The story continues...

The Richard update: as you all know, Richard was admitted on Monday night. We did ultimately stabilize him that night, but I was initially worried that Richard would never make a full recovery, that, for whatever reason, he suffered brain damage during this whole process. Yesterday, I saw the first hopeful signs that this might not be the case; it was then that he followed a light, and even appeared to smile. It is only today, though, that I am convinced that he is cured. He smiled, he looked like a normal child. One might describe this as a miracle, but the word miracle implies that his cure was an inexplicable event. No, his cure was anything but inexplicable. His cure occurred as a direct result of the heroic efforts of the doctors and nurses here at the clinic.

I cannot fully explain why he was so neurologically depressed for so long after the resuscitation that night. Perhaps he was just so sick that it took him longer to recover. Perhaps he had meningitis in addition to the pneumonia and diarrhea, and that the daily Ceftriaxone injections ultimately cured him. We will never know, and, frankly, who cares? The only relevant point is that he is better.

I show you below two pictures of Richard as he was this morning when we did hospital rounds. He looks like a normal child; a normal and beautiful child.

Drummer boys and men

The following photos are the pictorial evidence of yet another unbelievable and amazing experience here in Kigutu; an experience that rivaled, and maybe even surpassed that of watching the girls' dance class.

There is a group of male drummers in Kigutu, both younger and older, that get together and play 2-3 times/week. They are led by two men: Peter, who works here at the clinic, and is also Deo's brother (Deo is the Burundian who started the clinic); and the second is Mandela, who also works in the clinic, and is basically, from head to toe, one big muscle. The drumming went on for about 45 minutes, and was truly stunning.

The first two pictures are of the drumming group, first forming a circle, and, then, marching together with their large drums on their heads. They beat the drums with batons as they go, and simultaneously sing.

The drummers marched and drummed and sang for several minutes, drums fixed securely on their heads. They then formed a circle, drums on the ground, and continued their drumming. Anyone who wanted to do so then did a solo dance to the music of the drums. What you see below are two examples of solo dances.

This one is a very cute and self-confident little boy, who clearly enjoyed his time in the sun.

One of the children in the hospital took a turn doing a solo. What is remarkable about that solo is that this is a 6 year old boy with something called a cardiomyopathy. That means his heart does not function well. This is not a correctable condition. It is not a structural defect, meaning that surgery will not correct it. Even if it were correctable, it would not be correctable here in Burundi. There are no cardiac surgeons here. If he were in the United States, he would be on multiple medications to improve his cardiac function, and, almost certainly, he would, by now, be on a list to get a heart transplant. Here, he is on one medication: Lasix, to help control the fluid accumulation that occurs as a result of his poor cardiac function. However, even with the Lasix, the fluid accumulates so quickly, primarily in his abdomen, that he becomes very uncomfortable. In order to lessen his discomfort, fluid is drained from his abdomen every week (a procedure called a paracentesis); as much as 4-5 liters is drained at each paracentesis. Very recently, he was started on oral steroids to decrease the degree of cardiac inflammation. There seems to have been some benefit, because now he may go as long as two weeks without needing a paracentesis. The point of the story is that this 6 year old boy, even with his poor cardiac function, was out there doing his two minute dance all by himself, and he was doing it as energetically as any of the others.

This is a picture of Muganga Petero, among my many Burundian friends, as we watch the drumming.

And, then, with my friend, Melino, as we take a turn on the drums. I hope that, by the end of my time here, I too will be toting a drum on my head in the Burundian style. If that does happen, then I will truly have become a Burundian. Right now, I will have to be satisfied with my honorary Burundian status.

Never a day without surprises

First of all, the "Richard" update. Against all odds and all expectations, he is improving. Last night and this morning, he consistently followed a light from side to side. More importantly, we even got two smiles out of him: conscious smiles. He no longer has a fever, and his breathing status has improved. I am cautiously optimistic at this point, with the emphasis on "cautiously." We go from day to day.

The second day at the clinic was busy, as I saw 15 patients. I admitted two more children for malnutrition. I have already gotten more adept at diagnosing malnutrition. All children, when they come into the clinic, have their weights and heights checked. There is a graph that we look at, which plots weight vs. height. If the child falls below a certain acceptable percentage of weight vs. height, then he is diagnosed with malnutrition. However, that graph is often misleading. Many of the malnourished children are edematous because of protein deficiency. They have excess fluid, and that excess fluid is usually in the abdomen and the lower extremities. But the edema artificially causes them to weigh more than they really do. When one treats the malnutrition, they often lose weight initially, because they lose fluid.

What is immediately evident about the malnourished children is that they all have the same look: the same total lack of expression, the same flat affect. They neither smile nor cry. They show no emotion. The picture below is an excellent example of a malnourished child. This is a three year old girl whom I admitted today. Note the swollen abdomen (filled with fluid), and, in particular, note the look on her face. That is the look of a malnourished child.

I have now become quite adept at writing orders for the malnourished patients; orders that include Vitamin A, Amoxicillin, Zinc, multivitamins, Iron, Folic Acid, and an anti-parasite pill called Albendazole. When they get to the unit, they are then started on a formula called F-75 (75 calories/100 ml.) made by the World Health Organization. There is a strict regimen that is followed in terms of how much formula per unit weight of the child per hour. More about that later.

My patient of the day was not malnourished. He was, instead, a four year old boy who had been bitten by a wild jackal. The jackal had gotten into their home, probably a hut, at night. The jackal had then bitten the boy's scalp, leaving three long linear lacerations. The mother had taken the boy to a local hospital the next day. Apparently, the wounds did not require suturing, but the doctors had appropriately put the child on antibiotics. They had also given the mother a paper telling her to come to our clinic for the anti-rabies vaccine. She eventually did so, walking nearly 60 kilometers (40 miles) to get to our clinic. When I saw the child, it was nine days after the animal bite; the scalp lesions had healed well, without any evidence of secondary infection. However, our clinic does not have the anti-rabies vaccine either, thus making her 60 km. trek pointless. We had to send her to another hospital, presumably another several hours away. The child does need the rabies vaccine, because there is rabies here, especially among wild animals. Will he get it? I have no way of knowing. One can only hope so.

I also learned today that, if a child in Burundi develops any type of childhood cancer, the chances of cure are zero. That's because there are no pediatric hematologist-oncologists in the entire country. Even if there were, there are no chemotherapeutic drugs here: too expensive. On the other hand, because of the available technology, it is unlikely that a child would be diagnosed with cancer here. But what's true in pediatrics is also true for adults: if an adult has cancer here, the chances of cure are also zero, again because there are no oncologists or chemotherapy drugs for adults either.

That is it for the day, signing off as I am known now: Muganga Petero

The first day of work

Before I go to the past, I will continue to give you updates on Richard, the little boy who we rescued Monday night. I wish the news was better. His neurological exam continues to be of grave concern: he is still not responsive, and continues to be very irritable. He is, at best, semi-awake. I fear that he had an ischemic neurologic event as a result of low blood flow to the brain that night. I will keep you all informed from day to day.

There were over 100 patients registered to be seen by 9 A.M. that day. They generally arrive by 8-8:30, many, if not most of them having traveled hours on foot on an uphill climb to the clinic. I saw only the babies and children, but there were plenty of those.

Simply learning the system was difficult enough. Each patient carries a small, paper notebook called a "fiche." The fiche contains the medical history. Much of the time, we have to make a new fiche at a given visit, either because they left the old one at home or because it is a new patient. I then register by hand all the data in a notebook, that data including name, first and last, age, sex, colline (hill), zone, and commune that they live in, followed by symptoms. The work was difficult, but, if nothing else, fascinating. I give you below a partial list of the patients I saw that morning.

1) 9 mo. old with moderate malnutrition, sent home on multivitamins and medication for parasites (Albendazole)

2) 6 year old female with scabies: treated with Benzyl Benzoate.

3) 6 year old boy, weight 24 lb., admitted tot he malnutrition ward for severe malnutrition

4) 9 year old boy with moderate malnutrition and pneumonia, sent home on Amoxicillin and multivitamins

5) 4 1/2 year old boy with fever and severe leg pain, past history of 5 transfusions, but no diagnosis made. Almost certainly has sickle cell disease, and is having a sickle cell crisis. Needs I.V. fluids and strong (narcotic pain medication). Appears jaundiced and very anemic, and presumably needs another transfusion, but can't do that here. Sent home on Paracetamol (their version of Tylenol), and father will have to carry him (child in too much pain to walk) two hours to a hospital that can do that

The last one is a bad story, and it is incomprehensible from our point of view. Such a thing could not happen in the United States. But, as I have learned already, this is Africa, and, even more specifically, it is Burundi. One cannot have the same expectations here as one has at home. My daughter asked me the next day if I knew what happened to the child after he left here. A logical question, but the answer is that there he is no way of knowing what happened to him; there is no ability to do follow-up. Occasionally, home visits are performed here, and I expect to go on some of those. however, this little boy in sickle cell crisis is a whole different situation. We have no way of communicating with these patients once they leave the clinic.

6) 9 year old girl with malaria and pneumonia. She was very sick, but not sick enough to be hospitalized. She was sent home on Quinine (for malaria) and Amoxicillin

7) 14 month old boy with moderately severe malnutrition. We advised that the boy be admitted to the malnutrition ward for treatment. However, the mother refused, because she has eight other children at home. She lives a four hour walk away from the hospital. She had to take care of the other children. The way it works on the malnutrition ward is someone, usually the mother, has to stay with the child in the hospital in order to feed him the high-calorie nutritional formula, first by syringe and then by spoon or cup.

This 14 month old child, who could not be admitted, was sent home on something called Plumpy-Nut, which is a very high calorie, protein supplement. It has has peanut butter in it (the kids love it). Also sent home on medication for parasites. As a demonstration of how tasty it is, here is a picture of a child on the malnutrition ward eating eating Plumpy-Nut. His enjoyment for it is obvious.

I will give you many more details about the malnutrition ward in coming blog posts. Will leave you now, with so much to tell, and not enough time right now to tell it. Muganga Peter (Dr. Peter, or as I am known now, Petero)

My newest friends in Kigutu

This was the best. I went down to the village in Kigutu, a five minute walk from the hospital. The girls from the village were all together, and I wanted to take their picture. At the direction of someone from the clinic, they all got in this group in about one second. after I took the pictures, they all gathered around screaming and laughing and crowding in to see the pictures. They were so excited that I wanted to laugh and cry at the same time. the girls, as you can see, are beautiful.

The next picture is of the woman, Claudine, who teaches the dance class, and her adorable baby. I went to one of her dance classes today. Pictures to follow.

The last pictures are of children from the clinic yesterday.

Pictures from Kigutu

This baby was delivered 30 minutes previously at the clinic. Here you have mother and baby.

Very friendly mothers and their children in the hallway of the clinic, before the clinic had opened.

This is the hospital ward at night, with family members sleeping on the floor on a mattress, next to the patients' beds.

This is Richard, the baby that we resuscitated on Monday night. You can follow his story in the Blog. This picture was taken early Wednesday morning.

A child did not die last night...

His name was Richard Haryarimana. He is 7 months and lives on Colline (Hill) Gotele. I jump ahead in my narrative to tell you his story.

The clinic here does not get many emergencies at night, primarily because the only way of getting here is to walk. That walk at night is at least an hour, and generally much more, of an uphill trek in the dark, carrying a baby or child.

Richard had been hospitalized at another clinic for several days last week. We are not sure for what, but we think perhaps malaria. He was sent home on Thursday, but he was clearly still very ill when he was discharged. He continued to have significant diarrhea, and intermittent fever. His mother continued to breast-feed him, but his intake was limited, and we're not sure how much milk she was producing anyway. Because of his continued symptoms, she took him on Saturday to a traditional healer, who made multiple superficial cuts on his chest and neck, and sent him home on herbs.

Richard's diarrhea persisted, and he was obviously still very ill. The mother made the decision last night to come to the clinic, and made the uphill two hour journey, partially in the dark, last night. She arrived at about 7 P.M., and we were alerted immediately. There was myself, Dr. Melino, and two nurses, including Brad, who went to to see him.

What I saw was shocking. The baby was severely dehydrated, having lost 15-20% of his normal bodily fluid. (Severe dehydration would be 15%, and this baby was at least that). His skin was dry and cold. When you pinched the skin on his abdomen, it formed a tent, and did not return to normal for several seconds.

This was a baby who would die very quickly if he did not have fluid. However, when a little baby like that is so dehydrated, the veins collapse, and there is no I.V. access. Many attempts were made to get an I.V. into the baby, but without success. Melino, in a desperate attempt to get fluid into him, put in what is called an intra-osseous needle: he put a needle through the top part of the tibia directly into the bone. We poured fluid into the baby as quickly as we could.

But the diarrhea was not his only problem. He had a cough, but, more important, his breathing was very labored: fast, and his abdomen was caving in and out with each breath. It was clear that he had pneumonia, and we gave him a dose of intramuscular Ceftriaxone. Multiple attempts were made to insert an I.V, probably as many as fifty, done by nurses as expert in this task as any nurses anywhere in the world. Those attempts were unsuccessful, but the fluid continued to be given through the tibia. The baby's color ultimately improved, his dehydration corrected, and, as proof of that, he urinated twice. He was stabilized.

I wish I could report that it was all good news. It is not. The child's fluid status is corrected, and he is now getting oral rehydration. However, his neurological status, even today, continues to be very worrisome. He remains extremely irritable, and is not really responsive. His breathing is better, but not completely. The concern is that he either has meningitis, or, because of the severe dehydration, a stroke due to insufficient blood flow to the brain. The potential meningitis, we are treating with antibiotics. If it turns out to be a stroke, there will be nothing to do. We will see how things progress, day by day.

The story is an amazing one, but primarily, at least for me, because of the skill and the dedication and the tenacity and the fortitude that Melino and the nurses showed in the face of overwhelming odds against saving that child. We worked on that child for five hours, until almost midnight. Yes, I was there, and, yes, I made certain suggestions that were helpful. However, I say this not with false modesty, but I know who the real heroes were last night: Melino and the nurses. There are too many people who are presumed to be heroes or given the status of heroes in today's world. Trust me, if you had been there last night, you would seen first-hand what real heroes do. Melino would never have left that child's side for a second until he considered the child to be stable. Any thoughts of food or rest would not and did not enter his mind during that entire ordeal. Simply put, he would not let that child die, and his efforts, at least for another day, have proved successful.

What was equally amazing last night was the reaction of the mother during the entire five hour process. That reaction was the Burundian way: she sat in a hard chair, no more than a foot from the action, expressionless, unmoving, not saying a word, not making a sound, and only responding to the occasional question put to her by Melino. She asked nothing, she said nothing, but, as I said, that is the Burundian way.

So that was last night. I would not mind if tonight was a little more peaceful. There is still much to tell about the last three days, but this story seemed too important not to tell now.

Signing off from Burundi, Peter

On the road to Kigutu

The last time I left you, I was tearing up the dance floor in Bujumbara. The next day began the final leg of my journey: the trip to Kigutu and the clinic. Ten of us crowded into the van, and among the ten of us, as you can see, were two soldiers, armed with AK-47's. I don't know about you, but I am not in the habit of being chaperoned by AK-47 toting soldiers. However, the protocol here is that we don't travel anywhere outside the clinic without our armed guards. I certainly don't have a problem with that.

The trip along Lake Tanganyika gave me a sense of elation. I was in Africa, certainly not as a tourist. No, I was about to begin what I had always wanted to do: work with local doctors in a rural clinic setting in Africa. I had trepidation on what I faced in the coming weeks, but there was also immense joy that I would actually be doing it in the next 24 hours.

We arrived at the clinic about 4 P.M., after having traveled 45 minutes over a bumpy dirt road up to the clinic. Every new bump radiated up and down my spine, especially because I was sitting in the back of the van, crowded in among eight other people. But any pain I felt vanished as soon as I stepped out of that van. I was greeted warmly, even effusively by several local mothers, their babies strapped to their back, African style.

I give you now some pictures of that first-day at the Clinic, my home for the next five weeks.

One of the most amazing life experiences I have ever had. The children are having a Sunday evening dance and music class in the community center.

Three small children watching the dance class.

On the mountain top overlooking Lake Tanganyika.

Overlooking the lake at sunset from the top of the hill above the clinic. Next to where I am standing is the water tower that supplies clean, filtered water to the clinic and the village of Kigutu below it. If only more of Africa had the ability to have clean, unfiltered water.

Thus ended my first day at the Clinic. Tomorrow, the real work begins.

As the proverb says...

There is an African proverb that says, "If you can speak, you can sing, and if you can walk, you can dance." I don't care how much I can speak, I will never sing. But let's talk about the dancing thing. I am not known for my dancing skills, or to put it bluntly, I am known for my lack of dancing skills. However, when in Burundi, do as the Burundians do.

My new friend Brad, the nurse at the Kigutu clinic, took me to a restaurant/club. We had large brochettes of goat and beef, Tasty, but tough. Very tough, in fact.

But before I even sat down to eat, the music and the dance had an irresistible pull on me. There were between 100-150 dancers on the floor at any given time, and it goes without saying that all of them, and I mean every single one of them, were amazing to watch on that dance floor. You want to talk rhythm, you want to talk moves, you want to talk grace, rhythm, and moves at the same time, they had it all.

And, yet, I was there with them every step of the way, although not every step of the way. I danced with men, (and, in Burundi, men do dance with men), I danced with women, I danced with both women and men. Perhaps my favorite dance was a kind of twist with a 6'4', 270 pound man, whom I think got just as much a kick out of dancing with me as I did with him. And I do not exaggerate when I say I danced with a series of beautiful Burundian women. If you don't believe me, see photos below. I know it amused them that a small, white man with no rhythm was able to keep up with rhythmic large and small African women and men. The evening of three hours of dancing ended with me in the middle of a conga, snaking its way along the dance floor.

The music was a mixture of African and American, and, trust me, if you had been there, you would have danced too. You could not have stopped yourself. There was such wonderful energy, such happiness, such plain "joie de vivre" on that dance floor that you too would have had to have been part of it.

What you're about to see in the pictures below may shock you, but only if you know me. If you don't know me, or maybe even if you do know me, you'll simply be amused. Have fun viewing them. Signing off for now. Peter

The arrival

I am now in Africa, having arrived in Burundi yesterday three hours behind schedule. More about that later. We could not go to Kigutu (the site of the clinic) yesterday, because it was too late when I arrived. One does not travel on the open road here at night. Very dangerous. So I am staying here in Bujumbara until tomorrow. I met some of my new colleagues last night, for they have come into Buj. (the name everyone gives for Bujumbara) for the weekend. Below you see Brad (on the left, whom my daughter describes as freaking hilarious: she skyped with him) and Elvis (on the right). Brad is a volunteer nurse, and has been here four months. He will stay for a year. I agree with my daughter: he is freaking hilarious, and supremely dedicated to his job. Elvis is a translator, and speaks multiple languages. Elvis seems to be friends with the entire population of Bujumbura.

Everyone from the clinic is very nice, and clearly very dedicated to their respective jobs. More about each of them with time. I have learned far more about the workings of the clinic over these past two days. I know that the average daily clinic patient population is right now about 100/day. I will be seeing patients in the clinic Monday through Friday. Plus I will be doing daily in-patient rounds on the patients in the hospital, and most of the children on the in-patient ward have been admitted for malnutrition. The average age of the malnourished children is three years old, and I have been told I will be seeing malnutrition patients on a virtually daily basis. It is difficult for us, if not impossible to grasp that concept, yet, for those who work in the clinic, it becomes a routine occurrence. Malnutrition and malaria: the two "M's," and two of the major diseases I will see, starting on Monday.

Back to the trip: the overnight flight from London to Entebbe was uneventful, and I actually slept for a few hours, thanks to the seat that became a bed in my business class section. The Ugandan airport in no way resembles what we know to be airports. The Kenya Airways desk is exactly that: a metal desk, where you check in. The flight was listed on the departure board as leaving at 10:30, but, actually left at 10 A.M. Thankfully, I checked my ticket, so I did not miss the flight.

I have not been to all the airports in the world, not even a small percentage. However, I cannot believe that any airport can surpass, or even match the Nairobi airport for its inefficiency. Take my flight for example. We sat on the tarmac for three hours, with the back door of the plane open (I assume, in order to let all the hot, humid air into the airplane from outside). Why did we sit on the tarmac? Because they could not close the cargo door. So they sent someone to the hangar to get a new part for the door. He returned an hour later, unfortunately with the wrong part. The final solution was to remove all the cargo, as well as the luggage from that part of the plane. They then put the luggage back on the other side of the plane, and ultimately closed the cargo door. And now you know why my plane was three hours late arriving in Buj. Who am I complain though? I made it to my final destination after a two and a half day trip that included five flights and five airports. Not only did I make it, but all my luggage did too.

So I ended up spending two nights in Buj. And far more about that second night in my next blog entry. But, before I leave you with this one, I want to show you the view from inside my bed during my two nights in Bujumbara:

What you're seeing, of course, is what it's like to sleep under mosquito netting. I personally don't like it. I don't have claustrophobia, and yet, that mosquito netting over my body made me feel claustrophobic. Luckily, in Kigutu, where I go tomorrow, no mosquito netting needed because we'll be at altitude. As an aside, it is not as if those nasty female anopheles mosquitos bite you only at night when you're laying in your bed. I don't know that any or all of them were female Anopheles mosquitos, but I had my share of mosquito bites of some variety over the last two days in Buj. And I doubt I'll be wearing mosquito netting around all day.

Reflections

I will be departing for Africa in two hours; overnight to Entebbe, and from there to Bujumbara via Nairobi. So far, a long trip, but I am feeling refreshed after a day of total relaxation in the British Airways Business lounge: food (a surfeit of food, in fact, drink, a shower, a shave, and, surprisingly, a massage. But these respite-filled hours will probably be my last for many weeks.

I have no clue what I face tomorrow, what I will see. Will it be a land and a people and living conditions that are so unfamiliar to me that it will also feel surreal? I assume so. I know that tomorrow, I will totally abandon all that has been familiar to me. I ask myself, even as I am on the cusp of beginning that adventure, am I capable of doing that? Yes, I believe I am. Not only can I, but, for my own personal being, my own personal worth, I have to do it. I need this trip. Forget whatever help I provide to those in need, for I need this trip just as much for me. I do not need the trip to reinvent myself. I need it to challenge myself. I could not and cannot, at this point in my life, accept the normal and customary in my life. Look, I am, in no way, expressing dissatisfaction with my present life in Los Angeles. I love what I do: my practice, and my work at Childrens. But I wanted more, or maybe I just wanted different. Burundi is definitely in the category of different.

My trepidation at this point is on a more professional level. Is it hubris on my part to think that I can do what I do in a completely different environment, facing completely different diseases than I have ever faced before? Facing children so sick that I may not know what to do?I know that I have raised these issues previously in my blog. But, as I get precariously close to my day of reckoning, my fears and anxiety grow exponentially. But, yet, I go forward, and I will encounter what is to be encountered. Peter

The journey begins

You will have noticed that my blog lately has suffered from a dearth of entries. Perhaps, dearth is understating the case. Absence of entries would be more accurate. We will now explain that dearth/absence by going back in time, followed by going forward to the present, and possibly the future.

As all of you who know me are aware, and many who don't know me, I have been fixated/obsessed for months with this great adventure that I undertake. Everything was in readiness. My daughter, Julie Rose Friedrich, came to my apartment on Saturday to help me pack. Actually, she didn't help me pack; she packed. She is the uber-packer.If packing ever becomes an Olympic sport, I put her down now as the Gold Medal winner. The real race will simply be for silver. One can remark about one's obsessive/compulsive tendencies, but one should never forget that an obsessive/compulsive personality does have secondary gain. The ability to pack efficiently is a prime example of that secondary gain.

Pictures having the ability to tell a thousand words, I show you pictures of what has accompanied me on my travels.

And #2:

I will also show you two items that, despite my pleas and entreaties, did not make the journey with me. Julie, My Packing Commander, refused to see reason, and would not let me take these two items.

Too bad, because the one thing Burundi needs is more Bichons.

Anyway, the point of all of this is that, after Saturday, all was in readiness to go. The packing was essentially done, and, on a more serious note, we were able to provide the clinic in Burundi with much-needed items: stethoscopes, otoscopes, pulse oximeters, bottles of hand sanitizer, packets of Bacitracin (a topical antibiotic), gloves, rechargeable batteries. So many of these things we take for granted, but are unavailable there. And what was so clear from the myriad of e-mails that I received from Burundi is that they are so grateful for everything that I bring them. I have no idea how much help I can or will be when I get there, but, at least, I know that, by bringing these items, I will have already helped.

So I was ready, my bags were ready, my psyche was ready, perhaps even my dogs were ready. What was not ready was the world at large, specifically, a small, inconsequential piece of that world that goes by the name of Iceland. All I have to say is god damned Iceland and god damned volcanos. Europe was closed, and there was virtually no other way to get to Africa than via Europe. If you don't believe me, give it a try. I finally found a way, and would have done it if I'd had to: L.A to New York, and then an 18 hour flight in coach to Dubai), followed by overnight in Dubai, and then a 5 hour flight to Nairobi, followed by a four hour layover, and, finally, a two our flight to my Bujumbara, my final destination. Fun trip, eh?

But, of course, the ban on European travel was lifted just in time for my trip. I have now completed two legs of the trip: L.A.-New York and New York-London. Don't underestimate the value of miles, because I was able to book my trip on Business Class, using the tens of thousands of miles I had accumulated over the years. It makes a major difference, simply in terms of comfort and amenities. For instance,I sit now in the British Airways Lounge reserved for First and Business Class travelers. All the food and drink, including alcohol (for free) that you could possibly want. Here I am in that Business Class Lounge:

I will sign off for now, because my free massage (thanks to British Airways) awaits me. What also awaits me in about 16 hours is the continent of Africa: about as far a cry as one could possibly get from the sybaritic splendor that I enjoy here in the British Airways lounge. I close by adding that I miss all of you, but mostly my two girls (and, of course, the person who has assumed, in my absence, the title of "man of the family," Mr. Garth Friedrich), and also miss my two boys, those of the canine variety, the ever-adorable and annoying Bichon brothers, Ozzie and Harry. Peter

D-Day minus 11

O.K., getting close to departure. Everyone asks me if I am nervous. Not really nervous. I would say I am now one or two quantum levels above nervous. What else would you call it if you woke up at 4:30 A.M. every day, and could not go back to sleep? What else would you call it if your mind was so preoccupied with the great adventure to come that you can think of nothing else? If you want no better proof of my state of mind (or perhaps, absence of such state of mind is more accurate), look no further than what I did this morning. I got dressed to go to work (my last weekend on call before the big trip), and put on my black shoes. I happened to glance down when I got to work, and noticed that I did indeed put on my black shoes: one from each pair of black shoes that I own. Hey, give me some credit: I got the color right.

So my newest morning routine is, after thirty or forty minutes of tossing and turning, I get up about 5 A.M., and exercise. Then I take the Bichon brothers for excessively long walks in the pre-dawn morning. (At least some secondary gain for the dogs: they'll be in the best shape of any two Bichons I know).

I am not so much nervous about what I face when I get to Burundi. That's because I don't have a clue what I do face. No, I'm more worried about the logistics of getting there: the acquiring of all the things I will need when I do get there; the packing; the trip itself; and all the myriad details that must be attended to before I leave (including various bills).

Speaking of acquiring all those things, today was the day when most of the remaining "acquiring" occurred. Today was what I call "The Trip to Target," or "Julie and her Dad do Target." Under the very strict direction of my daughter, Julie Rose Friedrich, (who matches me in her obsessive-compulsive tendencies), the two of us went through Target at warp speed. Who would have thought that two people could acquire so much stuff in such a short period of time? We were up and down those aisles like two finely tuned race cars. In less than thirty minutes, we were in and out of that store. Julie's very detailed list served as our guide, and what a guide it was. We literally filled a shopping cart with items anyone going to sub-Saharan Africa needs; items such as large bottles of insect repellent with 100% DEET (oh, yes, you want that DEET, for you really don't want to make friends with any of those female Anopheles mosquitos. For those who don't know, the female Anopheles is the carrier of malaria. Like many species I know, the male Anopheles is perfectly harmless); sunscreen; several bottles of hand sanitizer; toothpaste; toothbrushes; soap; soap-dishes; towels; power bars (again, something I never eat, but presumably will eat in Burundi); and who knows what else.

I feel that I am almost ready, but that feeling is presumably deceptive. It's like moving; whenever you feel like you're done packing, you unexpectedly come upon another bunch of stuff that you didn't think you had. However, the "Trip to Target" served its purpose; a necessary purpose at that.

Signing off for now. Peter

As the day approaches for my departure, I find myself contemplating what I face in this remote part of the world (we're talking rural Burundi here).

I have been doing this pediatrician thing for over twenty-five years, yet I still wonder how my skills and my expertise will translate to a medical, as well as a geographical setting that will be completely unfamiliar to me. Let's face it: I have never treated malnutrition, nor malaria, nor disseminated tuberculosis, nor even, in the last twenty years, bacterial meningitis (the latter, thanks to vaccines--yes, all of you vaccine naysayers, vaccines are one of the great advances in modern medicine in the last century).

Nor have I treated the host of parasitic diseases that I will see. However, even though the diseases will often be unfamiliar to me, the patients who have those diseases will not. What I mean by that is that, whatever their diseases are, these patients are still children. And that's what I do: take care of children. So, yes, I have enormous anxiety about what I am about to do, but I also have hope and confidence that I may be able to contribute to the overall health and welfare of these Burundian children. I know that I am not going to save the world by going to Burundi. But, perhaps, just perhaps, I can make a small, maybe even infinitesimal difference for these obscenely poor and medically underserved children.

Many people have said that this will be a life-changing experience. I doubt that at 61, and soon to be 62 years of age, I'm capable of much change. I imagine that I will be the same obsessive-compulsive, Bichon-loving/spoiling, Yankee fanatic, daughter-devoted, mechanically incompetent, eccentric human being that, for better and worse, I have always been. So I may not change, but what I do imagine is that my perspective on that life may change. And I will warn you that there is an excellent chance that I will be even more intolerant (at least about certain things, like vaccines) when I come back than before I left.

Signing off for now. Peter

Day 2 of the African Blog

Preparations are on-going for the great adventure. Nothing to report as of now, other than the fact that my mind is overwhelmed with thoughts and plans and needs for my trip. Today we purchase vitamins (something I never take), but also something I will take in Burundi based on a diet of primarily beans and rice. I don't even like beans, but necessity being the mother of invention, I will grow to like.

Pre-Travel Prep

Today, I'm learning how to use the blog and skype and other things that will make Burundi feel more like home. But there will still be no melons for breakfast.