JoAnn in Equatorial Guinea

JoAnn: Giving Birth in EG

The other day, my Cuban friend Dr. Enrique told me that many doctors come to Equatorial Guinea with previous experience working in the developing world. He says they are usually shocked because what they see in EG is way less developed than anything they've encountered before. This is my first exposure to health care in the developing world, but after observing two births, it's easy to believe Dr. Enrique.

The post-partum room at the hospital.

The labor and delivery room at Malabo Regional Hospital is extremely basic. Three stainless steel birthing chairs are lined up against one wall. Running water only comes for two hours a day, so each morning the nurses fill up large plastic barrels (with no lids) and use a bowl floating in the barrels to dispense water throughout the day. Two metal carts in the middle of the room hold the surgical instruments used during deliveries.

The door to the delivery room is usually closed and a curtain hangs in front of it to give the women a little privacy, but other than that, the women are completely exposed. Also, the women often deliver naked, because there are no hospital gowns, and they don't want to stain their clothes.

At around 9am, a fifteen-year-old was escorted into the L and D room. This was her first pregnancy, and she was clearly in a lot of pain, but here pain relief drugs are reserved for only the most severe cases. Her cervix was completely dilated but her water still hadn't broken.

The nurse poked around with a probe of some kind, and soon the floor was flooded with a brownish watery fluid. Uh oh. Meconium. The baby had had a bowel movement inside the womb. This usually is not too dangerous, but it can be harmful to the baby's lungs.

In the US, the neonatologists would have been called to stand by and check on the baby once it was born. However, here in Guinea, the obstetrician hadn't even arrived, and mom was ready to start pushing. This girl's contractions were coming hard and fast, and the nurse told me that we would have to deliver the baby without him.

"Es su primero. Tendremos que cortarla," she told me. It's her first baby. We'll have to cut her.

In the US, episiotomies, simple procedures in which an incision is made in the opening of the vagina to make more room for the baby's head, are always performed by doctors, and usually only after a women has tried to push for a while and failed. Here it seemed like they do them with every first pregnancy.

After numbing the skin of the vagina with an injection of novocaine, the nurse picked up a scissors from the instrument tray. It had been sitting out on the tray for the entire time I was in the room (probably about half an hour) so if it had ever been sterile, I'm fairly certain it wasn't anymore. Then she began the episiotomy.

Right away it was clear that the scissors was not nearly sharp enough. She was cutting through the poor girl's skin with all the sensitivity of a five-year-old trying to cut through a stack of newsprint.

After the episiotomy and a few strong pushes, the baby was out. A little girl. The one nurse had to take care of both mom and baby, so she plopped the wet newborn on the instrument tray and spent about a minute making sure that mom wasn´t bleeding too badly. Then she used one of those little suction balls to clean out baby's nose and mouth. Finally, the shivering little baby was dried off, wrapped in blankets and handed over to me.

"Vestela, por favor." The nurse asked me to dress the baby.

It had been a while since I'd held a newborn and I was a little nervous, but after some gentle wrangling, I got the baby into her little sweater and pants. With that sweet little baby sleeping in my arms, I quickly forgot about the horrors of the delivery. A little angel. I carried over to meet her mom. For the first time in hours, the new young mother smiled. "What are you going to name her?" I asked. "Valentina," she responded.

Mom had to be stiched up after the episiotomy, so I took little Valentina out into the post partum room to meet her aunties. They were excited and proud, but there was a certain hesitancy to their celebration. Fifteen-year-old moms are pretty common in Guinea, but it's still considered pretty young. The aunts thanked me, and I headed back to L and D, because there was another baby on the way.

"Es un caso de Retrovirus," the nurse informed me. HIV positive.

International experts estimate that the rate of HIV infection in Guinea is between five and ten percent. The government has faced the AIDS epidemic with an attitude of denial and continues to claim that less than two percent of the population is affected.

Because the government refuses to acknowlege the problem, distribution of antiretroviral therapy for HIV-positive patients has been slow to catch on. Further, there is still tremendous stigma against HIV patients. The nurses treated this poor lady with palpable distain.

In the US, HIV-postive moms who receive good prenatal care almost never pass the virus onto their babies. They take antiretrovirals throughout the pregnancy, and the dose is upped right before delivery. The deliveries are done by C-section under "dry" conditions, with very little blood. Then baby is given a regimen of antiretrovirals, and fed formula to prevent transmission through breast milk.

Luckily this mom was on antiretrovirals, but the baby was a month early, so pre-delivery dosage increase didn't happen. Also, the whole dry C-section procedure is not done in EG, so baby was delivered vaginally, also by a nurse. This birth was not complicated, no episiotomy. I got to dress this baby, too.

I carefully looked her over for abrasions, or any places where blood to blood contact could have been made, and didn't find any. Depending upon mom's viral load (which I'm not even sure they have the technology to test) baby could have as high as a one in three chance of contracting HIV.

I took baby out to meet her family. They had been given a prescription for antiretrovirals for the baby. I talked with them about how important these drugs were, and they assured me that they'd fill the prescription. I'm sure they did that day, but these drugs are extremely expensive, and eventually, families reach a point where they can't afford the drugs. Extremely sad.

It's pretty sickening to know that the technology exists to prevent perinatal HIV transmission, but for political and economic reasons it's not happening.

Seeing these births was a bittersweet experience. On the one hand, new life is always cause for celebration. However, the incredible disparity and injustice in the world is pretty shocking. I don't know what the solution is going to be, but we've got to find one.

JoAnn: Playa y Selva

On Sunday, I went on a little excursion to see some of the sights outside of Malabo. We headed for Luba, a city about a tenth of the size of Malabo, about an hour south of here. People with houses next to the highway sell bananas, caracoles (snails) and carne de bosque (forest food=monkeys, antelope, porcupine, squirrels).

We ventured into the jungle to pick some fruit from the cacao trees...

After a forty-five minute journey through the jungle, we arrived at the Playa de Arena Blanca, the white sand beach. Some people paddled out in these boats made of hollowed-out trees.

The beach was a very international place to be. I met a Chinese family, a pair of Brits, and swam with an Egyptian guy for a couple minutes.

There were lots of Guineanos, too, although, I was surprised there weren't more locals there on such a nice Sunday afternoon.

We left the beach, and continued another fifteen minutes south to Luba. The Spanish colonial buildings are much better preserved in Luba than in Malabo, and it's quite a bit cleaner, too. There is a canal that runs parallel to main road, so it feels a little bit like a Spanish Venice. In Africa.

Sunday was a day of celebration in Luba--these women were dancing in the street:

Malabo has its charms, but getting outside of the city showed me just how beautiful Bioko Island is. Unfortunately, the new highway will certainly mean more people at the beach and in Luba. I hope both stay clean and lovely.

JoAnn: A Typical Day in Malabo

Qui qui ri qui! Buenos dias Malabo!

Views from my balcony:

Bye bye Bryan and Bethel!

Car parts in the front yard.

Through the alley leading to the road.

Across the Plaza Central.

Past the port.

Mornings at the hospital.

Afternoons in the office.

Home again to Rosa and my guys:

Buenas noches Malabo!

JoAnn: Church with the Family

I went to church on Sunday. My host father Lucius (whom I now call Pastor Lucius) leads the local parish of the Redeemed Church of Christ. The service began at 9am with an hour of bible study. They divided the group into Spanish and English sections, and because I actually have more trouble understanding Nigerian English than Spanish, I challenged myself and joined the English group.

The subject at hand was the role of each member of the family. Uh oh, I thought, I'm going to have to lie. We started with the Father. People took turns reading a bible passages that referred the role of the father in the Old and New Testaments, and we discussed each one.

Directing the development of the family's values, providing for the family. Okay, nothing too objectionable. Then we moved on to the role of the Mother. We read about submission and obedience. One woman talked about the evil of this thing called Women's Liberation that started in the 80's.

Up until now, the leader of the group had kindly avoided calling on the obvious visitor to the bible study. But after a passage about how women should not ornament themselves with worldly things, I was on the spot. What do you think about that, sister? I was asked. Luckily, this passage had room for a pseudo-feminist interpretation. Well, I think it means that women shouldn't worry about looking beautiful for men, but should focus on living a good life. Correct, said the leader. Whew! Said I.

Bumper stickers on all the bedroom doors. Translation: "Your blood was spilled for me, Jesus Christ."

All dressed up and ready for church!

After bible study the service began. I had expected to sit passively with my host family, but when your host family leads the church, they sit in front, so I stayed in the middle, where I had been during bible study.

My normally quiet and subdued host-mom Elizabeth took the mike and welcomed the congregation: The Lord has done it again! He's made another beautiful day! Alleluia! Then she broke into a song leading the whole place in praise. And by praise, I don't mean mumbling along to the words in a hymnal. No. The house of God was rockin'!

In fact we spent the next hour singing and dancing in those pews. Elizabeth led a few songs, and then another women led a few more. We're talking 90 degrees, tropical heat, no air, a couple fans, about two hundred sweaty Nigerian and Guinean believers, and the sweatiest of them all, yours truly. It was more exercise than I've gotten during my whole time here, including the run I was able to go on up at the plant.

After the big opening song and dance, the service moved onto the skits. The youth in the community had put together some short dramas to teach the congregation moral messages and ways to avoid sin, false gods and most of all, how to fight the devil in your life. Now, in my Catholic upbringing, I had always viewed the devil no so much as a being, but as a concept: the general cause of evil in the world, the force pushing me not to act according to the best moral principles.

Here in Guinea, however, the devil is a monster: a sentient being sitting with a pitchfork in hell cursing people, possessing people. It's a much more literal notion of Satan. And Jesus isn't someone you strive to be like, the model of a perfect life, as in the Catholic Church.

No, here Jesus is like your bodyguard against Satan, and we praise him because we love him and we want him on our side in the battle against the monster. By dying for us, he has shown us that he's willing to fight in the battle. It would be interesting to consider the cultural psychology involved in the interpretation of Judeo-Christian tradition, but I'll save that for another day.

After the skits came the youth choir (five songs), and after the youth choir came the children's choir (another five songs), and after that, the money collection. The money collection here is also a bigger deal then in the US. In our Catholic church, they pass around baskets and people discretely place sealed envelopes inside. No so here.

First they have the tithers, that is, those contributing 10% of their income, come up and be recognized and blessed as they put their money in the box. And then they have a sermon that makes the non-tithers feel guilty about not tithing, and then they have everybody take out their money and say their prayers out loud with their money in hand.

It's like the Pentecost, people shouting in tongues. When people have reached the climax of their fervent prayers, the adult choir breaks into another loud song of praise, and people literally dance in lines up to the collection box and drop in their envelope.

Clearly, this church knows how to get people to contribute. In quiet protest, I stayed back and didn't contribute to the box. I like all the fun of this service, but I like my Catholic Jesus and Satan better than this protestant Jesus and Satan, and I wanted it to be evident that I wasn't a convert.

After four hours, of sweating, singing, dancing, my host mom Elizabeth came up behind me, and asked me if I wanted to go home and rest. I had to restrain myself from shouting a grateful "Alleluia!"

JoAnn: Maternity Ward, At Last!

Friday, I went to the maternity ward and for the first time saw where I'll be spending my mornings for the next four weeks. The building is very old-in fact, they're building a new labor and delivery ward right behind it and the contrast accentuates the sorry state of the current one. I walked up a rock path, past about a dozen women at various stages of pregnancy, and went into the building.

Sitting in the corridor, waiting to be seen were another two-dozen pregnant ladies. Now, I've been dealing with a good deal of bullshit for the past two weeks: paperwork, revisions, and meetings-meetings-meetings. But seeing all these pregnant women, all needing care, reminded me why I'm here, and re-infused me with energy for the project at hand.

The first person I met was Dr. Carmelo, a Cuban obstetrician who is chief of the ward. He responded to the explanation of my project with an affirmative and enthusiastic winks and clicking sounds. Cute.

Then I met the other OBs: Josephine (just like me), a local and Iliana, a Cuban. Each OB had their own room that functioned both as their office (big desks, lots of paperwork) and their exam room (bed with stirrups). I'm not exaggerating when I say that these three people were among the warmest I've met here. It should be a pleasure to work with them. Or rather, around them, so I don't get in their way.

My schedule will be based around their schedule. The docs come in to do their rounds at 9am. At that time they spend between five and twenty minutes with each patient who gave birth the night before, checking on her and baby, and making sure they're okay to go.

Once they've seen the doctor, mommy and baby typically clear out ASAP. Judging from they set up of the post-partum room (twelve beds, each with a little crib at it's foot) that is understandable. So, in order for me to interview all the women who gave birth the day and night before, I need to be there early.

I'm going to start coming at 7am, and see how much time that gives me. I'll work my way around the twelve beds, consenting, poking fingers, doing rapid diagnostic tests for malaria and anemia, and then asking the mom some questions about her use of malaria-preventing drugs during pregnancy.

I have no idea what proportion of women will consent to participate. I mean, I'm not sure I'd want to be poked yet again after having given birth the day before. I think they'll want to know if they have malaria though, so maybe when I come to that part of the consent script, I'll be especially emphatic.

I'm hoping to spend some time shadowing docs both in the OB ward and throughout the hospital, nothing set up yet, though. I think I'll give it a couple of days. Stay tuned.

JoAnn: Independence Day at the US Embassy

This past Saturday evening, I went to an Independence Day party at the American embassy. We showed our passports and were ushered through a metal detector into the embassy's front yard. Everything was decorated with red, white and blue: little flags and candles and miniature Statues of Liberty.

There were burgers and dogs on the grill, and a buffet with chips, kebabs, and potato salad. Louis Armstrong played in the background. We sang the national anthem, and the ambassador (who covers both EG and Cameroon) made a speech announcing the appointment of an ambassador specific to EG. Then they handed out sparklers.

It wasn't quite like the Fourth of July cookouts I know and love so much, but I found the cooler full of ice cold Bud, and made the best of it.

There was something a little uncanny about it, though. I mean, for one, it was a really formal event-everyone in suits and dresses. It was weird to have us picnicking in our fancy clothes. Also, it wasn't just Americans who were invited, but all the diplomats. And to be honest, diplomats aren't your typical barbecue crowd. They answer their cell phones in dozens of different languages, influence international policy, and drink wine, not beer. Perhaps the ten foot high cement wall surrounding the embassy also contributed to the eerie feeling I had at the party.

It wasn't all weird, though. I met two very interesting ladies from Pennsylvania who are working with an organization devoted to saving the primates (specifically mandrills) on the island. They've been pretty successful, too: this past year, over 40% of the land in EG was designated protected territory. On the way out of the party, they gave us a little gift: a baseball cap embroidered with the American and Guinean flag. Cool.

JoAnn: Power Out

Today my friend Blas at the office asked me if my parents were still alive. Sign number one that you're either getting old (did he see my grays?), or you're in a developing country.

I think the average life expectancy here in Equatorial Guinea is in the fifties. This is result of many factors, including a tragic number of accidental electrocutions (poor wiring + torrential, puddle-forming rain). Yikes. Other cues given that this is indeed the developing world:

1.)The water that is supposed to run from 7 to 9 each morning has come for only two of the past six days. But I don't smell. Nope.
2.)Power outages. Last night I returned home from the office around 6:30 to find my family in a dark living room...

I located my trusty purple Mag-lite and sat out on my balcony reading by twi- then flash- light. The power goes out frequently, so everyone was ready with candles and old-fashioned Ebenezer Scrooge-style candleholders.

Candle in hand, I took little Bryan out onto my balcony and did what my family always did when the power went out: told stories. Starting these stories and hoping I could remember how they went, I told him about Goldilocks and the Three Bears (I didn't feel like explaining porridge so I called it soup instead), Little Red Riding Hood, Jack and the Bean Stock.

After exhausting my memory of those secular tales, I moved on to the ones I remembered from the "Jesus, Friend of Children," book my dad used to read to me. I told him "From dark to light" where Jesus helps the blind man see by smearing mud in his eyes. I told him about the miracle of the loaves and the fishes. When I started on David and Goliath, he stopped and shouted that he knew this one. Of course he does. Son of a preacher man! And boy could this little guy preach.

Emphatically describing David's bravery, pounding his teeny fist on the ground yelling "Fear God!" Even Jesus himself made an appearance in Bryan's version of this Old Testament story. Then we sang church songs. I taught him "Halle-halle-halle. Lu-u-yah!" Remember that one? He taught me one about Simeo, the man who helped Jesus carry his cross.

In addition to facilitating some intense host-brother bonding, power outages have another upside: candlelight is beautiful. I have an intricate wrought iron gate between my room and my balcony, and the balcony has its own stonework design. The soft candlelight cast the most exquisite shadows out onto the balcony. There was a quiet peace, no Reggeton concert on the radio below, no Nigerian movies blaring in the next room. Just gentle candlelight, sparkling in the evening.

I am fully aware of the fact that I am here only five weeks more, and so I classify these inconveniences as challenges contributing to my adventure. Knowing my host family will deal with intermittent light and water for the indefinite future prevents me from feeling annoyed that I can't wash my hair.

Oh, finally, here's something interesting about Malabo: the phonebook lists people alphabetically by first name! When I found my friend Aurelio, and threatened to call him on Saturday night, he collapsed in a chair laughing. The people here are enchanting.

JoAnn: Safe and Sound in Malabo

First, some background. I am here in Equatorial Guinea to do research related to malaria prevention during pregnancy. I'll spend my days in the Family Planning and Labor and Delivery areas of the city hospital, where I'll interview and collect blood samples from pregnant women.

I'm assessing the prevalence of anemia and malaria, and collecting qualitative information about women's attitudes towards prophylaxis during pregnancy. I'll be working with a team of organizations called the Bioko Island Malaria Control Project. The project's partners include the local ministry of health, Medical Care Development International (my connection), and is financed by Marathon Oil.

Back to my journey: My Spanish host dad, JuanJo, accompanied me to the airport in Madrid. I think he was a bit nervous about leaving me there--a naive-looking blanquita on a plane full of strangers.

I must admit, I was nervous, too, but soon after we took off, I struck up a conversation with the nice lady next to me, and was calm for the rest of the six hour flight to Malabo. I landed safely at the Malabo international airport, which consists of one gate and one terminal. I passed through customs with no more hassle that I expected, and met Jaime, one of the directors of the malaria control project.

A few other Americans (Marathon employees) arrived recently, and Jaime took us on a minibus tour of Malabo and the surrounding areas. We picked up the others at the Marathon compound, which is totally secure. I had to give my passport as collateral to enter. We went directly to the ex-pat's residence, which has the eerie feeling of a deserted suburb.

The Marathon executives live in Western style houses all situated on one road. There is a pool, tennis courts, a bar, but nobody seems to be around. I met the others, almost all Texans with southern accents, and we hopped in the minibus and began the tour.

The area directly outside the compound felt like something from Jurassic Park--hotels under construction, thick foliage, giant prehistoric-looking trees. Instead of taking the main highway into the center of town, our driver veered onto a dirt road, straight into the jungle. We drove past a few little settlements, called Patios, of ten to fifteen houses build from found wood and scrap sheet metal.

Kids with swollen bellies ran around in their underwear or in nothing at all. Groups of young men parked their cars next to muddy puddles, and used pieces of cloth to wash their cars with the mucky water. A bustling market sold meat (antelope, porcupine, monkey), cheap things imported from China, second or third-hand t-shirts. Certain stands at the market had hand-painted "Bar" signs, and sold San Miguel beer. Others advertised haircuts and braiding.

We stopped at a place called "Cold Wata" where people come to get water and wash their clothes. The women soaped up their things and smacked them against the concrete to slap out the dirt. We passed through the hospital, which consisted of about 15 buildings, all housing different specialties: Pabellon de Pediatria, Pabellon de Planificar la Familia, etc.

We drove through the center of town, where the Spanish colonial influence is most apparent. There are mission-style houses (crumbling), a cathedral, and a wide road that runs parallel to the harbor, where three or four large ships are docked. We drove by some bars and restaurants where expats like to go with names like Paradiso, Tropicana, etc.

After the tour, we retreated, back to the compound. After having seen both the city and the compound, I felt glad that I was staying with a host family, and not going to be cooped up for my time here.

Jaime took me to meet my family. Within the center of the city, it's hard for me to distinguish between the poor and the very poor areas, so arriving at the house, I didn't really know what to think. I was lead through a narrow alley strewn with old car parts, springs from a mattress, and lots of trash. A hen and her chicks seemed out of place in the urban neighborhood.

My host mother, Elizabeth, met me at the door of her house and greeted me with warm "You are welcome!" I was incredibly impressed with the house--new-looking ceramic floors, a television and dvd player in the living room, ceiling fans, a clean bathroom. This is going to be fine, I think.

My room is very nice. For the first time in five years, I have a double bed, and my little balcony overlooks the neighborhood. Very fine. I met my little host brothers Ryan (4) and Bethel (2). They were just waking up from their nap, and were little angels.

After about an hour, my host father, Lucio, arrived home from a soccer game. He is from Nigeria and pastors a church near the house. When I thanked him from his hospitality, he said, "Thank God."

"Do you like Nigerian cinema?" Elizabeth asked me. I didn't know they were making movies in Nigeria. Elizabeth put one called "Don't Dare Me," in the dvd player. It was set in the 1940s in Nigeria, and touched on all subjects: temptress femmes fatales, choosing a wife, pleasing one's husband with good food. It was cheesy and full of dancing, but not boring.

This morning I was awakened by two sounds: the rooster crowing from below my balcony, and my host father leading the family in the morning prayer songs. I believe this family will take good care of me. Today I meet the ministry of health director of Malaria control--more to come.

JoAnn: Madrid me mata!

Hello friends. As many of you know, my Pre-Malabo itinerary involves a brief stopover in Madrid to take a descansito and catch up with my host family from a 2002 study abroad experience here. Two things have impressed me about my return to Madrid: first, how wonderfully little my host family has changed, and second, the art.

This awesome family of four contains Andrea (a German, progressive, tapestry artist/stay-at-home mom), JuanJo (a bearded Spanish gentleman, with radical tendencies, who's studying to be a lit professor), Lea (a 12-year-old pixie who's read everything and who's going to be the most interesting 25-year-old in the world), and the new addition, three-year-old Ulysses (who speaks way more German than Spanish and who replies with an adorable, Vas? to all my questions).

We've been enjoying my favorite foods: jamon Serrano, queso manchego, tortilla Espanola, vino lambrusco, along with a few German additions including a delicious kind of seeded bread.

To comment on the artistic highlights, I've seen a Picasso retrospective spread out over the two major museums, a remarkable series of giant color photographs by Yann Bertrand installed in the Retiro Park, and this amazing exhibit from Korean artist, Kimsooja, who used mirrors and transparent light-diffracting film to turn the park's Crystal Palace into a giant prism. I also saw "Volver," the newest movie from Pedro Almodovar (Spain's big cinema dude). I leave tomorrow for Equatorial Guinea (!). Visiting Madrid is a bit like coming home, but Malabo will be an entirely new adventure. Stay tuned for more medically oriented postings!