighboring countries, to come the hospital because of its reputation. sadly, most of the time there is not much we can do.

a common theme of medicine in the developing world is that people just take longer to present, so their pathology becomes more extreme. i saw a boy the other day whose toothache one year ago developed into indolent osteomyelitis of his jaw, completely reforming the shape of his face over the last year. likewise, many cancer patients present very late with huge masses. because of the continued strong animism here, some children have scars from cutting attempts by local traditional healers for things like abdominal distension. many people also take "herbs" given to them by these healers, some of which the hospital staff are realizing cause liver failure and resultant uncontrolled bleeding. there are also many premature infants, often born via caesarean, many of whom die because there are no ventilators if they have respiratory distress. there is the capacity to provide non-invasive positive pressure, however, and it is amazing how well some of them do. there are other cool work-arounds, like giving premature babies nescaffe instant coffee powder in their feeds instead of pharmaceutical caffeine to stimulate their respiration!

a day in casablanca

on out flight to togo we had a 16 hour layover in casablnca, morocco! i had read something obscure online about the possibility of an airline-provided hotel for such layovers, and indeed, after a quick inquiry after arrival we were being whisked away to the three star "hotel relax" near the airport! after getting some sleep, we headed into the sprawling city of casablanca. we had also previously watched the film casablanca to stoke us for the experience, though it isn't particularly enlightening with regard to the city today. it is a modern and huge city of about 6 million, honestly without a whole lot to see for a tourist. we went to the hassan II mosque, which is a massive and ornate mosque, the largest in morocco, on the atlantic. it was completed only within the last decade or so, and was built using different types of rack and stones from all the corners of morocco. we then stopped by morocco's largest mall before heading back to the airport. solid layover! then a short stop-over in cotonou, benin before touching down in togo!