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Tuesday, July 26, 2011

PatientView

The month of May was an exciting one for the Mali Health Organizing Project because it offered the first chance to test out Medic Mobile's long-awaited PatientView program. PatientView is a lightweight medical records system that will enable clinics to use FrontlineSMS, the world's premiere open source text-message (SMS) platform, to coordinate community health worker (CHW) outreach, follow patient health status, support in-home care, and gather public health data -- all through a low-cost mobile phone.

PatientView relies on FrontlineSMS' Forms application to gather patient information from the field. FrontlineForms allows mobile phone users to receive form templates, fill them in and submit SMS messages containing the condensed responses to a central computer server, eliminating the need for users to remember codes in order to send complex information with a single SMS. When submitted, PatientView automatically matches these forms to a patient's file; these records can then be searched by patient identifiers, CHW, form type, or even specific responses. Thus, physicians can review patient histories and submit new patient forms on the computer. Physicians can also retrieve population data (i.e. number of malaria cases), and send text messages to community health workers to provide advice for in-home care or to make a clinic referral.

Together, these functions create a simple and effective medical records system for small health centers, while also adding the mobility necessary to support the CHW outreach that is often a critical part of expanding health care access in resource-poor communities.

The Mali Health Organizing Project (MHOP) coordinates one such CHW program, in partnership with two small community health centers in the Bamako slum of Sikoro-Sourakabougou. Serving over 20,000 people with microfinance, women’s education, sanitation, and health education programs, MHOP works to increase healthcare access through a multifaceted approach: encouraging care-seeking by removing financial barriers and increasing health knowledge, while developing low-cost interventions to improve the care provided by community health centers.  Action for Health, MHOP's flagship program, aims to reduce Mali's astounding 22% child mortality rate to less than 2% by focusing resources and diagnostic services on the five leading killers of children under five: malaria, acute respiratory infections, diarrhea, malnutrition, and measles.

To increase prevention and early care-seeking in these families, CHWs make bi-weekly visits to evaluate the health status of each child under five. They help families recognize warning signs and symptoms of the five major childhood illnesses and encourage them to use community health services early and often by providing health education, simple diagnostic services, and referrals to the local clinic for free treatment when the child shows symptoms of a covered illness. To maintain personal engagement, improve community health and make free care more sustainable, indigent families commit to completing volunteer health activities in return for these services.

At present, the CHW program relies on paper forms to record both home and clinic visits, which significantly complicates the patient referral and follow-up process. The CHWs record every visit and walk these papers to a weekly meeting, where they are reviewed and problems identified (i.e. children who should have been referred but were not, or who were referred but not followed up on correctly). Of these past visit records only the referral record is accessible to physicians when children are sent to the community clinic for care. In fact, physicians in the community clinics currently have no longitudinal medical information for any patient, because visits are recorded solely in a daily log; organized for the purpose of monthly case load reporting and accounting, this system makes it extraordinarily difficult to review an individual patient's care and treatment history.

Fortunately, with Medic Mobile's PatientView, all of that is about to change. Two weeks ago, MHOP's eleven community health workers were trained to use FrontlineForms on low-cost, locally available SonyEricsson phones. During a short afternoon meeting, the Malian program coordinator and I walked the team step by step through the process of finding, opening and manipulating the application. Then, we sat back as they tested it out, calling us over for questions as necessary.

At the end of the training, nearly all of the CHWs were able to send a form without assistance. We sent them all home with their phones for practice; a week later, each CHW confidently demonstrated their new skills by sending me a test form. Even Oumou Camara, who reads neither French or English (Bambara is the Malian lingua franca) proudly exclaimed that her son had helped her, and though he may have been a bit exasperated after a couple of hours, she now was able to send a visit form herself!

Similarly, the training and testing of the PatientView program with the clinic staff went off without a hitch. Eight physicians and nurses at the two community clinics involved in the CHW program convened for two three-hour sessions, working for the first time with the low-power computers purchased for the program. After a brief explanation of the system and a demonstration of FrontlineForms, we proceeded through a "typical" clinic consultation: searching for the patient's records, reviewing their personal information and medical history, and then filling out a consultation form. Six of the trainees said they had little to no prior experience with computers, but within the first two hours everyone was able to navigate the program unassisted. We spent the next afternoon discussing changes that could improve their workflow and help them provide better care and support to the CHW team. Thanks to the tireless work of lead developer Dieterich Lawson and the rest of the Medic Mobile team, many of these changes have already been made!

With the initial trainings finished, and final testing underway, we will officially launch the program with the beta release of PatientView in the coming weeks. Using free SMS credit provided by Orange Mali, CHW visit reports are sent directly to the local clinic. When a patient is referred, the physician records the clinic consultation, diagnosis and prescriptions, and follow-up information is sent to the CHW to help the patient complete their treatment and/or return to the clinic on a certain date. If the patient is not referred but has some symptoms (i.e., a day of diarrhea or mild malnutrition), these reports will be flagged for review. In response, the physician can send decision-support messages to the CHW (i.e., rehydration solution / fortified porridge / come to the clinic if not resolved in two days), using the patient's medical history tab to help determine the appropriate course of action. Because critical childhood vaccination schedules are not reliably recorded or accessible, vaccination reminders will also be sent for all children enrolled in the program.

Beyond improving services along the entire continuum of care, PatientView will make Action for Health more efficient and scalable. CHWs no longer have to spend four hours a week bringing these records to the program coordinator; instead they will be able to make visits to more than 300 additional children and the coordinator will have more time to focus on developing the education modules and volunteer community health activities that improve prevention of these common childhood illnesses.

To help bring this program to scale after pilot testing, the Malian Ministry of Health's Office of Telemedecine (ANTIM) will help develop a distributed Medic Mobile system. Making records accessible to second-tier referral clinics and hospitals through a national server, a distributed system will facilitate the coordination of other CHW programs across the country and help ensure that patients receive high quality services at every level of care.

Facilitating everything from in-home prevention, to clinic care and treatment support, PatientView will dramatically aid MHOP's fight against preventable child mortality -- and surely will do so wherever else it is used. We at Medic Mobile and the Mali Health Organizing Project are thrilled to bring this project to life after months of development, and we thank all of our supporters who have helped us along the way!

Sunday, August 8, 2010

Watch Yourself!

I am sitting in a lovely house in Lilongwe writing this, contemplating how much different Malawi is from that other M-country in Africa. Yes, Malawi. I arrived here a month ago and will not be returning to Bamako until early September. I haven't written in nearly three months, and clearly, so much has changed!

It has been an exciting, stressful, frustrating, and awesomely rewarding spring, and I am relieved to finally have a minute to stop, breathe, and write about it. Funny to say now that I have left Mali for awhile, but I can't escape the feeling that I've just started to do the work that I came here to do. As my mother constantly reminds me, that is not entirely the case. There has been a lot of work to do to get MHOP's clinic and Action for Health projects off the ground, and I am very grateful to have had the opportunity to help. Selfishly though, I feel that the launch of the PatientView pilot is different. It is what I came here to do, and I have been itching to do it! Though I know I have had a hand in the successful opening of the Sourakabougou community clinic, the launch of Action for Health, and the ongoing development of our other community programs, there have been many times in the past nine months when I felt a little like I was stuck on a race track, speeding around without getting anywhere.

Starting out in January with the basics of the CHW program laid out, let me briefly describe the race highlights.

February:  Computers arrived at the airport customs office.
March:  Computers languished at the airport customs office.
CHW program launched.
April:  Computers rescued from the airport customs office. Wrote the PatientView user manual with the Ministry of Health's e-Health Office and began negotiating our partnership contract.
May: CHW and clinic training!
ORANGE Foundation $$$$$$$$$$$$ for the pilot year's SMS credit promised!
Then system testing...more testing...sleepless nights of testing...
... and finally, on June 20th, the pilot LAUNCHED!

The community health worker team for Action for Health has been seeing children for four months now, and more than 300 children have been referred to one of our partner community clinics, where they have received free consultations and treatment. For every patient encounter, our CHWs fill out a paper record to track the child through their in-home, in-clinic and follow-up care. The physicians can consult the paper referral form when the child comes in for a visit, but until now, they had no access to longitudinal medical information (a medical record beyond the CHW's report of immediate symptoms and reasons for referral). With 403 patients (and growing!) in the program, the coordinator has to process more than 800 records each month in order to ensure that each child receives appropriate services and that CHWs can be given proper field support.

With PatientView, all that has changed. Text message forms are filled out at every home visit and sent to the clinics, where they can be reviewed by a physician and monitored for developing illnesses or treatment problems. When a patient is referred, the clinician can pull up their record and immediately have access to their in-home and in-clinic visit history. They can enter their consultation into the clinic visit form and, with one click, send follow-up instructions to the patient's community health worker.

So, I feel as though the circling around has finally paid off. We have reached...well, not the finish line, but certainly a checkpoint. The Final Turn. Those of you who spent holidays playing RidgeRacer in your grandmother's basement will know exactly what I mean. In the words of the wisest race announcer to ever grace a PlayStation demo game: "Next corner's tough, watch yourself!"

For my less evolved readers, I would liken it to reaching the Willamette in Oregon Trail, a joyous event dampened only by the fact that you must now caulk your covered wagon and float it down a treacherous river full of boulders that are ready to splinter your floor boards and drown the last of your family who have not already died of typhoid or dysentery during the arduous journey.

(Apologies to my more ancient friends...I tried to think of a witty metaphor involving Pong but I just can't do it.)

Of course, I do not meant to say that the next few months will involve the kinds of crashes that end RidgeRacer careers or a crush a pioneer family's hope of reaching the land of milk and honey. My point is only that starting a program is one battle, and helping it survive, another.

Co-opting the term from the information and communications techno-lexicon, development folk often talk about the "last mile." Both a useful metaphor and a geographical reality, the last mile is the "farthest endpoint of connectivity," that final leg separating a population from needed services. Mobile phone-wielding community health workers are a last mile solution in multiple senses: using the only type of telecommunications infrastructure accessible, these outreach workers bring primary care to populations who are not otherwise connected to health services.

Yet, in development work, the last mile is not only a physical barrier, but a temporal one as well. How do you make a project sustainable in the world's most impoverished, inaccessible, and under-educated areas? Keep it simple. Both FrontlineSMS:Medic and the Mali Health Organizing Project are founded on the idea that solutions to health problems must be accessible to frontline health workers. Whatever we provide, it is precisely those under-resourced communities who must bear the cost of sustaining a program, which means the system must be low-tech and easily manageable by people who have more than enough work to do already!

The RidgeRacer devotee that I am, however, I must say I prefer the "final turn" metaphor to this "last mile" business. It implies a greater degree of unknown, an inability to see the obstacles that lie ahead. Despite how much effort you put into research and planning, the world is always going to surprise you. So we will not be resting on our laurels just yet. I am quite sure that our pilot testing will bring to light many of the problems we couldn't foresee -- my only hope is that we are flexible and responsive enough to deal with them. I know we are.

Leaving for two months during PatientView's teething period has caused me much anxiety and distress, but I am convinced it is necessary, even good. It is time to put our last mile philosophy to the test. After training our community health workers, physicians and nurses, and setting up the (relatively little) infrastructure needed to support the program, my job here is nearly done! I'm handing over the reins to Dramane Diarra, my colleague and a Sikoro native who has been an irreplaceable asset to MHOP's work in the community. He will now be putting his technical skills to use as the FrontlineSMS:Medic PatientView Coordinator, and I am confident that he'll do a great job. Even so, these next few months are going to be difficult for everyone as we uncover technical and programmatic problems we couldn't plan for or predict.

So, as tough as it may be, here's to hoping we round the Final Turn intact and on track.

Yikes!

Dear loved ones,
My apologies for my long silence, and the ridiculously belated posting below! I didn't realize I hadn't published that piece until I worked up the courage to look at my blog again (I swear, I've been meaning to write something for ages and ages). I'm a bit ashamed really. Things have been so busy these past few months, and there have been many changes to catch you all up on, so please stay tuned...

Sunday, May 16, 2010

Getting there.

When I arrived in September to begin implementing the text-message based medical record program developed by FrontlineSMS:Medic, MHOP was focused on establishing the two things fundamental to it: a clinic and a community health worker (CHW) program. So, I switched gears. I picked up the slack where I could. I spent my first few months writing grants, working on clinic contracts, CHW visit guidelines, developing partnerships with other NGOs and the Ministry of Health, and generally just not knowing what was going on -- but learning.

I always felt a little uneasy though, feeling as if I wasn't accomplishing what I had been asked to do. The goal was always in my mind: whatever I was doing, I needed to be laying a good foundation for the mobile records pilot in the process. And besides, I kept saying, next month we'll be ready. Next month.

Soon, however, the CHW program was starting to take shape and I was scrambling to figure out how we could start the pilot when the CHWs began making their visits. By the beginning of 2010, it became clear that -- for various, compelling reasons -- the pilot couldn't launch with the CHW program. Again I had to switch gears. I worked closely with Leona to design the paper records system that could be easily transitioned to the FrontlineSMS:Medic program when all was ready.

The clinic opened. The CHW program launched. Oh, how anxious I was to get started. It seemed like the time had come.

But then, Mali pulled a fast one.

I spent most of February, March, and April embroiled in a customs battle with the most incomprehensible government office known to man. In January I had ordered three super cool low-power computers from Inveneo, a U.S. based nonprofit. Though they arrived two weeks later, they were detained at the airport because we refused to pay a ridiculous 52% import "tax."

Nearly everyone I knew to ask advised me that there is no import tax on hardware (to be used in health care centers no less); I told that to the customs officer. No luck. I went to the customs office with the military ID of the Ministry of Health's eHealth Director and a handwritten note asking for the computers. No luck. We tried to use a go-between to re-negotiate the price. No luck. I was at my wit's end, and so discouraged -- Mali was showing me an ugly side I hadn't wanted to acknowledge. I felt like the people who should care just didn't.

Finally, in mid-April, Inveneo stepped in and helped us get the computers out. Now, things for the mobile medical records pilot are finally falling into place.

Last month, some representatives from Orange Foundation (the largest cellular network provider in the country) came to do a site visit after Erica and I had hounded them for what seemed like ages. The Orange representatives came to learn about the CHWs' work and about how the FrontlineSMS:Medic pilot will help them do it better; our CHWs could not have been more convincing. They were impressed both by the innovation and the need. As we toured the community in their SUV (backtracking every few meters because the road became impassible) they exclaimed about the poverty, the lack of infrastructure, the extraordinary fact that Bamako could be home to a community like this.

It was almost shocking to see them shocked; you'd think growing up here would mean you knew places like Sikoro-Sourakabouogu existed. But, I am happy we got to show them. Last week Orange informed us that they will be providing the pilot free SMS credit for 2010!

Mali, I can't stay mad forever.

Monday, April 12, 2010

Humility, or something like it.

A month or two ago, Mike, Leona and I decided to spend a Saturday night watching a dance performance put on by several local high schools. I was interested in seeing what a Malian dance recital looks like and happy for an opportunity to take out my eldest (but younger) sister, Batuma, since the event was respectably close to home. Like pretty much everything I have experienced so far, however, I really had no idea what I was in for when we took our seats before the performance began. The room was hardly full, people were milling about.

Being the awkward, entitled toubabs we are, we chose good (comfy) seats in the front of the stage and proceeded to ask each other about every five minutes when the show was going to start. After a painful two hours (!) of atrociously loud music and no dancing, things were starting to buzz and a slew of VIPs waltzed in, stopping in front of our seats and looking at us expectantly. Immediately we realized we were sitting in the "invitee" section and hastily jumped up to give them our spots, only to be waved back down. "No, no," they said, "you must sit here. We will find more seats."

We argued and tried to move, but instead they just asked Batuma to give up her seat and sent her to the back of the room to stand. I was horrified and embarrassed so I tried to go stand with her, but was requested to sit down again and so I slunk back to my choice spot. As the show began, the emcee started collecting money from all the invitees -- a standard Malian practice that includes singing to each invitee and sufficiently shaming them enough to throw money on stage (or raining it over the emcee's head, depending on how baller you are). We started to get uncomfortable because we really did not want to pay money to the emcee considering that we'd paid an entrance fee and that we didn't want to be sitting in their seats in the first place! Then, the man who appeared to be in charge waved me over and so I awkwardly blurted out something about how we didn't know they were the VIP seats, that we weren't sure if we were supposed to pay more money, that (again) we would move if that was the case. Much to my surprise, he said, "Oh no, no that's no problem at all. I'll reimburse you [for your ticket]. You're going to be a judge! " and shoved a paper and pen in my face. Excuse me? A judge?

None of us had realized this was a competition, and yet all of a sudden I am sitting on the judges panel, peering over my neighbor's shoulder to copy down his scoring matrix. I didn't even know the names of the competitors or the order in which they were to perform, let alone criteria to score a Malian dance performance! I was stunned. To make matters infinitely worse, the emcee then grabbed the mike and introduced the first round of competition -- POETRY!
Oh dear God.

Full disclosure everyone: I don't speak French that well. I can get by in most situations, but to understand mumbled poetry over a poor sound-system in a room full of teenagers who would much rather be watching their dance teams perform is waaaaaaaaaaaay above my pay-grade. In fact, I could't even be sure it was in French! Frantically, I peeked over my neighbor's shoulder again to see what I should put down for a score...10?.. 5?.. 2? ...I honestly had no idea. I couldn't see his sheet, so I decided to give 7s and 9s depending on the loudness of their voices and prayed to God that we weren't going to have to share our scores publicly. We didn't, thankfully, because after all the performances were over the judges huddled and everyone strongly agreed that the poesie was shit so they weren't even going to choose a winner; the kids got lectured instead. I, of course, agreed as vehemently as the others, quickly hiding my scores.

The dance portion of the evening was a little less stressful seeing as it didn't require a monumental amound of effort to understand what was going on. Each high school was represented by a dance team, ten to twelve girls and often a few boys, and I was required to give them a score from 1 to 20. What the scoring was to be based on remained unclear, as all the dances looked pretty much the same to me. After the performances, we shared numbers and chose the winners, and I was relieved to find out that I was in the right ballpark. I had managed to fool everyone into thinking I was totally competent.Finally, it was over and no one had found me out! As I made a move to sit down, the head man called me back up in front of the crowd of three hundred kids so that I could award the first place prize. Thankfully it was the high school from my cartier, so at least I knew how to pronounce the name. Oh oh, so awkward!

And why me?? The theme of the night seemed to be "honors that Alex would like to turn down but does not know how."

After this uncomfortable evening, and many other similar events, I have decided that buying a plane ticket to Bamako has bought me credentials I never even knew I'd want or need. To be completely frank, I am hardly qualified to be coordinating a pilot program for a community in Mali, let alone to be judging incomprehensible poetry and traditional dance performances! Of course, the stakes for the high school competition were limited to a small prize and my pride. With MHOP, however, the stakes are inconceivable. I can't think about the potential impact of this program (be it a success or a failure) without feeling my stomach turn. In fact, when I first agreed to join the team here, I immediately wanted to take it back. And now that I am here, with the pilot slowly taking shape and making splashes in the Malian government, the implications of my work are stretching far beyond what I had imagined on that day. I was terrified -- and still am -- that I'm not cut out for this work, that I'm just an imposter, a poser with nothing but a bachelor's degree and some good connections. I mean, seriously, who would put me in charge of an actual pilot program? And why in the world would a national Ministry of Health take me even the least bit seriously? Should I be honored? Then why do I want to run and hide?

Mali is a humbling place. I suppose that is an odd thing to say considering that I am constantly singled out, celebrated, given the time of day, simply because I am educated (and perhaps more so) because I am white. Of course, that may be cynical and completely off-base. Its hard not to feel that way, however, when every day someone draws attention to the color of my skin, the fact that I am oh so out of place. My whiteness makes little children cry (no joke) and young men propose at the drop of a hat. My whiteness is power in a place where many feel powerless. It is the power to get you a visa, to send your kid to school, to find you a job.

With all of the privilege that comes with my position here, then, why should I claim to feel humbled? After that night pretending to understand what the hell was going on during the dance competitions, and many subsequent conversations with my co-workers, I think I've figured it out.

Mali is humbling for three reasons.

First of all, I've worked hard for a very long time to build a resumé justifying my year working for a public health NGO, and yet, no one here even questions it. Characteristics completely out of my control (i.e. my color and my relative wealth) seem to automatically give me a Pass Go card. I have access to places, meetings, and partnerships that would be much harder to get in the States because there I blend in, I have to compete. Secondly, Mali is humbling because despite how much I stick out, many people in my community are still unable to distinguish between me and all the other white females they've ever known. I'm celebrated but reduced.

Most of all, however, Mali is humbling because even I -- with my limited expertise -- can have an impact as long as I am willing to jump in and play along. I can judge a dance performance, and I can direct a mobile medical records pilot, if only because I have been asked to and people seem to answer my questions when I ask them in turn. It is humbling because many many many people could do this work (most better than I), and yet I am here muddling along, doing my best because there is no one else to do it. Working with FrontlineSMS:Medic, with MHOP, and now with the government of Mali, has apparently never been about me and my qualifications but about the incredible need for these projects to happen with or without my help.

There. My current definition of humility: to be less committed to your sense of self and how that defines what you can or cannot do, and more committed to doing what needs to be done.

Better Long than Dead.

Possibly my new favorite phrase in Bambara, "better long than dead" is a response to "long time, no see" or something to that effect. Considering that I haven't posted in quite some time and that my last post left things a bit unfinished, I thought you might be wondering how I am getting along. It's been a long time, folks, but that's better than forever, right?

On January 26th, my mom did come, and I don't think I cried again until we said goodbye in the Paris airport.

I'm laying outside this evening, on Sunday the 12th of April, watching heat lightning flash across the sky and listening to the endless crying, screaming, and laughing of the kids that fill my house. It has been so hot. I woke up twice last night bathed in my own sweat because the power went out, killing my fan. I showered at 9pm, 12pm and 4am, carefully stepping over sleeping bodies as I made my way to the nyegen at the first morning call to prayer. I have a vague feeling that this should feel weird, laying out here, that I should feel out of place. But I don't. Instead, all I can think about tonight is the fact that my mom and Charles were here almost three months ago already, and that I've nearly reached my seven month mark here in Bamako!

So many things exciting things have happened in the months since my vacation with my mom and stepdad Charles -- Leona launched our Community Health Worker program, I secured a partnership with the Malian Ministry of Health for our mobile medical records pilot, Leona and I took a bus trip to Senegal, we officially opened our clinic and threw a big party -- and in the midst of it all, I think all of this madness is beginning to feel a little bit like home.

I've started a blog post about my parents' trip: our stay at my house and our adventures in Bamako, the bus trip to Segou and the pinasse on the river there, our car ride to Mopti and then the three-day hike in Dogon Country, our stop-overs at the mud mosque in Djenne and the eco-tourism resort on the river near Segou, and then...PARIS. It was all so fantastic, so frantic, and somehow still relaxing. I think I had forgotten how peaceful it is to be surrounded by people who love you, even when the world is crazy and spinning as usual.

It was a really special trip for me, but as I try to write about it, I'm finding that I don't have much to say but to recount our activities -- and I am not sure you'd find it all that interesting. We certainly did things I'd never done before, but Mali is so familiar to me now that I don't think it was quite as meaningful (in an intellectual sense) for me as it was for my parents. So, I think I'll follow Leona's lead and ask my mom or Charles to write a guest post about their experience here. For my part, however, I'd like to say that of all the amazing things we did during their whirlwind trip, the two nights we spent with my host family will probably be the most cherished. I was so happy to share my day-to-day experience with them, and to introduce them to the people that have so wholeheartedly welcomed me into their home. And, of course, everyone loved them. My mom and Charles did their best to cross the (double) language barrier, mostly by waving their hands around and laughing whenever someone talked to them. It was great.

I'm pretty sure they didn't like the food much (moni, saga-saga and tô), and they didn't find the bucket bathing too enjoyable, or sleep that well on Pedro's bed with my clothes rolled up for pillows (despite the fact that I generously loaned them my fan), but in the end I know it was worth it. When we returned from Dogon Country to say a final goodbye, Ami gave them a beautiful (fuschia!) comforter and left my mom in tears.

But, maybe I should let her tell you about that?

Thursday, March 11, 2010

I don't like this game anymore.

The story I want to tell you, and those involved, will not be done justice by my words; I have no intention of spinning a good tale or making a caricature of their lives. I debated long and hard about whether I could even tell this story in good faith and finally came down to this: the truth of the matter is that it is the truth. or at the very least, it is a thread in the common experience of women and children living in poverty here and all over the world.

I've been carrying around several things to share with you in my head for the past month and a half, never getting past the first few sentences of each because there always seems to be something else that needs doing. Where, where, where did the "winter" go?? March is full-on here, and with it the kind of heat that boils my water during the day (oh what I would have given for hot showers back in December...) and drenches my sheets at night.

Part of the whirlwind that has descended upon my life here in Bamako is a direct result of the amazing Mali--Paris vacation I had with my mom and step-dad at the end of January. I could not have asked for a more pleasant, relaxed, and paradoxically jam-packed fifteen days with the two of them. To be honest, it got me through. After the honeymoon of Bamako living wears off and all that's left is the endless dirt and dust, sharing that dust with two of the people you love most in the world is like a breath of fresh air. I guess, in the same way, this blog allows me to shake off a little of the dust of my life and share it with all of you.

So before I too excited and tell you about all the great times my parents and I had here, I need to say is that living in Bamako the way I (and hundreds of thousands of others) live is not fun, not really. After a few months, the high of being on a new adventure slides into the drudgery of a daily life so far removed from any semblance of my "comfort zone" that thoughts of it rarely even surface. The opportunity, then, to be with people whose only care is to know where I am allowed me to step outside my experience enough to appreciate being here all over again.

In the weeks before their arrival I had begun that downward slide in earnest. Work was stalled; friends were leaving Mali and me with an endless eight months to go; the happy blur of Seli Ba-Thanksgiving-Christmas-and-New Year's was over and gone, and so was all my chocolate. The frigid morning bucket baths, the pathetic light in my tin-roofed room, the fearless cockroaches, the hike to work, the chants of young children and catcalls of young men, the hack-inducing Bamako haze, the weekends of market-ing and saluer-ing and hand-washing clothes and rice and peanut sauce again...it was getting to be too much.

And then it got worse. I came down with the flu and everything went to shit.

While I was sleeping off my fever one Saturday morning, a neighbor gave birth -- in her room, by herself -- at only seven months. Sick with a jaw infection and too poor to fill the prescription given to her at the community clinic, she had subsisted for fifteen days on millet porridge. Later she explained to me that the inflammation had been so bad that, unable to swallow, the liquid had come back through her nose. Of course, I wish I had known that so I could have purchased her medicines and maybe prevented her miscarriage. But, unfortunately, there we were: a baby two-months premature, a weak mother who had given birth on a straw mattress in a dirty, sweltering room, a family that seemed disturbingly resigned to this tragic state of affairs, and me -- someone with the resources to do something.

So, of course, I promptly freaked out. Should I take her to the hospital? immediately? but what about the baby? How would we transport them? by moto? No way -- can she walk? Christ, I don't know. She seems okay, conscious, aware. What if she's hemorraging and I have no idea?

I searched for words I've never used in French, let alone Bambara, fumbling along as Ami translated. Mariatou, are you still bleeding? A lot? Does it hurt? A lot? And the baby?! Oh God, what do I look for, what should I ask? Is she feeding? How often? Do you know you if you are producing milk?

Had we been in the United States, the infant would have been whisked away to an intensive care ward where she would have been hooked up to IVs and placed in a sterile incubator to keep up her body temperature -- something she can't do herself. Being, instead, in an impoverished neighborhood of one of the world's poorest nations, the baby's risks of hypothermia or infection were astounding. I was terrified.

We need to keep her warm, I said (as if her mother didn't already know). Keep her against your skin. Can I take you to the hospital? We need to go to the hospital.

I consulted with my co-workers and called Hawa Gaku's son, a resident at a local clinic. "If it is not an emergency, try to get her to come in tomorrow morning," he said. "I will look at the mother and child then and write a referral for hospitalization if necessary." But. But. Isn't this an emergency??

She didn't want to go, she was afraid the doctor would be angry with her for not filling her prescription, for not making pre-natal visits, for being poor. Ami convinced her that we had to go, and the three of us walked the mile and half to the clinic the next day. We wrapped the baby against her chest under layers of sweaters, despite the 95°F heat. When we arrived, the doctor examined the mother and child. Mariatou was doing well, but the infant's temperature hovered at a hypothermic 92°F. He said hospitalization was necessary, but if the mother wan't sure that her family could bring her food during her stay then maybe it was best to try and care for the baby at home. My heart sank.

Prescriptions in hand, we went on our way.

Okay, I thought. We can make this work. Then I realized that it was me who was going to give this child the antibiotics. Oh oh oh...I have never ever ever felt less prepared for anything. I have never been more scared. The antibiotic oral suspension she was prescribed were supposed to be refrigerated after mixing (is that some sort of cruel joke?), and the directions said the vitamin drops should be diluted in 8 oz of milk or juice. 8 ounces? That's like a quarter of her weight in fluid. Should she even drink fluid that isn't breast milk? Shouldn't the fluid be warm? What the hell am I doing?? I don't want to play doctor anymore.

She took the antibiotic just fine as I slowly droppered it into her tiny mouth. When I started with the vitamin solution, however, my heart stopped. I droppered more than I meant to and she started to cough. She coughed with her whole body, and seized. I gave the mother a terrified look. Is she breathing? I watched her lungs, her diaphragm, praying they would move rhythmically again.

Mariatou took her from me, pulling on her toes and sucking the air from the top of her head. In my mind, I was screaming. THAT'S NOT GOING TO HELP. OH MY GOD I KILLED YOUR BABY. Your precious baby. Frantically, I put my mouth over hers, breathed slightly and but then stopped short --- I had absolutely no idea how much air her lungs could support. Oh god oh god oh god. Please. She coughed and seized for thirty seconds longer (or was it an hour?) and then started to breathe normally again.

Oh god. Oh god. Thank you.

No more medicine today, I said. I'll just make things worse. Mariatou assured me that it was okay, that she would be fine, that she'd keep the baby warm. I smiled weakly and shut myself in my room, feeling like I'd jumped off a building was just now picking myself up off the ground. What the hell was I thinking? I didn't want to be here anymore, it was just too much.

I wish I could pretend that the story ended well. I wish I could tell you that the rich white girl swooped in to save the day. I didn't. The baby didn't survive through the evening, and her family buried her that night without much ceremony. She was nameless, because babies are given their names on the seventh day -- but Mariatou said she had wanted to name her Laurel, after my mother. Break my heart.

I didn't see her cry, maybe she had expected it. She'd lost babies several times before and she had others she could barely feed.

Selfishly, though, I did. I cried because I don't like death, because I wanted to be the one to help. I cried because I couldn't stand myself, getting off on "living in Africa," romanticizing this place and my place here. I cried because I had held abject poverty in my hands and couldn't do a damn thing about it. I cried because this is someone's reality and here I am pretending to be a part of it.

I cried because I wanted my mom.
Thankfully, she was on her way.