GAIA Vaccine Foundation

Protocol:
We submitted the protocol to Dr. Flabou last wednesday. He emailed back with comments early this week, the most important being that we needed a signature from the Chef de Vilage of Sikoro and the Mayor. Once we fixed it up and got the signatures, Dr. Flabou told us to bring the protocol directly to the Faculty of Medicine (at Point G) which we did today. We met with the guy who seemed to be in charge of the Commite de Etique submissions, and he told us many things that we had not heard before. The two most important being 1.) We need to submit the protocol by Tuesday, in order for it to be seen that Saturday. This means that we will not go to the Committee until next Saturday July 26th. 2.) The cost of submission to the committee (as i think karamoko has written) is $500+. (S#e^%*Fge&^bK)!!!!!

Peer Educators:
We met with them last week, as I had emailed. It was a great productive discussion, that resulted in the decision to have a salary increase for the two month pilot period. We are meeting with them again tomorrow with a few goals in mind: 1.) To let them know that the budget was a go, and salary increase approved. 2.) To go over the curriculum with all 11 educators in French/Bambara, 3.) To go over the logistics of the TB BOLO project (specifically those that make it different from here Bolo, i.e cough questionaire, active screening for at risk patient) 4.) Introduce them to Salimata, from the clinic, who handles all the TB cases in Sikoro. We have asked Salimata to explain to the peer educators the process of a Tb patient in Sikoro, where to get tested, where to get meds, who administers meds, etc.

My thoughts:
- I’m going to ask Karamoko to send the name of the person we spoke with today regarding protocol submission. If we had spoken with him from the outset, we would have known all this extra information regarding the process of presenting to the Commitee and we could have moved faster! This has taken quite a while and I feel frustrated that we can’t get to the committee before the 26th, cause i’ll be gone on the 30th! Also perhaps he can send us a format that we can use for future submissions
- I’m worried about TB Bolo Pilot once I leave, because there will be nobody directly “in charge” of the project. Karamoko can take on this responsibility, but he’s got a lot on his plate (?) also I think it would be better for it to be one of the peer educators. I think that once the peer educators are out in the community, many questions/issues will arise (i.e regarding the protocol for at risk patients, regarding money, etc.) and I think it would be nice to have somebody solid that the peer educators can direct their questions to. Sophie S and I have discussed the possibility of having Ablo (a super motivated, and charasimatic peer educator) be in charge. Again, the issue of time and compensation arises…and here is where the thoughts that Sophie S has been expressing re: Rama come into focus….
- The $500+ is a huge bummer. Paying it strengthens my previous point that we need to make sure we follow through with the TB project. It would be very unfortunate to see it struggle after we’ve put all this time and money into it!!

Okay,phew!
-Binny

PS: Karamoko and I are definitely making way with the French/English barrier. haha, we drove to and from Point G today and it was not in silence! I even taught him how to say Awesome! haha and this morning he greeted me with a “Hi Binny!”

Hello–

Last Monday I went to Point G and “shadowed” Dr. Diallo (so handsome! Haha.) I sat with him in his office as he saw patients for the morning. He’s definitely got a mix of visits. The next day I went back and rounded on the TB floor with the medical students and Dr. Patrice. He’s wonderful, does research (Ousmane is his ultimate boss) on HIV and TB and is looking at cytokine levels at different time points. His English is great, and he was very nice to make sure to explain the important points of each patient to me. In fact, if I was ever out of sight all of a sudden I would hear “Where’s Bin-Tu?” He heads the TB rounds to keep up with clinical medicine. I think he’s a great person to have be connected with GAIA, because he’s a little less busy than the big wigs, he’s much more accessible and willing to help. He spent over two hours with me a few days later looking over the TB curriculum suggesting small but helpful changes (i.e people in Mali don’t know what stress is, therefore they won’t really understand that its connected to active TB, haha.)

Another day at Point G, I was scheduled to shadow to Dr. Patrice, but he was doing informed consent interviews for his research, so I kind of just roamed the halls until somebody picked me up, haha. Low and behold, not much time passed before I heard, “Bin-tu!” and this great doctor, Dr. Tolaba took me to his office. He heads the rounds for the non-TB pulmonary patients, I’m pretty sure he’s a specialist, definitely higher on the hierarchy than Dr. Patrice. Anyway I sat as he saw patients and he did his best to explain some things to me. I’ll send his contact info as well. (he gives me a fresh boisson from his mini-fridge every time I’m at the hospital! Haha.)

Yesterday I also went to Point G and rounded with the med students and Dr. Patrice again. The second time around I was able to follow it a bit more, and this very nice med student from Cameroon (great English) also helped to explain some things that were happening. They have a lot of interesting cases, there are about 28 patients, I know of 2 MDR cases and 1 XDR case, there was also two cases of Potts Disease and two other patients with co TB/Diabetes. I was only made aware of 1 patient with co HIV/TB, but I could have missed another one. Learned a bit about the treatment for MDR TB, and that to do the MDR test they have to send the culture to the faculty of sciences, and it takes about six weeks-two months to get the results back. & I’m pretty sure he said that for XDR cases they have to send cultures to Colorado?! Since it was my second time, I got in on the questions, as in “Bin Tu how many months of treatment for MDR?” 21!

Other than these Point G visits I’ve been working on the protocol with Sophie, which we handed in today for Dr. Flabou to take a look at before the Committee meets on Saturday. It was helpful to go through the protocol step by step, because it helped to organize the course of the pilot program in our minds and also helped to identify factors that we may need to better explain to the peer educators — i.e what is the course of a TB patient through the Sikoro health system, where are tests available, where are meds available, who administers meds, etc.

Also last Friday the 4th, sophie karamoko and I met with all the peer educators again about TB Bolo. Unfortunately about five of them were missing due to the rain, but those that were there were interested/attentive. we delved a bit deeper into the hard to grasp topics, ie. mdr, how to act when a person has tb, etc. sophie and I found a great website with comprehensive and easy to understand TB information in French, so we printed some of it and handed it out to the peer educators as a “booklet” they can keep it on hand when they go out into the community to do sensitization sessions. we were excited about that! anyway, we’ve been having a good time here. unfortunately dr. Patrice is leaving this friday for a month long vacation in southern mali. I’m not sure how best to proceed with the point g visits, bc dr. diallo is pretty busy dont want to get in the way much, but was thinking if i could get in with the med student from cameroon i could hang with her. also annie, how do I get in touch with the hiv docs? also once the protocol is approved, we’re going to proceed with training the five TB BOLO peer educators (karamoko will do a session to make sure they can do it in bambara, and we will also meet with salimata from the asacomsi and hope that she will be able to talk withthem about the TB process.) we will also meet with the tb people at the ces ref, dr. berte, etc. to keep them up to date with whats happening.

Cool,

Binny

Most of the past few days was spent shaping up the TB curriculum and with a lot of sophies help we translated it into French. We decided to lessen the emphasis on co-infection in light of stigmatizing hiv and/or tb patients.

Sophie did a great job of presenting the curriculum to the Peer Educators yesterday. We met with them for approximately an hour (they gather the last friday of every month at the gaia house to get their pay etc.) We had printed out copies for them to share. Sophie engaged one of the peer educators to read the curriculum aloud (& translate into bambara) which was very helpful. Some were more receptive than others, asking questions etc, but everybody seems to have an interest. Karamoko chimed in often to clarify some medical terms (such as resistance, bacteria, etc.) A major question that came up was how kissing individuals with Tb can be allowed. I’m going to do some more research so that we can present this information more clearly. Most took a copy home with them and are going to read it over and prepare any questions that they have, which we will discuss when we meet with them next Friday.

On the radar: Finish up the TB Pilot budget (how much will the asacomsi cover, show it to karamoko), meet with Flabeau, show the curriculum to Salle, decide which peer educators (& how many) will be doing Tb Bolo, figure out how the card system subsidizing the cost of consultation at the asascomsi will work…

Its always interesting to be at the clinic, but with my lack of french/bambara skills, its hard to pick up a lot of whats going on. So I’ve been trying hard to learn some french & Karamoko has been trying to get in touch with Dr. Diallo (who speaks some english) so that I can go to Point G and “shadow” him while he sees patients.

Binny

Just a few days ago, we participated in the official opening of the Hope Center Clinic. This long awaited event represents the culmination of much effort by the GAIA Mali team (Karamoko Tounkara in particular) and the ASACO (led by Mr. Guidé Diarra), who deserve our congratulations for the work accomplished. The clinic also represents action made tangible: since we believe that putting HIV medication at the reach of a patient’s hand, in their own village, and that the only way to put an end to AIDS is to do that everywhere that AIDS exists, world wide, we can say that we have put our thoughts and beliefs into action and we have accomplished our goal.

It was a glorious occasion. There were speeches, there were certificates provided to the women and men who helped found the clinic, and Sophie and I received Chiwaras (antelope sculptures), a sign of the highest recognition in Mali.

When it came time in the program for GAIA to speak, I asked the MC to translate my words directly into Bambara. I talked about coming to the clinic for the first time in 2004, and our decision to install a mother to child transmission prevention program in Sikoro. I pointed to the tree we planted at the time, a small mango tree that was just barely visible in the crowd of participants – and told the crowd that it symbolized the work that we were trying to do. For why should a person from Sikoro have to travel to the center of Bamako if they were hungry for a mango, when the mango tree could be planted right in Sikoro itself, putting the mango at the reach of a child’s hand? I talked about how the act of planting the tree represented the roots that we had put down in Sikoro, by putting the MTCP program here, and by bringing students to work at the clinic, and by helping the staff get trained, and by providing the reagents for HIV testing. I talked about how our donors had provided the fertilizer so that the mango tree could grow. I talked about how the ASACO (clinic administration committee) had protected our tree, and allowed it to go tall and strong. And I talked about how Allou Sylla and other members of the national health organizations had, from afar, provided the important sunlight that was needed for our mango tree to grow. I said that the mango tree was small but it had already borne its first fruit – the “bloc Espoir” (the Hope Center Clinic) and that there were more mangos to come, it would only be a matter of time. I closed by thanking all of the members of the community who made it possible to build the bloc Espoir and said that we believed that hope was within the reach of a child’s hand in Sikoro, like the fruit of the mango tree.

The local officials were smiling broadly by the time I finished the mango tree tale, and then some certificates were given out (to 80 year old Ba Raba who was one of the original founders of the clinic) and we went to the other side of the CSCOM to cut the ribbon. Once the ribbon was cut, the crowd poured into the “Bloc Espoir”, and the rooms were inspected one by one. We showed off the two new doctors’ offices, placed ‘cote a cote’ (side by side) to improve the dialog between the HIV specialists and the head doctor. We showed off the “day hospital” with its eight beds. We walked upstairs to the big open meeting space (a terrace under a sheet metal roof) and the new conference room. We showed of the private pharmacy for HIV patients (required by Malian health officials) and talked about our plans to institute computer training so that the staff could start using electronic medical records (already donated by Labtracker and available on site).

It was a wonderful occasion. We have much to be proud of. We have more to do, but for this day, at this time, we can say that we have done what we promised, and done it well.

We feel fortunate to have been here in Mali to witness this event. We thank you for your contributions, we thank you for believing that we could do this together, and we thank you for asking not ‘Why’ but ‘Why not?’

With Love and Gratitude

Annie De Groot, Sophie Sprecht Walsh

Please see the website for pictures -
http://web.mac.com/dr.annie.degroot/Site/Clinic_Opening.html

For pictures
http://web.mac.com/dr.annie.degroot/iWeb/Site/Bamako%20June%2015.html

But start with the words – the simple words of a doctor speaking to a patient, a very thin woman in a yellow headscarf, who is 28 years old and who waited for over two hours to have her turn in his office today. A small child sits quietly in her lap. The doctor asks her some questions. She speaks softly, coughing as she is answering. A medical student looks at her lab results. She has 20 T cells. He asks her if she had ever been given medication before, and she says yes, but it was a long time ago, and the medicine had run out. The doctor pauses, considering what to do. Her life is in danger, but she has no money to pay for emergency treatment, and the hospital is far away.

This story would be the same as one told today in Providence or in New York City. It is a story that is told over and over again, and but for the blue tattoo around the woman’s mouth, and the tattered chairs, the scarred desk, the broken screen and the view into the dusty courtyard beyond, the sweltering heat and the slow ticking of the fan blades, overhead, we might as well be in any clinic, anywhere in the world. But this scene is taking place in Sikoro, not Providence, and I am sitting behind the doctor, watching the scene unfold.

I am here with Sophie Walsh and a medical student (Binny Choksi) who are both outside, talking to the TB care nurse. We are here to contemplate a mission that we have accomplished. We are here to celebrate the completion of a clinic that it two stories high, covered in fresh paint, and filled with gently used but clean and functional equipment. That clinic is just on the other side of the wall from the clinic that I was sitting in, awaiting the ceremonial ribbon cutting, the opening of the doors, the celebration of the work of so many people over many months that has culminated in this dream come true. We are opening a clinic for HIV care in a place that might as well be at the end of the earth – this is Bamako, not Timbuktu, but as far from first world health care as you can go, and still be on this Earth.

This is a place where children look after children, while other children work near by. This is a place where goats, dogs and small boys pick through the garbage in the streets, making sure that there is nothing thrown away that is still good enough to eat. This is a place where one in three to four children dies before the age of five, where (in our small clinic) one hundred babies are born every month, where mothers die in labor without so much as uttering a sound. This is a place where, too, a small tree of hope can take root, where green leaves can shine on slender branches, and where hope and dreams can eventually bear fruit.

Our tree is a clinic named after hope – hope for health. We built it to ease access to care for the hundreds of HIV seropositive patients who are living in this village of 35,000 people. We planted the clinic here at an arm’s reach for the patients, like the one we saw today, because we know she will not wish to travel far for her care. We planned the clinic here for our patients because they prefer to see doctors they know will care for them. Those are the doctors who will pause for a moment when confronted with a young woman they know well, and think about her HIV infection in the context of her while life. What would it mean for her if the doctor made the decision to send her to the hospital far away on the top of the hill? Would she go there? How would she pay for her care? Who would take care of her small child? And what of the family members who would have to travel there to feed her and pay for her care? What of the burden of her care on the family? This is the context of HIV care in West Africa. These are the barriers to health.

Our new clinic has an infirmary where she will be able to get care. Our new clinic has a new laboratory, where we will be able to see if she has tuberculosis, and a conference room where we will be able to plan her return to her home (only a few streets away), where we’ll map out her directly observed TB treatment therapy visits, and her follow up care.

The need is great, and the cost is small. For less than $35,000, we have created a space where patients can receive the care they need right near their home. Right now, less than one in eight patients who need HIV care in Sikoro are receiving it. And less than one in five patients with active TB is getting treatment. We have plans in place to bring those patients to our new clinic, reducing the spread of HIV and TB and improving the chances that each citizen of Sikoro will have a chance for a productive, healthy life.
We have done much to be proud of besides building the clinic. We are improving care, opening eyes to the possibilities of care at the margins, we are using simple tools that are low cost to teach about HIV and to encourage people to seek care. Our ‘hand of hope” peer education program has increased the number of HIV and STD tests at our clinic by four fold. The number of patients in care has increased from less than 20 a year ago to 120 today.

We planted a mango tree in the courtyard of the clinic when we first moved here. That tree is still there – now taller than I am, but it has yet to bear fruit. I plan to be there when it does. Our clinic – our Hope Center Clinic, is opening on Saturday. This is the first mango to ripen. The tree is small but full of promise. We can see the future. We have set down roots. There is so much that remains to be done. Because we are here a young woman, 28 years old, who has a small child to take care of, will be here tomorrow, and the next day, and the next. She will get better. This much we have done. It is no small thing to do, in a clinic that sits at the farthest corner of this Earth.

On that Day, I will remember, I will not forget.

I will remember, and you will too, the sound of mothers crying over a lost child. I will remember, and you will too, the quiet look of desperation in the young girl who now knows that she is HIV-positive. You and I, we will not, we cannot forget the children left abandoned by the death of their parents. We cannot forget the children left in the care of the grandmothers. We can not forget the grandmothers who were the last ones standing. I will remember, and you will too, the lines of patients at the clinic, and our long talks with them, and the slow handfuls of pills that kept them alive, day by day, day by day. We will not forget, we will, we providers, all remember how few of our patients had medicine, how many could not get the test, or the x ray, or the pills.

We are providers of care in the age of AIDS. We are both the caring, and the afflicted. We will not, we cannot forget that there was a time when we could do nothing but give our hands and our hearts, and as providers of health care, we cannot forget that once upon a time, our only salve was give solace. At that time, we did not hold the cure. But even worse, we did not have then, what we have now.

There is no more terrible time than now, to be caught, as caregivers, in this great inbalance, between those that possess the future – our patients – and those that do not – our patients by proxy, in the other places we work - whether in prison, or in indigent care, or in clinics for the undocumented, or in Cambodia, the Thai border, the underbelly of Nairobi, Capetown, or Mumbai.

Someday we all will remember this. Because that day AIDS will be a memory. We will stand here, as we do now, and because we did what we needed to do, it will be past. It will be over, and we, working together, will have made a future without AIDS.

There was a donkey in the courtyard that night. The donkey stood, calmly chewing its cud, in the corner. I could see him behind the chief, out of the corner of my eye, behind the two counselors sitting with the chief on his purple plastic prayer mat. I sat listening to what they had to say, listening to the back and forth of French and Bambara. The donkey chewed quietly. The sky was full of dust. The courtyard was full of straw and dirt. The children were clustered at the chief’s feet, listening to us speak. There was a French to Bambara, Bambara to French rhythm that sounded like prayers.

We were talking about what Brown University students found when they came to work in the clinic in Sikoro, this summer. Besides the women who were too poor to pay the five dollars to deliver their babies in the clinic, besides the children taking care of children, and besides the lack of clean water and food, the students found that the women of Sikoroni wanted desperately to learn. To know more. To find out about HIV. To talk about it. And they made songs that they sang and the students captured those songs on film. They sang about the children begging on the sidewalks, about the poverty bringing HIV to Sikoroni. One of the women named Bintou made a song about what she learned. She sang about the girls ‘walking alongside the road” and the HIV that they bring home. That’s the song that I played to the chief from my shiny metal laptop with the large screen. I played Bintou’s song.

The chief thanked us (GAIA) and I thanked him, and he said, if he had a horse he still couldn’t catch up to all of the good things that we were doing for Sikoro. What could I say to that? - and I know this sounds trite - but it is true - I said that if by luck of birth he were to be born in Providence and I was born here, he would do the same thing, if he knew he could help in some way then he would come too. That is what we are doing here.

And yet there was more. There was a tree planting in the courtyard of the clinic, the day of our departure. This is a true sign that we will come back. We left our roots in Bamako, and our tender shoots, for the clinic to nurture. The students - Rebecca, Erica, Caitlin and Ally were introduced (and their African names were remembered). On that occasion, we passed the GAIA students on to the village. They will have the pleasure of getting to know the women of SIkoroni and learning about HIV, and will do their best to stop AIDS in that small corner of the world.

The chief came to the tree planting to thank us for our work and to accept the GAIA students into his village. We talked about the long cycle of planting - planting young trees that need nurturing, that need our care, but that will, when their time has come, bear leaves, give us shade from the hot sun, and bear fruit for us in recompense. And although I don’t say it often and I didn’t say it then, I am also planting future generations of doctors who will return, as I do, who will not be able to turn their backs on Africa, having been there once before.

I am sitting on the outbound from Bamako to Charles de Gaulle and thinking about what might have been the most amazing event that happened anywhere in the world today - the fact that Mark at Labtracker received an email from Maggie who was sitting in GAIA’s Hope Center clinic in Sikoro, Mali, working on the “donated” computer. The internet worked! Maggie asked Mark gently, politely for help from a place as far away from Ground Zero as one could possibly be. You are my heros today. You are.

If I give you the visual picture (or you can see it yourself using google earth at the northeast corner of Bamako, Mali) perhaps you will see why I am so amazed and thrilled and ecstatic - look and you would see mud, and dogs underfoot, and the rocks in the stream bed that we call the road in front of the clinic, and abandoned stuff, and happy kids (picture attached), and the worn desk that the even more worn computer sits on, and the patients patiently waiting

I can’t believe it myself. There are two travel-battered but functioning computers, that are sending email and receiving information about HIV/AIDS treatment right there at the fingertips of the Hope Center doctors, and they are working as of today. . . It’s like going to the end of the earth (practically speaking, since the taxis we take can go no further) and finding a superhighway right there. INTERNET!. EMAIL! COMPUTERS IN THE CLINIC IN SIKORO THAT ARE SENDING EMAIL!.

Here are the people who made that happen: Thank you Matt Berg of Geek Corps Mali who convinced me that it could happen, and Thank you Arturo Peres Reyes who took his own computer (and his wife’s) and put them in my hands outside a tapas bar somewhere in Berkeley, and Thank you Matt Obert who figured out which thing went with which and put open source (low giga) software on the computers to run them, and Thank you Dan Davis who donated the labtracker software, and Thank you Mark at Labtracker who patiently walked us through the install (over the course of quite a few days), and Thank you Maggie who was right there at the interface between internet and the dirt and the mud and the stones, making sure all the electronic bits worked after waiting literally six hours for the download, and Thank you Ludovic who simply walked in, plugged the cord in, did his magic, and “ping” sent me an email right away. That made it possible for Maggie to ask for help FROM THE CLINIC. That’s why, Mark, that email, that you received today, from Maggie, was a small miracle.

With that miracle, in that moment, in that magical moment, anything at all became possible.

If we can bring internet to Sikoro, we can do anything.

Look at the street. See the town that surrounds it in your mind. Cry some tears of joy.

If you know anyone else who wants to get on this team - this miracle team that can move mountains - tell them about this. Tell them we are building a clinic at the end of the earth, to stop AIDS in its tracks. Not only do we bring condoms, and medicine, and HIV specialists, but we are bringing information - the very latest, now, new, hot information to the doctors who are taking care of our patients. Send anyone who wants to help to http://www.GAIAvaccine.org. We’ve only just begun. There’s a clinic to build, and patients to care for, and somewhere in the future, a vaccine that will end AIDS.

This is amazing. We are a community of people who can make miracles happen. I believe we can.

There’s much that can be said in a sidelong smile. That’s what I had from Fanta Siby Diallo, the head of the DRS (Direction Regionale de la Sante) today at the end of our meeting, where we finally were given the OK to proceed with building our clinic. As she said, she’s really not the building expert, and she advised us to consult some, but she didn’t see why we couldn’t just get started! Words sweeter than honey, if you ask me! Of course, we agreed that the DRS would also get involved in doing a “survey” of Sikoro sometime in the future, and that Tounkara, our director, would come in and work on the survey with the team at DRS, and I told them we’d have to put it in the budget, but don’t hold your breath - what’s important is that we have a green light to proceed. Success! The groundwork laid by Sophie, and the hard work of Tounkara - when you think that we were at the bottom of a deep dark hole just in April (only 17 patients, no formal paperwork, a director that was to be fired, and Mme Diallo at the end of her rope). Thank you Sophie, thank Tounkara, thank you board for your patience as we worked this through. We have the “paper” we have the “green light” we’re going to meet with Guide and the Mayor of Commune 1 before I go, and if all goes as planned, we’ll be starting to build the Hope Center clinic on September 1. Hence the smile, and the comment by our most wonderful Diallo who has been our guardian angel over the past months - “we women need to stick together”. A sidelong smile, and a hug. We’re blessed. As Sophie would say “Champagne!”. or was it “Chapeau!”. I say BOTH!

Meanwhile we’ll be working on a Plan D’Action that will need to be approved by the DRS and the CSLS about the HIV care we’re providing, and we’ll work with the PNLTB on our plan to do cough monitoring. Data is getting entered slowly - Maggie has surmounted massive computer problems and downloaded a new version of Labtracker across that electronic smear that is the internet stretching between a very wet Bamako and Ground Zero right in the Haight. What possibly could be more perfect than that? I can see the bits and bytes streaming right out of the great big glass windows of Dan and Mark’s office overlooking the epicenter of AIDS in San Francisco (from years past, having shifted to this side of the globe, since then), circling once, before they take off towards the East, flying over a Providence that is shutting down for the day, and the wind whipped ocean, and the storm crossed Sahel, and around our mango tree, and into our garden, and into the blue plastic linksys box that Matt bought for us . . . Labtracker is here, Maggie has the data, and as I sit here (next to the dog, who is quietly ecstatic to be lying next to me on the couch) I can see her across the room typing furiously. . . Thank you Labtracker, and Mark and Dan - if all goes well, and the red rivers of mud do not keep us trapped in our garden, we’ll sally forth tomorrow to feed data into the computer and tell you all about the results.

We also visited Dr. Traore of Commune 1 who was as always gentle and polite and supportive. We visited Djeneba Maiga, the doctor to whom we refer our patients for free HIV meds at Commune 1. She was suspicious (why would we want data) but when I explained about the need to make sure that the team is doing the right thing, she warmed right up and promised us our results. Kara will follow up with a request to copy them, and if all goes well, and the electrons are aligned, and we don’t float away (rain is coming down again as I write this), we’ll have the data in the computer before Maggie goes. That, and a picture of the clinic being built (if it doesn’t crumble away entirely like a giant sandcastle under this rain, tonight) and we can count this trip as a huge success.

Oh but there is more - we’re working on the conference - meeting with Solthis and Esther tomorrow to talk about the conference, perhaps inviting Jeff Sachs and Sonia Sachs and someone from Gates and also IAVI to come and also Ralph Jurgens to talk about prison work.

But enough about that. What I really want to tell you about is the river of water that is coming down from somewhere over our heads. We are perhaps not in Mali but rather sitting somewhere under the Niagara Falls, the Sahel is no longer approaching and instead the entire desert will be green with grass and filled with flowers if this rain doesn’t stop sometime soon. The pieces of cardboard that people where as head protectors are useless against this, and since no one has rain gear, or umbrellas (unless you are the GAIA guards who have the complete get up), you are just out of luck. This rain keeps people inside and why indeed not, when every other road in Mali is really only just a dirt track (you can see ours on a sunnier day, attached). And so, today, when the faucet above our heads wound down to a trickle, we made our way to the clinic with an adventurous taximan who didn’t seem to mind the foot deep craters in the road and the rivers running through them. Everywhere, everywhere, red water coursed, ankle deep, over the red mud. Kids, cars, goats, donkeys and taxis moved through it because, if you were going anywhere, that’s what had to be done.

I, for one (and I am only that) am confident that the streets will be dry tomorrow. There is no reason why not. If we can find a way to build a clinic, out here in the land of red mud, surrounded by donkeys and wild dogs and the skeletons of cars who, rather than facing one more street full of stones, gave up the ghost, we can do anything. The rain will come down, the Sahel will be green, Madame Diallo will give us her sidelong smile, and there will be an end to AIDS.

Maggie went to the Hope Center clinic with Mamou and worked on labtracker, entering data. Sad to say but the data is pitiful. It is filed on bits of paper and collected in a pile in a three ring binder. There were only 28 patients in the binder, but 52 are being followed. I’m going with her tomorrow to find more. Then we’ll go up and see Dao at the Point G clinic and get the information that is missing. Rama is sick but she held together for the meeting with the peer educators- seven of the 11 came to the house today to give us their reports and get paid. We went over the 5 points of Here Bolo and they loved the T shirts and visors, and they posed for pictures (hopefully Maggie will send). Thanks Elizabeth and (brother!). We talked about the project and the results at the clinic so far - a big INCREASE in HIV tests and people testing positive for other STDs - which means the message is getting out there, folks are getting the message and the link between STDs and HIV and they are coming right on in. This is so exciting! We told the peer educators we were proud of them. They asked for the smaller condoms and after a back and a forth about that, and laughter about how the Americans were too big - all the while knowing that what we were really talking about were the small foil packets that easily fit in your pocket and are somehow ‘cooler’ then the ones we give them now.

My favorite event today was the meeting with the TB program folks. We met with them and explained who we were, talked about the TB/HIV infection and the cough monitoring program and and our hope that we’ll be able to get that set up at some point this year. And then we were introduced to the head of the national department of health, a man called Dr. Ibrahima Bamba.

What I wish I could write for you but can’t would be an auditory description of the slow pensive sound of this man’s voice telling the story of the measles vaccine campaign that was carried out here in the nineties (yes, just about 15 years ago). He talked about how it made such a huge difference for the farmers in the small villages - that it made them believe that medicine worked. One year they were burying a child a day in the measles season. The next year they weren’t. In fact he started this conversation when we were talking about the weather - the rain - he responded by saying that now is the time when the grain stores have all been used up in the countryside. Food is planted but it is not ready yet, there is nothing but sticks and insects to eat, he said. He said it so slowly and so pensively you could do nothing but sit and listen for the next sentence to come. This is when the children get thin, he said, and when measles was around, they would get a cough and a cold with the wet weather and the measles would follow and the treatment was not to give them any meat - and not to bathe them either - so they would get malnourished and infected and while he was saying this in a slow, melodic, deep voice I was thinking of the children that we used to vaccinate in Zaire, and the children (one of two twins I was remembering in particular) who died on the way back to the hospital in the truck we used to go out for vaccination campaigns. I remembered it, and he remembered it, and between the two of us there were images of the children that we saw, in different countries, at different times, dying from a disease that no longer exists because there is a vaccine that made it go away. We both turned to Kara and asked him if he had ever seen a child die of measles. He said no. I said - that’s what we want to be able to say too, when we have our vaccine. What a chance to see that. I want to be there.

Another sound I’d like to share is the one we heard last night - much like a freight train passing - it is a sound that comes when the humidity is just right, and is as close as you can imagine to an earsplitting, earthmoving roar. It’s a sawing, reverberating, deep noise that makes the air dense with sound right after one of those wonderful downpours. Tree frogs. Too tiny to see. Tonight they are silent - instead, the tinny sound of mosquitoes around our ankles as we sit and type.

Then, since you are listening now, mix in the sound of snippets of Habib in the restaurant where we shared dinner with the Drs Dao and Traore (our advisors in Mali) and Boubacar and Abdul from the Habib Koite band - and more snatches of radio mixed with diesel fumes of course as we drove from place to place - and the twisted sound of worn taxi doors shutting - and children laughing as they play soccer in the street - and the haunting whistle of the train as it is coming in from Dakar. The day today ended with the sounds of the dog talking to us as we came in the door, wagging her whole pregnant body and talking to us in small dog words telling us that she is hungry, she has puppies in her belly, and that she is glad that we are home.

Once again, we are so pleased to be here, so thankful for your support, and looking forward to another wonderful day making mountains move and hearing tree frogs roar, right here in Bamako.