Dr Cronberg’s visit in Mayemen 2011

On request, the travel blog in English from Dr Olof Cronberg’s study visit to Manyemen, Cameroon. 

Manyemen Blog

Bandja, West province, Cameroon

Wednesday, April 6th. Returned to Sweden this Monday. The luggage didn’t come until last night. However, it was not Cameroon’s fault, but it was due to slow process to Zurich airport. Hopefully the wellprepared food hasn’t been damaged by the extra trip to Stockholm.

It feels very cold here, and it feels very gray since the spring colours have not appeared. However, there is softness in the early evening light, which I was missing in Cameroon, where darkness falls on pretty quickly. Some say you can get tired of all high-income-country problems in Sweden, when you have been a long time in a low-income-country. We’ll see if I will feel that.

Leonie and I have discussed the possibility of organizing a two weeks trip to Cameroon coming winter, for any interested person. The trip would be partly a tourist trip and partly a trip to learn about the Cameroonian health care system. The idea is that participants in a part of the trip would be staying with families. Leonies team would help us. A slight complication have appeared since there will be a presidential election to be held in Cameroon in the autumn, probably in October. If you would be interested to join such a trip, please feel free to contact us to leonie@swedencameroon.com. FIXA

Thus, this is the end of the journey, and then it’s time to end this blog. Thank you all who have read the blog, and thanks for all comments on this blog and in other ways.

The office in Yaoundé

Sunday, April 3. Back in the capital, Yaounde, it is time to pack for tonight’s journey home. Leonie is busy arranging an office for her local organization in Yaounde. She has a team with a handful of employees. They have different tasks to do. They help to record data for various research projects, help Swedish students who come to Sweden. While Leonie gives instructions at a brisk pace about what should be done, who will perform the work, how it will be financed and who should report it.

At home, two friends are cooking in the kitchen a lot of food that Leonie will bring to Sweden. Everything is packed neatly into a large bag. Once at the airport, it turns out that it is 30 kg of food and we have to transfer some food to the other bags not to exceed the permitted 23 kg per bag.

Leonie has gone to fix the hair before leaving. Time passes. Finally, there is almost a rush to get to the airport. Just when we’re going, there is a terrible rainy weather so that it is almost impossible to see where you drive. The car rushes forward in the dark and water splashed over the car’s windshield. It all calms down, however, and we will come to the airport without problems.

Bandja Youth Center

Saturday, April 2nd. The day is devoted to arrange a house at Bandjas center. The house is an octagonal house that the family owns, and formerly used as a café. Here is the idea that it c

ould be used for a centre for health education for the children’s parents, adolescents and adults. Activities will be led by a nurse.

The house is quite charming with its unusual shape. There are quite a lot to do, to make the house nice. Today, two guys are put to work to clean the room. The roof is leaking and needs repairs. The walls are decorated, and prepared for health education activities. Leonie puts family and friends at work, and everyone gets task from their ability and all are very optimistic.

The health information that Leonie want to create is quite similar to the activities of our child health clinic nurses doing in Sweden.

After a short visit with Leonie 86-year-old grandmother Mamile who lives in a small stone houses with earth floors and wooden shutters. She can handle herself but her son and grandchildren who still live in the village looking for her regularly. She is happy when we visit. I think she does best to stay where she lives.

Friday, April 1st. Time for departure. In the morning I pack the last pieces. I pay my housekeeper and a few debts at the hospital.

Vincent, my driver, who arrived the night before, drives off with the car to a garage in the morning, and it takes several hours, so I almost get worried. At one o’clock, we will be off. With us to Kumba are Dr. Katherine has also will leave, and Dr. Gaëlle who is on leave over the weekend. The road is dry and good condition, so the trip to Kumba accomplished in record time of two hours.

Once in Kumba, Vincent thinks that we need to make a pit-stop, because a warning light lit. It turns out to cord to the battery generator has shaken apart. The brakes did not work well, and a brake disc must be replaced. The workshop has no spare parts, but one mechanic drives off to obtain them. After an hour he returns with the cord, but he has not found the right brake disc. It begins to rain heavily, and all activities cease and everyone hopes that the rain will quickly move on. When it is still raining after an hour, we ask them to fix the car anyway. The wheel that was bought in Kumba after the last trip to Manyemen turns out to be bad, so we go to the tire shops in Kumba. To get the tire replaced is not possible, but we must buy a new tire that is hopefully better.

Road block on the road between Kumba and Loum

Four hours late, we leave Kumba in the dark to go to Leonie home village Bandja in the Quest province. To avoid having to travel a detour overDuoala in four hours we will go 40 km on a dirt road to Luom. According to the information we receive it has been improved and the road passable with a travel time of 1-1.5 hours. We have not gone many minutes before Vincent begins to creep run. I do not understand why, because the road is smooth and fine. It turns out that the afternoon rains have made the road surface wet with an inch of clay so tires are sliding.

After twenty minutes there is a sudden halt. On one side of the road is the large gravel piles to be used to improve the road. In the ditch on the other side stands a large abandoned truck. In the middle stands a timber truck with five large logs, which had slide into the other truck. We quickly examine the roadsides, but the dicthes are deep and the edges are too high. A truck is trying to pull the truck that got stuck with no success. Another truck succeed to pull the truck a few yards, but then it stops again. The number of spectators to the spectacle becomes more and more as time delay. The atmosphere is not very hostile, but more like shit happens. Now we all hope that the truck will go away, and after an hour the helping truck succeed to pull the timber truck free to the audience’s cheers.

Five hours late, we arrive at last to Bandja, and for the first time in a month, I feel the night’s cool breeze, because Bandja is located higher than Manyemen, even if it is only 80 km to the east.

Thursday, March 31. It is my last day at the clinic. The atmosphere is a bit gloomy. It seems that there is a serious fault with the electricity generator. The generator has been overheated. The Swiss engineer is upset that in a tank where it will be oil, it is suddenly too much fluid, and perhaps not of the quality it should be. They have launched a small reserve unit which will supply the operating theatre and the lab with electricity.

If I quickly sum up this month’s work in Manyemen, I have seen over 400 patients. The panorama has been many infections with emphasis on malaria, gastroenteritis and respiratory track infections. I have also seen tuberculosis and sexually transmitted diseases as gonorrhea and syphilis. A dozen new HIV patients, but also many HIV infections as complications of the muscles, pneumocystis infections (particularly kind pneumonia), ugly infection of the mouth, Kaposi sarkom (skin cancer that affects HIV patients) and general health weakness. Some of these patients show improvements with the HIV treatment, while some are already too sick.

Pain patients, I have seen as in Sweden, but despite the pain they live a more mobile life here than in Sweden. Someone fibromyalgia sufferer, I have not encountered. I saw an elderly woman outside the leprosy hospital, which was folded and removed weeds outside the leprosy hospital. Crutches were thrown at the side. When I talked to her for a while, I saw that she had leg prostheses on both legs! I’ve seen a few people with anxiety that often erroneously received treatment for somatic diseases, but I have not really seen any depression. This type of psychic problems are probably better managed by traditional doctors.

For me, it was very interesting and instructive, and I’ve got skills that can surely be helpful to have at home in Sweden as well, when odd cases appear. I think that most family physicians would benefit from working a month in an African country. Had I been a specialist in Infectious diseases, I can’t understand how I could do without.

After looking at the mango tree for one month, finally the mangos were ripe

I feel quite satisfied with Manyemen now, but I still feel a certain sadness to I leave Manyemen like this in mango-time, not knowing if I ever come back or not. I have the entire month passed and looked at a large mango tree on the property. The mango tree looks like a huge apple tree, where the mango fruits hanging from the 30 cm long stalks. Today was finally mango ripe enough to taste. Fresh mango smells and tastes much better than the mangoes we can buy in Sweden. Now, when I will travel, I will miss the Mango-time.

Wednesday, March 30. Tonight, I have been invited to Mr. Stanley, together with doctors Gaëlle and Katherine. Mr. Stanley is responsible both for hospital transports and when he is not travelling he sits at the front desk and enter the new patients. All patients will tell you where they live, what tribe they belong to, what church they attend, what their profession and how old they are. Older women are asked not about age. Then the weight, blood pressure, pulse and temperature are measured. The temperature is measured in the armpit, so it is often not so reliable. But that means that if the patient has fever, it’s really high fever. They don’t ask patients why they come.

Mr. Stanley is living in a quite narrow staff house, at least if compared to my fairly spacious physician house. He lives there with his wife and two daughters. We are treated to foufou and a soup cooked in cow skin – oxhudssoppa it would probably be called in Sweden. Foufou is a dough that is made from casawa meal. You take a lump and dip into the soup and eating.

As darkness fell the electricity start flowing, but after just a few minutes it disappears. In Manyemen are accustomed to it and we must put our trust in the bushlamp – a kerosene lamp. The We also discuss Manyemens pros and cons …

Normal hiv test

Tuesday, March 29. Sometimes when a patient enters the room you can see a sadness in his eyes, which causes a cut through the heart. I am thinking particularly of a young boy who should have playfulness or possibly doctor’s fear in his eyes, but not sad eyes. Some of these patients say spontaneously that they are HIV positive. For others we understand it from a cryptic statement in the journal. A third group has a strongly suspected disease, and is probably very afraid of being infected with the virus.

Someone has moved from Douala when he became ill. A young woman is very worried of the knowledge that the virus is present in the body and she has not yet started treatment. She feels that the virus strain on her body. Unfortunately, denial is also common. Some patients will not come until she has lost weight to a thin stick, been coughing blood from tuberculosis and had a difficult infection of the mouth so that she can’t eat.

In Cameroon, treatment is free since 2007, says the nurse in UPEC, which accounts for the distribution of HIV medicines, but the lab tests still cost money. The normal cost of an HIV test 500 CFA (about 1 euros). To assess if it is time to start treatment, a complete blood count is done, which costs 3000 CFA (6 euros). All patients can’t afford this. Our lab has no machine to measure the so-called CD4 lymphocytes (a type of white blood cells), but makes the assessment of the total number of lymphocytes.

If you are symptom-free you will not start treatment until the lymphocytes reading go below 1.2. If you have lost weight or have some other signs of illness, the limit is 2.0. If you have serious infections like tuberculosis, the limit is 3.0.

The nurse says that it has about 200 patients on his list, half of whom actually come and take their medications. I have during the month I worked here found a dozens of new HIV patients. About a third of all tested, have a positive HIV test. I think it’s just too much, and I think it would require substantial information campaigns about HIV. In particular, that there is free treatment to get, and that it is important to start treatment in time, so maybe we’ll see fewer sad eyes in the future.

Blood group test

Monday March 28th. “Below reading”, said the nurse, when I asked about the blood value of a 15-month-old boy. In this case “below reading” was meaning below Hb 6. The boy had recently been to another hospital for gastroenteritis and now the symptoms were back after just a few days. The lab results also showed that he had more than 100,000 malaria parasites per ml and also a white blood count of 15,000.

“Paper white”, said dr Wungi, when he looked at the conjunctivas of an old lady, that I admitted the day before due to fever, vomiting and dehydration. Check Hb, cross-test and give her two pints of blood, dr Wungi added in a surgical manner. In the afternoon, I went to check this lady at the ward. The blood value was below 5!

At the lab, there are two machines measuring Hb. One shows down to 6, the other down to 5. If a patient has a blood value below 6, the lab automatically checks the blood group. There is no blood bank, but the relatives with the right blood group have to be donors. The blood is tested for HIV and hepatitis before blood transfusion.

It is a combination that makes it common, that many patients have anaemia. Malaria gives a haemolysis – the red blood cells are destroyed. Many worms suck blood. Monotone food habits and the lack of proteins could also add to the problem. I really must say, that I have got a new perspective of anaemia.

Sunday March 27th. Sundays are electricity free days. We only have electricity a few hours during the evenings. Since the computer’s batteries are empty, I suddenly get much time left over. What if we had electricity free Sundays in Sweden? What would happen then?

Manyemen is really far outback. Here is neither radio nor television coverage, which in a way is good. The tradition in Cameroon is to let the television stay on all the time. You don’t close the television went you get visitors or eat supper. The most common TV shows are the Brazilian soap operas, followed by the same from Nigeria in English or from Ivory Coast in French. But in Manyemen there is no TV. It seems as though nobody can afford the parabolic antenna, which would have worked, but the main reason is probably the lack of electricity outside the hospital.

This month, I haven’t even seen Cameroonian news. Therefore, I have rather limited information about what is going on in the world, such as in Libya or in Japan. When I the other day had a little stroke of homesickness, I tried to see Swedish news at SVT Play, but it didn’t work neither in my computer, nor in my iPhone. The bandwidth of the Internet connection is apparently not good enough.

The doctors in Manyemen.

Saturday March 26th. The tradition for polypharmacy and injections are rather strong, although many patients hardly could afford the medication. I saw a small boy with pseudo croup who received cortison injections and then should stay until we saw that he was better. When I passed in the afternoon the boy was fine, but he had also received Amoxicillin (against bacterial infection), Arteluz (against malaria), Aminofyllin (against asthma), Paracetamol (against fever) and Ferromyn (against lack of iron)! Pseudo croup is normally due to virus, and there is no indication for antibiotics.

Another struggle is to avoid antibiotic treatment when the patient has gastroenteritis. Here Metronidazol is considered to be the solution of all gastroenteritis. I try to explain with doubtful result that most gastroenteritis are caused by virus. Neither the guidelines from WHO or MSF supports antibiotics unless the diarrhoea is bloody.

Patient with pathological lab results are easy to treat. You prescribe the treatment such as Coartem for malaria and everyone is happy. When the lab tests are normal and there is no apparent disease to treat, it is more complicated. The most common way to handle it here seems to write medication anyway. I try to explain that common cold don’t need antibiotics and that it is perhaps better to decrease the pepper in the food rather to eat Omeprazol.

Thus, we make brave efforts to explain to the patients and the relatives. They are nodding and seem to understand, until it is time to leave. Then they ask, what to about medications. If they don’t get any medicines, then it was no reason for the visit.

The old leprosy hospital is now a TBC hospital

Friday March 25th. This afternoon I visited the Hanseniasis Rehabilitation Center (HRC), which is the name of the old leprosy hospital. Today, it is mainly a tuberculosis hospital. I walk a side road to HRC. It is a path finding its way down to a small creek and the up on the other side. The steps are made of concrete long time ago. I get a feeling that I am stepping into the novel of Thomas Mann The Magic Mountain. HRC is build like a European tuberculosis hospital from the beginning of the 20th century. It is situated at a hill with a view to the east. At the afternoon, when the sun is in the west, the trees offer a well needed coolness.

Mr Nemo is one of the four nurses at the hospital. They work in three-shift. There are about 40 tuberculosis patients who are admitted for treatment. There have been a few leprosy patients for rehabilitation, but now was only one left. The patients sleep in wards with ten beds, if nothing special. The other day, I release a mother who had been to the HRC since the birth of a child two months before. She had a single room to prevent the child getting sick.

The tuberculosis patients have to stay for two months, and during that time they receive the TB medication. The patients are often improving in just two weeks. I get a feeling that the patients are rather optimistic. For the patients who also have aids, the recovery is slower, and most of them start antiretroviral therapy after two weeks. During the stay at HRC, most patients gain 5-10 kg in weight. Even though the optimistic feeling, I am happy to be able to leave The Magic Mountain behind again.

The main street of Manyemen

Thursday March 24th. After work I went for a walk through Manyemen. The road is the center of the village. Along the road there is six pubs and three small hotels. There are the boys with motorbikes, petrol sale in one litre bottles, girls selling cell phone credit, women who cook food which is sold for 10-20 cents, boys selling bananas, women selling grilled maize. Between the pubs are the small shops – wooden sheds with roof – where you can everything you need (almost).

There are mainly two products farmed here, coco and kasawa. Coco is exported and you can get 2-3 €/kg. The price is fixed by the state. The kasawa is used locally.

26-year-old Elvis tells me about the village. There are 2 nusery schools, 2 primary and 3 secondary schools. The tribe who lives here is opabalong and they talk biangi if not pidgin. The village would disappear without the hospital. There are no other places to work. When the hospital was down, there was no doctors and no patients, it was hard times in the village, but since the restart of the hospital some six month ago, the villages is booming.

A grass hopper

Wednesday March 23rd. Since I am living just at the border to the jungle and since the windows always are open, I can hear the sounds of the jungle during night and day. In the evening, the grasshoppers are making their noise so loud that it sometimes is difficult to speak. They start playing as soon as it starts to get dark. Later during the evenings you here the frogs. All the time, the birds are singing – many different birds with different songs. The birds’ voices are strongest during late night or early morning. The coq makes some tries during the night, but is most active at 6 am.

It happens a little to often that lizards find their ways into the house, but if you stomp your foot the floor they rush out. It seems as though they know the house, because the easily finds the exits. Otherwise, they are mostly running on the roof and on the outside walls. You here a heavy landing on the roof follow by a quick rush. There are some mice within the wall of my bedroom. I hear them running and also biting during the night, but so far I haven’t seen them in the house or seen any traces in the kitchen, and perhaps it is best to let them stay in the wall.

When it comes to our smaller friends, there are a few cockroaches in the house, but the hide quickly when I turn on a torch. Ants are finding their ways into the kitchen, so food needs to be stored well. Some flying insects are also coming in, especially in the nights when the follow the light. The bat has only visited the house twice. You have to be animal friendly to stay here.

The awaited knife for skin transplants

Tuesday March 22nd. Normally Tuesdays and Thursdays are surgery days now when the surgeon dr Wungi is here from Tanzania. He worked at this hospital during a long time during the 90ties. Now he is back for three months. Dr Claudia do gynaecological surgery and dr Daniel is putting the patients to sleep when spinal anestesia isn’t enough. Dr Gaëlle is assisting to learn the surgery methods.

Last Thursday a special knife donated from the hospital of Värnamo, Sweden was used for the first time. It’s a knife to cut healthy skin when you do skin transplants to heal chronic leg ulcers. Two patients were transplanted last Thursday with good result.

I don’t publish surgical pictures since I don’t want sensitive readers to get nausea. Instead, you can se dr Chunke & dr Wungi, who grateful receive the knife. At the same time, I would like to say thank you, and I think the Benders fills in, for the donated equipment and books, which I brought here. It is good to have books to read in, when for example a baby with Hirschsprung’s disease (congenital bowel disease) shows up.

Filaria test – skin biopsy and blood sample

Monday, March 21th. Today was a skin disease day. Some diseases are easy to spot, since they are the same as in Sweden. For example a grandmother who has got scabies after having the grandchildren on visit. On Pidgin scabies is called ”come-no go”, since once you get it, it could be hard to get rid of it.

Other diseases are typical tropical diseases such as elephantiasis or tropical ulcer. But just as at home, we find here diseases that are hard to explain although we look at them together. We lack a good book on Dermatology, since don’t find all information in the good but summarized books in Tropical medicine. How long could you expect a chronic papular onchodermatitis stay after treatment of onchocerciasis? What to believe about a generalized dermatitis – should you think about “Swedish” diseases as atopic dermatitis or dermatitis herpetiforme or should you think about some treponematosis or is it a generalization due to immunodeficiency?

With permission from the patient, I take some photos of different skin diseases. However, I am not so keen on showing photos on the web, but when I come home I probably would be able to show some cases to doctors interested in Dermatology. This photo shows the two ways the lab looks for microfilaria – skin test and blood test.

Waterfall outside Manyemen

Sunday, March 20th. Today was the day for a jungle walk to a waterfall. We were advised to have long trousers and good shoes, and we were guided by Lucas who was armed with a machete.

First, we marched 20 minutes eastward along a well used path. We passed the old palm oil mill, and then we palm trees planted in long rows with precision. Some palm trees seemed to be still in use, since somebody had cleared the under-vegetation.

We then turned southbound on a path you barely could see. At times the vegetation was two metre high, and when needed Lucas cut some vegetation with his machete. We passed small fields with kassawa or cocojams. Then the path went steep uphill. Soon after the path went down into a ravine where the waterfall was. We arrived after ca 50 minutes of walk.

Immediately, I took a swim in the pond below the waterfall. It was very cooling. We were intensely courted by many different butterflies. I think there were more than 15 different species: red, brown, blue, yellow, white, transparent, big and small. I tried to catch some with my camera, but it was difficult.

After a welcome rest, we went the same way home and arrived soaking wet of sweat again…

Birthday party

Saturday, March 19th. Somewhat tired after yesterday’s party in Cameroonian style. The house had been decorated with new curtains, balloons and fresh flowers. To be able to cook all food, my housekeeper cooked some of the food outside on an open fire, while Leonie was cooking in the kitchen. At 4 pm, Leonie found that we had too much food, so we went away to the ward and invited some more of the staff. Since many of them live at the hospital area it was easy. In Cameroon, it is never to late to invite for dinner.

The party was to start at 7 pm. Of course, the Benders came first and congratulated on Swedish.  At 7 pm African time, the rest of the guests arrive one by one. The later the evening, the more visitors. No risk that food should be left over.

Leonie surprised me with a birthday cake with three candles in the colours of the Cameroonian flag. Then the guests sang “Happy Birthday”. I hadn’t heard the second verse before “How old are you now?”.

Normally, the electricity should be cut at 9 pm, but for 12,000 CFA (€20) we could have power until 11 pm.

Party preparations

Friday, March 18. Yesterday, Leonie arrived with her cousin Vincent as a driver. They had started at 4 am from Yaounde and arrived at 14 o’clock. That is about as long as it takes to fly from Yaoundé to Copenhagen. Nice to finally meet Leonie after three weeks of work here and get a little break.

Leonie have been busy with lectures at the University of Yaoundé, and now she will check whether it is possible to lecture via Skype on Monday.

Right now it’s full up with decorations to celebrate my birthday two weeks late. Leonie has brought nice curtains, a carpet, balloons and other decorations. Not least, different scent balls to get off some of the bad scent that is left in the house since it has been empty a long time. One advantage is that Leonie puts people to work to clear the garden, chasing mice, and scare away mosquitoes. I leave it to her to negotiate the price for gardening.

This afternoon it’s time to get down to cooking for the evening party. Meat is only available on Fridays when a cow slaughtered and must be ordered in advance. The food will be chicken, fish, meatballs, yams, rice, fried balls of banana and corn, green spinach with dried fish and shrimp and popcorn.

Tuberculosis recommendations

Thursday, March 17. Today was a coughing day. In the morning, I had ten patients who presented with coughing for a month or longer. Patients seek the doctor because they are worried that there have tuberculosis. We listen to the lungs and usually hear some creps or ronchi somewhere. Sometimes it really is bubbling in the lungs. We check ESR, white blood cells and acid-fast bacilli in sputum. I have been out of the lab and checked after the acid-fast rods, which are small red rods against a blue background mucus. We also have the opportunity to make a chest radiograph, but the quality could have been much better, so it is difficult to assess these images.

Some patients fail to produce sputum, but there was at least two who had acid-fast bacilli and thus tuberculosis. However, only 65% ​​of the patients have acid-fast bacilli. The problem is to sift out which of them do not have acid-fast bacilli, who still has the disease. Usually, we wait a little bit too long to start the treatment …

In the case of treatment we follow simply the WHO guidelines. First two months of intensive therapy with four drugs that called RHEZ. During this treatment the patients has to stay at the old leprosy hospital. After those two months, the patients often become much better and will then continue with the two drugs RH for four months at home with medical checkups once a month. I saw two patients today who had finished the intensive phase of treatment and could be discharged from the hospital and I sent down two new patients, so break-even.

Ultrasound

Wednesday, March 16. If X-ray is a sad chapter, so it’s more gratifying that there are two  ultrasound machines that works. One of them is used mostly by Dr. Claudia for gynecological ultrasound, and the other for ultrasound surveys in general.

In the morning, a number of women seek for “belly worry me”. When trying to deepen the medical history, many have low abdominal pain and vaginal discharge for a long time.Others are concerned that it was a long time since they had a “peckin” as children are called here. I order then ESR, white blood cells, urine sediment, vaginal discharge examination and pregnancy test, depending on symptomatology. Then they wait until the afternoon when Dr. Claudia has her clinic with ultrasound.

Unfortunately, there are much venereal diseases such as gonorrhea, syphilis and HIV. Many go for long with their problems, so that even if the right treatment, they will find it difficult to get pregnant again.

Some days it’s  antenatal clinic. The pregnant women are informed and examined by the midwife in the morning and some of them go for ultrasound in the afternoon.

Other things that we’ve seen on ultrasound is leverabscess caused by amoebic infection, but also nodular liver cancer in a younger man probably on the base of a chronic hepatitis.

Chest X-ray where the patient has to hold the plate

Tuesday, March 15. A patient who has coughed for two months came and wanted to have a chest X-ray. After lunch, he came back with X-ray plate rolled up. Unfortunately, the X-ray images are not of the quality that one would wish. Often there are strange shadows. My assessment was, that perhaps the distance or focus wasn’t set right, or perhaps the wrong dose was used.

In this case, we noted that there seemed to be a pleural fluid on the right side. Then the picture was more white-blurry the higher up in the lungs and any definite TB signs could not be seen.

Dr. Katherine and I realised that we could not really say anything sensible about the image, so we watched the lab replies. It turned out that the patient had acid-fast bacilli in expectoration from the lungs, so the diagnosis of pulmonary tuberculosis was confirmed anyway in this case.

The other day, Dr. Wungij and I and saw what happened when we ordered an x-ray. It turned out that an old C-arm X-ray machine was used, and the patient was himself holding the plate. There is a much newer X-ray machine, but it has never been started due to technical problems.  Technicians from Yaoundé have been in place in several times without success. Finally, they took no part should be changed, but it has never come back …

The junior doctor Katherine examines a newborn child under supervision

Monday, March 14. In the morning, we look after the patients at the wards of the hospital. Usually, I participate follow the round at the Medicine and Surgery ward. There are three rooms each with eight beds in each room. Fortunately, all beds are not occupied. Men and women are in the separate rooms, but since all patients must have a caretaker, there are many people in halls who are expelled when it’s time for the round.

The inpatient documentation is managed on a combined temp-curve and medication list. On the back is written some of the nursing notes and the results of lab tests. At discharge the doctor just writes discharge date on the temperature curve. If need of follow-up, it is written on patient’s outpatient card.

Most of the cases we handle are not problematic. Some cases are strange and hard to understand with the limited resources we have. Then it happens that we are thinking together: the gynaecologist Claudia Bender, the anaesthesiologist Daniel Bender, the surgeon Dr. Wungij from Tanzania, newly graduated Dr. Gaëlle from Cameroon and also Dr. Katherine from Germany and I. Sometimes we come to different conclusions, of which no one really feels particularly satisfying. (We lack Dr. House to solve the problem.) Then it may happen that the patient or the relatives want the patient to be discharged in order to contact traditional doctor instead…

On the image Dr. Katherine is examining a newborn baby before going home under the supervision of Dr. Claudia, when doing the round at the maternity and children’s department.

My house in Manyemen

Sunday, March 13. The morning hour is the golden hour. The best time of day is really the first hour after sunrise. The heat has not had time to become too oppressive. I eat breakfast on the patio in the east. A few rays of sunshine tend to penetrate. Otherwise, there is often a sort of heat haze during the days. At the same time, the gnats are getting breakfast. I never see them, but a number of itchy rashes.

This thing with doing exercise is difficult in this climate. When I am finished with the day’s work, often at four o’clock, so the heat is so oppressive that it is comfortable to stay indoors. It does not get cooler until darkness falls.

Before I went I took the opportunity to do a marathon session in the Friskis – meaning aerobics, box pass, mountain spinning and circle exercise combined with skiing one hour, but it feels long ago now, and I feel like I’m starting to stiffen. An opportunity to get some exercise would be to get up at sunrise at six o’clock, and take a half hour walk or so. I think I’ll give a shot tomorrow…

Hiv-test

Saturday, March 12. It was a very quiet Saturday clinic today. I was barely ten patients in the morning and no one was particularly ill, not even the boy who had sky-high malaria parasite levels in the blood.

Instead, I visited the lab and to learn the HIV-sampling.  HIV is a sensitive matter. For example, we can’t write HIV testing on patients’ cards, but 5 mls. It will interpret 5 ml due to the 5 ml of blood used for HIV testing. Screening test here comes from Abbott and named Determine. Is this a negative, the test result is written 1-0. If, however, it is positive, a confirming test is carried out with the test Hexagon from Human. This test also shows if it is HIV-1 or HIV-2 virus. When this also is positive, the lab result is 2-1 with a ring around either digit depending on which HIV type it is.

In the two weeks I’ve been here, I have certainly seen five new HIV cases, young and old. All but one has also had tuberculosis, or AIDS already stage 3. One was found during testing for gonorrhoea because of urethral discharge. All it takes hard to get the news. Although the treatment is free, it costs money to do the blood samples. It is not possible here to measure the CD4 levels to determine whether it is time for treatment. Instead we do a complete blood count with differential and look at the overall level of lymphocytes. If the number of lymphocytes falls below 1.2 we begin the treatment. Contact tracing is not free and because coco-season hasn’t started, there is a shortage of money, which slows down the process.

New parabol antenna

Friday, March 11. Today, we would switch satellite antenna to get a better Internet connection. The idea is to use a satellite dish closer to the hospital and be able to get Internet access via Wi-Fi in both the hospital and in the homes. It would be very nice since we do not realize how much we depend on Internet in Sweden today. For example, the other day a patient had taken an overdose of epilepsy medication (Tegretol). It would be quite easy to check how serious this is on the Internet.

Of course, nothing is as easy as you might think. As I passed by late in the afternoon the Swiss engineer discussed with the Cameroonian technicians on which direction the antenna should have. Although the Swiss engineer sounded very confident, I am not sure he was right…

As I write this, it seems that you have moved the equipment back to the old location, at the old garage.

Thursday, March 10. There are light and dark moments here, and then I am not thinking of the hot days and the black darkness of the nights.

When a patient is admitted to treatment in the hospital, they are expected to pay a minimum of 10 000 CFA (ie less than 160 SEK, €16) which is a huge sum here. Even when there are critically ill children with malaria or meningitis, the money will be presented for treatment to begin. You must also be able to pay for the drugs. We had a patient today who had received one day of intravenous antibiotic therapy, but has since been without antibiotics for a couple of days since she has not been able to pay the drugs. In this perspective, it feels good to child health care in Sweden is free.

However, there is light too. Yesterday, I met Mr. Beckly Ayuk Bisong, who together with his wife engaged in an orphanage and a school for poor children. It uses a school that was left over when the leprosy hospital operations decreased due to fewer lepers. They have a fund called Rechafond. On one hand, they have a hard time with the funding of teacher salaries, but on the other hand, I think Mr. Beckly have wise thoughts. He wants to make an investment in a pig farm and a coco-plantation to make the orphanage and school self-sufficient. I think it is easier to raise money for a temporary investment than to hope for money from for many years.

I am looking for malaria parasites

Wednesday, March 9. During a break, I had time to visit the laboratory. The lab is currently well staffed, as it has four students. We doctors order quite a lot of tests so there is work to do. To some extent, it is the same tests as we do in Växjö, but the analyzing is more manually.

Of blood samples, you can check Hb and glucose with small machines. There are classic ESR tubes. White blood cells are counted manually, but when I order a diff run they run it in a Coulter counter. There is also HIV and syphilis testing.

In the case of urine test you can check out a multi-stick and look at the sediments. In samples from the urethra they often find in so-called gram negative cocci (bacteria). In stool samples, one looks for the various types of worm eggs. Yesterday I received a test result that said TT ova. It would interpret Trichuris trichuria-eggs, ie eggs from whipworm. They were found in the stool from a small half-year boy who had anaemia with haemoglobin below 60.

Other special tests are that you are looking for microfilaria in blood (elephantiasis) and in skin (river blindness – onchocerciasis).

The international women’s day dress

Tuesday, March 8. The International Women’s Day is much more important here than at home. Last week, five-six women came and “cut grass” with machetes outside my house, and I was expected to pay an appropriate sum. The day after I received a “special invitation” to an event on Women’s Day.

Officially, the International Women’s Day no holiday, but all employers are expected to allow all women to be free that day, so that they can be at the parade. The hospital was open as usual, but it was like a Saturday. To mark the occasion made a special fabric, which many women sew up the dresses of.

During the day, when I worked, there was an event with appearances in the schoolyard. Different groups danced and sang. A group that received applause were the positive group, which was HIV-positive. HIV has been and is quite taboo, but it starts to become a bit more open.

In the evening it was time for the event I was invited to. It proved to be a soiree with additional fund-raising, awards to talented women and then dinner, which consisted of bush meat, plantains and stewed green leaves. After the chop-chop and drink-drink, it was time for dancing.

The hospital of Manyemen

Monday, March 7. So, another year gone. Thanks for all the congratulations.

Patients can arrive out-of-hours. Simple cases, the nurses care for or they have to wait until tomorrow. The hospital has a dormatorium – a patient hotel, however, very Spartan – for long distance patients who need not be posted.

Otherwise, the structure is the same as in our emergency departments. Anything that is not obvious simple curable diseases are admitted for observation, and the problems can be solved the next day. One difference is that the lab is closed after 14 pm, so you have to start the treatment on clinical grounds and take samples next day.

The Sunday Mass

Sunday, March 6. The mass is held in the morning at the little Presbyterian hospital church. Church service is between 9 am and 10:30, but the majority of worship visitors will not come until after 9:30. Three priests, officers of whom the youngest is a woman who beats the pace and swing with the hymns.

My impressions after a week of work is rather mixed. On one side the hospital is running pretty well. There is a good laboratory, which is able to make a surprising amount of analysis, although some important analysis is missing. We have time for patients without stressing too much.

On the other hand, we should have many more control patients than we have given that medication is usually not written for more on a monthly basis, for cost reasons. During the week we had a few patients with diabetes who have had >33 in blood sugar because the drugs (and money) is finished. It is also true that we do have the number of patients who come with symptoms of tuberculosis. About half of them turn out to be HIV-positive. It is high time to detect HIV, when they already have AIDS.

I spoke about this with the head of the Primary Health Care. He agreed that there was a problem, but they were too busy keeping up with prevention program for children. They are understaffed and the roads are in extremely poor condition.

The vaccination programme is similar to the Swedish programme

Saturday, March 5. I wished that I would get Citronelle tea. It turns out that the grass that in the French section called Citronelle here is known as fever grass.

Saturday is market day in Manyemen. It’s not a big market, but there are still some thirty vendors of all sorts of things. I had actually expected more fruit and vegetables than what’s available. Examples of what is sold is kasawa, yams, plantains, tomatoes, green leaves, leek, celery, beans, paprika, pepper, and of fruits banana, pineapple and papaya. Some of the vegetables are quite chipped and would not go to sell in Sweden.

There are not so much protein-containing foods. They sell one kind of dried, smoked fish, which are rolled into coils. In a cool box there are fresh Atlantic fish. In meat there is only bush meat. The bush meats are from monkeys, crocodiles and something called fotambou, which I could not figure out what it is. The meat from these wild animals is smoked for be preserved.

Most of what is sold on the market is costing between 100 and 600 CFA, ie between 1 and 10 SEK (< €1), so I could buy a bag full of fish and vegetables for less than 50 SEK (< €5).

Malaria treatment – a three day’s course with Coartem

Friday, March 4. During the past week, we have had several cases of malaria every day. We check malaria test on almost everyone who comes with fever, and the test is often positive. The lab result is the number of trofocyter and if there only are a few, it is estimated to be normal, because malaria is endemic here.

The standard treatment is Coartem, which is a combination product with the Chinese flower artemisimin and lumefantrine. Artemisimin-drugs are those that provide the fastest reduction in the number of parasites in the blood. The combination therapy used to reduce the risk of emergence of resistance, which has not yet been seen in Africa. Treatment is simple – 4 pills morning and evening for three days.

The differential diagnosis of severely ill children is otherwise meningitis. This week we have had at least two cases. One is a two-year old who probably had a serous meningitis and also a seven-year-old who had meningococcal meningitis. In these cases you have to covered both diseases and provide treatment against both meningitis and malaria. There is rarely possibility to reach a exact diagnosis, which we however chose to do in these cases.

Thursday, March 3rd. So it was time for the welcome party. Two technicians have come from Switzerland to see the technology in both large and small. Dr. Kohlmeyer who has worked here for three years before, was temporarily visiting. We were invited at 19, so the party began shortly after 20 pm with a long opening speech. It was both our European and domestic staff who were there. Then we were invited to African food: bush meat (ie meat from wild animals of various kinds), stewed green leaves, sharp tomato sauce, spicy fish and of course, boiled plantains.  After dinner, we foreign guest were supposed to speech, after which the party turned into a song while.

Unsuccessful serpent hunt

Wednesday, March 2nd. Last night when I was going to bed, a bat flew around the mosquito net in the ceiling of the bedroom. It was scared when I turned on the lights for when I would chase it out it was already gone. After a somewhat restless sleep, I discovered this morning that it was sticking out dry leaves from a cupboard in the hall.

I therefore asked my maid to clean the cabinet. When I went to lunch, she had not done that, because when they cleaned the house before my arrival they had found a long snake in the next cupboard. She called, however, for a man who came with a machete and opened the cupboard. It was full of leaves but no snake. Instead, the mice have moved in since the snake disappeared.

So it is in houses that have not been inhabited for a long time, they explain to me here. Jungle takes back its rights.

The junior physician Gaëlle

Tuesday, March 1. Today, Dr. Gaëlle and I shared the patients at a outpatient clinic. Dr. Gaëlle has just emerged from medical school, and not so thrilled at having been placed Manyemen.

The working day is between 8:30 and until the last patient is complete. Usually at 16 o’clock. Patients are expected to sign up before 10 o’clock. All samples should be ordered at the 2 pm.

We were a pretty good team. Dr. Gaëlle had easier to talk to patients than me and she also knew how to record the cards would be filled in. I had to stand for knowledge of normal non-tropical diseases, and investigation techniques.

Patients speak a kind of Pidgin English. “Chop well” means eating well. “Potch” means diarrhoea, “wata wata” water diarrhoea. “How You Feel”, “Ho fo yo” – how are you etc.. It takes a good few days before I really learn Pidgin.

My office at the hospital

Monday, February 28th. First day at the hospital begins with a morning prayer in the word’s meaning. Subsequently, we are greeted welcome by the hospital director Dr Peter Chunke. Immediately afterwards, there is a staff meeting, where Dr. Chunke tells the age-additions on the salary that have existed for many years now should be withdrawn due to the decision of higher authorities.

First hour is sacrificed to the morning rounds at the hospital’s medical and surgical department. Many of the patients have HIV or tuberculosis, and have had serious infections that must be treated in hospital. There is even a young patient with glomerulonephritis, which responded well to steroids and diuretics. Some patients with heart attacks or hip fractures are not in sight. The last room is a private room where I see the first diabetic patient who is a typical type 2 patient.

The rest of the day I then to follow with Daniel Bender at the clinic. A work similar to our work on the Emergency Medical Centre. Patients are quite unsorted. The classic diseases here in quick succession: young child with malaria, patients with suspected AIDS or suspected tuberculosis. In between, patients with nonspecific symptoms and those that I might as well have had in Sweden as a rib fracture or fracture of the hand.

The Doctor’s house

Sunday, February 27th. Together with Claudia Bender we spend the morning walking around the hospital area, which is very large. From the beginning a leper hospital was built in the 50s. Then the hospital for other patients was built with some departments – medicine, surgery, paediatrics and maternal health. All around are maybe 30 staff buildings. During the heyday of the hospital, there were 250 employees.

I have got in a small house of my own with a large living room, two small bedrooms and kitchens. The house is pretty Spartan but has toilet and shower, but water is only when there is electricity. The electricity is on when working at the hospital during the day, and in the evenings between 17:30 and 21:00.

The heat is oppressive and does not let during the night. Outside the bedroom window begins jungle, so it feels almost like sleeping in tents. In the evenings you hear the crickets play. Through the night, and especially in the mornings you will hear a huge number of birds singing.

Two and a half hours drive on gravel road – I am happy it isn’t rain season

Saturday, February 26th. After having stayed the night with a relative in Douala, it was time to go to Manyemen. The road out of Douala, which just a few years ago, five kilometres of holes is now a good tarmac road, so you get quickly out of the city. The road to Limbe is straight and fine and of high quality. We turn to the Buea and continue to Kumba. In Kumba, we make the last shopping of food in the local market – we buy vegetables, spices, some pork and some fish. In Kumba, we ask for directions to Manyemen because there are no road signs. Some of the boys laugh and say it takes at least 4-5 hours to get there. Then we go on to the road of misery. The first 50 km of gravel road with many holes alternating with sharp rocks. It is difficult to find the best way to drive. Although the rainy season not yet begun in earnest is the road here and there filled with water, so it’s hard to know where it is best to drive. It is best to follow the mince decreased wheel tracks. Suddenly an impressive viaduct is revealed that snakes its way through the jungle. A few km later released suddenly the road to becoming a bad tarmac of impressive breadth. After 2.5 hour journey on the bumpy road, we finally arrive to our goal Manyemen.

Lumber truck

Friday, February 25th. Then it was time to begin the journey to Manyemen. Since it is a long journey, we have divided it in two days, which proved to be wise. The road Yaoundé-Douala is known for being one of the most dangerous in the world. Yesterday, a bus collided with a timber truck with 30 people killed as a result. The timber trucks have often only three thick logs on the truck, and the top had slipped into the bus. The road is dangerous for a winding its way up, and there are almost no opportunities to overtake. Since last year, however, improvements had been made in several places with extra lanes in the hills. The journey of 240 km took about four hours.

We arrived in Douala after dark, and then met by a hail of wasps, so that it is difficult to get around. These wasps are more and more the closer to downtown you come. The wasps are the motorbikes that run on the inside, outside, sideways in front of the car but also against the direction of travel. This is one reason that I don’t want to drive myself in Cameroon.

Leonie leder ett seminarium

Wednesday, February 23. Today I am listening to a seminar in public health with a focus on how to control infectious diseases. My partner Leonie holds a course on a number of lectures for five novice doctors to specialize in public health.

There weere much discussions in this group – three females and two males. We discussed why it was difficult to reach out with the vaccination. One argument for not to vaccinate themselves mentioned was that they thought the vaccine was bad because it was free, it was difficult to get to the hospital or that in some provinces vaccinations were opposed by local tribal traditions. Mosquito nets were not popular in the north of the country though it was thought to be too hot.

The different hospitals should also write monthly reports on what diseases were present. These must however be rather incomplete, because at one of the major hospitals there were no statistics at the individual visits; at private clinics, it was not so popular to describe what you did; while public units would be inclined to exaggerate diagnoses to get more money. I think it feels like the same issues that are common in Sweden.

Yaoundé city center – the yellow Toyota wrecks are taxis

Tuesday, February 22. The picture shows how it looks in the centre of Yaoundé. There are many people on the streets. All yellow cabs are taxis. Almost all of these taxis are ancient Toyota cars from Europe. In addition to the taxi driver, these cars take six passengers. Two in the front and four in the back. As long as the car is not full taxi driver takes up new passengers to be at roughly the same direction.

Monday, February 21. Here in Yaoundé, Cameroon’s capital city, the weather is quite pleasant. In the morning you hear birds chirp as a Swedish early summer, then it becomes a bit more oppressive heat in the morning, to be followed by an afternoon breeze before it is time for an afternoon shower.

Since I have some spare time, I devote it to study what I should meet next week.

Sunday, February 20th. So it was time to travel. Of course, I got extra material from Värnamo Hospital to include, so suddenly I had 5 kg too much luggage. It took longer to go through what I would not take with me than what it took to pack before.

Apart from a one-hour delay in the Zurich trip went well. In the evening, I landed in the dark African night, where the oppressive heat hit me close to 40 degrees warmer than the -10 degrees that I had left in the morning.

Thursday, February 17. In March I will have the privilege to do a study visit at a small hospital in Manyemen out in the country of Cameroon. The journey undertaken with the support of the Scandinavian Medical Bank / Erikshjälpen.

Really what I expect I do not know. The last 80 km north of Kumba will be a gravel road that takes two hours to drive. Cellular coverage is poor, but there is access to the Internet when there is electricity. My hope is that I can write little stories about adventures that face me.

Sunday, February 20 I will be off to Cameroon, where I will spend the first few days in the capital Yaoundé and acclimatize myself. Then I’ll go the long way to Manyemen.

Olof Cronberg

Originally published February 17, 2011 by admin.

3 COMMENTS

Jane April 16, 2011

Great adventure Olof…Nice to read all these from you at that end.

Kimberly Ilg June 5, 2011

dear Olof, Wow, I had no idea what a great person you are. I am sorry I used up your time with my ancestry questions. I have read your blog and I am amazed at all the work you do. Thank you for sharing this with me and others.

Peter Chunke August 10, 2011

It was nice having you with us. Since your departure, there have been many changes in Manyemen but we pray that all these will lead to improved services to the patients. We look forward to working with you again someday.Stay blessed.Peter