Week 2: June 13-20, 2010

This was another busy week. It began with a quiet Sunday morning at the Southern Sun Hotel, but today I checked out and moved to the house of Peter Young, a young epidemiologist from near Boston who is on long term assignment as a surveillance epidemiologist.

Like all of the houses leased by the Embassy for Americans, it is larger than necessary, somewhat sparsely furnished, and well kept by around the clock guards who let you through the front gate when you come and go. The guards also seem to do basic yard work to keep things looking nice on the outside. Everyone also hires embragadas (maids) to help with cleaning, shopping and light food preparation. It's a very different lifestyle from what we are used to in the US. A typical embragada salary is $150 per month.

The day ended with dinner at the house that Jasmin and Rebecca are occupying. They invited all of us as well as Amy Boore, another long-term assignee who is hosting Terry at her house. Amy also brought Democrito, a softspoken young Mozambican who runs the library at the Portuguese school for children of wealthy expatriates and Mozambicans.

My week in the laboratory was highlighted by another trip to the Jose Macamo Hospital to continue discussions of implementation of the Meningitis Protocol to study the etiology of bacterial meningitis in patient populations. We didn't make a lot of progress because there were no lumbar puncture samples to work on this week. This week I presented some training on proper use of the microscope and showed some prepared slides to the younger staff so that they could begin to gain experience interpreting gram stains of clinical samples.

On Wednesday I went to the Maputo Central Hospital Bacteriology lab across the street with Charlotte, Lena and Yara from the lab to speak with a senior technician about how they preserve strains of bacteria in the freezer for future reference. The procedure was straightforward, but we may need to change the medium a bit since we are interested in banking strains of Cryptococcus neoformans, a yeast. On the way back we stopped by the lab that performs the cell counts and chemical analyses on lumber puncture samples and the senior technician described how she did the cell counts using a Neubauer hemocytometer. I think she actually had the multiplication factors wrong for determining cells per cc, but when I explained to Charlotte how I did the calculation in her presence the description of what she did shifted in that direction. I'll never know what she has really been doing, but I think she now understands the calculation.

On Thursday, "Doctor Mike" a young internal medicine fellow from UCSD presented his final talk before returning to California. He has been here for a year. He did his talk in Portuguese, but I did pretty well with it because of the English on many of his slides. He mentioned the name of Chip Schooley at one point. The thrust of his talk was to report on the problems identified with processing of lumbar puncture samples from patient to lab to reporting results. In a nutshell, over a 2 month period only 22 percent of samples were logged in, tested promptly in the lab and results sent promptly to the wards without something being done that was inappropriate.

For example, I personally observed a comatose 14 year-old girl this week with a presumptive diagnosis of bacterial meningitis who had undergone lumbar puncture, but her spinal fluid samples were never delivered to the lab for analysis. Sadly, this is common, because here is no person who considers delivering the samples to be in their job description. The cleaning staff will do it if someone remembers to ask them. In this case, they didn't. The patient is being treated empirically with ceftrioxone, a good guess, but data would be preferable. This sort of thing makes you want to cry. If they were to give me a call I would walk over to take the samples to the lab!

On Friday we had the first weekly meeting with the INS (NIH) Director, Dr. Ilesh Jani. I requested this series of weekly meetings, and he agreed. He asked that I bring Jose Paulo, Sofia (the most senior lab person who has been in Sweden for the past 2 weeks) and Beth Skaggs, my CDC handler. Everyone was present except Sofia who I should finally meet tomorrow. I had prepared an agenda and gone over it with Jose Paulo. This alone was a learning experience for him. The meeting was productive. We reached understandings about what was needed and how we were to acquire needed items. Ilesh made several useful suggestions about where to get advice for various aspects of laboratory operation, and we left with a short list of action items. Beth seemed pleased with the meeting, so I think we are on the right track.

On a personal level I also had a good week and learned much about life in Maputo. With much advice and guidance from Jose Paulo and CDC folks here on long term assignment I am now comfortable walking about the safe parts of the city during the daylight hours. I have found places to purchase groceries, lunch, take-out Chinese food for supper, fruit and bread from the street vendors etc., all within walking distance of the lab. This weekend began with dinner at the Waterfront Restaurant with Jasmin and Rhondette to watch the US/Slovenia soccer game. As those who are following the World Cup will know, it ended in a draw with 2:2 score. The American team actually scored a third goal, but it was disallowed by a puzzling foul call by one of the referees. Nobody could see what the foul was on the replays, but that's just how the game is played. I ate a traditional Mozambican dish of goat stew with a corn polenta type side dish. The seasoning was exquisite....a very nice meal.

On Saturday, Lisa Nelson, the CDC country director took our group to the Maputo wood market to shop for wood sculpure and other crafts. The wood sculpture is a specialty of Mozambican artists. The vendors are very aggressive, so I wasn't comfortable buying anything this trip, but I now have the lay of the land and will be more comfortable next time. On Sunday, Amy Boore, another CDC long-term assignee took the group to the local Art, Money and Geology museums. They are all small museums that can be toured in less than one hour each. The Art Museum was my favorite but they didn't permit photography, so I don't have pictures of that. Through all of this travel about Maputo, I have begun to learn the streets, and where things are relative to one another, so I'm gaining confidence that I can find my way about safely.

I will try to attach some pictures for the week's activities. Well, once again it is difficult for me to predict what the final placement will be when this is posted, but there are 5 pictures. The house is Peter Young's house, where I am currently staying. There are two pictures at the Money Museum, one of me with Democrito (Mozambican friend of Amy), Amy Boore (CDC) and Rhondette, and one of me with a statue of my Uncle Ebenezer. There is a picture of the Geology Museum with Terry (right) and Rhondette standing next to the sign, and an example of Mozambian oil painting that is hanging inside the Geology Museum where photos are permitted.

More next weekend.