**If you are in the mood for a disgusting human interest tale (in the "slow down to stare at a car wreck" kind of way), this is the blog for you! Welcome to the detailed (yes, detailed) stories of the three times I was quite sick in Senegal.
It might look like I was just pissing around in Africa for two years, but in reality I was a health worker, focused mainly on malaria, but I also did a bit of work with nutrition and sanitation.
Prior to my arrival in the village, I had not thought sanitation or nutrition to be things I would put much focus on. I wanted to work with malaria, as at the time I wanted a career in disease management in Africa. After my arrival in the village, however, I realized quickly that sanitation was going to need to take a bit more of a starring role than I had previously thought. This was not due to any difference in the importance of sanitation issues in the village over malaria, but more due to a relatively selfish reason - it was incredibly easy to prevent myself from getting malaria.. It was not easy to prevent illness in a community that never used soap and had little sense of proper hygiene techniques. This was especially true during the Rainy Season, when heavy rains allowed for fecal matter from animals and children to flow through the paths of the village.
To give you a general understanding of one of the main hurdles facing the global health sector, the germ theory is not known in much of the developing world. There are many educated Senegalese who are well aware of how one gets sick, but as a general rule in the rural villages, children do not go to school and thus are never told how disease cycles works.
People know that washing their hands is important, and that soap is a necessary component of proper hand-washing, but often they do not really know why. One of the main ways I would try to explain the germ theory was this: I would go to the market and buy a dried chili pepper. At the trainings I held, I would grab a "volunteer" and rub the pepper on their index finger. I then said, "kaa maa ila ñaa" - touch your eye. The crowd would gasp, giggle, and the volunteer ("volunteer") would refuse. "Munketta?" Why? "Kaatu a diminta bakke!" It would hurt! I would then go on to explain that this is how diseases work. Germs end up on your fingers, you cannot see them but you must wash your hands in order to ensure you will not be hurt by them. The pepper would then be washed off with the water and soap I provided, they would touch their eye, and all would be well because yay soap! Who knows how many people bought soap on the way home from the training, but hey, I tried.
Which brings us to an even bigger issue faced by health workers the world over - behavior change. People aren't stupid, even if they don't know how diseases are transmitted they still know the steps they should take in order to prevent them. They just...don't take them. Nor is this by any means constrained to the developing world. Imagine it is January, the height of flu season, and you find yourself at a fast-food counter. I'll be the first to admit that I don't go to the restroom to wash my hands before I eat my burger, and I'm willing to bet most of you don't either. Sure, we've washed our hands since the last time we went to the bathroom, but how many door handles have we touched since? It's that we are complacent about the flu, even though it is a dangerous disease that kills tens of thousands of Americans every year and millions more across the world. It is the same in Senegal, but instead of the flu they are complacent about malaria, cholera, tuberculosis, etc.
In addition, in my village and in much of the developing world, the left hand is used to wipe oneself after using the bathroom. Admittedly, it took me quite a long time to finally shed my Western disgust at this concept and start using this technique but now that I am back in the developed world I often find myself missing it. A kettle of water was available next to the bathroom (typically a hole in cement, as seen on the left. This photo was of my toilet, and no, the collapsed ground around it is not normal. We had just had a huge rainstorm and the sand had sunken in. Normally, the sand was as high as the top of the cement.) To use the bathroom, you squat and once you are done you pour the water over the necessary area while using your left hand to wipe. This system was certainly faster than toilet paper, and resulted in a lot less raw flesh during times of illness (the opposite of raw flesh really, as water is soothing). Now, when I used my left hand, I ensured to practically rub my skin right off my hand with the amount of soap and scrubbing I did afterwards. This was not the case with the locals. The kettle would run over their left hand for a couple of seconds, they would rub their fingers together quickly, and that would be that. No soap, and the right hand never even got wet. See the problem?
To further explain the situation, shaking hands is the most important form of greeting in Senegal. Every time one greets another, a hand shake that can last over a minute ensues as greetings are exchanged. On average, I probably shook about 30 hands a day, the same 30 hands I had shaken the day before. While it was always the right hand that was used, the fact that our left and right hands are constantly touching one another means that the right hands were just as dirty as the other. In addition to this issue, meal times in Senegal see families gathered around one bowl, eating the rice not with utensils but with their right hand. Not to mention everything that is touched throughout the day. Etc. Etc. Etc.
Basically, its pretty much a guarantee that everything is covered in fecal matter. I was very careful about my eating mates (usually my 13 year old host sister Amine); they were always required to wash their hands thoroughly before we sat down at the bowl. But the cooking was done with dirty hands, my phone was dirty because my hand got dirty throughout the day, etc. There was no escaping it.
Somehow, my stomach was surprisingly resilient for the first four months in the country. One by one, my fellow Peace Corps members fell ill, but I magically stayed strong. Until I didn't. And hoo boy, how the mighty fell. In total, it took three bouts in Hell before my body finally gained what I have since referred to as a stomach of steel.
July 13-14, 2014. Dysentery, round one: I only remember the exact dates of this, the first and most dramatic of my illnesses, because it was the day of the World Cup final and my team (at the time), Germany, was playing. I, along with two other Peace Corps friends, were visiting a third PC friend in his village. I had only been in the country a few months and this was to be my first time visiting another PC village. I was excited for the experience, but I also brought along my little transmitter radio because I wanted to listen to the game.
I was going to describe the trip but my friend already wrote a blog describing the whole weekend and she has more writing talent in her pinky finger than my brain ever will, so do read this. I promise you will not regret it (but don't forget to come back!)
For my side of the latter half of that blog: I woke up the morning after the training feeling completely fine, but as we walked through the market I began to feel tired, weirdly so considering the excellent night of sleep I had (sorry again, Kathleen, but I still blame Miles because he was the one who had pushed everyone to the edge of the bed. I was just taking advantage of the open space!). As I sat with them while they ate lunch, I realized just how heavy I felt. Luckily, we decided shortly thereafter that our shopping was done, so we all went back to our host's compound and took a nap on the bed, from which I felt no refreshment upon waking. We then wandered over to the area where the horse carts were going back to Miles' village. The other three stood around and joked with each other, but I sat on the ground while we waited. I was just too tired. Finally, a cart was leaving and we hopped on. While a bouncing ride was not exactly what I needed in that moment, at least I had two good friends with me (Adam was following on his bike) who were making me laugh. As the photo above indicates, you can smile through even the worst fevers if you've got friends!
Upon arrival, I felt too sick to greet Miles's villagers. This should indicate just how bad the situation had become, because forgoing the greeting process is a huge faux pas. But I simply could not do it. So instead, the three of them went to greet while I crawled into the bed Miles had outside. To add insult to injury, I tried to turn my radio on to at least try to experience something enjoyable, but my batteries chose that moment to die. I didn't find out that Germany had won for days! Instead, I slept on and off for the rest of the evening, forgoing dinner. I fell asleep soon after they ate dinner and woke up the next morning feeling somewhat better. However, I still did not feel well enough to join my friends as they explored the village, so I stayed behind and napped. As I lay there alone, my stomach finally gave out.
Now, a reminder that the bathrooms in Senegal are holes in the ground. With my fever back over 104 (40 C), I kept having to crawl out from under the mosquito net, get over to the bathroom, take my pants and underwear completely off, squat with every ounce of strength I had left, and then somehow struggle to put my legs through two articles of clothing again and get back to the bed. In total, I had diarrhea (and thus that entire process) about 15 times that day. This experience was made especially horrible when I didn't quite make it to the bathroom one time, and so had to not only to do all of that physical work with the fever but also had to scrub my pants with soap in order to clean them.
As a fun aside to help you forget the image I just created, the Mandinka word for diarrhea is one I always enjoyed - konobayo (cone-oh-bye-oh), which directly translates to stomach fabric. As in, your stomach is losing its lining. Love it.
Anyways, we called the Peace Corps doctor and were told that I needed the medicine that somehow none of us had. It took a few hours of stressful travel, but eventually we got back to her town. I vaguely remember getting off of the motorcycle, walking through the door of Kathleen's hut, and promptly face-planting onto her floor. She came in a minute later (after paying the drivers), made me roll over, and administered a quick malaria test (a finger prick) even though we both knew I did not have it. She then kindly gave me her Cipro, the miracle drug of miracle drugs (but you'll have to wait for Story #3 for a better explanation as to my affections for that little drug), That's the last thing I remember for several hours. I slept and slept hard. I woke up that evening to find her sitting in her chair, finishing the blog that is linked above. I was feeling a bit better, and due to the long nap I had taken, I did not fall asleep again until well into the night. The next day, I felt completely fine. Ah, Cipro.
As a fun side story to this experience that further emphasizes the importance of greeting in the Senegalese culture, while I lay deeply asleep on Kathleen's floor, her host mother came in to say hello. She first greeted Kathleen and then tried to greet me. Obviously I did not respond. She tried again, nothing. She then turned to Kathleen in an angry voice and said, "your guest is not greeting me." According to Kathleen, it took her a very long time to forgive me for this transgression.
Late July 2014. Simple food poisoning, I think, but god damn: Just two weeks later came the end of Ramadan. As I detailed in the Eid blog, there is a large celebration to mark the end of this long month of fasting. I had been looking forward to experiencing my first Muslim holiday. However, around 2am the night before, I awoke and rushed to the bathroom. Luckily, I was sleeping outside that night (the photo is of my bed in the Rainy Season) and thus only had to walk a few feet. Hoping that was a one-time thing, as I was still traumatized by what had occurred two weeks prior, I nervously went back to bed.
These nerves turned out to be justified. I was terribly ill for three days. The first day was a day of nightmares. I kept track out of morbid curiosity - I had diarrhea 32 times and threw up 12 times that day. Yeah, you read that right. The second day it was somewhat better, at a mere 18/7. Finally, day three saw fewer than 10 diarrhea incidents and no vomiting.
*To keep with our Mandinka education tradition: vomit = foono (f-oh-no).
Though I had no fever with this sickness, when I reflect on my times of ill-health in Africa, this is the time that scares me the most. To this day, I do not understand how I wasn't in a lot more danger than I seemingly was. Not only is that a loss of fluid on a monstrous level, but I was taking nothing in. I could not eat, and every sip of water was torture. I could barely drink it and thus did not. I lost all of that liquid without replenishing it and yet somehow was ok in the end.
I do remember how incredibly weak I was. By day two, I couldn't even walk anymore, I crawled rather than walked from my hut to the toilet, had to use my hands to hold myself up as I squatted, and then crawled back. I didn't have the strength to get into bed, so created a nest of blankets on the floor of my hut. I did read the entire Hunger Games series during this episode, so at least I was somewhat keeping my mind off of the possibility of death. Well, my own anyways.
Why did I not take Cipro the Magic Drug, you ask? Well, dehydration makes you stupid it seems. Only two weeks earlier, I had had serious diarrhea (though nothing in comparison to this), but I had also had a serious fever. My temperature did not even raise one degree this time and thus I decided that I did not need any medicine. Yeah. Stupid. Again, there is a reason that it's this time that scares me from the ole' "what if" perspective.
What was especially frustrating was that, again, this was Eid. It was a big day, plus it was my first holiday! People kept coming into my hut to ask why I wasn't out celebrating, though once they saw me huddled in my nest they merely wished me well and went on their way. Some came back later with bowls of the meals they had made, but I couldn't eat them. My host mother nearly force fed me hers, saying that I needed to eat (which was very true) but I can be stubborn and ultimately she left in a combinational huff of exasperation and concern. The photo is of the two of us at the next Eid three months later, when we were both in much better spirits.
The fourth morning, I finally woke up and was feeling better. Weak, but no more stomach issues. It took a few days for my appetite to return but I did catch up on my water levels as quickly as possible. To this day, I do not know what this was. Diagnostic mechanisms necessary for such things do not exactly exist in the bush of Senegal, ya know? My best guess is food poisoning from poorly washed hands, but I don't know.
Mid-October 2014. Dysentery, round two: Another three months passed, and I was lulled into a false sense of "my immune system has caught on!" I went into my regional capital of Tambacounda one day in order to get some work done (read: use the internet to Facebook with folks back home and whatnot) at the Peace Corps owned house there. I arrived to discover that several other Peace Corps members had the same idea, and there was a small party. Halfway through the day, a large storm rolled in. While October is still Rainy Season, it is the tail end and thus this caught us off guard. It also took the power out, and without power people decided to head over to the local bar and start drinking. I wasn't in the mood, however, and my laptop had a full charge. So instead, I bade them farewell and watched "Boyhood." At nearly three hours, this was a long movie. I enjoyed it immensely, though about halfway through I began to realize that I was not feeling tremendous.
As luck would have it, right as my laptop was showing signs of a dying battery, the power came back on and I was able to finish the movie. However, I was not paying nearly as well attention as I had in the beginning, due to the fact that I felt as though I had been hit by a truck. I dug around and found a thermometer, and was shocked to discover that my temperature was at 104 (40 C) again. 0 to 104 in less time than a movie takes to finish. I needed to use the bathroom shortly afterwards, and then immediately found my Cipro and began the five day treatment. The similarities were too strong between this and what had happened in mid-July - both times, I went from being fine to having a high fever in the matter of hours, followed by stomach issues. And I wasn't going to make the mistake of not taking medicine this time, like I had with the mother of all food poisonings. I called the Peace Corps doctor to tell her that I was taking the Cipro and would need a new bottle of it. She promptly ordered me to come to Dakar, the capital of Senegal.
Now, this I was not expecting. It was an eight hour drive to Dakar from where I was, plus a taxi ride in Dakar itself. It was expensive, and I had work to do in village. I argued with her for a minute or two before meekly apologizing and telling her I would see her the next day (damn, if she couldn't be scary when provoked). I went to bed, and woke up the next day feeling 100% fine. I called her again and asked if I still had to come. The answer was yes. Eight hours cramped into a tiny, uncomfortable car was not my idea of a good healing time, but I followed orders and about nine hours later I arrived at the Peace Corps medical team's doorstep. They gave me the key to the sick bay, where I was to remain for the next week while they observed me.
This began a whole different ordeal. Peace Corps pays its workers once a month, and this occurred at the very end of an expensive month. Aka I had no money in the country's most expensive city. Nor would I be getting any for three days. I grumbled to my Dad about this, and he researched how to wire money to Senegal from Minnesota while I went to bed hungry. The next morning, I awoke to a message from him from the night before, saying that he had sent money via Western Union. I went to the nearby bank and after an hour of quietly swearing as I tried to figure out how on Earth to collect the money, I walked out with the funds and promptly headed for anywhere that would give me food (as at this point I had not eaten in nearly two days, which is obviously unideal when fighting an illness!).
Despite it's poor beginnings, this turned into an enjoyable week. Dakar is a lovely city, probably one of Africa's best. Now that I had money to enjoy it, I had a blast. The Cipro ensured that I felt fine, and I spent the week eating Western food (a treat) and relaxing at a nearby hotel's pool. I mean, just look at that! Woe was me, amirite?
Plus, this week gave me the knowledge of that pool! Seven months later was my 26th birthday, and two of my good friends helped me celebrate at that very same pool (and the beach next to it, as the photo shows). And I can't really complain about a week of pizza and swimming, now can I.
*Back to the Cipro. I promised I would tell you about its miracle ways, didn't I? To explain just how powerful this drug is, I began to take it Thursday night. It is a five day course, so my last pill was Tuesday morning, right before I had a blood test. I had felt completely fine since hours of taking the first pill. Yet, when the blood test came back, it showed my white cell count nearly off the charts because my body was still fighting a nasty infection. This little pill allowed me to lead a normal life while my body dealt with the rest and I will forever be grateful for whoever created it.
Following these three events, my immune system was finally able to handle the Senegalese sanitation levels. But they were a reminder as to the dangers of not washing ones hands properly and they spurred me to focus more of my work on sanitation.
As I worked, I used different tactics depending on the audience. For example, men are in control of the money in Senegal. Women often cannot buy things without their husband's permission and thus I needed to target the men in order to convince people to have soap in the first place. The excuse given when I asked why a household had no soap was always, and I mean always, "saafuuno kodo siiyaata" - soap is expensive. Now, in reality, soap is not expensive. Every single household in that village could easily afford soap, this was merely the excuse they used whenever they did not want to spend what little money they had on something. And I can't blame them per se, who would want to spend their limited funds on something as unsexy as soap when they could get themselves a new outfit, or, more excitingly, the mint tea that is popular across the Islamic world (called "wargo" (wah-r-go) in Mandinka, the local specialty was to add about 20 pounds of sugar (ok, so maybe I am exaggerating slightly) to the mint tea bag and then pour it into shot glasses and slowly sip. See photo above for a picture of this delightful little drink. It is one of the things I miss the most about Senegal). I tried to explain to the men that more money was lost in wages due to sickness than was lost on the soap, but this fell on ears that never quite wanted to hear it.
With women and children (school groups, mainly), I focused more on the facts. I loved the pepper trick that I described above, and I would try to convince them to talk to their husbands/fathers about the importance of soap. I always ended each training, no matter who the audience was, with a demonstration of proper hand-washing techniques. Length of time needed, how much soap to use, stuff like that. It felt a little weird sometimes, teaching grown adults how to use soap, but it was just another check to throw in the "wow, the experiences of the world's seven billion people vary dramatically" category.
However, as my immune system did its thing and I became more used to (read: less grossed out by) the sanitation levels in the village, I unfortunately joined in the complacency. I went back to working nearly entirely on malaria efforts. And this is what happens. People know how dangerous these diseases are, every single one of them has been as sick as I was. But they are so common, so widespread, that the problem seems too big to tackle.