Madagascar

I spent two weeks in Madagascar as part of a joint CDC/USAID team on an assessment visit to help us get start figuringo ut how to spend the money the President's Malaria Initiative has allotted to Madagascar. There are 4 major interventions supported by PMI: indoor residual spraying of insecticide, insecticide-treated nets, treatment of cases with artemisinin-based combination therapy, and prevention of malaria during pregnancy. Our job was essentially to meet with the national malaria control program and all the organizations already doing malaria work in Madagascar (WHO, UNICEF, PSI, CARE Iinternational, etc) to figure out who was doing what and what the gaps are, especially as far as funding is concerned. The first three days were meetings all day that were grueling, but just fascinating. It was a lot of fun to meet with the various groups and find out what people are doing.
Antananarivo is the capital of Madagascar, and is in the center of the country on hills on a high plateau. It's relatively cool, and looks very European. This was the view from our hotel, which was one of the most elegant places I've stayed in - even had a very nice spa and gym! There is a lot of French influence, and consequently a lot of incredible French restaurants. We ate ridiculously well - foie gras, duck, escargots, filets, creme brulee...After three days of meetings and workshops, we split into three groups to do site visits. I went to Mahajanga, on the northwest coast. We visited health facilities at all levels from university hospital to community health center. This is the team in front of one of the community health centers. Learing how things are actually working (or not working) at that level is key!

Our team had a great time together, too. We very much enjoyed going out to eat in the evening and laughed uproariously most of the time! Below are several members of the national malaria control program, as well as representatives from USAID, Basics, SanteNet,WHO, UNICEF, and PSI.

Malagasy (people from Madagascar) are descended from Indonesian peoples who settled here from across the Indian Ocean centuries (maybe millenia) ago. They look very south-east Asian, and the language and culture are also more Asian than African in many ways. (The darkest-skinned person in this picture is actually a guy from Cameroon working with one of the American NGOs!)
A scene from Mahajanga. Though there are taxis, the most common way that people get around is still the rickshaw. It's so hot that sweat pours down you while sitting in the shade, and these guys literally run these little rickshaws around with several people in them! It was mind-boggling. There's so much deforestation in Madagascar that the ocean is red with silt where the large rivers run into the sea.

Sunset over the Mozambique channel, from our hotel. The hotel was called "La Piscine", or the swimming pool - they have a 50 meter pool! It's tiring just to do one lap!

The next week was back in Antananarivo writing our report and wrapping up meetings, before doing a briefing on our findings for the Ministry of Health and partners on our last day. I had volunteered to do the malaria in pregnancy and insecticide-treated net sections, and had my hands full.

I was hoping to have one day to get out to a national park and see some of Madagascar's wildlife in their natural environment. We ended up, as usual, working every single day. I did manage to get to the local zoo the morning before I left - so here's my lemur picture. :)

Ski tripping and future plans

I spent the evening of March 7 - March 11 in Colorado, ski-tripping with a group of EIS classmates and connecting with old friends. One of my best friends from medical school (Mark - now an orthopedics resident in Denver) picked me up from the airport and put me up for the night. Another medical school friend, Dave (who went to Cameroon with me after 1st year of medical school and just finished an ER residency in Denver), was in town, so we hung out with some of their friends. This is Dave.
On Thursday morning, my medical school roommate's mom (who is much fun, and just got inducted into the the Colorado Tennis Hall of Fame) picked me up for brunch the next morning, and then swung by her house with me and completely outfitted me with all the winter sports gear I needed - what a blessing!
I took a shuttle up to Keystone, where the crew was staying - we had rented two condos. My friend from high school, Clay, was spending the week in Vail, and came over for dinner Thursday night, and then came back over the pass Friday to hang out.
I am a complete snow sports novice, and decided to try snowboarding. Clay snowboards, and spent Friday morning patiently teaching me. If it hadn't been for him, I don't think I would have stuck with it - he's a fantastic teacher! (and apparently doesn't need a coat)


Clay got to board by himself that afternoon while I took a lesson, and became quite familiar with planting my tail whenever I felt like it (and sometimes when I didn't). It's a lot easier to sit than stop! :)
This was the crew (or a substantial bunch of them) at lunch - we would meet up and chow down together between morning and afternoon runs. I was amazed at how dehydrated I got!

I took a second full day of lessons on Saturday and became more proficient at standing up all the way down the hill - I find it much easier to go down forward (heel edge) than backward (toe edge)! Definitely still a beginner, but thought I made a lot of progress - sorry I don't have a picture of me looking cool on the snowboard. :) My friend Mark came Saturday for skiing (he's not a boarder) and dinner.My tracks! It snowed a LOT on Saturday, and Sunday dawned bright and clear, so I went snow shoeing. I climbed up about as far as I could make it, sat down on the snow for a while, and had a good chat with God. It was spectacularly beautiful!

Mark came back over the pass to pick me up for the ride back to Denver on Sunday - the combination of clear blue sky and lots of fresh snow over Loveland Pass made for some great photo ops!
I think I'm going to try snowboarding again - improving, however slowly, at something that challenging is sort of addictive! So what's next? I have a CRAZY spring schedule!!!

March 17-31: Madagascar
April 1-9: back to Kenya
April 16-23: EIS Conference (I have to make a presentation on my Niger work, and recruit my successor!!)
April 30-May 15: back to Madagascar
May 16-30: Lord (and ERC) willing, back to Kenya
June 2-8: Paul and Christy (my brother-in-law and sister), my niece Jessica, and my nephew Casey in town!!!
June 28-July 2: in Dallas for my sister Laura's wedding
July 3-July 7: in Madras (India) for my former roommate Aruna's wedding!

I will try to keep this updated! Thanks for your thoughts and prayers!!

Staying busy in February

When I found myself back in the US a full 10 days earlier than planned with a 3 day weekend, I called my friend Lee and drove down to Florida (February 18-20). The rest of the country was under a hard freeze, and it was still chilly in Florida, but it was still fun to fly kites barefoot on the beach and soak up some sunshine and wisdom.
This is Lee flying one of her stunt kites - she very patiently taught me for over an hour, and I started getting the hang of it enough to keep it in the air for 30 seconds - she makes it look so easy!
Taken off the balcony - I bought those pants as my retort to uniform wearing. Back during hurricane season, they had "fatigue Friday" in place of "casual Friday" (to get people used to wearing fatigues), so I found a cute little pair of camo pants at Old Navy (along with little camo flats with a bow on top) to wear this summer on Fridays. :)

Speaking of which, many of you have asked to see a picture of me in uniform. Khakis were not made to look good on women! We had a three day epidemic influenza preparedness training that all the EIS officers came in for, so we once again spent a few days all together in the class room. Sorry - no party pics (I figured they were getting old).

The weekend after influenza training, I drove up to Nashville to reconnect with friends. I had such a wonderful time seeing folks - I miss Nashville so much and am so blessed by all the people who were and remain good friends. My best friend from residency (Sherstin) and I met up there - we're scheming on how to both get back. There's nothing for bonding like getting pedicures together. Can you figure out whose feet are whose?

I stayed in my old place with my Nashville rooommate Aruna, who is getting married this summer. This is Aruna, Sherstin, and I at dinner. And if you noticed a major hair change from the picture in uniform a few days earlier, yes, I still drive up to Nashville to get my hair cut. :)

Back at work..... one of the biggest changes from residency is my activity level. As a resident, you can clock a lot of miles walking around the hospital during the day - you're constantly running around. Since starting at CDC, I have had days where I only get up to pee... had to do something about that....
I bought a pilates ball in place of my desk chair at work - so now, I can bounce around on the ball, wiggle, or roll down it for some crunches or to stretch my back whenever I please. (Thank goodness for an office with a door that closes.) I'm very excited about this new development - it also makes me sit straighter. One of my colleagues commented that it's amazing the lengths I'll go to to show that I'm on the ball....

And finally... the Moscow Festival Ballet included Atlanta in its US tour of Swan Lake this year, so I got a bunch of gals together to go - Swan Lake is my favorite ballet, only they made the ending happy instead of tragic - I prefer the "both of them jumping to their death" ending that the Boston Ballet did the very first time I saw it performed. Hmmm.....

MalariaGirl gets malaria!

I've been back from Kenya for about 10 days and am getting the second installment of my blog for my blog done - it was strategically delayed due to the news. :)
One, I got sick - more below. Two, due to bureaucratic snags in Kenya, it looks like we won't get to run this study after all, which is disappointing, but after the difficulties we've run into with essentially every step, I think anything else I try to do later will seem easy in comparison. :)

This is the clinic at the district hospital where we planned to run our study - this is where all the kids come for their vaccine and sick visits.
I stopped at another clinic and took a peek at what the microscopist was looking at - in this case, a blood smear absolutely chock full of malaria parasites. They look like a little ring with a darker dot to one side. There were probably 100 little rings in every microscope field. The child it belonged to was pretty sick.

So, I am typically very bad about taking my malaria medicine. I can just never remember every day. I usually take doxycycline, which can be hard on your stomach if not taken with food, and can't be taken at night before you go to bed if you've forgotten all day unless you want esophageal ulcers. This time, I took malarone, which has the fewest side effects of any malaria prevention medicine - it's great! Any I remembered to take it every day! Well, 12 days after I got to Kenya (hardly even long enough for it to incubate), I was training our staff and just didn't feel good - stomach stuff and felt weak. I talked to one of my Kenyan colleagues and we decided it was just a little viral bug, but I asked him to pick up malaria treatment at the pharmacy that evening for me. The next day I felt much better. At noon, I was eating with friends, I felt my hand go numb and looked down and saw that my nails were blue - like when it's freezing outside - only it was 85-90 degrees outside! I started getting chilly, then I started getting goosebumps, then I started a real teeth chattering shiver, at which point my friends (my friend Meredith, whose office is 2 doors down from me in Atlanta, was there that week) said I looked pale and mottled and marched me to the lab, where Martin, a Kenyan microscopist who has been doing nothing but look at blood smears for 40 years, did my smear. He didn't find anything on the first slide, but told us he wanted to repeat it in 1-2 hrs. By that point, I had stopped shivering, but my temperature had shot up and I felt horrible. Meredith arranged for a car to take us back to the hotel, and did a blood slide in the car when we got back to the hotel and sent it back to the lab with the driver. By this point, I had some ibuprofen in my system and was starting to feel slightly better - and my temperature was 102.7! So I laid there and waited. We called the lab an hour later - and they said they had found one little sad looking parasite on my smear, but were very excited, and the director of the lab and two guys came over to get venous blood to run some more tests on. I made them do another smear, too, as I knew people back in Atlanta would be skeptical - there were 2 on that smear! My first smear is below - didn't come out very well. The parasite is the darker round dot in the upper left hand - you can't really see the ring.

So I started taking the treatment that my colleague had fortuitously purchased the day before, and felt a good bit better the next morning. My branch director, Larry (in the last installment) came to check on me. I felt good enough to go into work that afternoon, though I rested over the weekend. My stomach still hurt for a couple days, and my appetite didn't really come back for a week, although Meredith persistently dragged me to go eat something. She's so good!

Points this experience really brought home to me:
*I had malaria several times as a child, but I don't remember the bone-rattling chill - something to be reckoned with.
*Malaria is not a big deal if you have access to rapid diagnosis (I had the best imaginable - even in the US it might have taken a couple days) and treatment. The reason it still kills a million people (mostly young children) every year is because they don't have access to the same - whether they live too far from the nearest clinic, or they can't afford the treatment (cost me $6)...or if you're a dumb American (no offense) and you sit at home and don't see a doctor for a week with fever after you've traveled to a malarious area .... or your health care provider doesn't think of and test for malaria... (but there are only a handful of those every year - 7 in 2005 to be precise)
*You can still get malaria after taking prophylaxis (although this is extremely rare - they are testing my blood for drug levels to see if I don't properly absorb malarone), although this is NOT an excuse not to take it. You just have to know it can happen. Because I was taking prophylaxis, there were very few parasites on my smear and they looked atypical (although clearly enough to make me feel really yucky!!), which could have made diagnosis tricky.

Anyway, glad to be back and feeling back to 100%!

Kisumu, Kenya

Hi from Kisumu! I'm here to set up for a clinical trial - we are testing three different antimalaria regimens (all approved drugs) in children with malaria. We are still trying to get the protocol through the approval process, but in the meantime are out here making sure our data collection system, lab supplies, personnel hiring and training, and study site are ready to go the minute we get approval.
Below are "the team": Meghna (in the middle) grew up in Tanzania and has worked in Kisumu before. She is Atlanta-based and is supervising me on this project. She was absolutely fabulous to travel with (even 5 months pregnant), completely in her element here, and great to work with. On the right in Frank, who is Kenyan and the study coordinator for the main trial that ours is a part of - Frank is incredible, totally organized, and one of those people who makes things happen, plus he's really nice! Chris, on the right, is the study coordinator for Meghna's and my study - also incredibly terrific. We have worked so well together over the past few weeks - he's a very hard worker, and totally on the ball.
Here we are in the clinic room of Bondo District Hospital that we will use for registering and examining the children in our study, planning clinic flow.

So, I haven't gotten out on any wild adventures yet, but it's fun to sit by Lake Victoria, only sometimes you wouldn't necessarily realize you're by a lake! Several years ago, water hyacinth was introduced to Lake Victoria, according to local tradition, by a British woman. Since then, it has practically taken over much of the lake in huge mats, and according to Frank, "looks like a football pitch" (soccer field). The green "field" in the background of this picture is actually part of the lake. It has resisted both mechanical and biological (special beetle that eats water hyacinth) attempts at control.

Close-up of water hyacinth - apparently the mats get so thick you can walk on them. It seems maybe they are not all bad, even though the fishing industry has tanked. Formerly, the Nile Perch (another introduced species) was decimating the Lake Victoria cichlids (colorful little fish, often found in pet stores, many species found only in Lake Victoria). Since the introduction of water hyacinth, the cichlids are making a comeback. Another ecologist had predicted that Lake Victoria would be "dead" due to industrial waste in a decade, but the water hyacinth seems to play a role in re-oxygenating the water and keeping it healthy. :) Oh, the tangled web we weave!


Back to people - this is Mary Hamel, the malaria branch chief here in Kenya (and the Kenya-based primary investigator of the study I'm working on - there are many cooks in this kitchen) and her daughter Yala (named after a river here). It has been fun to get to know the CDC community here - they often all go out to the same place to eat, usually a place where all the kids can run around together and then adults can socialize in peace. Reminds me a little of my growing up. Yala is a lot of fun - very high energy, needs constant stimulation - I love grabbing her and going for a walk, picking flowers, touching the hippo signs at Kiboko (hippo in KiSwahili) Bay.


Me by Lake Victoria - can actually see some Lake in this picture!


Sunset over the lake


Some EIS officers work a lot with their supervisors - not so much in the malaria branch. My predecessor crossed paths in the field with his supervisor once - by accident. I don't think I will ever cross paths outside Atlanta with my primary supervisor, Rob, but my secondary supervisor is the CDC Atlanta Malaria Branch chief (Larry Slutsker), and he was here for an unrelated visit, so I had to get documentation that I had been in the field with one of my supervisors once. :) Below are Larry and I. He just finished a 4 year stint being director of the field station here and just loves Kisumu.

Hanging out in Seattle (and Victoria)

I spent the week between Christmas and New Year's, staying with Jay and Jennie, being a slug - although a slug having a lot of fun (no salt) - we went to a hockey game, went out for sushi, hung out with Jennie's friends, had Starbucks (and Starbucks, and Starbucks), watched movies, met up with an EIS classmate, took Grandma out for lunch, raided each other's digital music collections....
Here I am in front of the UW library - Jennie works in the U District on the Ave, so I walked around campus with Jay on our way to pick her up from work. (He's an archeology PhD student at UW and does field research in Corsica during the summer - tough gig!)

Out with Jennie's friends from work - definitely a fun bunch!

Coffee with Jennie and Jay! Wouldn't be a trip to Seattle without it!

December 30-31, Jennie and I drove up to Vancouver and took the ferry across to Victoria to see some friends I had met in Costa Rica earlier this year. On my May vacation, I went to a tiny little beach town on the southern Pacific coast (Uvita). The only other people in the hostel when got there were three Canadian college guys. They were going to eat when I got there, and I was hungry, so it was a natural alliance. :) I hung out with them all week and had a blast! They were so good about hanging out with a girl and totally made my vacation - Costa Rica picture after swimming in a waterfall for reference below.....So, I decided to go see them in Canada ... different attire, but just as fun! They put us up, let us meet their families, showed us around Victoria...... fed us, entertained us, took us to a hockey game.... I asked Jennie if all Canadians are this great, or if I had a biased sample - she thinks they're mostly this great. Maybe I should move to Canada, eh? I like the flag. :)

Christmas in Seattle

For Christmas, I flew up to Seattle to spend time with the Thwing family. I'm very close to my cousin Jennie, who is 6 weeks younger than me. Her dad is my dad's older brother, and I have spent Christmas with them almost every year since my parents went back to Cameroon. This is brunch on Christmas morning with Uncle Ted, Jennie, her husband Jay, Aunt Cathy, my cousin (Jennie's brother) Andrew and his wife, Christy. It's always delicious!


Stocking and Christmas present time! I think Jennie and I have a picture of us just like this at age 2, and for a good many of the years in between!

Jay "wearing" the tree skirt - you know, when you're six foot four, no one can make fun of your clothes!

Later in the afternoon, the extended Thwing family comes over for our family Christmas celebration. This is my grandma - it's such a treat to spend time with her!


After a great dinner, we play our own version of a white elephant gift exchange (although the presents are actually nice), which gets very funny and occasionally rowdy! Here are some aunts and uncles enjoying a good laugh.

After presents, we always have Jesus' birthday cake - one candle for every family member and guest - some guests become permanent family members (this year, we had a third Christmas engagement announcement) and some last a year or two, but everyone gets a candle. It takes longer and longer to light! And the youngest - this year Payson - gets to blow them out!

Merry Christmas!

Pre-Christmas

December was unseasonably warm, even for Atlanta - we had multiple 70 degree days - I took myself to the zoo on a particularly gorgeous Saturday afternoon. I love the gorillas!
Sapna and I got a Christmas tree and had the "ashram" over to decorate - this is Vishnu, who came from India this year to marry my friend Nandini, decorating his first Christmas tree!

Class Christmas party - any excuse to wear a little black dress, right?

I actually also got a lot of work done in December - we finally finished the analysis of the Niger data, and I spent a lot of time on the final report, both written and power point, which I had the opportunity to give for some visiting representatives of the Canadian Red Cross, who had funded the bednet distribution. I'm also working on getting a study for the coming year in Kenya off the ground, as well as hounding the states to get their last few reports of malaria in for 2005 so I can start working on the 2005 domestic malaria summary. There's an annual summary of all the cases of malaria treated in the US that the first year EIS officer does - and this year, that's me! I've been telling people I'm giving birth to triplets - trying to juggle all the projects and keep them all going forward.

I flew to Dallas for my former roommate's (Aruna) official engagement ceremony. It's a pretty long ritual, involving the whole family - I think you must feel very engaged after it's all over! This is the whole family gathered around to take part....

And the beautiful couple - those wreaths around their necks weigh a ton!

Being in Dallas all weekend allowed me to hang out with my little sis and catch up with some extended family. My Grandpa Will has had a rough patch lately and is now in a rehab hospital, so I went with my Grandma to visit him. He's looking pretty good for his 90s, eh?

My mom's youngest sister Gayle was in from Arizona, so I got to spend some time with her. In the picture are: my cousin Jodi, my aunt Gayle, my sister Laura, me, my Aunt Jeri, and my Uncle Rick. I hadn't gotten to see them in awhile, so it was a special treat!

Thanksgiving!

Yes, these were my feet at Thanksgiving! I drove down to Florida for Thanksgiving to visit my friend Lee, who lives not too far from Destin, Florida. It was spectacular! One afternoon, I took a walk down the beach several miles to the town of Seaside, where "The Truman Show" was filmed....Bought some fresh seafood and made Lee and Dave my favorite shrimp and my favorite mussels..... Read on the balcony......

Sunrise off the balcony in front of my room - Lee's house is the kind of place that beckons you into conversation with God. Who can wake up to a view like that in the morning and not feel compelled to say hi (and thank you) to God?

At sunset, Lee, her son Dave (who was there from the Navy base in Pensacola), and I would haul wine, cheese, fruit, and crackers up the turret to the top balcony for happy hour and sunset watching. This is Dave and me.

Lee and Dave at happy hour in the evening sun

The last rays of the setting sun...I hope to be back!