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!