It's shocking to realize how big a city feels when you've just arrived from living in a tiny town for nearly two months. Kayes only housed 10 000 and i was plenty big; the advantage was that you could often run into your neighbors or colleagues at the market or in the bar ("the" being correct here, there was 1 reasonable bar, the rest were non-active countertops serving warm beer). Bamako is home to over 1 milion people, so it's comparatively VERY busy and far less friendly, even though our impressions had been precisely the reverse when we first arrived in Kayes. But then again, somewhere along the line, you have to admit that 10 hours of travelling on a cramped bus, sweating into an already damp seat and eating peanuts for lunch does tnd to leave one a bit drained from the trip, and thus prone to judging their destination a but harshly. At least, that's what it seems.
Right now, I am sitting on my bed in my hotel room in Bamako, typing this and very much enjoying the MUCH cooler Bamako climate. I hardly flinch at temperatures in the early thirties anymore. The neighborhood we're staying in is named Torokorobougou (now "bougou" just means "neighborhood", so that makes the name less intimidating), and this time, I'm hoping we'll be able to enjoy it more than when we were under the shock of arrival. There's a diversity of people, little cantinas and beauty salons and shops, not to mention the occasional goat taking a nap in the street!
Today, we're heading to the artisans' market in the city center. This is where all the regions of Mali send their arts and crafts to be sold, from pottery to fabric to instruments and sculptures. And because Mali isn't touristy yet, the quality is wonderful and there's never any risk of getting something kitchy.
Must also stop at the travel agency and buy more luggage credits. I have no more room!
Love all of you guys, and I'll post probably one more time from Paris, then I'm home!
I really want a glass of milk. Not powdered. 1% cow, limpid milk in all its cold glory.
Monday, August 17, 2009
Friday, August 14, 2009
Final Days in Mali
As our journey comes to close in these last days of summer, I find myself reflecting on everything we've learned and seen in these past two months, and while I feel ready to come home, I find it difficult to believe I'm going to be leaving this place in less than a week.
In two days, I leave Kayes.
In five days, I leave Mali.
In seven days, I will be home.
And then, back to family, work and school. A third and final year of nursing, the beginning of a job search for after graduation, and most of all, the all-important task of trying to transplant the African values I've come to admire into my everyday life. Little things such as saying hello to one's neighbors; keeping an open-house policy; not being afraid of being unafraid, and so on.
As much as we think, in our Western minds, that we can help Africa and the various difficulties facing its countries, the reality is that if we could look for a moment beyond our delusions of grandure, we would see that not only can we learn extraordinary things about community living and human decency, but we would realize that we are not the ones who hold the future of this continent.
Only Africans will make their future brighter. No one else can, and no one else will do it in a sustainable and truly African manner.
I will try to write more before I reach Paris, but from here on end, I mostly look forward to being able to regale you with adventures and anecdotes in person.
In two days, I leave Kayes.
In five days, I leave Mali.
In seven days, I will be home.
And then, back to family, work and school. A third and final year of nursing, the beginning of a job search for after graduation, and most of all, the all-important task of trying to transplant the African values I've come to admire into my everyday life. Little things such as saying hello to one's neighbors; keeping an open-house policy; not being afraid of being unafraid, and so on.
As much as we think, in our Western minds, that we can help Africa and the various difficulties facing its countries, the reality is that if we could look for a moment beyond our delusions of grandure, we would see that not only can we learn extraordinary things about community living and human decency, but we would realize that we are not the ones who hold the future of this continent.
Only Africans will make their future brighter. No one else can, and no one else will do it in a sustainable and truly African manner.
I will try to write more before I reach Paris, but from here on end, I mostly look forward to being able to regale you with adventures and anecdotes in person.
Monday, August 10, 2009
National Women’s day
We took part in Panafrican Women's Day on July 31st, 2009. A wonderful day in solidarity, this day is celebrated by the women (and many men!) of every African country each year, and each year has its own theme. This year's theme was "The Prevention of the Exploitation of Women and Children".
Unlike many marches and assemblies we have in North America, no Womens's Day goes by without the deposit of one law proposal per region. In Kayes, we carried a proposition regarding the prohibition of female circumcision, or excision. At last.
With the support of the local and regional governments, these proposals then get to be examined by the high officials of Mali, who then determine a vote. Bear in mind however, that a law only has power if the people have the knowledge and education to know and enforce the rights granted to them by this law. With literacy rates skimming only 25%, there's still a lot of work to do.
We were especially touched byy the current status of women in this country: the laws currently in place make a woman only worth 1/3 of a man. In concrete terms, if a man beats a woman and she presses charges, it takes her and two other victims to testify to make the crime as serious as if he had assaulted another man. Even then, the prosecution isn't always as stringent as it could be.
One of the other reasons for this year's theme was that with modern times, more and more young women (ages 14-25 on average) head to the big city from rural areas to earn their dowry. Unlike our concept of a dowry, a girl must have in her possession all she needs to set up a household before she gets married. Consequently, she must find the money to purchase a coal stove, pots and pans, utensils, etc., as well as clothing and bedding. With limited time and little education, many girls work for unregulated salaries or worse, must prostitute themselves to earn the necessary items to be an honorable bride. This, of course, puts them at risk for contracting HIV, experiencing violence or worse, never being able to leave the city to accomplish their primary goal: get married and have a family.
Mothers often have even less education than their daughters and are thus in a disadvantaged position when faced with the decision to send the girls to the city or not. Fathers may find it more important to marry their daughters than to consider the potential dangers of the urban environment.
And so we marched, together, through the streets of Kayes, singing, dancing and showing our solidarity in the face of womens' issues throughout the country. It was an incredibly powerful moment of unity and we were very honored to be a part of it.
Saturday, August 8, 2009
Yesterday, Laurence and I, as the two remaining troopettes, went to the regional hospital ER to observe and help out. Observe, we certainly did. Here are a few of the cases to consider.
The first case we witnessed was a 34 year-old man who had been in a motorcycle collision (I’m unaware of whether I made it clear before: EVERYONE drives scooters and motorcycles; cars are a minority. There are no helmets). Now the collision had been with an gas truck, so you can imagine the impact. He had experienced inner ear hemorrhaging (in french otorragie) and was lapsing into a coma. Most of us imagine a comatose person as being limp, calm and unresponsive. This patient looked as though he was having a panic attack, and was in major respiratory distress, probable because his brain was shutting down. So they gave him mannitol, a substance to reduce the pressure between his scull and his brain (thus minimizing the damage should he survive) and monitoring him. Unfortunately, due to equipment issues, monitoring, in this case, means only checking his pupils and taking his blood pressure (which was at 230/170, which for those of us who aren’t in a medical field is critically HIGH). We asked if they planned to intubate, and I was brought back to the harsh reality that Malians face most days. They have access to the equipment needed to intubate, but nothing to hook him up to.
He will most likely die in the next 24 hours.
He was struggling to breathe so much you could see his jugular through his neck muscles when he inhaled. His lower ribs protruded sharply from his thorax with each seemingly agonizing breath and despite my medical rationale, I couldn’t help but fear for him, because it looked as though he was AWARE of the fact that his own brain was suffocating him and there was nothing he could do about it.
I’m officially thankful for my bike helmet, but I wonder how much more could be done in a modernized, equipped setting. Could we save him, rehabilitate him? His Glascow (coma) score was 6, what were his chances upon impact? We’ll never know, and certainly he won’t.
The second case we saw was one that reminded us of how deep cultural roots really go. Much like the taproot of the great baobabs, they seem indestructible, and just as unchanging.
This patient was a 25 year-old man who had suffered a stroke. It isn’t uncommon to see high blood pressure in people as young as 20, due to both environmental (dietary) and genetic (people of African descent are much more prone to HBP) factors. High blood pressure, in layman's terms, often occurs because of reduced blood vessel size. Blood tends to take a bit longer to get though, and the slower the flow, the more odds there are of platelets and cholesterol and all sorts of little debris to collect into a neat little blob that adheres to the vessel wall, like a ticking bomb. The formation of blood clots is also much, much more frequent (ladies, this is why most African girls our side of the ocean have to avoid high-dose contraception, as this increases the risk of blood clot formation).
When a blood clot forms, it has three destinies:
1-it remains attached to the vessel wall where it formed
2-it detaches and travels to the lungs and you suffer a pulmonary embolism
3-it detaches and travels to the brain and you have a stroke (most of us are very familiar with this)
In his case, it chose Door #3.
When we did the rounds, this man was paralyzed on his entire right side (known as hemiplegia) and had emerged from a coma only a day earlier. Now here's where our notion of medecine has to go take a coffee break:
His family wanted to have him discharged and take him home because they believed his condition was caused by a djinn, or evil spirit.
Their belief was that while coming home on his bike, he passed through the house of a sleeping djinn (these are assumed to be invisible, in case you're wondering) and the djinn cursed him for disturbing him.
Fair enough, I can understand the futility of trying to explain thrombosis to people whose spirituality permeates their health. No problem, really.
The problem is that the medical staff here refuses to do anything other than insist of the scientific interpretation of the situation and the family isn't about to give any leeway to science either.
The patient's condition, regardless of its source, ISN'T any different, so why the difficulty.
I wonder how interesting it would be, just for a moment, to develop a compromise: let them take him home as he is, and encourage them to help him rehabilitate. Show them way to stimulate his mind and the right side of his body to eventually regain maximal use of it. Don't discuss magic or science, just give them tools accessible enough to help the patient.
I'm seriously contemplating doing a master's degree in Intercultural Mental Health Nursing. Now there,s a challenge (imagine that in Mali, there's 1 psych hospital, it's expensive, and it's much more of an asylum. Therapy for burn out and depression just isn't available, and furthermore, it's possible people would not be receptive to therapies we use in the West)
Our third case of the day was a young woman of 26 years with the following symptoms (see if you can guess what she has before I tell you. Remember, this IS Africa):
-severe weight loss
-opportunistic infections
-very anemic
-very low T-cell count
-exhaustion
-no appetite
5...4....3...2...1...time's up!
She had HIV that had progressed to AIDS. she never even had a chance, because she had progressed to full AIDS ( the phase of the disease where any bug you catch can potentially kill you) by them time she was diagnosed with HIV. Traditionally, the earlier you identify the virus's presence, the better the person's chances are of slowing his or her progression to AIDS.
She will be evaluated by Dr. Touré, the regional HIV case worker (for whom everyone here has great respect, because he is highly dedicated to his patients and the cause itself), then probably put on anti-retrovirals (the same ones as us, luckily Mali doesn't have a supply problem) and transfused to give her strength the fight the infection.
She was blood type A+. So am I.
So, in highly sterile conditions, I went to the lab to offer up a pint of blood, much like all the other girls in the group had done, inspired by Maude's initial gift to a critically ill mother. That patient had hemorrhaged behind her placenta, the baby was dead and she needed surgery, but because of blood loss was going into shock. Maude offered, was crossmatched and within one hour, a pouch of fresh, healthy blood was given and the woman pulled through. I've never felt more honored to know my colleagues.
At the lab, they tested me for syphilis, HIV and Hepatitis B, all clear. Yay! Then A+ blood type was confirmed and my baggie of blood was popped in the fridge. I'll never know whether she got the blood or not, but I do know that as opposed to North America, where 44% of people are Type A, the proportions are reversed here, making Type A both rare to find in a patient and just as rare to get for a patient in need. Because they also have no blood bank facilities, blood (when there is any) is stored in a standard fridge with the vaccines, giving it a lifespan of 10-15 days only before too many clots form and it is rendered useless. The older the blood, the more clots in it and the less helpful it is to the patient.
In Mali, most people are extremely hesitant to give blood, and finding a donor often implies dealing in a sort of informal black market. The families of patients hospitalized all come to the hospital and camp out during their stay, so most of the time when blood is needed, a family member will do the rounds, looking for a match. If the donor consents, and fee for the donation is set. On average, a person may earn around 4 000 CFAs per day on a good day. A single pouch of blood may sell for anywhere between 10 000 and 60 000 CFAs.
Sometimes a family must choose between giving life-saving blood and the medication that will treat the actual disease.
I really hope she got the blood.
The first case we witnessed was a 34 year-old man who had been in a motorcycle collision (I’m unaware of whether I made it clear before: EVERYONE drives scooters and motorcycles; cars are a minority. There are no helmets). Now the collision had been with an gas truck, so you can imagine the impact. He had experienced inner ear hemorrhaging (in french otorragie) and was lapsing into a coma. Most of us imagine a comatose person as being limp, calm and unresponsive. This patient looked as though he was having a panic attack, and was in major respiratory distress, probable because his brain was shutting down. So they gave him mannitol, a substance to reduce the pressure between his scull and his brain (thus minimizing the damage should he survive) and monitoring him. Unfortunately, due to equipment issues, monitoring, in this case, means only checking his pupils and taking his blood pressure (which was at 230/170, which for those of us who aren’t in a medical field is critically HIGH). We asked if they planned to intubate, and I was brought back to the harsh reality that Malians face most days. They have access to the equipment needed to intubate, but nothing to hook him up to.
He will most likely die in the next 24 hours.
He was struggling to breathe so much you could see his jugular through his neck muscles when he inhaled. His lower ribs protruded sharply from his thorax with each seemingly agonizing breath and despite my medical rationale, I couldn’t help but fear for him, because it looked as though he was AWARE of the fact that his own brain was suffocating him and there was nothing he could do about it.
I’m officially thankful for my bike helmet, but I wonder how much more could be done in a modernized, equipped setting. Could we save him, rehabilitate him? His Glascow (coma) score was 6, what were his chances upon impact? We’ll never know, and certainly he won’t.
The second case we saw was one that reminded us of how deep cultural roots really go. Much like the taproot of the great baobabs, they seem indestructible, and just as unchanging.
This patient was a 25 year-old man who had suffered a stroke. It isn’t uncommon to see high blood pressure in people as young as 20, due to both environmental (dietary) and genetic (people of African descent are much more prone to HBP) factors. High blood pressure, in layman's terms, often occurs because of reduced blood vessel size. Blood tends to take a bit longer to get though, and the slower the flow, the more odds there are of platelets and cholesterol and all sorts of little debris to collect into a neat little blob that adheres to the vessel wall, like a ticking bomb. The formation of blood clots is also much, much more frequent (ladies, this is why most African girls our side of the ocean have to avoid high-dose contraception, as this increases the risk of blood clot formation).
When a blood clot forms, it has three destinies:
1-it remains attached to the vessel wall where it formed
2-it detaches and travels to the lungs and you suffer a pulmonary embolism
3-it detaches and travels to the brain and you have a stroke (most of us are very familiar with this)
In his case, it chose Door #3.
When we did the rounds, this man was paralyzed on his entire right side (known as hemiplegia) and had emerged from a coma only a day earlier. Now here's where our notion of medecine has to go take a coffee break:
His family wanted to have him discharged and take him home because they believed his condition was caused by a djinn, or evil spirit.
Their belief was that while coming home on his bike, he passed through the house of a sleeping djinn (these are assumed to be invisible, in case you're wondering) and the djinn cursed him for disturbing him.
Fair enough, I can understand the futility of trying to explain thrombosis to people whose spirituality permeates their health. No problem, really.
The problem is that the medical staff here refuses to do anything other than insist of the scientific interpretation of the situation and the family isn't about to give any leeway to science either.
The patient's condition, regardless of its source, ISN'T any different, so why the difficulty.
I wonder how interesting it would be, just for a moment, to develop a compromise: let them take him home as he is, and encourage them to help him rehabilitate. Show them way to stimulate his mind and the right side of his body to eventually regain maximal use of it. Don't discuss magic or science, just give them tools accessible enough to help the patient.
I'm seriously contemplating doing a master's degree in Intercultural Mental Health Nursing. Now there,s a challenge (imagine that in Mali, there's 1 psych hospital, it's expensive, and it's much more of an asylum. Therapy for burn out and depression just isn't available, and furthermore, it's possible people would not be receptive to therapies we use in the West)
Our third case of the day was a young woman of 26 years with the following symptoms (see if you can guess what she has before I tell you. Remember, this IS Africa):
-severe weight loss
-opportunistic infections
-very anemic
-very low T-cell count
-exhaustion
-no appetite
5...4....3...2...1...time's up!
She had HIV that had progressed to AIDS. she never even had a chance, because she had progressed to full AIDS ( the phase of the disease where any bug you catch can potentially kill you) by them time she was diagnosed with HIV. Traditionally, the earlier you identify the virus's presence, the better the person's chances are of slowing his or her progression to AIDS.
She will be evaluated by Dr. Touré, the regional HIV case worker (for whom everyone here has great respect, because he is highly dedicated to his patients and the cause itself), then probably put on anti-retrovirals (the same ones as us, luckily Mali doesn't have a supply problem) and transfused to give her strength the fight the infection.
She was blood type A+. So am I.
So, in highly sterile conditions, I went to the lab to offer up a pint of blood, much like all the other girls in the group had done, inspired by Maude's initial gift to a critically ill mother. That patient had hemorrhaged behind her placenta, the baby was dead and she needed surgery, but because of blood loss was going into shock. Maude offered, was crossmatched and within one hour, a pouch of fresh, healthy blood was given and the woman pulled through. I've never felt more honored to know my colleagues.
At the lab, they tested me for syphilis, HIV and Hepatitis B, all clear. Yay! Then A+ blood type was confirmed and my baggie of blood was popped in the fridge. I'll never know whether she got the blood or not, but I do know that as opposed to North America, where 44% of people are Type A, the proportions are reversed here, making Type A both rare to find in a patient and just as rare to get for a patient in need. Because they also have no blood bank facilities, blood (when there is any) is stored in a standard fridge with the vaccines, giving it a lifespan of 10-15 days only before too many clots form and it is rendered useless. The older the blood, the more clots in it and the less helpful it is to the patient.
In Mali, most people are extremely hesitant to give blood, and finding a donor often implies dealing in a sort of informal black market. The families of patients hospitalized all come to the hospital and camp out during their stay, so most of the time when blood is needed, a family member will do the rounds, looking for a match. If the donor consents, and fee for the donation is set. On average, a person may earn around 4 000 CFAs per day on a good day. A single pouch of blood may sell for anywhere between 10 000 and 60 000 CFAs.
Sometimes a family must choose between giving life-saving blood and the medication that will treat the actual disease.
I really hope she got the blood.
Friday, July 31, 2009
Cuisine et Médecine (bilingual)
Cooking diaries - Girls’ Night
Not that we’re prone to excess, but by the end of week one of interning, we were all a bit homesick, but I figured it would be a good idea to pull off a girls night. So we found oursleves the fixings for our two biggest comfort foods (within reason, the ice cream cravings are still pretty pungent!).
I still had two chocolate bars in my bag from Bamako, so we chopped those up and wound up with the world’s biggest bowl of chocolate chip cookie dough. One spoon each, life was good.
Then we discovered the joy of popcorn made with palm oïl. Wow. Perhaps it was because we were so sick of the usual, or maybe it was because the evening had all given us a soft, inner glow, but that giant kettle of popcorn hot from the stove top and a couple of cold Cokes was the best damned snack we’d had in a long time.
This time, I get to quote Anne-Isabelle on my popcorn:
“On dirait que ton pop-corn a une âme!”
Way to boost the ego. Life was good.
Of course, the sugar high later crashed, and we passed out for the night. A nice little break in the gloom.
Crounch va l’épisiotomie et la naissance
L’épisiotomie est une technique généralement réservée aux cas extrêmes, et nous avons appris à l’école que l’épisiotomie est à éviter, car le risque de déchirure sévère augmente avec l’emploi de l’épisiotomie, particulièrement lorsqu’elle est latérale (verticale).
Au Mali, l’épisiotomie est une pratique courante, et elle est effectuée en médiane. Alors que notre première réaction est souvent une d’horreur, il faut admettre que dans certains cas, les femmes donnent naissance si jeunes qu’elles sont simplement trop petites pout donner naissance toutes seules. Évidemment, l’excision n’aide pas, car l’infibulation (cicatrisation des petites ou grandes lèvres) rétrécit l’orifice vaginal, parfois jusqu’à ne laisser qu’un trou la taille d’un pois pour laisser passer l’urine et le sang menstruel. On effectue donc l’épisiotomie lorsque la tête est entièrement engagée dans l’orifice vaginal.
Malheureusement, on coupe souvent à la course, de travers ou encore avec des ciseaux si vieux que leurs lames ne sont plus alignées. L’entaille est souvent très profonde, allant jusque dans la fesse et pour ceux qui ne le savent pas déjà, toutes ces procédures se font à froid. Il faut d’ailleurs très souvent tenir le bassin de la patiente contre la table pour qu’elle ne se débatte pas, car elle peut se blesser encore plus si elle sursaute au moment inopportun. Dans ces moments, nous sommes avec ces femmes dans leur douleur. Nous leurs tenons la main, nous les encourageons à bien respirer, à prier, à faire tout ce qui les soulageraient dans leur souffrance.
Après l’accouchement, la réparation est le geste médical le plus difficile à observer, voire effectuer. Souvent à vif, la lidocaine étant réservée à celles dont la famille peut payer (et veut payer), le médecin recoud le périnée avec du fil de nylon et une aiguille de 2.0 (se rappeler que le gauge le plus petit est du 6.0, imaginez que du 2.0 ressemble plus à un hameçon de pêche). Selon le degré de lacération ou d’épisiotomie, cela peut prendre 5 à 20 points.
Il semble ridicule à première vue, de ne pas insister sur une césarienne, car pour certaines mères, elle meurent avant même que l’épisiotomie puisse être fait (la cause la plus fréquente de ce drame est qu’elles ne sont admises à l’hôpital que lorsqu’il est trop tard). Cependant, selon les conditions et le matériel disponible, le risque d’infection suite à une chirurgie telle qu’une césarienne est plus élevé que la douleur suite à l’épisiotomie. Il faut se rappeler qu’il n’y a pas deux mois de convalescence suite à l’accouchement; souvent la femme retourne au travail dès qu’elle tient sur ses jambes, et d’ailleurs, dès qu’elle a accouché et a été réparée, elle doit se lever, se rhabiller et se rendre elle même à la chambre de repos, où elle s’allongera avec toutes les autres femmes ayant accouché dans les 6 heures la précédant, et elle obtiendra son congé 6 heures plus tard à moins de saignements importants.
Effectivement, c’est un peu plus bref que chez nous. Il n’y a pas d’enseignement pour l’allaitement, ni les soins du bébé; cette information est passée de mère en fille. Le placenta, les pagnes souillés et les caillots récupérés de l’accouchement sont mis dans un seau et remis à la famille, laquelle a la responsabilité le ramener à la maternité propre.
Cette approche très simplifié fonctionne, malgré les limites de l’environnement. Les bébés en revanche, sont d’autant plus extraordinaires, venant au monde avec de grands cris and de grands yeux. Leur réflexe de succion est triomphant, alors qu’ils sont mesurés, pesés et laissés sous un incubateur jusqu’à ce qu’on ait fini avec la mère. Nous passons le plus de temps possible à les tenir et les cajoler; les matrones rigolent un peu en nous regardant, car l’attention que nous portons à ces petits doit sembler terriblement excessif comparé à la norme sociale. Ils n’ont jamais critiqué ce geste, par contre, alors au moins nous n’offensons personne.
Le gros choc que nous avons toutes eu, étant toutes éduquées selon la philosophie du caring, est justement l’absence de celui-ci. Les femmes se font tenir les lèvres fermées lorsqu’elles veulent crier leur douleur. Elles se font traiter de désobéissantes et les matrones (un compromis entre une sage-femme et une doula) les giflent si elles se plaignent. Les lits de naissance sont trop courtes et les femmes manquent de s’assommer sur la barre à la tête du “lit”. Les avortements (suite à une fausse couche) sont effectuées sans cérémonie, la canule d’aspiration pleine de caillots souvent visible à la mère durant la totalité de la processus. Lorsque le médecin a fini, c’est hop! Debout et au tour de la suivante.
Et pourtant personne ne proteste. La naissance est une réalité, un élément de la vie d’une femme, pas un miracle ni un évènement spécial. Et tant bien que je sens dans mes mots un jugement que je me suis juré de garder pour moi-même, je sais que lorsque je suis en salle d’accouchement, m’indigner n’aiderait pas la patiente et ne changera rien. Je m’abstiens donc des commentaires et je fais ce que je peux dans la limite permise: massages dans le bas du dos pour soulager la douleur, une compresse froide pour une primipare terrifiée, quelques mots de bambara pour encourager une jeune femme dont l’agonie se prolonge des heures de plus que prévue, une berceuse pour celle qui se fait avorter...
On fait ce qu’on peut. Les yeux des patientes en disent beaucoup.
Not that we’re prone to excess, but by the end of week one of interning, we were all a bit homesick, but I figured it would be a good idea to pull off a girls night. So we found oursleves the fixings for our two biggest comfort foods (within reason, the ice cream cravings are still pretty pungent!).
I still had two chocolate bars in my bag from Bamako, so we chopped those up and wound up with the world’s biggest bowl of chocolate chip cookie dough. One spoon each, life was good.
Then we discovered the joy of popcorn made with palm oïl. Wow. Perhaps it was because we were so sick of the usual, or maybe it was because the evening had all given us a soft, inner glow, but that giant kettle of popcorn hot from the stove top and a couple of cold Cokes was the best damned snack we’d had in a long time.
This time, I get to quote Anne-Isabelle on my popcorn:
“On dirait que ton pop-corn a une âme!”
Way to boost the ego. Life was good.
Of course, the sugar high later crashed, and we passed out for the night. A nice little break in the gloom.
Crounch va l’épisiotomie et la naissance
L’épisiotomie est une technique généralement réservée aux cas extrêmes, et nous avons appris à l’école que l’épisiotomie est à éviter, car le risque de déchirure sévère augmente avec l’emploi de l’épisiotomie, particulièrement lorsqu’elle est latérale (verticale).
Au Mali, l’épisiotomie est une pratique courante, et elle est effectuée en médiane. Alors que notre première réaction est souvent une d’horreur, il faut admettre que dans certains cas, les femmes donnent naissance si jeunes qu’elles sont simplement trop petites pout donner naissance toutes seules. Évidemment, l’excision n’aide pas, car l’infibulation (cicatrisation des petites ou grandes lèvres) rétrécit l’orifice vaginal, parfois jusqu’à ne laisser qu’un trou la taille d’un pois pour laisser passer l’urine et le sang menstruel. On effectue donc l’épisiotomie lorsque la tête est entièrement engagée dans l’orifice vaginal.
Malheureusement, on coupe souvent à la course, de travers ou encore avec des ciseaux si vieux que leurs lames ne sont plus alignées. L’entaille est souvent très profonde, allant jusque dans la fesse et pour ceux qui ne le savent pas déjà, toutes ces procédures se font à froid. Il faut d’ailleurs très souvent tenir le bassin de la patiente contre la table pour qu’elle ne se débatte pas, car elle peut se blesser encore plus si elle sursaute au moment inopportun. Dans ces moments, nous sommes avec ces femmes dans leur douleur. Nous leurs tenons la main, nous les encourageons à bien respirer, à prier, à faire tout ce qui les soulageraient dans leur souffrance.
Après l’accouchement, la réparation est le geste médical le plus difficile à observer, voire effectuer. Souvent à vif, la lidocaine étant réservée à celles dont la famille peut payer (et veut payer), le médecin recoud le périnée avec du fil de nylon et une aiguille de 2.0 (se rappeler que le gauge le plus petit est du 6.0, imaginez que du 2.0 ressemble plus à un hameçon de pêche). Selon le degré de lacération ou d’épisiotomie, cela peut prendre 5 à 20 points.
Il semble ridicule à première vue, de ne pas insister sur une césarienne, car pour certaines mères, elle meurent avant même que l’épisiotomie puisse être fait (la cause la plus fréquente de ce drame est qu’elles ne sont admises à l’hôpital que lorsqu’il est trop tard). Cependant, selon les conditions et le matériel disponible, le risque d’infection suite à une chirurgie telle qu’une césarienne est plus élevé que la douleur suite à l’épisiotomie. Il faut se rappeler qu’il n’y a pas deux mois de convalescence suite à l’accouchement; souvent la femme retourne au travail dès qu’elle tient sur ses jambes, et d’ailleurs, dès qu’elle a accouché et a été réparée, elle doit se lever, se rhabiller et se rendre elle même à la chambre de repos, où elle s’allongera avec toutes les autres femmes ayant accouché dans les 6 heures la précédant, et elle obtiendra son congé 6 heures plus tard à moins de saignements importants.
Effectivement, c’est un peu plus bref que chez nous. Il n’y a pas d’enseignement pour l’allaitement, ni les soins du bébé; cette information est passée de mère en fille. Le placenta, les pagnes souillés et les caillots récupérés de l’accouchement sont mis dans un seau et remis à la famille, laquelle a la responsabilité le ramener à la maternité propre.
Cette approche très simplifié fonctionne, malgré les limites de l’environnement. Les bébés en revanche, sont d’autant plus extraordinaires, venant au monde avec de grands cris and de grands yeux. Leur réflexe de succion est triomphant, alors qu’ils sont mesurés, pesés et laissés sous un incubateur jusqu’à ce qu’on ait fini avec la mère. Nous passons le plus de temps possible à les tenir et les cajoler; les matrones rigolent un peu en nous regardant, car l’attention que nous portons à ces petits doit sembler terriblement excessif comparé à la norme sociale. Ils n’ont jamais critiqué ce geste, par contre, alors au moins nous n’offensons personne.
Le gros choc que nous avons toutes eu, étant toutes éduquées selon la philosophie du caring, est justement l’absence de celui-ci. Les femmes se font tenir les lèvres fermées lorsqu’elles veulent crier leur douleur. Elles se font traiter de désobéissantes et les matrones (un compromis entre une sage-femme et une doula) les giflent si elles se plaignent. Les lits de naissance sont trop courtes et les femmes manquent de s’assommer sur la barre à la tête du “lit”. Les avortements (suite à une fausse couche) sont effectuées sans cérémonie, la canule d’aspiration pleine de caillots souvent visible à la mère durant la totalité de la processus. Lorsque le médecin a fini, c’est hop! Debout et au tour de la suivante.
Et pourtant personne ne proteste. La naissance est une réalité, un élément de la vie d’une femme, pas un miracle ni un évènement spécial. Et tant bien que je sens dans mes mots un jugement que je me suis juré de garder pour moi-même, je sais que lorsque je suis en salle d’accouchement, m’indigner n’aiderait pas la patiente et ne changera rien. Je m’abstiens donc des commentaires et je fais ce que je peux dans la limite permise: massages dans le bas du dos pour soulager la douleur, une compresse froide pour une primipare terrifiée, quelques mots de bambara pour encourager une jeune femme dont l’agonie se prolonge des heures de plus que prévue, une berceuse pour celle qui se fait avorter...
On fait ce qu’on peut. Les yeux des patientes en disent beaucoup.
Les noms de famille maliennes
Il existe peu de noms de famille au Mali; en quelque sorte il faut s’y faire avec une trentaine de noms de famille, et tous ceux ayant le même nom de famille se reconnaissent comme cousins (à ne pas confondre avec la notion de cousinage, sorte de lien d’amitié entre deux membres de clans différents). Les moqueries douces en résultent: les Traorés sont toujours pressés, les Koulibali sont l’ami de tout le monde et sont simples, les Sidibés sont des Peuls arrogants mais intelligents, etc...
Il va sans dire que nous avons maintenant été baptisées maliennes:
Maude R. = Mariam Diakité
Vanessa L-M. = Samaka Koné
Laurence L-B. = Binta Koulibali
Christine N. = Nana Sidibé
Leyla D’A. K. = Aminata Koulibali
Jenny W.= Salimata Koné
Karelle D.= Aramatha Djarra
Vanessa R.= Oumou Keita
Où que l’on aille, l’emploi du nom malien aide à bâtir des ponts transculturels et à faciliter la connaissance. Imaginez l’effort requis pour un malien de prononcer un nom tel que “Christine” (qui d’ailleurs incite un peu la moquerie, puisque la majorité des maliens trouvent que de se nommer d’après Jésus Christ est arrogant, sans compter que le pays est à plus de 75% musulman) alors que “Nana” est facile et approuvée.
Le système de castes est encore très vivant au Mali, et même si l’esclavage n’existe plus officiellement, il en demeure des exemples dans les interactions entre clans (par exemples, une Kanté serait “propriétaire” d’une Keita) et l’esclavage est encore présent dans le nord du pays, chez les Touareg.
La famille d’où l’on vient suggère parfois la profession, bien qu’avec les temps modernes les jeunes prennent plus de liberté et choisissent une carrière selon leur instruction (mais souvent avec le coup de pouce de la famille). Kayes est la région la plus pauvre au Mali, et une grande partie du revenu familial vient de membres de famille en France et en Europe qui envoient jusqu’à 40% de leur salaire pour contribuer à leur survie.
Quelle que soit le sort des maliens qui quittent le pays pour des pays plus lucratifs, il semble que la pauvreté est immuable dans ce pays.
Il va sans dire que nous avons maintenant été baptisées maliennes:
Maude R. = Mariam Diakité
Vanessa L-M. = Samaka Koné
Laurence L-B. = Binta Koulibali
Christine N. = Nana Sidibé
Leyla D’A. K. = Aminata Koulibali
Jenny W.= Salimata Koné
Karelle D.= Aramatha Djarra
Vanessa R.= Oumou Keita
Où que l’on aille, l’emploi du nom malien aide à bâtir des ponts transculturels et à faciliter la connaissance. Imaginez l’effort requis pour un malien de prononcer un nom tel que “Christine” (qui d’ailleurs incite un peu la moquerie, puisque la majorité des maliens trouvent que de se nommer d’après Jésus Christ est arrogant, sans compter que le pays est à plus de 75% musulman) alors que “Nana” est facile et approuvée.
Le système de castes est encore très vivant au Mali, et même si l’esclavage n’existe plus officiellement, il en demeure des exemples dans les interactions entre clans (par exemples, une Kanté serait “propriétaire” d’une Keita) et l’esclavage est encore présent dans le nord du pays, chez les Touareg.
La famille d’où l’on vient suggère parfois la profession, bien qu’avec les temps modernes les jeunes prennent plus de liberté et choisissent une carrière selon leur instruction (mais souvent avec le coup de pouce de la famille). Kayes est la région la plus pauvre au Mali, et une grande partie du revenu familial vient de membres de famille en France et en Europe qui envoient jusqu’à 40% de leur salaire pour contribuer à leur survie.
Quelle que soit le sort des maliens qui quittent le pays pour des pays plus lucratifs, il semble que la pauvreté est immuable dans ce pays.
Monday, July 20, 2009
Cooking diaries - Crème Brûlée & Paella
True to character, my need to cook surfaced all of two days after our arrival in Kayes. We have access to a gas oven, which I thought would be a dream, except that it proved exceptionally difficult to do (more later). I decided my challenge would be to make paella for dinner and crème brûlée for dessert. Let’s run through the issues at hand in Kayes:
-forget fresh dairy. Milk is powdered and cream dosent exist unless you milk a goat and churn it yourself. Considering the elevated risk of brucelloses (a harmful bacteria), I thought it best not to chance it. So we made concentrated milk.
-if you want chicken, you have to go to the chicken market and pick out a chicken. They then kill it and clean off the Feather for you. However, the birds here just don’t have the same kind of meat on them as at home. A chicken breast is about the size of a St-Hubert chicken finger.
Leyla and I went to the chicken seller for the meat tthe night of our meal, and watching the beheading (and subsequent last dash of the headless bird - this is NOT an urban legend) was enough to remind me of why I was a vegetarian for so long. On the other hand, there is something very powerful that occurs when you connect with your food in a most basic way; it reminds us that there is a very real cost to our gluttony and to acknowledge the loss of life associated. It was both humbling and touching: it goes without saying that despite our being 12, we only had 2 chickens killed.
If only everyone’s appetite were limited by their tolerance for bloodshed.
-the final obstacle to our cooking fiesta lay within the cookware (or lack thereof). All dishes are made in large enamel tubs here (so obviously my little ramequins from home weren’t sitting on the shelves. We therefore needed to use a metal bowl too deep in an improvised bain-marie.
Necessity is the mother of invention, after all, so that night was highly creative.
The girls and I got working as soon as we got in. The crème brûlée needed to be ice cold, so we started early. The eggs here for some reason have fragile yolks, so instead of wiski 12 yolks, we wound up with 12 whole eggs, and we could look forward to a very firm crème brûlée. Leyla nearly lost her eyebrows when she tried to light the stove, as we had not figured out whether to light the top or bottom burner. Needless to say, mystery solved now! J
The oven cooked unevenly and the surface of the flan was scorched despite all our efforts and the dessert was tossed into the freezer to cool down for a few hours. Freezers here are about 2-3 degrees lower than our fridges, so you can imagine that the fridge would have been quite ineffective.
We moved on to the paella.
Leyla and Laurence prepped the onions and garlic and began sauteing them, and I got started on the chicken.
Thus began the madness...
Our dear butcher had not gutted the chickens, just cleaned the OUTER part. Aside from the fact that they were still warm for their former lives, I squirmed when I reached for the bird’s head and my fingers groped something grainy and gritty.
I forgot about the stomach. Ew. One thousand Ews.
It was, however a magnificent opportunity to engage in an impromptu dissection, and that is exactly what we did, taking turns and facing our fears. Jenny had the time of her life facing her fear of blood and guts (especially with having the pull the ribcage apart to access the intestines!) and after an hour or so, the chickens were deconstructed, meat removed, cleaned and the remains discarded with great pomp and ceremony.
The paella was made in the oven and came out quite well, despite the fact that I found it lacked its usual kick, most probably because we didn’t have the usual shrimp, mussels and sausage to top it with; it would make sense, wouldn‘t it? The girls liked it, however, and we made homemade flatbread and salsa to balance out the flavors.
For dessert, we sprinkled the crème brûlée with granulated sugar, lit the broiler and hoped for the best. The broiler flame however, was too far from the immensly tall bowl to caramelize and so the sugar half melted and the pudding came out piping hot.
But hey, let’s face it, we made CRÈME BRÛLÉE in AFRICA.
So all things taken into perspective, it was a success, and either way, we were happy to eat something other than goat and couscous.
-forget fresh dairy. Milk is powdered and cream dosent exist unless you milk a goat and churn it yourself. Considering the elevated risk of brucelloses (a harmful bacteria), I thought it best not to chance it. So we made concentrated milk.
-if you want chicken, you have to go to the chicken market and pick out a chicken. They then kill it and clean off the Feather for you. However, the birds here just don’t have the same kind of meat on them as at home. A chicken breast is about the size of a St-Hubert chicken finger.
Leyla and I went to the chicken seller for the meat tthe night of our meal, and watching the beheading (and subsequent last dash of the headless bird - this is NOT an urban legend) was enough to remind me of why I was a vegetarian for so long. On the other hand, there is something very powerful that occurs when you connect with your food in a most basic way; it reminds us that there is a very real cost to our gluttony and to acknowledge the loss of life associated. It was both humbling and touching: it goes without saying that despite our being 12, we only had 2 chickens killed.
If only everyone’s appetite were limited by their tolerance for bloodshed.
-the final obstacle to our cooking fiesta lay within the cookware (or lack thereof). All dishes are made in large enamel tubs here (so obviously my little ramequins from home weren’t sitting on the shelves. We therefore needed to use a metal bowl too deep in an improvised bain-marie.
Necessity is the mother of invention, after all, so that night was highly creative.
The girls and I got working as soon as we got in. The crème brûlée needed to be ice cold, so we started early. The eggs here for some reason have fragile yolks, so instead of wiski 12 yolks, we wound up with 12 whole eggs, and we could look forward to a very firm crème brûlée. Leyla nearly lost her eyebrows when she tried to light the stove, as we had not figured out whether to light the top or bottom burner. Needless to say, mystery solved now! J
The oven cooked unevenly and the surface of the flan was scorched despite all our efforts and the dessert was tossed into the freezer to cool down for a few hours. Freezers here are about 2-3 degrees lower than our fridges, so you can imagine that the fridge would have been quite ineffective.
We moved on to the paella.
Leyla and Laurence prepped the onions and garlic and began sauteing them, and I got started on the chicken.
Thus began the madness...
Our dear butcher had not gutted the chickens, just cleaned the OUTER part. Aside from the fact that they were still warm for their former lives, I squirmed when I reached for the bird’s head and my fingers groped something grainy and gritty.
I forgot about the stomach. Ew. One thousand Ews.
It was, however a magnificent opportunity to engage in an impromptu dissection, and that is exactly what we did, taking turns and facing our fears. Jenny had the time of her life facing her fear of blood and guts (especially with having the pull the ribcage apart to access the intestines!) and after an hour or so, the chickens were deconstructed, meat removed, cleaned and the remains discarded with great pomp and ceremony.
The paella was made in the oven and came out quite well, despite the fact that I found it lacked its usual kick, most probably because we didn’t have the usual shrimp, mussels and sausage to top it with; it would make sense, wouldn‘t it? The girls liked it, however, and we made homemade flatbread and salsa to balance out the flavors.
For dessert, we sprinkled the crème brûlée with granulated sugar, lit the broiler and hoped for the best. The broiler flame however, was too far from the immensly tall bowl to caramelize and so the sugar half melted and the pudding came out piping hot.
But hey, let’s face it, we made CRÈME BRÛLÉE in AFRICA.
So all things taken into perspective, it was a success, and either way, we were happy to eat something other than goat and couscous.
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