"So, you want to take a trip to see the 'Real Mozambique'? Well, that can now be arranged, possibly, since the de-mining operations have largely cleared the road of most of the two million and mines seeded throughout this vast, largely vacant nation through over a dozen years of brutal civil war. There are problems enough to be encountered, some of them recognized and programs alleged to be instituted, some solutions are even said to be completed by the scores of voluntary and multilateral donor aide agencies, but there is no infrastructure in the collapsed state and the only way to know what is really going on is to go out and see for yourself. Don't assume that any of the basic services you might need would be furnished, since you may even have to build the road ahead of you; but at least platoons of the U.N. and others such as "Project Halo" have made it unlikely that the road will blow up under you. That assurance, however, cannot be given for washouts during the rainy season, particularly following Cyclone Bonita in this unusual rain-soaked season that has broken the drought of many years. The rural poor people will be very happy; the urban squatters in flood plains will be devastated; and the Ministers of agriculture, finance, interior, are all already writing their reports and speeches on how it is, due to their wise strategic planning and policy making, that the nation's production has progressed to the point of averting starvation and decreasing dependency upon donor food aid, despite the fact that two-thirds of all government expenditures come from donor agents abroad. Each of these agencies will take full credit for an act of God as they never would have for an act of war and the human mismanagement and malfeasance that has marked the history of this fledgling nation. This is the right time to look at it, since you are here and right now we can; so, come along and let us see what we can!"

With this introduction Dr Paulo Ivo Garrido, Professor of Surgery at University Eduardo Mondlane and chief of one of the surgical services of Hospital Central de Maputo and I launched on our safari through Niasa to Nampula. After an introductory visit in 1993 and much planning in the interim, I have launched my Senior Fulbright Program in my "destination travel", the (no longer "Peoples'") Republic of Mozambique. "No one arrives in Niasa on his or her way to anywhere, since you can not get there unless you are deliberately trying to end up there. It is on the way to nowhere, and if air travel is in your plans, there is a one week 'window' since there is a once per week last-stop-on-the-line by LAM in Lichinga, the Provincial capital of Niasa, and no one used to the comfort of a Ministry post with the relative conveniences of Maputo is eager to spend a week in this remote province getting along without electricity or running water, considered basic elements of civilization elsewhere, but never secured in Niasa", "Dr Ivo" (as he is called) explained. "But, you will see the real Mozambique, the fertile, vacant Highveld with abundant water in the Lugenda River watershed that now appear so attractive and inviting to the Boers twenty-five hundred kilometers south in their newly reorganized, democratically elected state. You will look at the land, and understand it, the Niasa (people of the lake), and the Boers much better after you have come to know and appreciate this northern province of Mozambique--bigger than all of Portugal."

I had already been one month in Africa preparing and staging my later visits and accommodations in the Universities in Pretoria and Johannesburg meeting with my hosts and faculty in Pretoria and Witwatersrand Universities. I had been a regular South African visitor during the previous political administrations, and was eager to learn of the changes underway in the new era since the election of President Nelson Mandela. This very encouraging development has had considerable professional and political repercussions in university administration, health and health education and policies as well as redistricting South Africa's provinces and causing quite a stir within university credentialing review processes. I ushered in the new year in this dynamic new setting and made courtesy calls among U.S. Embassy Personnel, University and hospital faculty, Dean and administration. I picked up the textbooks I had mailed through the diplomatic mail pouch that I will be distributing as gifts and in support of my teaching from the United States Information Service and packed up to fly into Maputo, Mozambique.

I was greeted by the very accommodating personnel of the USIS Maputo, and within ten minutes of my arrival I witnessed an unfortunate collision of voluntary NGO aid agencies and the poor people they were here to help, and within forty-eight hours I had personal experience of my own in the collision of the richest of the First and poorest of the Third Worlds. I lost some personal property, which unfortunately crippled my usual photojournalism garnering of information (dictaphone and tapes, notepad, computer transformer, A/C adapter, surge protector, and camera and film rolls) but fortunately I lost no blood in one of the few fast-paced stop-action sequences experienced in Africa--an armed assault by two men who jumped from a tree wielding bayonets. This setback was coupled with the timing of my arrival at the peak of staff holidays in the Hospital Central de Maputo such that there were skeleton crews in service and students and faculty on holiday. After meeting with the Ambassador and settling into my Maputo apartment and borrowing the facilities of USIS when the University Eduardo Mondlane Email server was intermittently operational, I set up the facilities for my later return and moved on to Swaziland, where I was expected to be returning from my period of a month's voluntary service two years before.

I made the road trip to the border crossing at Namacha where I walked across the border through immigration to be met by USIS driver Dumisa on the Swazi side. As we drove off to the capital Mbabane and then back to Manzini, I could note afresh that Swaziland had followed South Africa and its development (upon which it was heavily dependant) as is evident from the roads, vehicles, and industries along the way. The contrast is apparent with what underdevelopment had taken place in the former "Portuguese East Africa" and then was followed by the deliberate sabotage of the prolonged civil war that targeted infrastructure blown back to a pre-industrial society, and made the contrast with Mozambique more striking. I operated, once again, at Raleigh Fitkin Memorial Hospital, an institution with many good friends on staff and with the exchange of multiple senior medical students for international medical experience in the interim since I was last working here. I gave several conferences to the staff and lectures for the students currently in residence, and as a special holiday went off by a "hire car" through the heavy rains into Hlane Royal Reserve, where I served as the "PH" guiding on the game drive through this largest of Swaziland's small and restocked wildlife reserves. Maputo, smallest of Mozambique's Provinces, is still larger than all of Swaziland, and I was headed toward the largest of Mozambique's Provinces, which, as Ivo had pointed out, is larger than all of Portugal. There the game is not fenced in, and in fact, supports a flourishing and unrestricted poaching "international industry".

After I had celebrated Martin Luther King's birthday (a holiday for USIS if not for the Swazi and Mozambican counterpart societies) I returned to Maputo by a taxi I hired in the center of Manzani after taking one look at the "bus rank" and deciding I would choose an "up market" transport system instead!

For two weeks I operated regularly in Hospital Central de Maputo with daily lectures to the surgical staff and major conferences in the Ministry of Health, Faculty of Medicine of the University Eduardo Mondlane, UNICEF, the Dean and research director of the faculties and each department chairman in Hospital Central de Maputo. With Albertino (Chairman of Medicine Department) and his wife Bella de Soussa, , I explored the small but vibrant cadre of the artists and intellectuals of Maputo, including the most renowned of the Mozambican artists who has initiated an art colony here to which Bella contributes, Malangatana.

I went to a nearby Indian Ocean beach by crossing the Nkumati ("here there is water" in the Shongan language) by a rickety ferry boat that could contain only a few cars, most of them with C.D. ("Corps Diplomatique") license plates. I ran along the rough surf of the Indian Ocean to watch nets being hauled to the beach sand for their catch, and then ran back in the rain while our prawns were being grilled for lunch under the thatched roof of the rondavel. This was once a popular holiday spot, and the elegant Clube Marraquean was a place Ivo could remember being brought for tea and cakes on Sunday afternoon while looking out over the broad bend in the River Nkumati where over a hundred hippos would be wallowing. The ruins of the Clube remain as they were after their sacking by rebel RENOMO Forces this close to the central government's headquarters twenty-five kilometers away, and the hippos suffered a worse fate. There was easy access to the beach this day, since no "right thinking Mozambican" would venture out to the beach under threat of rain. I enjoyed a weekly institutionalized event, the Garrido Friday evening dinner en famille, in which case Ivo's mother could do her best to fatten up both her son and his guest, and his father could tell me of his appreciation for "ol' blue eyes" as a dedicated Sinatra fan. We made our way up to the apartment by torch light and an elegant seafood entre by candlelight, courtesy of a citywide blackout. Even the FRELIMO party headquarters facing the building was blacked out with but one generator causing lights to be still lit in one office--the Brazilian wealthy upstart Universal Kingdom of God Church, the landlord of the building whose ruling political party is their tenant. Despite the discrediting of their Brazilian leader through a videotape made by one of the disaffected members in a meeting in which he claims no spiritual authority but a very clever Ponzi scheme for a tithing pyramid for fleecing the gullible public. Even though broadcast, this evidence does not seem to have slowed the growth rate of this unusual sect in Mozambique, and we could see regular baptismal ceremonies in the Indian Ocean beach front off the Marginal Road most Saturday afternoons encouraging new tithing members into this sect.

I had been to an unusual ceremony during the course of an afternoon in which I was the Eduardo Mondlane University representative at the first graduation ceremony for ABDD's (Danish) educational project called Escola de Professores do Futuro, a unique and successful teacher training and community development project. Although he and the government had nothing to do with it, "success has a hundred fathers" according to Abraham Lincoln, and the Minister of Education thought that this would be a fine opportunity to come to congratulate both the graduates and his own ministry on this happy occasion and deliver a quite lengthy speech which was far less informative and entertaining than the spirited foresinging, choreography and imaginative low technology project each student brought to the convocation event. TV cameras were covering both the education minister and the project he had come to see. Since I had also come to see it, the TV cameras had captured me as well, and when electricity was restored during the Garrido family dinner, I had my brief moment in the sun on Mozambican TV along with a not very brief hour of the education minister's remarks. The graduates themselves had not had the chance to stay around to see themselves so honored, since they were already packed into Shapa's (the cattle-car-like lorries that serve as public transportation) on their way to the northern provinces to start up the new school year classes along with their continuing community development projects. Sadly, this outside donor-supported teacher training project is one of the few successful models of the priority that should be given to education and human investment in the redevelopment of Mozambique which really has to start from far behind this starting line.

Jeffrey Sachs, called by the New York Times the "world's most respected economist", was recently in Mozambique and restated the World Bank and IMF priorities for Mozambican investment. They were and are (1) infrastructure, (2) health, (3) education. With these priorities seemingly in agreement by most aide agencies, there is only one of them that seems to have actually happened. "If you want to know what has changed since your last visit, I could say it in one word," said Ivo to me--"roads!" That part of the infrastructure has been less developed than it has been de-mined and repaired where major bridges had been blown away. No new roads have been built of consequence, but those that existed, in name only, are now made to work in fact in at least most instances, at least so far as sabotage had made them impassable. Acts of nature seem much more recent than acts of man, and I would be meeting them up front and personal in experience. It is a point of pride to point to a railroad line that has been reopened or a road that is now passable--parenthetically, much to LAM's detriment, since the only way to travel during the war was by air, since each side lacked the stinger missiles or other antiaircraft devices that had plagued such other civil wars as that which had occurred in Afghanistan, Pakistan, Rwanda. Ivo cited his own development priorities which seemed to make good sense as sustainable investment with an amplified return: (1) education, (2) education, (3) education." When I cited his list of priorities to Jonas Lichtenberg, the Danish director of the EPF, he smiled in agreement with this list of priorities, but added "Still, it would be nice to have at least one telephone line that works!"

Among all the meetings and conferences that I had had, one was both urgent and highly important. I was introduced to Minister of Health Dr. Aurelio Zilhao, a young, concerned no-nonsense fellow who can tell you quickly if something can or cannot be done and he commissions experts to fix what is fixable. Minister Zilhao asked me directly, personally and professionally to "Go out to the real Mozambique and report back to me what the problems are in this goiter and cretinism endemic that I am told about, see if you can assess the extent and severity of it and what can be done about it. Judge what reasonable means can be undertaken to control it and find out what is, and--more importantly--what is not being done about it, and come back immediately directly to me with your opinion and recommendations, and I will do whatever I can based on your evaluation." I accepted his commission, thanked him for his offer of support, and insisted that I would pay my expenses. Dr. Garrido would be accompanying me throughout, and was further commissioned to resolve several delicate and highly publicly charged interpersonal issues involving leadership and administrative authority in two of the northern provinces--Niasa, with a newly appointed governor who had mistakenly meddled with medical policy and occasioned some editorial headlines with malicious unrefuted charges that expatriate physicians were poisoning patients through intravenous drugs which brought Lichinga to the impasse of an ultimatum and similar interpersonal rivalries had brought Nampula to a standoff. The high-stakes medical diplomacy might have been a full time job for the conciliatory skills of Dr. Garrido, ideally placed for this commission as an authority since he had been teacher of each of the medical personnel and frequent active visitor in the capacity of medical assistant to the goiter control project in coming up quarterly to operate on goiters. He was trusted by all sides, and therefore could give advice to each that could result in resolution with some degree of facesaving for what has been boiling up to quite public ultimata that threatened any medical service in these remote parts to which no government official wishes to be assigned and few voluntary agencies elected to go. If this "rider" were not enough of a burden, he was also going to act as my official tour guide and adventure fellow traveler!

This part should be easy. Afterall, I bought an airline ticket--not the first time I've done this in my life--and got up early, well packed and prepared for Ivo's pickup, standing outside in the predawn with my carryon bag at the ready. Ivo was uncharacteristically late. He drove up in his own car. There had actually been a contest at sendoff between the Ministry of Health and the Hospital Central de Maputo directorate, each saying it was their primary responsibility to be sure that he was being sent off and well looked after on this official mission. Each assured him that they would send a car and driver to pick him up at five o'clock a.m. Ivo said, "I have been down this road before. With all the assurances you can give, there will be no driver who will appear at this critical time, and this is one occasion when timing is critical!" On one official mission to Geneva Switzerland, Ivo waited for the delegation for the pickup by the official ministry car and driver who didn't get around to collecting until it was too late, and they missed the flight to Switzerland. That experience would be a sufficient learning curve for anyone who values promised punctuality, so very cautiously and with multiple caveats, Ivo allowed the assurance of Joao Aleshander, hospital director, who promised that the driver would be punctual "without fail". He failed. A half hour after the appointed time, Ivo left a message that the driver could come back at Elisa's leisure, and despite her tight schedule of events since she is going to Asmara, Eritrea, for a U.N. delegation to discuss the problems of rehabilitation of war torn countries later this week, she would be brought to the airport by the highly apologetic driver so she could retrieve Ivo's car which we would leave in the VIP parking lot with the key.

This is the point that was made quite dramatically by Mazula, currently chancellor of Eduardo Mondlane University, appointed to the post after Ivo had declined it. Dr. Mazula may be the most respected man in the country, since he engineered the election process which was U.N. supervised, but entirely Mozambican in pulling off the transition from war to democracy. During the very acrimonious debate between the formerly warring factions of FRELIMO and RENOMO there were multiple points at issue. Some point "number sixteen", concerning an issue that all have since forgotten and which was unimportant even at the time, stalled not only the entire debate but the election timetable had to be pushed back many months. This was not insignificant, with the U.N. peace keeping force UNOMOZ costing the world's donors one million dollars a day, opposing sides spent sixty days discussing point sixteen to no apparent purpose that could be seen by the donor community. This postponed the elections beyond their patience, but Mazula insisted that this process had to work its course, since these people had no sense of urgency as to calendar time, but worked instead with a strong concept of "cultural time". What he meant was evident all around us as we went through the airport to reconfirm tickets that were already quite secured and paid for and acknowledged with the passengers present in timely fashion to board the open seating aircraft--still one did not simply come here for the business at hand. First, all greetings must include preliminary formalities, and then personal references to the health and well-being of family members, with special reference to intimate details that are known such as the recovery of the maternal grandmother from an operation recently sustained and best wishes for a granddaughter recently named. At the conclusion of three-quarters of the meeting time, in which each party is assured that they really know each other and therefore can trust each other, whatever business reason there is for getting together is mentioned in passing as an afterthought, but by then it is a foregone conclusion. No doubt Ivo's driver this morning did not get through these preliminaries in his leave taking or startup on the business at hand.

However, Dr. Mazula pointed out that the sixty days in discussing point sixteen were not relevant to the resolution of point sixteen which is forgettable now as it was then, but since these two warring factions did not really know each other all that well since they had been isolated from each other by hostility, they needed this time to get to know each other in order to trust each other enough to make an agreement. Dr. Mazula pointed out that these sixty days--whatever it cost the international donor community--were necessary for a sustainable and lasting peace agreement, and he seemed to have been proven right by the outcome, since the Mozambican peace process is the one bright spot in the U.N.'s recent multiple peace keeping or peace making efforts from Somalia to Rwanda to the Balkans to Kapuchea and other places that are costing even more on a daily basis. I have been spending a good deal of African "cultural time", and it seems that this pays long-range dividends, since that trust and confidence is not granted anyone upfront because of a simple declaration that one promises to fulfill a given contract. Business does not come first, but follows as a consequence of relationship which is that which seems to be primarily cultivated through the passage of this time.

As we walk into the gate area--through a metal detector that, characteristically, has not functioned in months--carrying our carry-on bags past an X-ray unit which, characteristically, has not functioned in years--to one of LAM's two 737s, this one named "The Lugenda", after the Niasa River along which the Boers hope to settle and farm, that is, if the long bureaucratic negotiations build sufficient confidence to allow the Mozambican government to permit this.

"Now", you might ask, "if every other instance of any piece of infrastructure in every other system of communication, transportation, energy, water, food production and delivery, telecommunication has gone to seed and with a deterioration so dramatic that it is a wonder when anything works, why should aircraft maintenance and safety be the exception to this rule of general entropic collapse?" That very question was asked three times at the gate around me, once in Makua, once in Nanja, and once in Shongan which Ivo understands so he could translate for me--"The Lugenda is OK? It will not fall?" These would be assumptions in some other world where standards are enforced by some intact functioning state. Some community acceptable levels of competence are expected such that the participants perform up to this level or they fail. If the State itself has failed, individuals are free to set their own standards of acceptable performance. Welcome aboard LAM number TM 190!

The Lugenda will make three stops enroute to its once weekly trip to the end of the line--or as some here would phrase it--the end of the earth. In one hour and ten minutes we will go from Maputo, the first city of Mozambique and its capital to the second stop, Beira, the second city in the nation and the provincial capital of Sofalo, the stronghold of the RENOMO "former rebels" referred to as "our brothers" sardonically in this forced reconciliation. As soon as we reached cruising altitude, the crewchief came back to invite us forward to first class. "Of course, she is my patient," smiles Ivo, "which is one of the good things about being one of four surgeons in the nation. She and several of the crew have clustered around asking if it is true what they have read in the Maputo newspaper from a reporter who never left the capital reporting malicious acts on the part of expatriate medical staff allegedly volunteering to help the poor people in remote Mozambique? If Ivo is on this plane, it is clear that he is on his way to fix this, and he has spent enough "cultural time" with each and every one of the participants in this dispute that he can get to the business of resolution much more quickly than any other could. We arrived in Beira in a downpour. This "Beira corridor" was the vital link to the sea of Ian Smith's (Southern) Rhodesia and when the U.N. wished to enforce sanctions against the white minority government, the idealogue Samora Machel simply said, "It is the right thing to do, so we will do it." No matter that it cost him most of his nation's hard currency revenue from servicing with access to seaports what later became Zimbabwe under majority rule. It was in Beira that Ivo was working during the darkest part of the war years when in 1983 he literally had nothing to eat and could not find anything to feed his family. Even with money in hand, there was simply nothing to be bought. Through these lean years, Elisa did not complain since they were waiting for better days still to come: those days are now, and they must be made to work for them. As we flew out, even through the rain, I could see a lighthouse on the Indian Ocean shore, ironically with a shipwreck hulk at its foot--although which came first, the lighthouse or the wreck, I could not learn. Just behind the lighthouse, Ivo points out the house where he stayed when he had nothing to eat. And now we are both flying over that landmark.

Another hour and ten minute flight brings us to the third city of Mozambique, capital of Nampula Province, also named Nampula. This is one Province with nearly a homogeneous single tribe, the Makua, the largest single ethnic group in all of Mozambique. Their dominance has led them to form an association with aspirations to be a political force, although the constitution that followed the Treaty of Rome outlaws any political party based in tribal, language, or religion distinction. It is important to note that the constitution is a national document and affirmed by an election. It is even more important to note that the Province has no such constitution and its governor is appointed by the president and not elected. In the Samora Machel era, governors from all different ethnic, language and religion backgrounds were assigned all over Mozambique in the name of national unity. They lacked authority and credibility with the local hereditary chieftainships. In Africa, even more than elsewhere on earth, all politics is local. RENOMO skillfully exploited this effort at nationalization to say to local chieftains who lost power and privilege in the effort toward the creation of a centralized state that they would be given some part of their previous powers back which were acknowledged as legitimate by the local population since they knew only this form of tribal leadership. This is not a nation-state in which electioneering politics reaches television, radio and newspaper penetrance. If elections take place, the populace votes as their chief orders them to, and it is an "electoral college" efficiency of small numbers that allows a great multiplier at the polling place to secure favors with local chiefs. Current President Chasano is now dropping many of the ideas of ideologic purity, giving up much of the strong leadership exhibited by Samora Machel which he wistfully conveyed to his "closet cabinet" of four young intellectuals, confessing to them that he was worried about confirmed rumors of his imminent assassination and he wanted to stress to them the primacy of national unity. This empassioned plea was made before these four young future leaders, one Paulo Ivo Garrido among them, two days before Samora Machel's plane crashed inside South Africa on return from Zambia. Chasano, the transcendentalist meditating chess player, is now governing by consensus with apportioned representation of local tribal minorities appeasing disgruntled small blocks of ethnic and single issue voters offering some form of power-sharing participation--a la William Jefferson Clinton. Unlike Mr. Clinton, however, Chasano the serenely meditating chess player keeps his own counsel and doesn't feel it necessary to explain his immediate moves when he is thinking of the outcome for moves far out into the future. "To combat the imminent threat of hunger in this nation, I would sign a pact with the Devil himself" is one of Chasano's very few epigrammatic quotations--which explains his cagey invitation to the apartheid hard-line Boers, refugees from now democratically-elected ANC South Africa. Whatever their politics, they carry with them expertise in farming and food production and know how to get things done with a commitment to the land. They will have to develop a civilization around them since it certainly will not be furnished by the State, but the State will retain any residual infrastructure they build In one of the ironies of modern Mozambique, the Boers are now pleading with the South African government to assist Mozambique in development of the infrastructure they had targeted for destruction through their support of RENOMO during the long civil war! And in yet a further irony in history, I reflected on migration from the rural farmlands of Mozambique of the youth to the "informal sector" (as the World Bank calls it while trying to ignore its existence) the "Dumba Nenge" clustering in and around any urban center. There is an export of rural labor to the urban setting, therefore away from agricultural production. This was once the case when "the darkies" were exported as slaves to the New World or "the kafir" were indentured as perpetual servants by the white Africans of Anglo-Dutch Afrikaaner origin. Now, in one of those amazing twists of history, the irony is that Mozambique will have to import farm hands for rural labor to till the soil, and is going to be importing the "Blankies"--the Boers in a histrionic turnabout of major political irony! What residual social consequences this importation of labor and expertise might have in the future is only a guess right now, but it might be hoped that the world may have matured by the time we reach the twenty-second century in which Mozambique is now already wedged!

This calls to mind my long conversation with Dennis Jett, the U.S. Ambassador to Mozambique who makes quotable aphoristic observations that embroil him in controversy. The undiplomatic language is heard on both sides, such as the headline in the newspaper last week "Dennis Jett, please go home!" In discussing investment potential in Mozambique, he said to me, "This is a market for big fish or bottom feeders." In discussing the comparison of long years of the civil war with the savagery and brutality of the Dark Ages he had told me, "Mozambique is not the nineteenth century, certainly not the twentieth century. It is much more like the twenty-second century will be." There must be some lesson in that, principally one of prevention.

Destination travel! Swooping down over wide verdant vacant highvelds along the scattered well-organized hut compounds "The Lugenda" touched down within the province of its namesake river and within line of sight of Lake Malawi, as it is now renamed. David Livingstone, my intrepid hero of "Surgical Exploration" came trekking through this area of what was Portuguese East Africa (Mary Livingstone is buried in Zambezi Province where her grave can be seen at the Zambezi River) and he approached this very imposing lake through the highveld. He asked one of the Nanja-speaking peoples living near the lake, "What is the name of that body of water?" "Niasa", was the response. So Lake Nyasa spelled in British English gave rise to the name British Nyasaland on the western side of the lake and the area was claimed by the British largely through Livingstone's exploration. Livingstonia is on the corresponding scarp on the other side of the lake. This could be considered one of the little jokes perpetrated on the naive adventure traveler--such as I--if I should make so bold as to compare myself with David Livingstone. He perpetuated this in naming this body of water "Lake Lake", since "niasa" is Nanja for "lake". Considerably worse malapropisms had been foisted upon innocents abroad, so we will forgive both Livingstone, and to a lesser extent, the British, weighing the motives of each.

When British Nyasaland was independent thirty-four years ago under the direction of Dr. Hastings K. Banda, the London general practioner who married a British wife he left behind to come and rule his police state for the ensuing thirty-two years, dressed smartly in his three piece tailored London suits, advertising his renamed Malawi and its lake with the same name as the healthy inviting vacation spots for catering to pampered white Europeans: "The Warm Heart of Africa". It was a wonderful place to be on holiday, particularly for water sports in the Lake Malawi that was allegedly bilharzia-free. Not only has that been disproven in a fairly dramatic way, but the good Dr. Banda's police state was overthrown in elections two years ago and his mistress and nephew who were effectively running the state were jailed for the murder of four opposition leaders in which the senile Dr. Banda was implicated but excused for reasons of such sclerosis of this aged infirm oligarch that it would make no sense to punish him. Malawi was the only state in black Africa to recognize the apartheid regime of South Africa as legitimate, and consequently was a point of refugee retreat and RENOMO insurgency during the civil war. One of the other peculiarities of the state of Malawi is that it is a crime against the state to discuss or speculate about the age of Dr. Hastings K. Banda since it is well known that he is at a least a decade older than the last published reports before such information became illegal. He is a bit out of touch, just now, still believing he is in absolute authoritative power, sending out orders for the detention and the beheading of various individuals who displease him, and the reward of the wonderful white folk who are to be attracted to this area as the mainstay of the economy.

On the other side of his lake was the Mozambican principle naval base, since the Portuguese used the road developed through Niasa to supply their naval station on Lake Malawi to help interdict the support to FRELIMO from Tanzania and other guerrilla camps that infiltrated the northern provinces. The Portuguese liked Niasa and situated its capital where no other resources would have made it likely for a provincial capital to be built, simply because it reminded them of their home in Portugal. The elevation is 1,369 meters at the airport (4,492 feet) so the climate is cool, and the green hills and valleys look like the River Duoro near Oporto so they began their colonial capital here with broad boulevards and parks and stately colonial homes in a province bigger than the whole of their native Portugal. In the elegance of one such home was the quarters for my visit, and actually serves as the home of the speaker of House of Parliament who, coincidentally comes from Lichinga. The governor's house is next door and the "provincial palace" where the government of this large province is housed is situated on one sector of a sleepy boulevard in spoke-and-wheel circles. But, do not be deceived by the grand design of what was once elegant living, since the governor must ladle water from a bucket drawn from a well and pour it over his head for his morning shower the same as I, and he can read by flickering candlelight just as I do. The E.E.C. invested a huge amount of money in the rehabilitation of the provincial hospital. It was all cleaned, whitewashed, and structurally rehabilitated. In a ceremony marking the completion of this rehabilitation, vice-minister of health Dr. Abdul Nur-Mohammed came to supervise the ribbon cutting ceremony as Joao Paulo, the medical director of the hospital, around whom much of the current controversy is swirling, publicly thanked the E.E.C. donors for their support in rehabilitating this hospital, and, as quoted ironically in all the newspapers, "With the possible exception of two small deficits--that we still have no running water nor electricity--it is really all quite splendid." Since the ceremony in which Abdul made his visit on Monday fitted in with the weekly arrival of LAM TM 190 he flew in for this sardonic celebration; however, no ministry official wants to be trapped in the incommodious facilities of Lichinga for an additional week until the return of the same flight, so an aircraft was chartered to get them out right after the ceremony to a real city from which there could be daily flight service expected--so they paid for their flight to Nampula, bureaucrats terrified of banishment far from the paved streets, lightbulbs, and--in my case of Maputu luxury--cold running water almost thirty minutes each day!

I met with each of the provincial and district representatives, hospital, health ministry, government and voluntary agencies and reviewed their records, registrations, program initiation, suspension, interruption and then--termination when hardly halfway begun on the first of three doses. The well-intentioned and frustrated personnel have been sold multiple empty promises and have passed along these promises of imminent services forthcoming only to be later told that the program was aborted almost before liftoff! UNICEF said it has supplied the social marketing for the program, survey and assessment and promotion to the population. Only the latter seems to have been successful, since a goiter control program is readily accepted by the population, particularly with its consequences for prevention of cretinism. However, in the three dose regimen, I could find no one who had completed all three, and if the numbers were counted up for the target population, there were inadequate quantities of capsules delivered to even half complete the first dose before it was announced that the program had been satisfactorily concluded and no more capsules would be forthcoming. UNICEF is not interested in continuing this program that it had viewed as a stopgap measure, since, it was going for a long-range solution with iodized salt incentives. The fabrication of iodized salt along with the iodine enrichment sceme was set in place in multiple locations through the nation, one at the port of Nocala which supplies this entire region along the road that I would be traveling through the Niasa Province which also supplies nearby Malawi. Should iodized salt be available--as UNICEF insists it already is being produced--although none could be found anywhere in evidence--it would originate in Nocala and be shunted directly into Malawi where there is far more money to be made by selling it there. Lichinga, and particularly the outer remote areas of Niasa Province, are the last stop in any supply route for any program that occurs in Mozambique. If they ever get iodized salt, it would be because Malawi has become completely saturated with all it can consume from the same point of origin. That program has not yet come to be, and the interim measure of iodized capsules was stillborn.

A very reasonable resolution that would cover at least the eight year interval for which UNICEF had projected five years would be iodized oil injection. A consultant "expert" from Finland advised UNICEF that needles are not to be used in Africa, since we all know that they spread HIV. Given that that could be the case, does the expert from Finland believe that no needles, therefore, will be used in Africa since they are not being used in any contribution to goiter control? Every health post is well supplied with abundant needles, usually of the disposable kind by first world standard. There is nothing in the first world that is called "disposable" that is not infinitely reused in any third world setting, so the solution is to make safe reuse of real needles possible. They are absolutely required for each individual who participates in the EPI program (Expanded Program in Immunization) which WHO would like to represent as equal to the globe's population. Furthermore, everyone in Africa with a fever gets a shot of penicillin before a diagnosis which sometimes follows if they didn't respond positively to the antibiotic injection. Injection is the only real medicine acknowledged by the population, largely from acculturation through their own traditional healers. "Curandeiros" practice scarification and even mock injections and have done so for eons before the arrival of Finnish experts who have not had the opportunity to visit rural Mozambique before torpedoing the single effective one-shot approach to the management of this problem in the absence of complete assessment, surveillance, implementation, evaluation, target outcome of this program of interval iodine capsule administration. The people in Niasa, and that includes the personnel in the health field who are the real heroes trying to cope with problems, have "been failed". In Maputo I learned from the UNICEF chief in charge of this program that there is so little capacity in the government that all one could hope for was to institute a program of some sort and then consider anything close to forty percent a complete success. Looking at the problem from the other end of the scope that does not magnify from the Niasa perspective, it seems that UNICEF has declared victory after promoting its promise and failing to deliver. Many of the people I questioned had heard of the program; none had been beneficiaries of its completion.

I arrived in Chimbunila health post in the very colorful setting of hundreds of women swathed in their colorful kanga cloth and headdresses each with a baby slung over the back or swivelled around to the front attached to an exposed breast. The health post is isolated in the middle of a field some of which is cultivated in maize, some in manioc, and a small space in potatoes. What did people do for calories in this area before the Colombian exchange? All around the cistern in front of the whitewashed building with a red cross on it were sixty women waiting patiently for "the expert from Maputo" as I had been billed. It was exotic enough to think that they were going to have a visitor from far away Maputo to come to see them, so it would be quite a bit of overkill to suggest that this man had actually fallen from another planet, which would stretch their imagination beyond its elastic limit. They were patiently waiting for me to talk to them, examine them and then do something!

What I did was go in and enjoy the colorful scene of the "under fives clinic". All the women were carrying in their babies who would be dangled indignantly in a sling suspended from a scale while their charting ws done in the classic "road to health" growth charting that is the first component of the WHO acronym GOBI, (growth charting, oral rehydration, breast feeding, expanded program of immunization) all component parts of primary care, which these people had been practicing for over twenty years since Mozambican independence. Socialist states, particularly the heavily ideologic ones, do not have a lot to learn from the western world about the importance of basic elementary primary care. However, for targeted vertical programs, for that you need experts to give advice from Maputo--such as I--or, even, Finland!

I looked over the facilities and personnel within the health post including the Infermada Basica, a nurse who has actually been to school, but for only four years of basic primary education. This was the most advanced health credential I encountered in the district level, however, since the most usual was the Infermada Elementar, literally "a person who has some experience acting in health but without any schooling whatsoever". For such an individual to get any credentialling, they would have to quit what they are doing--most at them at an age of thirty to forty with four to six children each, and go to primary school and work their way up to become Infermada Basica that would entitle them to do even less than what they are doing now. In other words, there is no incentive toward or career ladder opportunities upward in continuing medical education and each job is an end-stage one without advancement, regardless of potential. Beneath the Infermada Elementar are Cervantes--these are technicians who do not wear a white shirt but a blue apron--distinguished as once were white and blue collared workers. These technicians do the work of scrubbing the floors, cleaning--to the degree they know possible--the needles and syringes, and doing small incidentals like most of the deliveries, all the dressings, many of the treatments. As in a good surgical house officer training program, all the work of the world gets passed down to the lowest level.

I then had to go out and face the music. I gave a public health pep talk of the importance of primary prevention and early detection of problems and all the time felt quite hypocritical since, as I expressed to the person in charge of this and other vertical programs in the province, Felipe Sarde, "We are following empty wagons." I focused on things that they could do, rather than implying there was some great government program or some voluntary agency that would promise to take good care of them, since they had heard that promise and still had not taken delivery of the services they had come to expect. I then examined each person's goiter, including those that had never been in the target population, namely all men, women beyond reproducing age, and the children who were not now in, and never would be, in school. Even given the limited population that had been targeted in the original UNICEF goals, that would be a quite limited scope of the population in need, less than half of those who might benefit. By my estimate of the limited scope, a quarter of that population had been served, and that inadequately, once, if at all. Waiting for iodized salt to replace the aborted iodine repletion program would be a bit like waiting for Godot. To illustrate that the culture of dependance has not yet been replaced, one of the women immediately saw the iodized salt solution: "That is a good idea--so, Padrone, you will give us now the money to buy it!"

We went on to Musa, the smallest health post serving the largest population. We repeated the same observations, examinations, public health talk, and frustration of being participants in the process of evaluating a failed program. The "expert from Maputo" had a lesson of his own. One older woman (who would not be a candidate for the oral iodine under UNICEF's restricted scope in any event) came to tell me that she had had a goiter, and no matter what I said, she knew the real reason why she got it. Wizardry! When she had figured this out, she had set about the only reasonable solution and had paid for the traditional ceremonial treatment, and it disappeared. "See?" When I had mentioned operation as one selected treatment for very specialized problems affecting only some patients with goiter that could be treated at the local hospital, the response was immediate, "We know you would just want to cut our necks like chickens, since we have been hearing what happens at that hospital!" The jungle telegraph is extremely efficient in "social marketing". Whoever begins malicious rumors for whatever secondary agenda never knows how far those ripples will go out to cause harm!

I went to the local market in Musa and saw each of the three of life's basic commodities; rock salt (by the cupful), "wild manioc" (by the cluster) and Good Luck cigarettes (by the cigarette). I asked the--should I call him--salesman?--if they knew that iodized salt was going to be forthcoming and that after March the Mozambican parliament was passing a law that this regular rock salt that came shipped from the same point in Mutala that distributed it to them would be illegal. Rather than being disappointed, they were delighted. "We will be able to charge four times as much for it if you say that it is medicine instead of just salt only!" I asked if they knew about "konzo" the kind of poisoning that comes from cyanide in cassava. "Oh yes, Padrone, but not from ours since this is wild manioc, not cassava." When I asked where does the wild manioc grow? "We plant it right here in the fields along with the maize."

I went on to an unannounced village visit in Musa, going through the rather well-planned architectural and urban layout which reflected the social structure of extended families. The outside of each hut, each elevated granary platform, and the cooking space, hut for boys, sleeping quarters for "marinas", (a "girl", any insignificant female who is not a real woman, that is, not having borne children, so even a twenty-five to thirty year old--heaven forbid!--can be a "girl" if she is so cursed). But there are few marinas who pass puberty. There is no lobolo (bridewealth or dowry) and there is no ceremonial betrothal of any intended but a simple perfunctory moving in. Four and a half percent of the entire population or 22.2 percent of the women of reproducing age are pregnant at any time for a total of six to seven live births per woman as a mode. Divorce is easy without property settlement. Life is relatively casual, STDs are frequent, and they have heard about "SIDA" from the posters but it has not changed their behavior much since there is no immediacy of effect.

After a lunch break and a view of the political process in the hospital and the resolutions being worked out diplomatically by Ivo in the scandal and conflict over false allegations politically motivated, I gladly retreated to my health care survey project while Ivo continued in his conciliatory efforts at resolution of this problem with minimum loss of face and maximum promotion of health programs. I went out to the Malika health post, a large building under the imposing shadow of Chidimbwe, a landmark granitic halfdome. The healthpost is large because it was converted from a store. In it there was the usual cot for a delivery bed, the Infermada Elementar, Cervantes, a few medications, multipli-used disposable needles being presumably disinfected in some form of cold sterilizing solution, a USAID "EDP" kit, B ("essential drugs program" donated to second class district health posts courtesy USAID), and a number of waiting patients eager to hear from the Maputo expert. This time I gave them their full value for their long wait. I not only examined each of their goiters and spoke to them each about prevention programs but I broke out the color linguistic kit and did interviews in characterizing both Nanja and Jao languages which for an hour and a half each stretched the patience of both informant and observer. As a reward, however, they all got to participate in the flag raising ceremony in front of Chidimbwe. In this remote outpost in the back of beyond, the ceremonial flag commemorating the 175^th anniversary of the George Washington University was flown in the Niasa Province with five tribal languages participating in the salute! Glory be to tribal allegiances of all their different sorts!

Are you ready to roll--and in the rain at that? The objective of the first half of this road trip is a three hundred kilometer drive down the highveld escarpment along Lake Malawi from Lichinga to reach the Malawian border at Mandimba going on to Cuamba district of Niasa. Our host Anvar had asked us if we could come for lunch, and Ivo was cautious, saying, "More like early for dinner." Cuamba, which is a subdistrict of the Niasa Province could not be more different in its basic facilities than Lichinga. By contrast, this is the land of milk and honey--in the middle of this remote part of this end of the world, we will come upon a parabolic dish and will sit comfortably with twenty-four hour electricity, watching the Africa World Cup "football" semi-finals. In contrast to the capital, not only does Cuamba have running water and electricity, they urge all the residents to leave their lights on all the time, to save the wear on the lightbulbs from being switched on and off. Hydroelectric from an adjacent dam generates so much electricity that at full use they cannot consume twenty-five percent of the output and there seems nowhere to send it, given the very limited infrastructure that remains after "our brothers" have been working on the transmission lines. No donors seem to be forthcoming with the considerable investment to put up basic infrastructure that was once there and seems highly vulnerable to be disrupted through rather inexpensive efforts again. So Lichinga is rather gloomy in the "lights out" after nightfall and Cuamba hums with activity well into the night. But we have to get there first!

Now a roadtrip in the rainy season through remote rural roads of red clay which turn to muddy rivers rutting the roadbed is an adventure in hopeful assumptions. I had been told by local haulers that "the road is very good all the way to Cuamba--except for the first seventy-five kilometers down the escarpment, one thousand meters descent; the problem will come after Cuamba since, as you know, the bridge has washed away." Well, that sounds like a problem we'll have to look into when we get that far, which, if still true and unrepaired means that we would have to reverse and drive back up the thousand meter scarp to Lichinga and wait for the once a week window when LAM would return and fight our way back onto the overbooked plane since we have a confirmed ticket to fly out of Nampula on Saturday. Just like any good government minister, we were not looking forward to the idea of returning for extra time in the ambiance of the provincial capital. So, we set off in the rain, hoping for the best, expecting to make three hundred kilometers easily within the day, since, after all, weren't the roads reported to be in good shape?

Now, by "good shape", you surely didn't expect pavement, did you? Good! You will not be disappointed. Protocol demands that both professors be crammed into the front seat, straddling the four wheel drive levers and gear shift even though there is abundant room in the back in the Land Cruiser. We have front and rear tanks filled with diesel and our handpicked experienced senior driver, Victor (whose Nanja name is "Oshenda") at the wheel. He looks to be about mid-fifties and he weighs about seventy-five pounds, but with his seniority, any other traffic must give way, or seriously violate protocol for which there will be family retribution. Before we leave Lichinga we stop for the "transit police" who have put plastic cones out on the roadway to stop vehicles for their inspection. Presumably this means they can come to see if we are belted in, that the windshield wipers and lights work, and check other features of safety and preparedness. Our white Toyota Land Cruiser is clearly labeled "Estado" on each side, and it would be rather unusual for one state agency to pull over another, but the police officer puts on his hat and walks over from under a tree, through the rain to begin the usual conversation. "How are you feeling? How is your family? Where are you going?--I see you are on a mission!", noting the white Padrone squeezed in front. "Tell me, Padrone, how is your family?" "Quite well, thank you." Lucky me, I have nowhere to be at any particular time. Since I have no particular point of business to discuss, what is his problem? "Ah, Padrone, I have a problem in my family! You see, my two cousins--", pointing under the tree each with two large sacks of maizemeal and a couple of chickens. "They must get to Mandimba, and they have no money. So, I was wondering, Padrone, if all of you are well, ..." "Oh, all right, get them over here quickly and we'll be on our way." "Oh, thank you, Padrone", addressing the white man, the only power structure he has learned to know very well, despite the fact that the white man is neither the driver, nor the chief, nor the transit authority in this expedition. So we gain a little weight in back and take off down the road.

The white vehicle is now red. We are passing a few hardy souls balancing sacks of maizemeal on bicycles mired in mud. Each of these well-soaked couriers has a red stripe up their backside and over their head. I have quite a long time to see these same people, since they are going to beat us by a considerable length, since the next time we come to a halt we do not move for an hour and forty-five minutes more. A very large lorry is stuck crosswise in the road on our red clay hill up ahead. He is racing the engine with tires spinning in the sound so familiar to me from comparable noises made back home in the snowdrifts. But these spinning wheels throw out a cast around one that would make a very good mold for a "lost wax" casting. One by one, the driver, onlookers, and other vehicles trapped behind us come forward to reconnoiter, commiserate, give random advice, cut a few branches from the bush to throw under tires and give out opinions, such as "only four wheel drive vehicles can move today, and no trucks will be able to go anywhere." This, specifically, seems to apply to the truck straddling the road in front of us. There is a brief discussion about when is the next truck likely to come along, when one of the onlookers suggests we leave all of the women behind and get all the men out to push. "No, if the women want to ride, then they also push." "How come you only bring up women's rights when it is time to push?" comes back the good-natured response from scrub nurse Condelaka's wife. She is a fellow passenger dolled up in all the finery of her kanga cloth to be carried by us as far as Mandiba where she is going to be continuing the daunting trip by road across Malawi in a Shapa, the open flatbed lorries that are used as public transportation cramming many more passengers than a cattle car would allow through the rain all the way to Maputo, a trip of three to five days under the best of circumstances and with unknown accommodations enroute.

Just when I run out of topics of conversation to pass the time at standstill during the lengthy consultations among drivers about the unsolved predicament of an occlusion of the only route, I look out across the vacant verdant bush in a rain-soaked valley where there are no huts or dwellings anywhere within view. This fertile land with abundant water is, of course, a magnet for someone with a dedication to the potential of fecund land to support life--of course, the Boers will be coming against all odds. They need to and they are are needed. As I am staring, I see a small figure in the bush coming toward the road through the rain. As he gets closer, I can scarcely believe my eyes--but it has happened to me before. A handsome well-formed lad emerges from the bush wearing--Go Blue!--a Michigan teeshirt! I pulled out the little Michigan blue and gold pennant that I carry everywhere and sang him a chorus of "Hail to the Victors" to the bemusement of my fellow passengers. "Who says we benighted Africans are the only ones suffering the afflictions of tribalism!" they could be saying in whatever language people speak who are so uncivilized as not to recognize the deep latent symbolism in "Hail to the Victors!"

Well, it is time for me to raise my blood pressure to barely palpable levels from my innervated lethargy and to give some advice to a "Victor" quite close to me. "Why don't we put it into four wheel drive and go offroad through the bush around him?" Victor looked startled as though such a thought had never occurred to him. Then, I realized, he thinks it would be not so much audacious as unfair to make progress while a fellow driver is so thoroughly stuck. But after due consideration and recognition that these professors probably do eventually have to get to some form of business he is willing to give it a try and--hail to the Victor--to pull it off. I slapped him on the slim shoulders to call him "Oshenda" and gave him a Michigan button to wear for which he will have some explaining to do later.

It is now downhill, which is not the same thing as saying "a piece of cake" unless mud cakes are what you are referring to, since, afterall, we are in four wheel drive which is highly significant going uphill, but all cars are four wheel braking which has to do with going downhill, and the co-efficient of friction of red slick clay leaves something to be hoped for additionally, particularly when you are making a downhill turn on an unbanked road over one of the spectacular valleys in this green wet land. We encountered several small couple-of-log-bridges with sticks uprights on each side marking the limits of support. Victor brakes on the downhill before we reach them and then powers over them to be on the far side before we slow enough to risk getting stuck on the bridge. The streams are swollen.

We pass a group of huts that were not here the last time Ivo made this road trip. There are clusters of them, two common features to each. The most universal flag in evidence around here is a blue plastic sheet used for a waterproof seal over thatch labeled UNHCR. Eight hundred thousand of the 1.1 million refugees from the Mozambican civil war fled to Malawi, and these refugees have returned a few kilometers over the border to this road, and now have set up shop with the two items carried from the refugee camps, the UNHCR blue sheet (which can be seen everywhere in markets, over lorries, under drying cassava) and one hundred kilogram maize flour sacks with USAID and a red, white, and blue handshake. Food and shelter--courtesy of the other world. There are so many returning refugees that they may have taken up about one percent of the sites along this roadway. They are also doing good business, since out front under the blue sheet are little kiosks displaying Malawi-label Carlings' black label beer and Peter Stuyvestant cigarettes--life's basic elements far more essential than the previously mentioned food and shelter, so therefore commanding a much higher markup--a lesson learned, and in part returned, from Malawi with the refugees.

As we round the bend at the brink of one hill we see a spectacular valley beneath us with a vast sweep of the green bush with tall grass and some scrub trees under an occasional acacia and a few scattered baobab--Africa, straight from the hand of the Creator. But on the road ahead, is an artifact by the hand of man: the roadbed leads to a wooden bridge across which a heavy duty truck and trailer are carrying heavy equipment, an earthmover road grader by "VanVliet of Holland". This heavy equipment made it halfway across the bridge when it went through the bridge thereby blocking the roadway and destroying the bridge and its use. Now it is time for some serious reconnoitering. I remember I have my hiking boots in the duffle bag in the rear of the Land Cruiser. With some dismay at the thought that the professor intends to get wet and muddy, I changed into my hiking boots and put on my Mozambican ASEA (Association of Surgeons of East Africa) cap, putting my pocket Nikon in a pocket that I hoped to be waterproof and set out to reconnoiter. In the big truck, the equipment operators are taking a nap for a couple of days. "Esculpe!" they say with a smile, "That's life!" I say with a wave, quoting Ivo's comments to the previous driver of the truck that had been straddling the road. Up the road there is a small diversion that leads upstream to an area that was apparently a ford probably during the building of the bridge now crushed. I go down to inspect it and find that there are large rocks exposed by the gurgling rushing of the rainswollen stream. Well, why not try? I got down in the stream and started throwing large rocks up to the roadway, where Filipe and Victor got the idea quickly and started piling them up in caisson fashion across the streambed itself where the roadway had been washed out. It took us perhaps half an hour and every once in awhile one of the passengers would get very splattered when the rock I would toss up would hit the muddy earthbed and they would chuckle and rinse it off later in the nearest puddle. While we were working, another four wheel drive Land Cruiser came by, this one holding the Bishop from Mandimba. A vehicle approached from the other direction, saw what we were doing and abandoned all hope, and turned around and went back. The Bishop, however, was much more directed in his purpose. He didn't wait for us to complete our task, but with a honk of the hooter starting rolling downhill at our still incomplete bridgestones. They hit on an angle with all four wheels spinning and disrupted the foundation but successfully managed to cross. When they looked down and saw a white man in the streambed, they rolled down the window and waved, "Bless you!" and drove on. Reconstruction was a bit faster with the building blocks in place, and I waited in the streambed as Victor made his approach, shooting a couple of photos of his stream crossing on our road reconstruction. "Hail to the Victors", once again!

We made it to Mandimba where we stopped at the hospital. The evidence of the savage targeting of this district healthpost is evident with bullet holes from automatic weapons'fire, explosives that ripped out all electrical systems and fire-scorched the structure, still with rooms full of patients with dingey surroundings, one suffering cerebral malaria, another in active labor, and several being treated by the Infermada Elementar who is heroically doing what he can under these circumstances of deprivation. We congratulated him and encouraged him to the degree that is possible without doing more than moral support. Our scrub nurse's wife, the policeman's cousins and several other hangers-on jumped ship at this point to continue their journey by whatever means they could connive and we stopped for a Coke in the well-supplied outpost of the cross fertilization of any border crossing anywhere --wiith Malawi a stone's throw away over an unguarded border with "kwacha" worth more than "metacais" and smuggling going on in each direction under the more honorable title of subsistence.

We got back in the Estado" Land Cruiser at the pyramid with the star atop commemorating the fourth party congress of FRELIMO, the chief landmark of this border town, and took off down the "good" parts of the road where we didn't get stuck more than three times. We also crossed the magnificent Lugenda River on a real bridge--that is, not one made by other travelers ahead of us, and I shot a few photos from this vast sweep of fertile vacant land, with the promise of the Boer's interest in coming being even more fertile and productive to the rising bourgeoisie of Niasa than the land itself. Many fledgling "administrateurs" are lying awake nights hoping to farm the Boers--a new class riding on the backs of imported labor.

Since the last hundred kilometers into Cuamba was relatively uneventful, we had a chance to speak of previous passages down this same road. Ivo told me that on one trip down the mountain toward the lake a group of soldiers had come to him and asked him to carry the body of one their comrades, a soldier who had been killed, and whose family lived at Lake Niasa and wanted to have his coffin to bury it there. Rather reluctantly, Ivo agreed to this request, as one that hardly could be turned down, but about which he was less than enthusiastic, so the coffin went on top of the four wheel drive vehicle and he and the family continued on. At seven o'clock p.m. they got solidly stuck and could not either go forward nor return. So, they left the stranded vehicle in the mud, and camped out in the rain under a tree. Early in the morning a group of hunters had come along the roadway who were out after small game with bows and arrows. Ivo explained what he was doing and why this vehicle with the coffin on top was stuck in the middle of the road. The hunters went out and recruited helpers from out of the bush where no one had previously been seen. Soon a memorable sight appeared in the morning light as a four wheel drive vehicle with a coffin on top of it was being carried fifty meters forward to the hard road by a large crew of willing workers to get it on its way. Ivo offered one of the chief hunters money for his efforts but the hunters were offended, and refused it. "We did not do this for pay!" Ivo then said, "No, but the money was for the village from which the helpers had been recruited." "But, there is no village, so you would only be giving it to one of us," was the response.

On arrival in Cuamba we saw the rail head that makes this town an important district resource along the vital link of the rail corridor from Nampula's port at Nocala to Malawi, their principle access for all the materials they can import and export. Something was wrong. There were any number of trains accumulated on one side of the tracks and none were moving. That was our first clue.

We went on to the very hospitable home of Anvar Musagy and Janet Mondlane. Thereby hangs a second tale, which I will have to tell in explanation of how I spent the night in Janet Mondlane's bed, the day before the national holiday commemorating the assassination of her husband, the George Washington of Mozambican independence. However, lest you think that I am tapering off from the high point of our road trip from Lichinga to Cuamba and then filling in with adventure stories of other times and places since I have no such continuing adventures on this excursion--AH, read on!

We are not through with rainy season washouts! We will be hosted in unusual settings, see unique sights, carry extra-ordinary patient problems along with us, learning lots of things along the way in conveyances ranging from four wheel drive Land Cruisers to a "night train in the rain--in a "rail test car", no less, on a bridge inspection run with a newborn on my lap--all this before I reconnect with LAM in Nampula to fly away back to Maputo which for me now represents civilization at its high point!

I entered Cuamba less dramatically than I exited. Cuamba is a vital rail link that services Malawi, so that we knew something was wrong when we saw a great number of trains piled up and none of them moving. This was an ominous portent of some news that we picked up immediately upon arrival as guests of Anvar Musagy and his wife who was currently away in Los Angeles, Janet Mondlane--remember the name and the date!

Sure enough! The road was out. The bridge had not been restored, even the rail bridge was questionable which is why no freight had moved in over a week bottlenecking all of Malawi's exports and most of the income to Mozambique through this vital corridor. It was almost like it once was during the war when the RENOMO saboteurs had knocked the rail system out for two years and eight months once by blowing the bridge, and with restoration efforts going full speed supervised by the chief railway engineer of CFM (Central Ferrocarril Mozambique), Oscar, whom we later got to know well, it was a point of honor to get the rail reconstructed during the course of the war and it was. It was blown up an additional four times with abundant derailments and lots of railcar carcasses and undercarriages visible along the way, but an average of three months later it would be back in action thanks to the dogged efforts of Oscar who knows every centimeter of this vital raillink as his baby. However, his baby or otherwise, cyclone Bonita and its heavy drenching aftermath had interrupted both road and rail as surely as RENOMO had in the height of the war, and the road bridge was definitely out for the duration and there was some considerable question about the railway bridge which is why Oscar had been diverted to Cuamba to evaluate. Our choices at this point were to trust Anvar to make some arrangement with Oscar or to turn around and head back up the same road of clay mud we had just taken a day to transit, with the difference being that it was uphill for a thousand meters in the last seventy-two kilometers in the dark. There was no point in hurrying, since our only way out of Lichinga would be to hope to extort a seat from the always over-booked LAM departure run on next Monday as it picks up many additional passengers who are also practiced in the art of "value-added ticketing". No matter what, if this is the option that were chosen, we would be taking off a couple of days after Elisa, Ivo's wife, was scheduled to fly to Asmara, Eritrea which didn't seem satisfactory. All those officials of the railroad could be put on hold for the moment, since Anvar insisted that I be put up in the best quarters in the house which was a special room indeed.

This is how I came to pass the night in Cuamba sleeping in Janet Mondlane's bed on the eve of the national holiday commemorating the 20^th anniversary of her husband's assassination as the founding leader of Mozambican independence. The "George Washington" of Mozambique was in exile in Tanzania where a friend of Janet had an Indian Ocean beach house near Dar es Salaam which I will ve visiting, to which the political security police PIDE mailed a book. They seemed good at that, as was evident from another Portuguese dissident in Lichinga's airport that I had spotted upon the aircraft's arrival who had hooks where his hands should have been, since he also received a similar package in the post. But Eduardo Mondlane died before any help could arrive, facing the same Indian Ocean beach one country north of the nation he had hoped to see become free.

Janet, his American wife, daughter of an American GE engineer, had met and married Eduardo Mondlane in America where he was sent to a mission college after graduating from a mission school. He had been discovered by one of the missionaries when he was a lad tending goats, and his obvious brightness caused the missionaries to champion him for education both within, (at the time) "Portuguese East Africa", and in America from which he wrote and championed the cause of Mozambican independence. He rose through many diplomatic ranks to become a U.N. representative and paid an official visit as the U.N. representative to his native, still colonized country, when Ivo remembers seeing tears in his father's eyes to see a black Mozambican in an exalted post from the United Nations chastising the colonizers in power for violations of human dignity. Much after independence, Janet Mondlane has been continuously in Mozambique, and has made a new life, marrying Anvar who has family business timber interests headquartered in this Cuamba district of Niasa Province, so eschewing the higher profile scene in Maputo, she has moved here although she retains an apartment one hundred meters from my own in Maputo. It was there that Anvar and she were driving in when one night when thieves jumped their vehicle as they waited for the security gate to open and shot Anvar in a robbery attempt. A thoraco-abdominal gunshot wound was the occasion whereby he met surgeon Ivo Garrido, and after the outcome turned positive they have become very fast friends, and he would hear none of our passing through Cuamba without staying as his guest and enjoying the facilities that Janet has largely oriented toward the community, such as the parabolic dish over the top of their house with a color television on a spacious enclosed veranda with scores of seating for very exuberant fans of the "Africa World Cup" football! So, if you can believe my departing from the provincial capital without running water and arriving in Cuamba where the lights are not to be turned off because they cannot possibly consume a quarter of the hydroelectric generated, I then could sit with Anvar and Ivo and 80 neighborhood fans to watch South Africa beat Ghana three to zero--noted by a few groans of disappointment around me, I noted.

We went out to work in the morning after breakfast with Anvar when I had heard my first suggestion that the dry season would be ideal for four wheel drive overland vehicles to head out into the northern reaches of Niasa where one could drive for days without seeing any settlements amid teeming herds of wildlife and the open veld--so long as you took along with you a local who still knew where the minefields were located. He had me salivating thinking of kudu steaks and an impala braai, and I hastened the plans for my return to take on Niasa as my own private province with respect to its hypothyroidism problem!

When we made rounds in Cuamba district hospital we were met by the medical students on their senior assignment from Eduardo Mondlane who make a three month rotation in district hospitals to see what they could contribute after graduation when they are assigned to the provinces. There was also a young couple from Pretoria with an evangelical South African mission in an alliance called ACRIS. They wanted to present us two patients before we went into conference with the overtaxed and under-supplied goiter control team who are responsible for implementation of the prevention program despite its apparent suspension in fact if not in the "promos", still being issued.

The first patient was a forty year old man with a scaphoid thin abdomen and a very large bulge between his knees. He has had a very large hernia for some time, they said, but we thought it would be a challenge to fix it. And I said that the bigger the hernia, often the easier the fixation, but then the question would be "can the patient breathe afterwards?" I mentioned the "loss of domain" for a gut that is resident in the scrotum for such a length of time, and that they should reduce it first to see if he could still breathe and swallow and eat, and if he couldn't, it should be gradually reintroduced into the abdomen through the use of bedblocks under the foot of his bed, suspension through whatever traction device could be used to raise it up on a sling, and pneumoperitoneum introduced over a period of weeks. Therefore, much as I would have liked to have taken on this exercise, I thought the technique took second place to the judgement, and that lesson was passed along to the students on our rounds.

The second was a newborn. The baby was born during the course of the night, and unknown or at least not asked by the staff and midwives was the apparent excessive amniotic fluid lost, by the mother of three children already and quite experienced by her early twenties estimated age. She spoke only Makua, and for me and for her as we got to know each other through a long night she was "mama" and I was "OK".

The struggling small baby boy with a sponge of curly dark hair had imperforate anus. At what level the anal atresia was, was not apparent. I pointed out to the students that about the only value left to a metacais coin is that it could be taped at the point where the "anal wink" could be elicited by stimulating the sphincters, and then hanging the child upside down in front of an X-ray plate; the height that the colonic gas bubble rises in the rectum would tell us if we might be able to undertake a relatively simple maneuver, or whether it would require a colostomy and maturation to the point where the child could have a takedown of the colostomy and a pull-through at a later age. I instructed the husband and wife recent graduates of University of Pretoria in the quick and simple method of a diverting childhood colostomy, but again, the surgical technique was going to be relatively simple compared to the higher risk of anesthesia in such an infant. We placed a nasogastric tube and an intravenous line and pondered what we do next since, of course, the X-ray unit in Cuamba district hospital has not worked in a long time, and the supervisor charged with assuring that they can be brought up to function is one and the same Joao Aleshander, director of Hospital Central de Maputo. He obviously cannot take on that big job and these district hospitals' breakdowns simultaneously, but there is no one to relieve him of one of the several jobs he also still holds. He is and was Mozambique's single radiologist. With no X-ray, and no clear understanding preoperatively what would be required, the options were limited to colostomy now and then transfer, or if we were going to get out of Cuamba by some means or another, we would take the mother and infant with us. We did. The some means or another could scarcely be imagined at the time, but I assure you it will make for an interesting scene when it happened!

We made a field trip of about twenty-five kilometers through stunning background scenery where thousand meter rocks resembling El Capitan or Half-dome in Yosemite Valley loomed on either side. At the foot of one lies a former catholic mission station. Since education and healthcare were nationalized with independence, the mission expropriated by government has fallen to ruins, including the hospital now converted to Ministério da Saúde de Mitucue. What we saw in this health post would have been appalling, had we not seen it many times before and admired the people carrying on despite the lack of almost anything they had and reliance on only what they knew or could do. When "Medicins Sans Frontiers" (MSF) had a program here to train and retain traditional birth attendants, it was hailed by some as a great success in this environment. But the birth attendants were paid from this outside source; then when MSF left Mozambique to go seek out other active shooting wars, the traditional birth attendants said, "Either you pay us the same inflated hard currency salary that the foreigners did or we quit and go back to the dumba nenge." Of course the money was not there, the program was not sustainable, and quit they did, abruptly leaving an Infermada Elementar, Technicos Pharmacia, and a single Servante to do the simple routines such as eleven to fifteen deliveries per month, all dressings, drainage of abscesses, and anything that could not make it twenty-five kilometers down the road. Here was an institution that had both hydroelectric and fresh water fountains springing from high on the spectacular rockface behind the hospital--both acts of God and not of governments, and therefore sustainable. If the piping hadn't been sabotaged and the electricity lines cut--and even that was difficult to repair to the point of just reconnecting the hospital--this hospital would have two elements missing in the provincial capital's hospital at Lichinga. The government offered to give back the mission station to the church, and one look at what was left of their beautifully laid out and organized compound in this stunning setting, and the church officials sadly shook their heads. I would love to adopt Mitucue as a right-sized rehab project of my own; each time I would get discouraged I would just look around 'lifting my eyes up to the hills'." If I were here three hours longer, that mountain needed climbing. We interviewed a father and mother both with WHO III goiters who had brought their two children to the health post walking from two hours' distance over that hill, where their children were plugged into IVs recovering from severe measles attacks. We asked them if they had ever heard of a goiter prevention program, and they said that they had not. "But of course," they suggested helpfully, "we come from quite far away where we would be unlikely to hear about any news;" presumably that the disease that nearly claimed the lives of both of their children was also successfully controlled by the EPI program they likewise had not heard of with higher penetrance than the iodine program. We walked around for only a short time in the setting where mothers were bathing children in the fresh streams coursing off the rock, tilling fields along the flooded riverbank, and all aspects beneath the mango trees looking like the garden of Eden, if only the ruins were not in ruin. This entropy was given an accelerating push.

We had to leave abruptly. Rumor had it that Anvar had made contact with Oscar and Oscar was willing to transfer us in the departure of his own private rail test car for inspection of the bridge footings in question since the flooding. The "Zorra", nicknamed "the fox", was first described to me as what sounded likely to be a handcar pumped in from turn-of-the century cartoons by prospectors riding the rails. It turned out that it was a diesel-fired rail car with half of the platforms holding a derrick and repair equipment, with an enclosed cabin up front. It was headed toward Malawi from Cuamba. For a moment, the prospect of riding backwards for three hundred kilometers through a rainstorm struck me as funny if not nauseating, but when told to scramble for an afternoon departure, I quickly got ready. Then in the course of the next couple of hours a barrel of diesel fuel was rolled to the Zorra and bucketsful were dipped and splashed mostly around with only a little supplied into the tanks. By this time one of the Malawi-blocked trains was moved down track (no worry about a collision from the direction from which nothing was moving) passing the gandy dancer which could switch us to a side track and turn us around. The "hurry up and wait" escapade about cost Mama her source of food, since it was all left behind in the scramble to get her and the baby mobilized. With Ivo supporting Mama and I cradling a thirty-six hour old neonate with an IV bottle held high, we situated this stoic brave woman for quite an adventure, supporting her feet upon my duffle bag. We sent back to the hospital for her food wrapped up in a swaddling cloth for the transit of we-knew-not-how-long and knew-not-how-far.

Meanwhile, baby has passed neither stool nor urine, unable to do either with a nasogastric vent and IV drip. I was happy that he occasionally burst into lusty squirming and gurgling which Mama, experienced as she was, responded to invariably by nursing the baby, nasogastric tube not withstanding. With a spectacular sunset behind us over Malawi and large thunderheads rolling ahead of us into what looked like for all the world Yosemite Valley on either side of us and rain beginning to spatter the head of Zorro, we rolled out of the station. Zorro was a Noah's Ark of one ailing newborn, one postpartum working Mama, one very nervous chief railway inspector engineer with loud bruxism increasing as we got closer to the questionable area, and one Eduardo Mondlane University Professor of Surgery, and one white man who had just slept in the namesake widow's bed with two relatives of the conductor scrambling on the back near the door with three live chickens snatching at the corn scattered for their amusement in transit. When Ivo called me over the din and the clatter of the wheels rumbling beneath the floor, I was at first concerned that I might have heard only half of the mixture of Portuguese and English in the three-way conversation with Oscar about the conditions on the track ahead. I suddenly realized that I was worried about missing some information in an unfamiliar setting and I knew all of one language and a part of the other; and here was a woman who had just given birth clutching her only son who had very limited prospects facing at least significant surgical treatments and understanding not one word of anything that is being transmitted in a totally foreign environment having surely made no trip of this kind before in her life! I smiled and tried to reassure Mama and when she looked concerned about something, I would explain it to her in mainly pantomime to which she would respond with my name "OK, OK!" One of us was a lot braver and much more trusting than the other.

We went hurtling down the track as night approached and nightjars flew up into the oncoming light and would smash with a blood splotch against the glass. They are slow birds and late on takeoff. What was less humorous than the name Zorra was the name for the new diesel engine of the big train for which we were trying to test and approve the track that it might follow. The older engines could only pull six to eight cars, but the newer engines are bigger, more powerful and much faster pulling twenty cars. People from the bush have taken to walking the rails, since the traveling is far easier. They have known that when they hear the approach sounds of an oncoming train, they have time to turn around, look and leisurely walk to the side or run forward, particularly on bridges. They always made it and this experience has been habit reinforcing. The human problem with the bigger more powerful locomotives is that they are much faster and cannot be outrun, and the learning curve is such that anyone who has had the encounter with one of these new engines does not have a chance to pass along this information. So those who know refer to the new locomotive as "Ninja", since it always kills. I prefer to think about our "Zorra" like a bat-eared fox slipping down the track through the night, a night train in the rain overrunning the narrow tunnel its headlight made in the pelting of raindrops, insects, and occasional birds.

Since the theft of my dictaphone, I felt bereft of opportunity to capture the "ambient sounds" of certain experiences, such as birdsong at dawn as I most often do. Stopping in the Dumba Nenge in Lichinga before departure, Ivo had bought new medium sized batteries to fit the tape recorder I borrowed from him that had otherwise been used only with the D.C. wall line in those environments that had electricity. The prior new batteries had lasted less than an hour, so there was a gap in my recording of some exotic adventures, but blessings upon the Dumba Nenge's long-lived batteries, they captured it all in this most exotic of "adventure travels"!

We slowed to a stop near the eroded embankment, and got out and checked the bridge with my torch in the rain. Oscar looked with some satisfaction on the new crushed rock that had been piled along the side as building material, since it could simply be pushed down into the faults against the retaining barrier. This would divert water and also diffuse the weight of the passing big train. We went over it and backed up, there was no change in this bed of tracks and he was very pleased. He had repaired this stretch before, when it had been disrupted by unnatural means. He still hunkered forward staring down the track ahead, but the bruxism became less vibrating, whereas before it was noticeable despite the rumbling of the wheels beneath the floor.

We passed signs that marked villages and train stations. There poor people who had already exhausted their food supply waiting over a week were overjoyed to see an approaching headlight and dismayed when the Zorra slipped past them in the night. On one occasion when we stopped, a cluster of people with long faces all approached me--"Oh, Padrone!" I would shrug and point to the authority on board but they knew better about who controlled things. Certainly better than I, since I was not deceived. I was delighted to be included in this adventure which now looked like it was going to go the distance. We might arrive in Nampula in the small hours of the morning, but we might thereby have arrived. There is one major hurdle still to come, it is better that I not know about it at the time. As we rumbled down the rail again, there were increasingly urgent calls into the radio microphone, in Portuguese pleading for an answer. But none returned. As we rumbled on, Ivo said to me, "Note the work of our brothers"--and there was a jungle of railcar carcasses on either side of the track in multiple locations. It would seem to be a worthwhile enterprise simply to derrick up all that scrap metal creating a mining enterprise for recycled ferrous metal along this highly contested rail corridor. However, the only reason I could see these was in the reflected beam of the Zorro's headlamp. "We are going past towns," Ivo pointed out, "but there is no way to prove that, since it is all in the darkness. These were well organized villages with running water and lights, roads, electrification, the same way your nation looked in turning the last century." After a pause, "Our country has lost over fifty years, at least, through our brothers with their help from South Africa which tried to assure that we would never in a century be able to compete with them. I must forgive, but look around you; I cannot forget!" RENOMO had been working on the railroad.

We rumbled through a corridor of rusting carcasses as there was increasing urgency to the Portuguese radio calls without response. When we finally came to a station, there was a man outlined only by his own torchlight standing over the gandy, and he was irately asked why he did not respond. "Radio no functionando." But of course. This turned out to be more than of casual significance. With the crossing of the rail inspection car over the bridge in question, the message had gone on into the Nampula side and one of the Ninjas was coming headon toward us with no knowledge of where we were without the radio relay which at this point was strategic since it is placed at the two hundred and twenty kilometer point passing messages from this midpoint in each direction to Cuamba and Nampula. Now I joined the rail inspector in straining my eyes as far ahead of the lamp as we could see looking for a speck of light of an on-rushing Ninja freight train somewhere ahead of us that we could now not only not outrun, but we were closing in on them at half the rate they were coming toward us.

With a shot in the dark, we headed for a spot about ten nervous kilometers ahead just beyond the bridge that had blown away rail service for two years and eight months during the war. If we could make that with bells clanging we might alert the Gandy Dancer to throw the switch since there was a side track at that station where we could wait out the passage of the Ninja to our right. There was the Gandy Dancer, this one scarcely visible in the blackness, since he had no torch, but he got the message, and after we passed, he threw the switch and we backed up into the sidetrack. As we came to a stop, Mama had a problem. She needed to pee. So I took "Bebe" and Ivo handed her down to squat between the rails and he and I exchanged roles as I went to fetch her back up, not an easy task for her or for me in a black rainy night fumbling among steel wheels of the undercarriage for the rungs to climb to La Zorro's cabin.

Then we saw it. It really was fast! By the time we were sure that it was a headlamp, it was almost upon us and we heard its radio. It was surprised to encounter us with no previous information from the dead radio at midpoint and not sure whether La Zorro with its headlight on was on the main track but it had no hope of slowing the long freight at full speed. As they swooshed by to our right, I snapped the last flash photo. This illuminated the complete startling of the railway personnel on the engine passing us to see a white man standing here in the derrick in the rain next to a woman being handed a newborn hooked to an IV bottle. "Why, doesn't this happen all the time?", I would have called after them if they were still in shouting range.

Yes, we made it. It was approaching two o'clock, as we slowed down in a rail sorting yard with the suddenly startling appearance of city lights diffused by the falling rain. We scrambled across the rail marshalling yards alternately helping Mama and carrying a baby over the railsleepers and trash at trackside to the platform where we had to work hard to boost ourselves up let alone a blood-dripping Mama. The police at the station were so nonplussed that they didn't stop or ask us what we were doing, since there didn't seem to be an explanation that would be satisfactory given any amount of imagination.

We got the Hospital Central de Nampula ambulance, a closed truck with benches inside, and the driver had Ivo beside him in front while I took Mama and baby in back. This may well have been the most bone-jarring and life-threatening component of our trip. To say that the streets of Nampula have potholes is not quite correct. There is a bit of pavement, just enough to cause disjointing collisions by each wheel each second at first gear speed. I was thrown to the floor and the luggage all overturned and the water bottles were smashed and food spilled but I managed to hang on to the IV bottle and she still clutched Bebe. She is a good Mama. We delivered her complete with a written transfer note into the casualty ward and saw her into a ward bed notifying a pediatrician on call. Lest you think this specialization is quite "up town", the pediatrician is a recent graduate of medical school who is so-called because he or she will be taking pediatric calls. Hospital Central de Nampula is the third largest hospital in the nation in the third major city of Mozambique, 401 beds and no specialists by any degree of training or certification. There are, however, forty Mozambican specialists in all of the nation, one of these is a surgeon in Beira and one an obstetrician, also in Beira, and the other thirty-eight are all in Maputo. To the degree that there is anyone with any specialty certification or credentials anywhere else in the nation, they are volunteer expatriates on more or less short term, and one cannot count on a specialty expertise needed simply by requesting the "pediatrician on call" even in the third largest major provincial capital hospital in the nation. Nonetheless, they are well aware of the fact that the patient came with two professors of surgery, one of whom is very well-known throughout Mozambique and, Ivo shrugged, "If they need us, they know where to find us; so now, to bed."

We went on to the Hotel Lurio, the top of the line. It did have vacant rooms, in fact, all of them, so we took two. As we walked into the hotel a policeman was standing in front and stopped Ivo as he grabbed his bag and trundled into the lobby. "Sir, I am obliged to ask you where you are coming from, where you are going to, what your business is here, and you will have to come along with me to the station right now." Ivo looked at this young man in uniform, looked back at the visiting professor from America, looked back at the policeman and said, "I am sleepy, I am going to bed, you can go to hell." The young officer shrugged and walked away. He had done his duty, and we had done ours. We checked in to the Hotel Lurio which by my translation comes down to U.S.$18.00 for the top of the line suites--$2.00 short of the national median wage per month. It had electricity, but, that did not necessarily mean that the elevator with its door beckoning wide open has worked in the last decade, and it certainly wouldn't now, so we trundled up three flights of stairs carrying our bags and checked into adjacent rooms 313 and 314 to be issued a towel and bar of soap. We checked and found running water--not to be picky and complaining pettily that it is only cold water--we did think toilet paper might be a nice addition and hoped that it might be furnished generously rather than by the sheet. I unpacked things briefly and set out all my records of this adventure travel through this terminus to get up early in the morning to work on them before we went around Nampula. Ivo said, "Do not count on me waking you too early." He didn't. In fact, Nampula was one of his lower points, since he woke up ill, and got worse. After a later breakfast near noon (my own principle foodstock for a stubborn nuchal rigidity and fever with myalgias has been as generous a ration of Motrin as I could figure I might use without exhausting my supply, and a couple were required before the thrill of the cold shower upon arriving).

Nonetheless, we got out and about with the newly transferred provincial health director, Dr. Moises Said, who is pleading now to be reassigned after five months in Nampula. He was born near Lake Niasa and has lived the last several years in Tete. "However, Nampula is a one-ethnic group province, and it happens to be the biggest; if you are not Makua, you are nothing." His welcome to Nampula was that thiefs visited his home nine times in five months; but, as Ivo points out, "These are equal-opportunity sorts and not respecters of religion or ethnic groups."

For that, you have to get into the higher diplomatic intrigue of medical politics, which we did immediately. We made a courtesy call on Dr. Amarchand. Dr. Amarchand arrived in Hospital Central de Nampula in 1969 and has been a fixture ever since. As Ivo had expressed it, the popes may come and go, but the cardinals remain watchful and wary. The cardinal expresses a problem. "The problem" is his province's biggest blessing. Down the road seven kilometers is a former mission station and church, nationalized now to the Ministério da Saúde de Marrere. Patients are flocking past the Hospital Central de Nampula to go this former mission station where an expatriate American medical missionary with Grace Church has been for seven years operating in one of the choir lofts while patients fill the nave looking up at stained glass beneath the pulpit. One such patient I saw had a hemoglobin of three, requiring transfusion, quite clearly with a bad bout of hemolysis from malaria. However, Dr. Charles Woodrow, MD, FACS ex-U.S. Air Force from San Antonio, my son's hometown, has devised a system. On one day he saw 250 patients, booked fifty-eight of them for surgical procedures, during which time ten hernias and hydroceles were expertly repaired by his handpicked and trained Infermada Basica. This skilled technician was taught well and performs adroitly. In the seven years that he has been here, Dr. Woodrow did seventy-five percent of the hernias and hydroceles which constitute most of the surgical load, and did what other cases could come along, including eleven thyroidectomies in the seven years. He reports openly and honestly that in the second half having trained the nurse, the nurse then did seventy-five percent of the hernias and hydroceles, with the difference in the outcome being that Dr. Woodrow had an (insignificantly) higher complication and recurrence rate than the nurse. Further, he reported his morbidity and mortality statistics as he might have in any JCAHO accredited program, presented them to Dr. Amarchand as well as to Dr. Fernando Vaz, the revered professor and chairman of surgery at Hospital Central de Maputo who came out in October to observe his operations, facilities, personnel and gave his blessing to his standard operating procedures.

What seems to annoy Dr. Amarchand is that this upstart of only seven years has surpassed in volume, quality and compassion the third ranking hospital in the nation and its clinical director. There are two levers for his inquiry, one is the audacious attack on the thyroid gland in the eleven instances over seven years wondering whether this was necessary or well-advised, particularly since nothing like that is done in the central hospital, at least not with the same results which were excellent but for one exception in which reoperation encountered not hemorrhage but a rapidly growing anaplastic carcinoma which was evacuated twice more before the patient was discharged presumably to die of inanition at home. The second lever is the open and honest reporting of a nurse performing hernias and hydroceles operations not only with greater frequency, but with better results than not only a skilled and certified surgeon that trained him, but also the unreported series of those quite sensitive in HCN. Dr. Amarchand suggested that now would be the right time for renovation of the HCN's theatres, and closing down of Marrere to do the surgical cases brought over from HCN by the appropriate staff from his unit. Once again, Ivo finds himself deputized in the delicate diplomacy position between sensitive factions in the medical political arena where there is more than abundant patient problems to require the investment of the effort, but some delicacy about who is getting credit for it. Dr. Vaz has come down strongly in support of Dr. Charles Woodrow, and that, further might cause the cardinal some plotting of further recompense to be paid at a later time. He has the patience of twenty-seven years to wait out any initiative or unorthodox resolution of such problems as an expanding six month backlist of patients in queue now being efficiently done by a fully competent certified surgeon, whatever certification means in this foreign system, and his designate, whose results show competence beyond that expected from the less rigorously recorded physician-operators.

In working out a three way relay, Dr. Garrido attempted a return visit to Dr. Amarchand with the information that I picked up in my visit from Dr. Woodrow and we both met with Dr. Lucio Said to caution patience, and one small step at a time for any markers of progress toward an objective that one can--like Chasano--keep as one's own counsel. These examples are added for those who feel that a wide open system with an ineffective state that can make no law or policy that might regulate medical practice, and with very few very well acquainted practitioners with a flood of patient opportunity around them and limited resources for all, there might be an opportunity to put political squabbling aside and get to work since there is more than enough to be done by everyone concerned. If that is the dream of those involved in petty political struggles a first world surfeit of services, I have reached Nirvana in this environment, and I encourage you to dream on without venturing further into an exotic environment you might know and appreciate less in the vain hopes that it would be free of petty human foibles among those privileged to assume the authority and responsibility to treat.

And now for my last week in Maputo I have a barrage of lectures, reports, public and professional meetings and conferences coupled with a further plan that I have made for a trauma symposium, breast cancer conference, report on surgical endocrinology in comparative settings of Zaire and Mozambique before the ASEA in Tanzania in June, and then a trip to the Ituri forest to operate on Pygmies from which I will attempt to return to Mozambique for an important reason. I have also organized a physical therapy rehabilitation and training program for the finest of nepotism traditions, soliciting the volunteer support of my son, Michael, physical therapy graduate student in the University of Texas Health Science Center in San Antonio. In a full report to the Minister of Health which I will append to this tale of adventure travel, I can summarize the impressions and recommendations from the sustainable projected future forthcoming from the Mozambican experience. It may seem to me now that I have personally adapted a province of my own, but I welcome it having seen people and places in the pristine environment of this verdant land straight from the hand of the Creator, messed up a bit, as all are, by devastating episodes of savagery by the hand of man, but with great potential and unimaginable leverage to actually accomplish something from a zero base forward. In my discussions with Professor Fernando Vaz, my close colleague and confidant Professor Paulo Ivo Garrido without whom this would not have been possible and the poor people of Mozambique for whom I feel strong sympathy, a lot of focus has been drawn upon the feeble capacity and extremely limited resources with a very tiny cadre of dedicated people against overwhelming odds. What does this all mount up to?

There is "enough to start" and more than reason enough that it needs doing starting now. I am very happy to have had the privilege of being a participant in that start and will commit to a sustainable continuation of this effort through the investment in education, education, education--priorities in health and infrastructure not withstanding that make for just so much more potential from so little realized already in the face of so many big problems for which ingenuity and initiative have already shown effectiveness elsewhere in the world. There is just enough of that inspiration here carried in a committed group of people to warrant optimism enough to start. Let us begin.