Thursday, June 25, 2009

Wednesday, June 24, 2009


After returning to Yawpasi from Baixao Novo, we had to wait around for a little while to find a canoe to take us back up the river. The man who had been so sick days before was now walking around just fine, playing pool with his friends. I was feeling better too. I liked the idea of rejoining the group, of not have to ever ride on that road again in my whole life. Hedley had seen one of the ATVs flip over the first night we arrived in Baixao Novo. It frightened him, even though no one except the driver was riding and somehow he didn't even get hurt. He said later that maybe there are just some places that are not worth the risk to the team to reach. He said, when people make a decision to live that far away from the rest of the world, they can't expect that we could help them. And they probably don't expect any help.

We took the three hour canoe ride back to near Cabana-Fort. The river was so beautiful and peaceful. Even as it got dark and a little cold, I was feeling happy that I had this oppurtunity to see this part of the world. We are taught as young children that the rainforest is this special place, so to actually spend so much time in did make me grateful. I saw lots of interesting plants and flowers, bright blue butterflies. I only saw one monkey in the wild, and three that were kept as pets. I also saw a domesticated macaw and Amazonian deer. The first night in Baixao Novo I woke up in the early morning to the most horrible sound I have ever heard. It was a low, airy growling sound. Not the way a large cat would growl, but in my sleep I imagined a giant, ancient sloth-monster being disturbed and expressed his displeasure. In the morning Hedley asked if I had heard the howler monkeys. I'm glad he told me what they were; I might have gone on thinking that the terrible noise was something created only in my mind.

Out of the boat and into trucks and down a dirt road to Benzdorp, and then on to Antino where the rest of the group had already gone. The campsite at Antino was worlds better than any other place we had stayed. There was toilet paper readily available, and running showers. At the other places I had had a hard time even getting confirmation on where I was supposed to use the bathroom. This was the first place we stayed that was not a sometimes brothel, the first place lacking amorous graffitti on the walls and stains on the mattresses. I never really figured out just who normally slept in the dorm-like rooms at Antino, but the food was good and the people who worked there were really cool. And the roads around Antino were so much better than at Baixao Novo that I really started having fun on the ATVs when we went out to visit the little garimpeiro camps surrounding the area.

We would go out in teams of two to test for malaria. I would just do the intake form and teach anyone who owned a bed net how to treat it with insecticide to make it more effective against malaria. I also took GPS coordinates of the camps, asked about anyone absent at the moment we were there and took pictures of the lack of bednets in the hammocks where the garimpeiros slept.

The night we returned from Yawpasi we had to drive through Benzdorp to reach Antino. This is a fascinating town. There don't seem to be any structures that are simply houses; everyone has a bar or grocery or pool table in front so that they can make some money. There were colored lights at all the bars and forro and sertaneja music drifting out of them. In most places there was a television playing the current novela, Caminho da India, coming in via satellite. The roads were unpaved and people drove ATVs through the streets instead of cars. When I went back to Benzdorp to help with a net-treating presentation, I learned a little more. Everything is priced in gold. Nobody wants Surinamese dollars, nobody speaks Dutch. I took a great picture of a sign in a Chinese grocery store of food listed in Portuguese and Chinese and priced in grams of gold.

For example: one litre of coca-cola would be 2 decigrams of gold, or 4 euros.
one can of beer might be 3 decigrams of gold, and a case would be 1 gram
What occured to me was that I would never be able to afford to live in this city. The streets were unpaved and most buildings seemed not to have indoor plumbing- and I couldn't afford to buy a coca-cola here. It must be the most expensive slum in the world. I asked Hedley about it, how lacking indoor plumbing was an indicator for poverty, but you could argue that people walking around with little pouches of gold couldn't really be called poor, could they. He said, well, who makes up these indicators anyway? Do these people think they are poor?

The priorities of the garimpeiros are strange. You may not have a toilet, but you might have satellite tv. You might not pay for a mosquito net for 5 euros, but you would buy a beer.

But the garimpeiros were also very generous with us. Every camp we went to we were offered coffee or cola or even beans and rice and cake. Knowing how much food costs in retrospect makes these offers even more heartening. It's hard not to like these people- for me anyway. They are destroying the rain forest and releasing mercury into the air- but they are good people, respectful and generous. I was nervous about the men before I went. I thought I might get harassed. I was told it was dangerous in the gold mines, that I should never be alone. But I think it's dangerous in the mines the way it's dangerous in New Orleans. If you don't have a big cord of gold around your neck and aren't walking about insulting someone's don't really have to worry. I felt totally comfortable walking around interviewing people by myself- I received nothing but respect. It probably helped that I was wearing a uniform with a name tag and was talking about malaria, which is a real concern for people here.

playing shoebac with my colleagues

We left the following Monday. I'm sure I forgot several good stories, maybe I'll add them later. I hope I didn't leave you with the impression that the trip was a negative experience for me. It was an amazing thing that I feel very lucky to have been apart of. From a public health perspective, from a pushing-your-personal-limits perspective, I can't imagine a better internship. Today at the clinic I saw a young woman just in from France. In every one of her front teeth shined a small diamond. But she didn't have a mosquito net.

Tuesday, June 23, 2009

All Terrain Vehicle (ATV)

Warning: This post is not safe for mothers to read.

This trip was hard for me. I think it was the hardest thing I've ever done. I just wanted to say that upfront. I think if I had been a different person there would have been several meltdowns along the way. Instead, I just dealt with it. A major reason it was hard was the road from Yawpasi to Baixao Novo, a garimpo in the middle of nowhere Amazon. The road coupled with the ATV almost broke me in half.

So, an ATV is like a magical 4-Wheeler that never gets stuck in the mud, can walk on water, can climb vertical mountains and not flip over. Well, it almost never flips over. Hedley at one point said "I've seen them do things that shouldn't be possible with the laws of physics." At one point on the road, I noticed a warning sign on the ATV. It read:

Never carry a passenger. (insert picture of just one person on the ATV)
Always wear eye protection and a helmet. (insert picture of googles and helmet)
Never operate while intoxicated.

There were some other rules, but I can say these first three were all broken right away. Three was the minimum number of passengers, sometimes four and when ATVs popped a tire sometimes five people rode up and down the mountains on these machines. We had life vests unless the canoe sank, but no helmet for the ATV. And our drivers, awesome though they were, didn't think anything of whiskey and beer before taking our lives in their hands. One even filled up the ATV with gas with a cigarette hanging out of his mouth.

The ATV was fun when it was just three people and for the first few hours. But it went on for hours and hours and people got added to each vehicle as one lost a tire. And the mountains got steeper and the mud thicker. And then it wasn't fun at all, it was hellish. I don't know how long the ride was, but it went on forever. We were nowhere. It isn't even on a map. At one point during the trip I was introduced to the man who had built the road. Someone pointed to him excitedly and said "He's the one who built the road from Yawpasi to Baixao Novo!" I didn't know whether to be impressed or angry. I don't think God meant for those two sites to have a road between them. Frank turned out to be really cool, he's Surinamese and speaks 6 or 7 languages including Portuguese. But the road is not a work of great engineering; no effort was made to prevent erosion, to zig-zap instead of plow straight up and down. The road went right through streams, no bridge or anything. Why build a bridge? ATVs were built to swim! It was work to ride, sometimes we had to get off when the road was too steep and muddy; but how the driver decided what was too steep and muddy was beyond me, I felt like at any moment we could have slipped backwards or flip over completely. And what would we have done if it had flipped? If someone had broken a leg? I asked Hedley. "We would call in the plane." But a plane isn't going to come get you on the side of a mountain. You still would have had to ride the hellbeast to the nearest airstrip miles and miles away. All you could do was not think about it.

It helped that no one else seemed disturbed by the situation. No one complained or asked about safety. It made it easier for me not to be scared. But of course I was scared. I'm American and Americans think a lot about risk. The CDC makes everyone take malaria meds when coming to a pretty-much malaria free country. I've been trained to wear seatbelts my whole life. And now I was clinging and balancing and just hoping I wouldn't fall or fly off. By the end of the trip though, I understood how to balance on the ATV- you didn't really have to hold on that tight to stay on. By the end I was having fun again.

Risk assessment. Brazilians risk a lot to come to the garimpo. Malaria, isolation, deportation, robbery, alcoholism. In one garimpeiro camp in Baixao Novo, we met a woman who was 5 months pregnant. What was she planning on doing? There was no mid-wife in the little camp, certainly no doctor. She isn't a native to the area with centuries of traditional medicine behind her. To go anywhere she'd have to take the road to hell we'd just been on. The garipeiros are already risking so much to be there that riding an ATV straight up a mountain can't be the worst thing they do every day.

This part of the trip was hard for another reason too. Helena stayed in Benzdorp with the other half of the group- which meant Hedley was really the only person I could talk to. The rest of the team spoke Dutch, but mostly they spoke Surinamese with each other. The little English they knew had long ago been exhausted by "What is your name?" type questions. I'd never felt so alone. When out in the field, talking to the garipeiros, I felt good. But back at the camp we were staying at, the night full of stars and no one to talk sozinha, I can't even explain. Language is so important for human beings. I'm so used to being able to talk to many types of people, that to be unable to talk to anyone, to understand any of the laughter and story-telling going on around was very, very isolating. But the trip would get better.

Nos Garimpos

French Guayana from across the Lawa River

Garimpar: to search for
Garimpo: where one looks for gold
Garimpeiro: one who looks for gold

The gold mines aren't what you are thinking. They aren't underground, you don't carry a pick axe and a helmet. The garimpos are where the miners have dammed a creek and created large mud pits. The mud is pumped through a long pipe lined with mercury. The mercury attaches itself to the specks of gold and gets filtered out as the mud is poured into a different pit. The mercury is then burned off, while the gold remains. This is how it was explained to me. From the plane, they are exposed patches of yellow earth dotting the endless forest.

The Malaria Program was given funding to combat malaria in the gold mining regions were it still persists, despite erradication in most other parts of Suriname. Most of the people in these regions are Brazilian and are in Suriname illegally. As I've said before, I really respect that the Surinamese government is dealing with the malaria problem at hand, without letting politics and immigration policies ruin the program. French Guayana is another story.

So, what was I doing there? In the weeks before the trip, I had been working at the Malaria Clinic in Paramaribo. Let me introduce the people I've been working with: Hedley, a Surinamese doctor who runs the clinic and Helena, the only Brazilian working at the clinic. They are both amazing and it's been wonderful getting to know them. Almost everyone working at the clinic (which serves a mostly Brazilian clientele) went on this trip. We were to go to very hard to reach garimpos, test everyone present and treat those who tested positive for malaria. While I trained to test for malaria, that was not my job on this trip, (though I have been testing since we've returned). My job was to help with the intake forms, help conduct a census, interpret, teach people how to treat their nets with insecticide, take GPS coordinates and tons of pictures on behalf on the program. If I didn't speak Portuguese, I probably wouldn't have been of much use to the team. Language was a real issue on the trip, not many of the people on the team spoke Portuguese.

We flew from Paramaribo to a little island called Lawa Tabiki. I don't know if it would be on any map at all, but it was Southeast on the Marowijne River, which serves as the border between Suriname and French Guayana. We were about 20 people, carrying microscopes, malaria testing equipment, rubber boots, raincoats, life vests, hammocks, food and water for all of us for a week. Everything is outrageously expensive in the garimpos, so we didn't buy any food the whole time we were there. After testing a military post on the island we took a short boat ride to a river town called Cabana Fort or Vila Nova depending on who you asked. This was a good sized town- though I'm not good at estimating numbers of people. It was like stepping into Brazil- all signs were in Portuguese, samba was bursting out of the open bars. But the town didn't accept Surinamese dollars (SRD) or reais. Prices were set in Euros. Many people in this town, and all along the river, work in French Guayana, which is technically part of France and deals in Euros. A bowl of acai - which would normally be 2-5 reais in Brazil, maybe 3-6 USD was a crazy 7 Euros. It was the only thing I bought the whole week- but I really wanted it and it tasted perfect.

That night we spent in Benzdorp (more about that crazy place later) and the next day the team broke in two. Some stayed in Benzdorp, but I went with Hedley and about 10 others in a motorized canoe to Yawpasi, a much smaller town further down the river. Yawpasi is not really a town at all, but rather a post, a resting place for people coming and going through French Guayana- or France, as people call it here. There are few proper houses where people live permanently. There were several structures with no walls, only a thatch roof and hooks for hammocks. People spent all day laying in their hammock, waiting for whatever was coming next in their life in the Amazon. They slept completely in the open, very few people had mosquito nets or even a blanket. There were both men and women; it was hard not to speculate that almost every woman you met, both young and old, was probably there as a prostitute. If she didn't own her own business, bar or beauty boutique...why else might she be in a mining town? There were no children in Yawpasi as there were in Vila Nova, and that really said something.

Yawpasi had one of the highest number of malaria cases of any other town we visited- though I don't have the numbers yet. I feel strongly this is because so many people are coming back from Fr. Guayana infected. Fr. Guayana has a no-tolerance policy for immigrants. If they catch you you will be deported. The Brazilians know this and don't often use the medical system there. There is no anti-malaria campaign especially for them in France, no net distribution, no free testing. In many ways, I feel Fr. Guayana's policies are counter acting all the good the Surinamese program has done.

One man there was so sick his friends had to half-way carry him up the hill to the bar where we had set up. Hedley was irritated with the friends; they didn't have any intention of taking him to a doctor up the river. We just happened upon him by chance, who knows what might have happened if we hadn't.

How bad must things be in Brazil for people to travel all this way to live out in the open like this? I thought about this a lot. Most people were coming from Para or some other Northern Brazilian state. I usually think of immigrants leaving their country of origin in search of a better life in terms of material improvement. I think too of their ancestors from Europe, the original Pereira or Souza or da Silva or Araujo who left Portugal for the New World...did he have any idea that his descendants would be living in the rain forest without even a wall to protect them from the elements? These people are not natives to the rain forest, they are not indigenous to this land, they don't know how to live here without generators and imported beer. They don't even have latrines. To leave nothing to come and still have bad must things be there? And how much money can they really make in the garimpos? Maybe it's just that in Brazil, their nothing is hopeless, but here their nothing has the potential to turn itself into gold.

Sunday, June 14, 2009

International House of Cat Calls

There's such a variety: they hiss at you like snakes, they make kissing noises, they whistle, they might honk their horn or slow down in the car and stare at you. I get told I'm pretty or asked if my hair color is natural. Paramaribo is not the worst place I've ever experienced this type of attention, but it's worth posting about.

I think the worst place I've ever been, as far as cat calling goes, is Merida, Mexico. Of course, back then I didn't modify my dress at all. I used to pity the Mexican girls who worn tight jeans no matter how hot and humid it was. And I couldn't understand it, why they didn't feel free enough to wear shorts like me. I don't know if they got as much unwanted male attention as I did, with or without hiding their legs. I don't know if it would have been that much better if I had conformed and suffered the heat in denim and long skirts. I usually cover my legs here, and still the bobagem persists.

It's not like there aren't any places in the United States where women get harassed just for being women. Canal St., New Orleans being a prime example. But I stand out here more than I do in most places in the U.S. (Although most people think I'm a Dutch girl, not American). Maybe Surinamese women get heckled too, but I know most of the attention I'm getting here comes from my being white, female and foreign at the same time.

What I want to know is just what men 1) want to happen and 2) they think will happen. I would like to conduct a survey, randomized of course, of Surinamese men's opinion on these questions:

1) What do you want when you (whistle, hiss, kiss, honk, heckle) women on the streets of Paramaribo?
a) I want her to smile at me
b) I want her to teach me English
c) I want her to marry me
d) I want her to get in my car and have sex with me like I see in the movies

2) What do you think will really happen?
a) She will love me forever
b) She will give me a rude hand gesture
c) She will ignore me but secretly like it
d) Yes, I really think she will get in my car and have sex with me. It happens in the movies.

There are a variety of ways for women to deal with this annoying phenomenon. You can ignore it. I don't believe that in any culture it is rude for a woman to ignore a stranger when he talks to her in the middle of the street. But ignoring it can only last for so long before you get really mad and flick someone off. And that can be rude to the other people who witness it and don't know you were being harassed. You can learn something clever in the local language and make a joke out of it. Or you can engage the man in dialogue. This might not always work- but sometimes when you confront a man about his bad behavior, he is at the very least shamed in public. That has worked for me just a few times.

Yesterday I was walking home from the malaria clinic when I heard "Sssssss, Sssssss" hissing at me. Usually I do ignore these things, but I turned around and said "Ssssss, Ssssss, what?! what is that? what is it that you want?" The man was at a table with his friends drinking beer. I think he was a little surprised. He threw up his arms and said "But- but I love you!"

Tuesday, June 9, 2009

Malaria: BOG vs. CDC

So, my internship is developing nicely. The Bureau voor Openbare Gezondheids Zorg(BOG) is the Bureau of Public Health here in Suriname. They have just received a lot of funding to combat malaria in the final hold-outs of the disease: the gold mines of the interior. Since I've been here I've learned a lot about malaria and something I hear almost everyday is how in the last 5 years Suriname has experienced a 90% reduction in malaria cases. BOG has campaigned agressively against the disease; Active Case Detection means teams were sent into malaria-endemic areas and tested EVERYONE and treated all who tested positive. Bednets were distributed for free and villages received education about prevention and treating their nets with insecticide. Essentially, malaria has been eradicated in most of the country (especially here in the capital). I will later include a BOG map of Suriname in green and about 20 red dots showing where malaria still persists.**

In this map, the red dots represent areas where there is a risk of malaria. As you can see, malaria is in very specific areas of the country- gold mines in the interior. Most tourists/travelers will never make it to one of these areas so they are not really at risk.

So, why did my school's travel clinic insist on making me buy 2 months worth of Malarone (one of the most expensive anti-malarials available to us)?

Because the CDC recommends it. Apparently, the malaria present here is chloroquine resistant. Which the travel clinic interpreted to mean no mefloquine for me. The CDC page actually says mefloquine is ok. Here's something I don't understand: if the malaria is resistant to chloroquine, then why does BOG recommend it for treatment of vivax (followed by primaquine)? Maybe it just can't be used for prevention but could still be used for treatment. I will find this out later*.
(* Yes, I found out later that you can't use chloroquine for prevention because the falciparum parasite is resistant, but not vivax. So it can still be used to treat the vivax parasite.)

I feel that the CDC needs to update its recommendations for travel to Suriname. The BOG has made great gains in eradication, yet the CDC keeps its page on Suriname written in such a way that travel clinics freak out when they have patients going there.

Here's the CDC's page on Suriname

(Notice they use the wrong map! The one I got scolded for using in an earlier post!)

Note: Chloroquine is NOT an effective antimalarial drug in Suriname and should not be taken to prevent malaria in this region.
Malaria risk area in Suriname: Risk in all areas, except no risk in Paramaribo and coastal districts of Nickerie, Coronie, Saramacca, Wanica, Commewijne, and Marowijne north of latitude 5°N.

The way this is written, travelers would believe the whole country minus a very few places have a high risk of malaria transmission.I think they would have done better to print exactly where malaria is an issue instead of where it isn't. The regions mentioned are the most populated and most likely to be visited by foreigners. It should simply say: Risk of malaria in the interior.

What are your thoughts on this?

Saturday, June 6, 2009

Parbo: Thoughts on Bami and Belenzinho

First, I apologize for no pictures. I've been taking them, I just can't post them at this internet cafe. But I assure everyone that the intense sun makes everything very lush and beautiful. And the summer storm clouds are as dramatic as they are in Florida.

My professor's family has been wonderful to us! They came by and pick us up for a "drive" which turned out to be a small trip across the river (Paramaribo sits on the Western side of the Suriname River and there is a bridge to the less populated other side.) We drove through a more rural area where most people are of East Indian descent. You can tell when a house belongs to Hindustanis (as they are called here) because there are usually little red and yellow flags on bamboo shoots indicating some event in the life of the family. We then got in a little boat and crossed the river again, to a more rural point. We saw an old sugar plantation that had been converted into a hotel. All the colonial buildings here are wooden, which is kind of rare in the tropics. Usually a building from the 1700's would have long rotted away in this kind of weather.

When we went back to the city, the Calors took us to Warung Pawiro, an Indonesian (Javanese to be exact) restaurant. No question about it, one of the top 5 meals of my life. This food is amazing! We had noodles and peanut sauce, similar to what we had our first day. We also had sateh, beef kabobs with peanut sauce. It's too hard to explain- I just wish I knew where to get this food in the States!

My work is slowly coming together. It looks like June 15 I will be going to the Benzdorp mine on the border with French Guiana and help conduct a survey of Brazilian miners and their attitudes and behavior towards malaria. Like, whether they use bed nets, how they treat themselves for malaria, etc. I'm very excited about this.

Paramaribo has a true rainbow of people. Indonesian, Chinese, Maroon- which is what they call the descendants of slaves that successfully ran away into the forest. There are a few Dutch people, but most of the Dutch here are my age and have come to study or work- they are not left overs from the colonial period (which ended in the '70s). And there are Brazilians. My neighborhood is close to the area informally called Belenzinho, after the Brazilian city of Belem, Para. And there are many many Brazilians in the mines.

My take on immigration in the States is generally positive. Immigrants helped rebuild New Orleans after Katrina, there's no doubt about that. But here in Suriname, the Brazilian presence is often negative. Gold mining is terrible for the environment. They clear rainforest, create large holes in the ground which fill with water and worsen the malaria situation. The methods used to extract the gold release mercury into the environment and pollute the rivers and fish. And the gold truly belongs to Suriname, but no taxes are paid on it, so it is of no benefit to the country. Someone at the office commented how it seemed strange for the Global Fund to give so much money to treat malaria of illegal immigrants. But, here's how I feel about it: it doesn't serve anyone to let them suffer; malaria is contagious and if you neglect one part of the population because they are illegal, everyone is put at risk.

Suriname is extremely close to eradicating malaria altogether- the gold mining regions are the final hold-out.

Much love to everyone. I miss you!

Monday, June 1, 2009

Paramaribo: Arrival

I don't have much time to write! But things are going well here. After some confusion with our schedules, we didn't get picked up at the airport by our original contacts. But we had met the president of the University on the plane and he took us with him. On the hour-long drive from the airport to the city, the president, the driver and another professor from the University discussed (in Dutch) what to do with us. For some reason, none of them wanted to take us to any hostel or hotel; they were convinced that everyone would be asleep and that they wouldn't attend to us. So we ended up going with the driver, he said we would stay at his house. But first, he had to pick up his wife at a wedding. So, at 1 am we went to the tail end of a wedding party. Even the bride and groom were asleep...only a few family members remained drinking and watching the little boys clean up. Of course we were fed. This family was of Indonesian decent, they served us a soup called souto and fried plaintain chips and beer. It began to rain and the little boys played in it. The driver got a call that his son had already taken his girlfriend home and so there was no place for us to sleep there. He took us to his sister's house instead. So at 3 am we woke her up, and were shown our room. We quickly realized that a least one little girl had been woken up and moved from this room; it was covered in princess decorations and High School Musical posters.

In the morning we met the little girls, and the rest of this very generous family. We were fed again- this time noodles (bani) and peanut sauce. Then we were taken to the family that was originally supposed to pick us up. They felt really bad about the mix-up, they thought we were coming the next night. They had bought all this food for us, so we took it and went to the apartment where we would be staying. They also took us to buy cell phones and then insisted on taking us for an enormous Chinese lunch.

So, so far we have been in very good hands. Everyone has been extremely generous to us. We like our apartment, it is safe and we are figuring out the bus system to get to work. More about work later...when we know more ourselves.

Kisses to everyone.