My Summers in West Africa: The Account of a Medical Missionary

By Dr. Richard D. Evans

Medical personal since the days of Dr. Livingston in the mid-1880s have traveled to Africa for a number of reasons. First is to satisfy the innate curiosity which tends to infest every member of the medical profession. Two is the natural desire to lend a helping hand to our fellow man. And three would be to expand our knowledge and understanding of infectious diseases and the medicines used to treat them. It is for these reasons that my book will have an expansive market.
Any physician who is contemplating an expedition to West Africa must first research and seek advice from those who have gone before him. He will also find it necessary to brush-up on the tropical diseases he will be exposed to and will be expected to treat. My journal summarizes those. Prior to embarking, a physician may well find it necessary to receive some in-services on the unfamiliar surgical procedures which he may be expected to perform. My journal covers those procedures as well. Medicines and essential surgical instruments must be collected and packed ahead of any mission. My journal lists the pharmaceuticals and instruments I found in short supply. To travel into that corner of the world, a physician must also receive the recommended vaccinations and start his/her anti-malarial medication in a timely manner.
From publications like mine nurses and physician assistants can get a good idea of what might be expected of them during such a trip. And since the hospital I served is associated with and supplied by a religious organization, this book will help parishioners of any faith better understand how they can best serve their organizations medical missions. It will also give them encouragement and a better appreciation of the importance of their efforts.

• Language: English
• Publisher: Xlibris US
• Release date: Apr 2, 2015
• ISBN: 9781503558052

Dr. Richard D. Evans

CURRICULUM VITAE Richard D. Evans, DO, FACOS PERSONAL Address: 147 Pine Woods Road Ormond Beach, FL 32174 [phone] Birth Date: March 30, 1950 Marital Status: Married with four children Health: Excellent EDUCATION University of Central Florida 2000 – 2002 Orlando, Florida B. A. in History Midwestern University 1973 – 1977 Chicago College of Osteopathic Medicine Chicago, Illinois Doctor of Osteopathic Medicine Southern Illinois University 1969 – 1973 Carbondale, Illinois B.A. in Physiology/Anatomy TRAINING ICD-10-CM 10-5-2011 ICD-10-PCS 10-8-2011 Mount Clemens General Hospital 1978 - 1982 Mount Clemens, Michigan General Surgery Residency Mount Clemens General Hospital 1977 – 1978 Mount Clemens, Michigan Rotating Internship RESIDENCY INCLUSIVE OF: Fourteen months of Peripheral Vascular Surgery Three months of Intensive Care Training at Mount Carmel Mercy Hospital, Detroit, Michigan Three months of Pediatric Surgery at Michigan’s Children’s Hospital,Detroit, Michigan Gynecological and Laparoscopic Surgical Rotations throughout Residency program BOARD CERTIFICATION Certified Professional Coder 6-30-2011 The American Osteopathic Board of Surgery 2-17-1986 General and Peripheral Vascular Surgery PROFESSIONAL ASSOCIATIONS Florida Osteopathic Medical Association 1983 – 2005 2007 Apalachee Parkway Tallahassee, Florida 32301 American Osteopathic Association 1979 –Present 212 East Ohio Street Chicago, Illinois 60611 American College of Osteopathic Surgeons 1978 –Present 123 North Henry Street Alexandria, Virginia 22314 HONORS Instructor of the Year, Everest University, June 2007 – 2008 Teacher of the Year, Peninsula Medical Center, 1987 – 1988 Outstanding Resident Award Mount Clemens General Hospital, June 1982 Mead Johnson Award for research, National Osteopathic Foundation, January 1982 Literary Award for research performed on post-operative pain management, American College of Osteopathic Surgeons, October 1981 Chief Resident, Mount Clemens General Hospital, Michigan, 1980 -1982 PUBLICATIONS “Gastric Rupture as a Complication of Cardiopulmonary Resuscitation”, report of case and review of literature, Journal of AOA, Vol. 80, No. 12, 830/104, August 1981. “The Subject Review and Study of Post-Operative Pain Management Utilizing the TENS Unit”, accepted for publication in the Journal of AOA, 1981. OFFICES HELD Chief of Surgery 1999 – 2000 Memorial Hospital-Peninsula Ormond Beach, Florida Member – Board of Trustees 1997 – 1999 Atlantic Medical Center Ormond Beach, Florida Professional Case Reviewer 1991 – 2000 Department of Professional Regulations (ACAH) Tallahassee, Florida Chief of Surgery 1991 – 1995 Peninsula Medical Center Ormond Beach, Florida Chief of Surgery 1985 – 1988 Peninsula Medical Center Ormond Beach, Florida Chief of Surgery 1983 – 1987 University Hospital Daytona Beach, Florida TEACHING POSITIONS Adjunct professor at Concorde Career College, Orlando, Florida, 2012-Present Adjunct professor of Allied Health at Florida Metropolitan University, 9200 Southpark Center Loop, Orlando, Florida, July 2003 to 2012 Associate professor of Medicine and Surgery at Florida College of Integrative Medicine, Orlando, Florida, July 2001 to July 2003 Visiting surgeon and clinical instructor at African Christian Hospital, Aba State, Nigeria, West Africa. Duties included training residents in the practice of surgery, providing surgical care and procuring medical supplies and equipment, 1994 to 2001 Training surgical residents in gastrointestinal endoscopy for Mount Clemens General Hospital, Michigan, 1987 to 2000 ACLS instructor for American Heart Association, 1985 to 1990 Training residents and interns at Peninsula Medical Center, 1983 to 2000 Chief Resident, Mount Clemens General Hospital, 1980 to 1982 **Curriculum Vitae Updated and Current as of October 10, 2014

Book preview

My Summers in

West Africa

The Account of a Medical Missionary

Dr. Richard D. Evans

Copyright © 2015 by Dr. Richard D. Evans.

Library of Congress Control Number:   2015905142

ISBN:      Hardcover        978-1-5035-5803-8

                Softcover         978-1-5035-5804-5

                eBook              978-1-5035-5805-2

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

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Rev. date: 03/31/2015

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Contents

Prologue

Unit I

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12

Chapter 13

Chapter 14

Chapter 15

Chapter 16

Chapter 17

Chapter 18

Chapter 19

Chapter 20

Chapter 21

Chapter 22

Chapter 23

Chapter 24

Chapter 25

Chapter 26

Unit II

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Unit III

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12

Photo Gallery

Curriculum Vitae

PROLOGUE

T HE YEAR WAS 1995. I was finally able to embark on an adventure that had been conceived back in the year 1977. That was the year when a good friend of mine and a fellow hospital house officer returned from a medical mission in Africa. Randy had just completed a six-month assignment in Tanzania. At that time, he was an enthusiastic young medical resident seeking the hands-on experience and the excitement that can be found only on the continent of Af rica.

As young schoolchildren, when we thought of Africa, we envisioned that single setting, which displayed the first protohumans, as a fitting prototype for either our Maker or Mother Nature to improve upon. That was arguably some three or four million years ago. Africa is where earliest man had roamed and, preceding him, where Ardi and Lucy roamed. We thought of the venerated stage that hosted the hotly debated and sometimes contentious leap from the hominid Homo erectus to Homo sapiens. Modern man had finally stepped onto his grand stage. That event is believed to have occurred between 200,000 and 160,000 years ago. This is the place where, just on this side of three million years ago, our most distant ancestors became recognizably human. This is one of the few places where earliest civilization learned the magical qualities of seeds and came to appreciate the fact that the mighty oak tree arises from the tiny acorn. With that knowledge, man learned to grow his own food. This is also one of the places where man learned to domesticate animals and form tools from stone, seashells, and bone. And of course, as schoolchildren, we thought of the starting point of those footprints that trailed behind the most distant of our European forefathers. Those footprints led man out of Africa and away from the warm and nurturing climate, which had been so kind to him during his developmental stages. That event occurred at a somewhat more reliable date of circa forty-five thousand years ago.

While this may seem like a very long time ago, in comparison to the grand scheme of things, it is a mere flash of a bright strobe in the eyes of our paleontologists. After a century of centuries and a handful of minor adaptations, man’s intellect and his manual dexterity took a sudden leap forward. This made him the only animal capable of surviving on all parts of the globe. It was this superior intelligence and man’s penchant for adaptability that finally allowed him to break away from Africa’s more hospitable atmosphere. He had now matured enough and grown wise enough to overcome the obstacles which had for so long discouraged man’s venturing away from Africa’s warm and reliable climate. Man had finely mastered all the skills and developed all the tools needed to enter, conquer, and populate the more foreboding regions of the globe, including the Great White North. He had mastered the magic of fire, and he had learned to keep warm by wearing the skins of other animals. Earth had seen the reign of many life forms come and go. And now the age of man had arrived. The many centuries of crouching deep in the crevasses of caves had come to an end. No longer was man at the naked mercy of intrepid weather and fierce predators. It was in this Great White North that our ancient forefathers found and interacted with a temporary soon-to-be-vanquished neighbor, the Neanderthal. These ancient events appear to be surrounded by enough unresolved theories and speculations to keep our academics in their argumentative mode for a century of eons to come.

From an anthropologist’s point of view, the African continent is indeed a land of many untold riches. It is common knowledge and a frequently published fact that the African continent has been and is being exploited for its tremendous mineral wealth and natural resources. But if we could peer behind that veil which conceals the future, we would see that the continent’s resources have barely been scratched. Africa is also revered for its unique animal wealth and its human assets. The long history of those human assets can be found in the form of discretely concealed tokens, which were discarded by visiting humans tens of thousands of years ago. These dried tokens consist of archaic artifacts, such as tools, trinkets, works of art, and, of course, skeletal remains. When closely analyzed, these objets d’art have revealed many secrets which help us to better understand our most distant of forefathers. This is the place where artifacts from prehistoric times mingle with those of ancient times, which in turn mingle with artifacts of contemporary times. These are but a few components that make this great continent shamelessly seductive.

Microbiologists see Africa’s treasures from a more dynamic and nuance viewpoint. To them, this is a land where old microbes and old macrobes are evolving into extinction on a daily basis, while an equal and balancing number of new and better-adapted species are evolving into dominance. Darwin showed us long ago that Mother Nature is very kind to well-adapted genes, while she will heartlessly toss aside those life-forms with poorly adjusted genes. Thusly, this is a place like no other—a place where entire species are revolving through a continually evolving change, a sort of here-today-gone-tomorrow landscape. One of my biology professors explained Darwin’s genetic selection something like this: It is like a broken copying machine. Each copy has a slight error. Some of those errors are for the good, while others are not. The good copies are kept, and the species invigorated, while the bad copies are discarded to be thereafter observed only in books of natural history. No sooner does one species fall from existence before another will rise to fill the void left in its wake. Before modern man was created, there were many predecessor humanoids or protohumans who were deemed bad copies. Those bad copies were tossed aside by Mother Nature to sink under the many layers of Africa’s terra firma. These are just a few of the things that generate an overpowering magnetism—a magnetism that draws men of all walks of life. This omnipotent allure applies doubly to those of us in the field of medicine.

Africa offers a clinical display and an intellectual arousal that health-care workers can experience only by traveling to this far corner of the globe for a firsthand look. Every profession, every guild, and every society benefits from such a muse to guide its members. Places like this are necessary to help physicians periodically realign their professional interests as well as their moral compasses. Africa uniquely provides that very muse for many health-care societies. Here and only here can one find, diagnose, and treat the wide array of primordial and tropical maladies that have survived for eons. Many of these maladies exited the Western medical theaters decades or, in some cases, centuries ago. Today’s pharmaceutical companies and medical research institutes see this particular aspect of Africa as the most valuable of all Earth’s natural endowments. It is a sanctuary, a living and breathing laboratory, where the natural defenses of various plants and animals can be studied. Once understood, the unique features can be either harvested from that species or through reverse engineering be replicated in a test tube. To some individuals, this will mean a cure to a fatal disease or the eradication of a deadly epidemic. To others, it will mean nothing more than a path to great financial gains.

Included in the rich and never-ending milieu of exotic diseases, we find such energetic players as malaria, dengue fever, Lassa fever, Ebola, monkeypox, yellow fever, and African sleeping sickness. These are the time-honored titans of the microbial world. Some have existed on Earth since a time long before man walked on Earth. Although many of these microbes have ravaged the Western world in centuries gone by, today they are persevered only in this part of the globe. For the Western nations, these microbes are no longer feared, but they do still provide a great source of marvel. The preservation of this multicourse banquet of organisms is most useful in our study of medicine. In addition, it provides a source of enlightenment to our high school biology students as well as an occasional source of entertainment for the evening TV shows and even the big screen. These excitants have a magnetism to many clinicians, which is stronger than the songs of sirens. For some clinicians, the intrigue and seduction is so overwhelming that the African continent becomes their Hotel California—a place that once entered, one cannot bring themselves to leave.

These microbes are but one of a few things that prevents ours from being a dull planet. Despite the negative image they conjure up, only 1 or 2 percent of bacteria actually cause disease in humans. In other words, while we swim in a sea of bacteria and viruses, there is actually only a handful that harms us at all. By far, most microbes are either beneficial to us or have no effect whatsoever. This cohabitation is usually a peaceful one with a mutual compatibility that sometimes evolves into an actual codependence. The sine qua non of a beneficial bacterium is the colonic bacteria which produces vitamin K. This vitamin is absolutely essential to our clotting system. Another example is the cellular organelle, the mitochondria. It is found in every one of our cells and originated as an ancient invading parasitic bacterium. It ultimately became symbiotic and is now absolutely essential to man. It now is the powerhouse for each and every one of our cells. And the list goes on.

Today’s relationship exists because of the decades of centuries that man and bacteria have evolved into a practical coexistence. Other times, the relationship becomes contentious with bacteria-killing man and man-killing bacteria. If a man’s immune system is too weak to withstand the onslaught of his contemporary bacteria population, he will not survive, and his weak genes will not be passed into the future generations. If a bacterium is so toxic that it kills every man it infests, it will not survive very long since it will have been buried or burned along with its victims. The goal of every parasite is to live off its prey without killing him or weakening him beyond a level of usefulness. If the host perishes, the parasite will perish along with him. After centuries of the baddest of the bad bugs being buried along with their victims, the surviving bugs are those that have adapted to the needs of their host. The successful parasites have over time become more benevolent. The host and his cohabitating bugs learn to tolerate and often to benefit from the other’s presence.

Of the microbes that have proven themselves survivors, the virus responsible for causing the dread poliomyelitis is one of the most famous. Nigeria, in fact, is the only place on Earth where it remains alive and active today. Before coming to Africa, the last case of polio I had personally seen was in 1956. A grammar school classmate of mine had been stricken and severely crippled by the virus. Shortly after her malady came the development of Jonas Salk’s widely celebrated vaccine—a cruel fate of timing. The virus crippled my classmate so badly that she was able to walk only with the assistance of gaudy stainless steel leg braces and a pair of crutches. Her father was our basketball and track coach and the staunchest of all advocates of physical fitness. He held physical strength, agility, and athletic achievements in the highest esteem. It broke his heart to see his little girl fall victim to that era’s crippling epidemic.

Even the bubonic plague, referred to as the Black Death in the Dark Ages, continues to make regular visitations to various parts of Africa. That medieval contagion greatly terrified fourteenth-century Europe that even today, its name is readily recognized and feared by schoolchildren. This is a disease that totally depopulated many parts of Europe and overall claimed one of every three souls residing in the known world of the time. Simultaneously, Africa entices health-care providers with a tantalizing display of the more recent pestilence found crawling out of its jungle. Probably the most infamous of today’s microbes would be the Ebola and the HIV viruses. The first documented human case of HIV/AIDS was identified in the frozen sample of plasma that belonged to a man who had died of a mysterious illness in the Belgian Congo in 1959. The actual date of the first case of the HIV virus infecting man remains deep in the realm of speculation.

To this day, greater than 70 percent of HIV victims either dwell in or are known to have originated from the continent of Africa. That age-old disease, tuberculosis, has been making a rather dramatic comeback riding on the coattails of its new friend, the HIV virus. About 90 percent of the world’s malaria victims, another ancient disease, reside in equatorial Africa, and the list goes on. Malaria, along with many of our timeworn bacteria, is building resistance to our most powerful drugs. This continuum of dour statistics has always and will always keep Africa in the leading articles of our medical journals. These and other ever-adapting microbes are most efficient in steadily grinding mankind into dust. It seems that many factors have conspired to extinguish man’s residency in this corner of the globe. But strangely, in spite of all this, Africa is well accepted as the cradle of humanity, and since man’s conception, Africa has continually and increasingly supported a very heavy human population. These are but a few of the many components to Africa’s lure. The following is the journal that I kept during my three trips to a rural hospital in West Africa. From 1994 to 2001, I was one of many Americans who collected and supplied the hospital with medical supplies and lifesaving medicines.

UNIT I

CHAPTER 1

I T WAS DURING a medical externship at Mt Clemens General Hospital, located on the north side of Detroit, that my first serious fascination with the state of medicine on the African continent occurred. Randy, a medical resident at the time, had recently returned from a rotation in East Africa. After long arduous days in one of the Detroit hospitals, a group of fellow students and residents would occasionally gather to enjoy a beer and listen to an account of one of Randy’s many exciting exploits. During his assignment in Africa, Randy followed and assisted a seasoned Anglo physician who had devoted his entire professional life to the care of that region’s tribes. Randy’s assigned duties were necessarily a stark contrast to the mundane chores doled out by any of the Western residency prog rams.

A prime example is the vaccination manifest that his mentor maintained. This document listed only the names of tribes, the types of vaccines, the dates of administration, and the number of vaccinations administered. There were no individual patient names. If and when the doc was fortunate enough to acquire a supply of polio vaccine, he would first check the manifest. Let us say that the Xriver tribe last received this vaccine nine years ago. He and Randy would visit that tribe and receive permission from either the chief or the council of elders to set up camp. During their visit, they would vaccinate all of the children under the age of nine and address any other ailments they might discover. Their diagnostic tools were crude, being pretty much confined to a simple stethoscope, an otoscope, and their two God-given hands. This all seemed very unorthodox at a time when we were all being taught to never treat any medical condition until our clinical impression has been double-checked and confirmed with a barrage of laboratory tests, X-ray studies, and CT scans. And of course, half of the studies we order in the United States are tailored to the prevailing litigations. These conventional wisdoms are turned upside down when one crosses the Atlantic. Many of our old habits of thought must be cast aside.

Most of their treatments were directed toward parasitic types of infections. Drainage of large liver cysts that had resulted from Entamoeba histolytica or another of the various migratory worms was a common chore relegated to Randy. Ocular myiasis also was a frequently seen problem. Sometimes the medical team would encounter an entire village suffering from blepharo-conjunctivitis caused by those parasites. This is a phenomenon today’s medical resident will never see unless he leaves the States. The way this disorder works is as follows: While sleeping under the stars, tribal members will be visited by flies, which will quietly sip a drink from the corner of a tribal member’s eye. During its visit, the fly will deposit a clutch of eggs. After a short incubation period, the eggs will hatch, and the fly larva will begin trampling across the delicate cornea. Randy and his chief would sometimes devote several days to the application of an ophthalmic ointment to tribal members. Once the larvae were dead or paralyzed, they would be removed with saline irrigation and a pair of forceps.

Roundworms and their larva migrans, which are capable of infesting any of our various organs, were also familiar sights. Their crude portable formulary was 90 percent occupied by only a handful of pharmaceutical agents—those included are chloroquine, metranidazol, ampicillin, tetracycline, and a sulfonamide. The narrowness of the list was more than compensated by its depth. Apparently, the Anglo doctor was quite successful in maintaining a generous supply of each of those drugs. On the other hand, what were rare findings among their patients were the very ailments that we see every day in clinics across America. Heart disease, for example, was practically nonexistent. Its absence can be attributed to three primary factors. First and foremost is that practically every African maintains an unusually high level of physical activity. Second is Africa’s near total absence of obesity. In fact, words like plump, chubby, and portly simply will not be found in most of African’s tribal lexicons. This thin body habitus is especially welcomed by any visiting general surgeon. Third would be the fact that the tobacco companies have not yet found a profitable means to exploit most of these third-world economies. Since cigarettes are conspicuously absent, emphysema, bronchiectasis, and lung cancer are also conspicuously absent. Breast cancer, however, did show its ugly face on a regular basis.

Since neither Randy nor his mentor was trained as surgeons, only the most rudimentary surgical procedures could be offered. The most common of these by far was the drainage of abscesses. Randy would occasionally hear of tribal members who had gone to bed with abdominal pain and died after three or four days. These most likely represented cases of appendicitis, cholecystitis, or, possibly, colon cancer. The regular occurrence of birth-related deaths was another all too familiar scourge. This was a fear that haunted every expectant African mother. It was apparent to all of us that those six short months in Tanzania would probably provide Randy with 95 percent of the excitement that his entire medical career will have to offer.

CHAPTER 2

I N 1991, I finally got around to inquiring about the available medical missions to Africa. I first contacted Doctors Without Borders, the largest and best-known of our profession’s volunteer organizations. I found that they were requesting a two-year commitment from any general surgeon who wished to participate in one of their projects. At that time in my life, I simply could not afford to leave my practice and family for such an extended pe riod.

Then, in 1994, I caught wind of a 110-bed hospital in Nigeria that was in dire need of a general surgeon. Two years had lapsed since a general surgeon had last visited the hospital. In the interim, a large number of surgical patients had accumulated. Another enticing feature was the fact that the hospital sits right in the middle of a goiter belt, and thyroid surgery has always been one of my favorite. Their terms could not have been more agreeable: date of arrival and the length of my stay were entirely at my discretion. My financial obligations would consist of my airfare, any specialty supplies that I might consider necessary, plus an obnoxiously reasonable rate for room and board. The hospital provided a manservant to prepare our meals, clean our living quarters, and do our laundry. I eagerly accepted a one-month assignment.

Within the week, I received in the mail a thick packet. This included a list of prevalent tropical diseases of which I needed to familiarize myself. Also included was a series of news clippings and Internet printouts that described the salient features of the country, its people, their culture, and social code. A list of medications that I could expect to find in the hospital pharmacy was also enclosed. My local health department provided me with a barrage of mandatory vaccinations. Included with the vaccinations was malaria prophylaxis. That was to begin one week prior to my departure with the maintenance dose and be continued for one week after I return. The drug they recommended is called Larium (mefloquine).

A Texas friend called and provided me with a little additional insight on malaria prophylaxis. His advice was of the best kind. It was based on his own personal experience. He had recently returned from Africa where he had accompanied a medical team to Rwanda. Their mission lasted a total of three months, and during that time, their primary duty consisted of treating a cholerae epidemic that was decimating a Rwandan refugee camp. Cholerae is one of those plagues in which quick action is the most important part of the treatment. The speed and magnitude with which the pathogen causes diarrhea can quickly overwhelm even the most robust of patients. It is the dehydration and the electrolyte imbalance from the diarrhea that kills the patient, not the results of some toxin or the destructive action of the bacteria. The diarrhea is meant to be a protective reflex and will completely flush out the offending organism, Vibrio cholerae. Therefore, no medications are required. If the physician is successful in replacing these depleted fluid and electrolytes, he will save his patient’s life.

His team had initiated their malaria prophylaxis upon departure and continued it only one week after leaving the endemic area. Lariam also was their drug of choice, and they had elected to not begin with a loading dose. Instead, they began with the maintenance dose. Their regimen for the three-month period consisted of Lariam 250 mg Q one week times four weeks and then 250 mg Q two weeks. This was in accordance with the recommendations from their medical adviser and, of course, their own Internet research. Shortly after their return to the States, every member of the group came down with an active case of malaria. For some members of the team, contracting malaria kept them away from their gainful employment for an additional six weeks. That means they were off work for a total of four-and-a-half months. After our discussion about malaria, it struck me that I had just glimpsed a parasite, which I would have to come to understand completely.

Lariam prophylaxis works by preventing the malarial protozoan—in this case, Plasmodium falciparum—from obtaining a foothold in one’s tissues. The most notable tissue to be invaded is generally that of the reticuloendothelial system. The inhabited individual must be comfortable with the fact that the malarial protozoan is swimming freely in his bloodstream and setting up housekeeping in some of his red blood cells. The individual will be transformed into a parasite hotel of sorts. That is where the interloper must be stopped. It is imperative that the tiny guest not be allowed to reproduce unchecked in the red blood cells, the liver cells, or the spleen.

My research of the subject revealed that today, most African enthusiasts prefer to start their prophylaxis one week prior to entering an endemic area with not a maintenance dose but rather with a loading dose of Lariam. That loading dose consists of 250 mg per day times three days followed immediately with the maintenance dose. Some individuals, however, do not tolerate the side effects that accompany the high-loading dose. While in the endemic area, the individual should continue his maintenance dose of 250 mg every week. After leaving the endemic area, the maintenance dose should be continued for an additional four weeks. If any fever or rigors are experienced, the Lariam is to be continued for an even longer period of time. The greatest danger occurs at that moment in time when the volunteer finishes his/her course of therapy. If any of the organisms remain in a red blood cell or a liver cell, the parasite will begin reproducing and quickly spread throughout the body. I plan to heed every bit of this advice and take the higher just-in-case dose. By doing so, I will hopefully avoid my Texas friend’s unpleasant experience.

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For the better part of a year, I have been procuring and shipping medical supplies to my African hospital. These supplies consist primarily of discarded packets of every type and size of suture—an absolute must for any surgeon. For these packets to be safely used, they must still possess an intact and sterile inner packaging. As an added precaution, each packet of suture originally possesses two sterile barriers: an outer and an inner wrapper. As long as the inner, or second sterile wrapper, has not been violated, the suture itself will remain protected and safe to be used at another time and another place. Here in the States, the average surgery produces a dozen or so of such unused packets of suture. A complex procedure would yield many more. My U.S. hospital’s wasteful ways is to my African hospital’s advantage. I have also been fortunate enough to send a generous number of intestinal staplers and Foley catheters. Unlike the packets of suture, these items will require resterilization after they reach Africa. Two children at the hospital’s orphanage suffer from asthma, and I was asked to bring them any asthma medications I might have access to. I was most fortunate to acquire ten Provental and ten Azmacort inhalers.

Our destination is in the most populated of Africa’s fifty-three nations. The latest census indicated that a recent population explosion has caused Nigeria’s citizenry to swell to approximately 125 million. In spite of this overcrowding, the population continues to expand at a breakneck pace. There are always individuals who wish to abandon their less glitzy rural life for the faster paced and more exciting way of life in the congested city. Lagos has a mixed reputation: infamous for trickery, which is as cunning as any of our Wall Street law firms, and admired for a productivity that rivals the brawn of our Midwestern industries. Since humans have occupied the African continent much longer than any of the others, one would expect the numbers to have stabilized long ago. But that simply has not occurred. It is my understanding that the population had in fact stabilized prior to Africa’s colonization by the European powers. That event took place in the mid-1800s. The natural checks and balances, which had evolved over the eons, were disrupted by various policies of the colonial rulers. Those checks and balances have yet to shuffle back into place. When one compares Nigeria’s population-to-landmass ratio to that of the United States, it is equivalent to herding one-half of our citizens into the borders of Arkansas and Oklahoma—a very tight fit indeed. Nigeria’s population continues to double every twenty years despite a short life expectancy, a plethora of deadly infectious diseases, and an appalling infant mortality. This growth is clearly unsustainable and may well be the tipping point for Nigeria like the murder of Archduke Ferdinand and his wife in Sarajevo was for the start of World War I.

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A population explosion along with an accumulation of other stresses, comparable to Nigeria’s, recently had devastating consequences in Rwanda and Burundi. The resultant crowding caused such an environmental stress on those countries’ citizenry that a short but brutal civil war erupted just last year. Since those countries are located practically next door to Nigeria, I will find that many are still talking about their conflict. The basis of that war was an ethnic cleansing of the Nilotic Tutsi tribe by the Hutu tribe. The motive for the conflict was to provide more living space for the Hutu tribe. This is a pair of tribes that had peacefully coexisted for centuries. The Tutsis’ ancestors were herders who migrated to and settled in Rwanda approximately four centuries ago. Since that time, members of the two tribes have intermarried and worked side by side, and their children have enthusiastically played and schooled with one another. When I would ask what disrupted the social harmony that once existed, I would repeatedly get one of two answers: First, It was simply the result of millions of feet crowding a small corner of the earth. A second explanation was, It was the imbalance in the society’s hegemony, which was long ago imposed by a more powerful third party.

It seems that the origin of this ethnic antagonism can be traced back to the German colonial rule of the late 1800s. Germany was the perennial troublemaker in those days, not only in Europe but also around the globe. Since the Tutsis were perceived by the Germans to have a lighter shade of skin color and finer facial features, the Germans saw the Tutsis as also being the superior of the two races. I have never personally met a member of either tribe, but my Nigerian friends maintain that today there is no physical difference whatsoever between the members of these two tribes. In the 1800s, the German elite, as well as many American scholars, were obsessed with eugenics and the superiority of races. Of course, we all know how that attitude worked out for Germany.

The Germans proceeded to establish the minority Tutsis as the ruling class over the Hutus. This was in spite of the fact that the Tutsis made up only about 15 percent of the total Rwandan population. History has told us time and again what happens when a minority of any population rules over the majority. Any forced hegemony, such as this, breeds contempt, resentment, and often leads to open hostility. Once they begin, these hostilities will become ingrained in everyday life. They will enter the work environment, social organizations, and of course, eventually, the schoolyards. In Rwanda’s case, historic hatreds were amplified by the stresses that naturally accompany overpopulation. These stresses and hatreds were then allowed to build upon one another over the years until the restive population finally erupted. In retrospect, the mistakes made are now ever so clear, and there were ample opportunities to correct the errors. For instance, at the conclusion of World War I, Germany was mandated to cede control of her Rwanda colony to the Dutch. The Dutch, however, chose to maintain the ill-advised status quo that had been previously established by Germany. As a result, this recipe for ethnic friction created over a hundred years ago continued to fester and build throughout the remainder of the twentieth century.

Leading up to the conflict, the Hutus quietly built and cultivated a civilian army. This was an army that lacked any formal military discipline, protocol, and training. It was more like the marauding armies of the Thirty Years’ War rather than the highly disciplined forces we saw in World War II. The Hutus also lacked any modern equipment. For arms, they chose a simple agricultural implement—the everyday machete. The machete is a simple tool that seems to be carried by every African male and is used to facilitate every task. It cuts the firewood, which is used to cook meals, it severs the stalks of kernels from the stately African palm, it cuts down the banana trees, it cuts the grass in the front lawn, it opens cans of vegetables, and it slaughters the chicken for supper and is then used to butcher it. The machete is necessary in almost every chore. It is practically a natural extension of every African’s hand. I suppose Westerners should not have been so surprised when it was selected as the weapon of choice.

In any event, the machete would prove to be devastatingly effective against an unsuspecting civilian population—a population that consisted primarily of women, children, and elderly men. Since no firearms or explosives were being stockpiled or imported, suspicions remained low, and rumors of the impending genocide were generally dismissed as rubbish. Most Tutsis saw the initial hostile overtures as nothing more than a reflection of long-standing ethnic prejudices. Few, if any, imagined the magnitude of the storm, which was brewing just over the horizon. But the gulf between peace and war was slowly spreading wider. And once the killing commenced, only a few weeks of well-coordinated slaughter were needed to take the lives of an estimated eight hundred thousand members of the Tutsis tribe. In the long and colorful history of human conflict, I do not believe the Europeans have much over the Africans when it comes to voraciousness.

Being a well-educated people, the Tutsis were ably schooled on the world’s revulsion toward the Holocaust. Surely, genocide would never be allowed in the modern world. For this reason, they assumed outside help would soon arrive. For this reason, many sought out a place of temporary refuge. After all, machete-wielding civilian rabbles would be no match for the well-equipped and well-trained armies that would undoubtedly be dispatched by the Organization of African Unity, NATO forces, or by a United Nations mandate. This was not a civil war. It was a systematic widespread genocide based on ethnic prejudice. A civilian militia armed with machetes could inflict few, if any, casualties when facing a modern well-equipped army.

But those armies never materialized. The Tutsis’ policy of hide and wait proved to be, at first, futile and, later, fatal. As has practically become a tradition, the West chose to stand back and observe the genocide from the sidelines. This genocide changed reality. The noble reality that all Western politicians swore to in 1945 after seeing the horrors of the Holocaust has been traded for a not-so-noble reality of 1994. The new reality is that some genocides will indeed be tolerated and allowed to go forward unchecked.

Although not moved into action, much of the world was startled as they watched such a large massacre unfold before their eyes. The fact that this deed was accomplished in such a very short time frame and with nothing more than cheap garden-store machetes made the event even more astounding. Western leaders had come to assume that any mass killing or genocide would require more sophisticated machines such as the ovens of Auschwitz or a nuclear arsenal. While the West remained palsied and discussed various options, images of the slaughter and the mass graves began to materialize and appear at our doorsteps on the front pages of our morning papers.

Even the infamous genocide of the Australians against the native Tasmanians took several decades for completion, not days as in the Tutsi genocide. The Tasmania event was a contest that pitted not simple machetes but guns against sticks and stones. This was a campaign of post-Napoleonic firearms and explosives in the first half of the nineteenth century against Stone Age hunter-gatherers. The Tasmanians were not highly educated people like the Tutsis. In fact, the Tasmanians were even noted for their lack of any knowledge of the wheel or of fire. Their few rudimentary tools were constructed from wood and stone, not iron. For these reasons, some academics had even postulated that the Tasmanian natives may represent that forever elusive missing link. During the course of their genocide, the Tasmanians were further hampered by the fact that they were confined to their small Pacific island. They possessed no sea-faring crafts, nor did they have any knowledge of ocean travel. The Australians, on the other hand, were highly mobile both on land and by sea, leaving the Tasmanians as easy a target as ducks in a barrel. In light of all these sharply conflicting comparisons, one could only assume that the Tutsis were much more capable of defending themselves than the hapless Tasmanians. But history once again has taught us that everything is not what it appears.

The Rwanda occurrence had proven that with sinister determination, even a low-tech and unsophisticated farming implement, such as the machete, can get the job done quite efficiently. And get it done with remarkably speed. Many individuals in the West were saddened by the lack of sadness that this genocide generated. But despite the dismay of the citizens of the globe, there was little governmental compassion, as one by one, the European powers refused to intercede as did our own President Clinton.

Genocide is one of the hallmarks of the human race. It separates us from all of our lower primate cousins. Every other species is known to commit assault, murder, and thievery against members of their own kind. As far as adultery is concerned, that is a common practice in every species on earth save a few sea birds. But genocide is a wholly unique and ugly characteristic of the human race. We can only hope that Nigeria’s population explosion and the resultant overcrowding will not guide her down the same slippery slope that led her Rwandan neighbors into their decimation.

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The Rwandan genocide is just one of many failed policies the West has followed in regards to Africa. For instance, Nigeria’s colonial history began in 1851 when a handful of British warships sailed into Lagos Lagoon and seized Victoria Island. The pretense for this action was to shut down that port’s slave trade. In 1861, Nigeria was officially declared a British protectorate. I do not believe anyone was fooled into believing that bestowing the status of a protectorate was a wholly altruistic ploy. Nor was anyone fooled by the mantra that it was the white man’s burden to serve his captives’ needs. In fact, it has been events exactly like this one that has caused historians to give Britain’s days of empire such a tortured legacy. History for the most part has judged this to have been nothing more than a naked act of territorial aggression. It was only one small step in Britain’s long march that would eventually bring one of every four of earth’s inhabitants under some sort of British jurisdiction. Over the succeeding two decades, Nigeria’s geographic borders would be created in fits and starts. In a London map room, those borders were randomly and sporadically penciled in while giving no consideration to cultural divides, religious practices, or linguistics. This, of course, created a pluralistic society that, from that point forward, has been forced to get along or face a stern martial action. In retrospect, it appears that the author responsible for pinning Nigeria’s boundaries had a more ready access to the British Empire’s West Indies’ rum than he did to her East Indies’ tea.

Subduing the Ibos proved to be a much more challenging and time-consuming endeavor than the British had expected. The reason behind their difficulty was that the Ibos were governed, much as they are today, by the local village and tribal rule. Their community leaders characteristically consisted of an assembly of elders or a chief. Common people rather than a deified king ruled. The British were accustomed to dealing with great African kingdoms like those of Mali, Ghana, and Benin. In those large kingdoms, the control of a single powerful king meant control of all his people. In Igboland, there was no such central political authority. All ruling governments were small and regional. The British found themselves in the unusual situation of negotiating and settling with one small Ibo tribe, only to then move on to the next small tribe and start the whole process over again. This Mickey Mouse game of dealing with the independent minded Ibo tribes individually rather than simply subduing a single powerful king proved to be a new and frustrating experience for the British Empire.

Because of the British government’s tradition of keeping accurate records, Nigeria’s past is well documented from 1860 to the present day. Unfortunately, events prior to that have been pretty much delegated to history’s dust bin of irrelevant events. However, if one does choose to look deep into Nigeria’s precolonial history, he will find that its antiquities reflect a civilization and culture that is much older than most. Like all aged civilizations, Nigeria has seen its fair share of high points and low points. Its Nok culture, an Iron Age civilization, thrived on Nigeria’s Jos Plateau as far back as the ninth century BCE.

Over the eons, 250 indigenous ethnic groups with as many different dialects have evolved. While Nigeria has 250 different languages, the continent has over 3,000. Many of these remain today because of ethnic isolation and the remoteness of many tribes. These can, in turn, be divided into three major ethnic groups: the Hausa, Yoruba, and Ibo (also known as Igbo). Despite this, a language that is totally foreign to the region, English, is the nation’s lingua franca. This seemingly strange custom was firmly ingrained during Britain’s one-hundred-year tutelage.

Prior to the forced acceptance of the English language, there was no linguistic unity and precious little commerce between neighboring tribes. The three great ethnic groups and many of their some 250 individual tribes had previously regarded one another, at best, as advisories and, at worst, as mortal enemies. They respected one another’s tribal boundaries under the threat of life or limb. Then came the British. After establishing a common language, a unified system of weights and measurements was adopted. Next, a common system of coinage was incorporated into every tribe. These steps stimulated a vibrant commerce among peoples who had long before had a vague dislike for one another. The natural laws of economics then took over. River trade increased, roads were built, and a postal system was established. The British instituted new mechanisms to resolve conflicts in a civil manner. These practices were much less confrontational than most Nigerians had been accustomed to. These steps went a long way in erasing historical hatreds, in removing ancestral blood feuds, and in dampening many of the prejudices that had formerly existed. The people of Nigeria had witnessed a sea change in tribal interrelations over a very short period of time. Prior to the colonial period, a man born in Nigeria commonly spent all of his living days without crossing outside the boundaries of his tribal area only to be buried in the backyard of the very abode he was conceived in and born in.

Like the citizens of many other African countries today, Nigerians are provided with everyday challenges, including poverty, starvation, infectious diseases, and exploitation by the military juntas. Nigeria has the typical hourglass economy, the haves and have-nots. Those who have control of Nigeria’s oil wealth are in the upper compartment and bathe in obnoxious wealth. The middle class is practically nonexistent. The have-nots are in the lower compartment of the hourglass and suffer abject poverty. Today’s per family income is estimated to be a meager 124 U.S. dollars per annum. Many jobs pay a paltry ten to fifteen U.S. dollars per month. It takes a month for the average Nigerian to make what an unskilled American can make in an hour. This leaves the average citizen wedged between that proverbial rock and hardship. The rock is the citadel of Western versus third-world economic policies. The hard place is the subjugation by the omnipresent machinery of a military dictatorship.

The hospital I will be working in is nestled in the tropical environment that straddles the great rivers Niger and Cameroon. Many of the locals refer to this region as Biafra, a geographic region that became a household term during a brutal civil war that raged from 1967 to 1970. That war was waged in an attempt by the Ibo tribe to break away from the Hausa-dominated government. Along with them, they would have taken approximately one-quarter of Nigeria’s landmass and created a separate nation with the name Biafra.

This conflict was preceded by the demise of Britain’s colonelship in 1960. That year, Nigeria adopted a modern constitution, and the young nation’s future never looked brighter. The brightness soon dimmed, however. The first freely elected republican-styled government did not see a long life, as it was soon overthrown in the usual Africanesque coup d’état manner. Since that time, the government has seen a string of military dictatorships come and go. They are typically separated by the short intermissions that follow the obligatory political assassinations. To the letter, these dictators have been wholly illegitimate. They are neither elected nor heir to a royal house. Each coup brings in a new dictator who plays a very old game.

But the motivation behind these African rebellions cannot be compared to those of our American Revolution, the French Revolution, or the Decembrists. The benefactors are the few who have invested heavily in their own personal agendas. The purpose of these coup d’états is usually a bald-faced capture of the nation’s natural resources. Nigeria is no exception to this rule. Once confiscated, those riches will then be appropriated to the few by the few. Those few will then be grotesquely enriched until someone who is younger and more ruthless but generally no wiser rises to provide a successful challenge. These challenges never commence with a chivalrous throwing down of the gauntlet in the light of day. Instead, they begin with a slinking in the shadows of the dark and a toss of the dice. No time is taken to ponder moral or ethical issues. And there is no conscience to be bruised.

Gen. Sani Abacha is Nigeria’s current dictator. He was the architect, director, and main benefactor of Nigeria’s latest successful coup. That occurred just two years ago in 1993. This made Abacha the most recent newcomer in the musical chairs of African tyrants. These dictators generally have no qualifications for the job and no gravitas. In reality, Abacha is considered to be nothing more than the head ruffian in a gang of thugs. He could never actually win a popular election, nor would he fare very well before Nigeria’s court of public opinion. History tells us that he will eventually be uprooted by another ruffian as the wheel of fortune will continue to spin. One thing seems certain though, Africa does not produce wise and benevolent dictators, not like the kind that made Rome great. The Roman Empire managed to produce a balanced mix of the good, the bad, and the mediocre when it came to dictators. But Africa has never seen an equivalent of Rome’s Marcus Aurelius, Hadrianus, or Rome’s other great emperors.

Since seizing power, Abacha has ruled Nigeria with an iron fist. And the almighty dollar has ruled Abacha. He has a widely accepted reputation of treating Nigeria as if it were his own private fiefdom. The only natural resource that concerns Abacha and his lieutenants is the vast oil reserve that Nigeria has been blessed with. Of course, even more important is the steady flow of U.S. dollars that all that oil transfers into Abaca’s back pocket. I suppose some would argue that the pilfering of a nation’s natural resources is somewhat less odious than a ruler who simply transfers wealth directly from a countries lower class to its upper class by manipulating the nation’s laws and regulations. Because of his practice of imprisoning and executing political opponents, Abacha’s government has been internationally shunned and economically sanctioned. Ironically, the only major item the U.S. government will allow American companies to import from Nigeria is oil. Today approximately 40 percent of Nigeria’s oil finds its way into the tanks of American automobiles. It is this oil that ossifies the relationship between our two countries. And it is oil that causes our administration to view Nigeria’s human rights abuses through a clouded lens.

In response to mounting pressure, Abacha finally allowed free elections. In spite of what most considered a fraudulent election, Abacha’s opponent, Moshood Abiola, prevailed. Abiola was promptly arrested and jailed for treason. The logic follows that if one wins in a freely held election, then he is clearly and openly attempting to overthrow the existing government. And that my friends represent an undeniable case of treason. As evidence to prove their case of sedition, Abacha’s brilliant lawyers have impounded and sealed a long paper trail of evidence: the voter’s ballot boxes. Rarely does the public get a chance to witness such a stunning hypocrisy. But while in Nigeria, I will see several more hypocrisies that defy the base definition of sanity.

A leader who dares to carry out such appalling actions could not do so in an open society, especially one who prides oneself in public exposures and the freedom of speech, for such hypocrisy can only exist when a leader has no concept of disgrace and feels no remorse. There is but one item that can make a leader like Abacha rethink his agenda, and that is the threat of physical might, a force that is more powerful than his own.

The most remarkable thing about many of Abacha’s actions such as this one is that he seems totally blind to the inevitability of his antics. He and his lieutenants have no long-term plans. Their thoughts and decisions never see beyond a week. And their actions seem to focus only on the present and not a minute past it. They see the detention of Abiola as a way to retain power for another day. History has proven time and again that in the long run, such exploits always prove to be self-destructive. Overnight, with one quick and decisive action, dictators like Abacha attain unimaginable wealth and power. But rarely are either long lasting. He will have wealth for only the time he is able to pilfer the country’s natural resources. And he will have power for only the time he is able to fend off challenges to his control of the country’s military.

CHAPTER 3

O N THE MORNING of April 3, 1995, David Oliver, my medical resident, and I boarded a plane in Daytona Beach. With layovers included, the trip is expected to consume approximately sixty hours of flight time and layovers. Our first layover was an eight-hour stopover in Miami. From there, we boarded a Lufthansa jet for a red-eye to Frankfurt, Germany. By American standards, the Frankfurt airport is very Spartan—in fact, tragically bland. The walls are painted a dull institutional green or gray and totally unadorned. The only artwork is a row of vending machines with colorful bags of chips, crisps, and candy bars. It seemed odd not seeing the usual colorful and assorted posters that the American travel agencies so prominently display to promote their never-ending lists of paradise getaways. I had never before appreciated how uplifting those painted scenes of palm trees on white sandy beaches with clear ocean water and shapely bronze sunbathers are. The predominant colors for the walls, floors, and even the airport uniforms consisted almost entirely of drab earthen tones. It seems that everyone in the airport speaks fluent English with little or no accent. I was amazed at how much clearer and grammatically correct the German’s command of the English language is when compared to the British. Security in the Frankfurt Airport is very tight and serious, nothing like our lax, easygoing U.S. airp orts.

The next limb of our flight took us over the Mediterranean and the Sahara Desert to touch down in Lagos, Nigeria. The U.S. State Department presently ranks this airport as the least safe on the globe. Upon disembarking the plane, I was immediately taken back by the hot, tropical atmosphere. The thick and sultry air sucks the previous breath right out of your lungs. It is as if the ether of Newtonian physics suddenly returned. Everyone was funneled to a single line that led us through customs. It was moving at a snail’s pace—a very old and arthritic snail at that. The forty-five minutes wait in customs provided sufficient time for my perspiration to penetrate completely through my shirt and cover its surface. David and I found everyone in the airport friendly and helpful, quite the opposite of what we had been led to expect. One of things that I quickly noticed was the complete absence of any paper products in the public restrooms. There were not even hand towels. I hastily made adjustments to this deficiency by making an addition to the toiletries in my shaving bag.

In the lobby, we hooked up with Cliff Jerrel, the hospital’s administrator. There was no overlooking him; he was the only person sporting a lily-white face in the crowded airport. Cliff is a thin, soft-spoken gentleman in his forties. Despite spending very little actual time in the United States, he has managed to retain a strong Texas accent. His parents were missionaries, and missionary work is likewise Cliff’s chosen career. An ever-present wide-brimmed hat and a long-sleeved shirt protects his fair complexion from the unforgiving ionizing radiation of this equatorial sun. A wispy red Confederate beard and a jester’s mirthful smile are Cliff’s most salient features. I will find Cliff to be a supremely modest gentleman.

We loaded our luggage into a Mitsubishi van and departed for the Baptist mission house. This guesthouse is one of many operated by the Baptist Church. It is but one of those integral parts of their extensive missionary system, and it functions to accommodate Baptist missionaries as they pass through Lagos. If there is room at the inn, they are gracious enough to rent space to pilgrims like us. The drive through Lagos was quite an education in and of itself. Actually, it is quite similar to the documentaries we are accustomed to seeing on the Discovery Channel. The only difference is that this experience is on a much grander scale and incorporates all five of one’s senses instead of only the two that a TV is capable of stimulating. Cliff informed me that Lagos currently has a population of fifteen to seventeen million and about five thousand move into the city every day. Despite this, the city possesses very few municipal services.

I asked Cliff why so many would want to move to Lagos, and he explained it this way, Lagos is the second largest city in Africa, second only to Cairo, Egypt. If someone is going to be successful in Nigeria, this is the place he will come. It has always been that way. The city first established its prominence as the hub for the Portuguese slave trade. Next, it served as the administrative center of a major British colony. Until a few years ago, Lagos was the capitol of the most populous country in Africa. It remains the commercial and industrial capitol of Nigeria. But when growth and corruption made the city chaotic and unmanageable, the government simply packed its bags and moved to Abuja. That was in 1991. Government officials thought that it made more since to simply move than to try to tackle this city’s overbearing and mounting problems.

While driving through the city, it seems strange to see no Golden Arches, no Starbucks insignias, and no Walmart signs. We passed through mile after mile of wooden and corrugated tin shanties fronted by scantily clad natives. This thick moist atmosphere certainly makes clothing lose its glitter. The side streets were adorned with a seemingly never-ending supply of small children. They were in every stage of dress or undress except for shoes. Shoes seemed to be universally absent. It is the lack of shoes, the marginality of clothing, and the items the children choose for entertainment that speak so bluntly to the depths of poverty. A gaggle of kids were entertaining themselves with water-filled potholes and other small septic ponds. Others chose a sundry of even less sanitary items. I am sure that most of these potholes contain fairly harmless rainwater, but others are no doubt filled with the assorted excrements and garbage. Sewage and human wastes are dumped into open ditches, which have no place to run and receive none of the present-day sanitation treatments. This city is in dire need of a major venture such as a cloacae maxima. Every child seems to be perfectly happy with simple toys and an array of everyday items that have been converted to toys. This proves that pleasure can be found despite a lack of the handheld electronic devices that our American children covet. Apparently, no one has yet told these children that they are poor.

At no choice of their own, these children have been born into the bottom level of one of society’s lowest basements. They have been given a lot in life, which is abounding with squalor and chaos. This is a setting where darkness and an ignorance of hygienic practices seem to be nearly complete. On a daily basis, these children are exposed to deplorably unsanitary conditions, malnutrition, tuberculosis, malaria-infested mosquitoes, and a sundry of other revolving pestilent things. This is an environment that places a child’s soul into a physical form that is destined to a life filled with a few precious days of good health and will be assuredly brief.

Numerous open fires lined the streets. Some were contained in fifty-gallon barrels, but most were simply lined in a perimeter by a stone or block boundary. The majority of fires were being used for cooking, to provide light, or to simply supply a soothing ambience. It is entirely too hot to stand close to a fire for any other reason. The large number of small fires created a stationary whitish gray haze that rose into the sky and leveled off at around ten to twenty feet. In the absence of any breeze, it simply settled over the city like a thick miasma over a swamp. Only, instead of swamp gas, this was a mix of smoke and humidity. It all added another uncomfortable element to the already unpleasant air we were breathing. This could be compared to the smog from a Soviet-era power plant or to downtown Los Angeles on a good day.

At