Back in BKO

Transition always leads me to contemplation. I tend to be overly self-reflective anyhow, a condition that my cousin Karen and I jokingly call “Wilson melancholia”. Even though I honestly feel quite eager to go home, I feel a sense of trepidation at all that is coming next. Will I be able to transition back into the demanding schedule of medical school and American culture with its fast pace and ever-changing expectations? In Mali my life is so simple compared to life at home. My house is smaller, I have much less stuff, I have fewer friends, and fewer leisure options. While these limitations have felt stifling at times, there is a part of me that deeply appreciates having boundaries fencing my energy in.

We returned from Morocco with the medical supplies from Sunrise Rotary in hand. Just before our departure the soccer supplies donated by the Passback Program arrived here. I had a really difficult time getting them without paying customs. The customs officer was demanding “a certificate of donation” and accusing me of receiving the used soccer equipment to sell. I think that a few years ago I would have freaked out and started crying, but the years and my experiences have left me a little cooler in the head than I used to be. I simply engaged the customs officer in protracted conversation. It was Friday afternoon, and I think he wanted to go home. I showed him an email from the Passback Program, apologized profusely for my limited understanding of Malian customs law and presto! I got the stuff for free.

Next week is going to be full of activity. We will be training the community health workers Wednesday through Friday, and I present to Rotary Koulouba on my activities on Friday evening. In addition, data analysis goes on, and another doctor’s appointment which will hopefully have good news for us. Given all of the people who have been commenting that I look fatter, I don’t think Dr. Fanta will be disappointed in my weight gain…

Last Minute Potpourri

The past few days have been an insane blur. I have just been trying to make major progress on every project before Paul and I head to Morocco for a week of travel with my sister Sarah and her partner Warren.

I introduced Alys, the undergraduate on study abroad here who is working on my research with me, to our tailor Issa. She came back with a fabulous outfit, and I had to have a portrait of us together in West African wear.

Alys and I pose

Happily, I found a few hours yesterday to go to the market with my friend Karen on a fabric shopping excursion. We bought bazin, a shiny cotton that has wax beaten into it. My goal is to make a quilt for the baby. Bazin gets soft over time, so I was mostly going for the brilliant colors and intricate tie dye rather than the stiff, waxy surface! These fabrics are very popular in Mali, and when the wax comes out people get it beaten back in!

My favorite

Love the bazin!

In the market I spotted some Barack Obama undies, which I have wanted ever since Karen told me that she got a pair. We also found an Obama hologram belt buckle, but it seemed like a little too much. Maybe if the baby is a boy I’ll go back and get it…

Full Circle Rain

In one month we will be back in America. Indescribably odd. I’m not ready, of course. Rather than conclusion, I get the sense of things just beginning. The rainy season marks the beginning of the end. The rains began on Monday. A cool breeze whisked through the neighborhood, evaporating the sweat from everyone’s faces and necks and covering the world with a fine layer of dust. The horse that is always tied in front of our neighbor’s house (marabou’s orders, for luck) stamped its feet and shook its head. Leaves whispered against each other and whisked through the air. And I was at home but still had a sense of coming full circle, back to the origins of my time here when a rain storm left me stranded in a sotrama and at the mercy of anyone who would help me. It’s funny because now I would never find myself confused as to how to get home from the market or shy about clawing my way into a taxi to escape the rain. I know what to do, how to accomplish things here in this formerly foreign place. I have people to call in case of trouble and I know that in the worst case scenario strangers here are almost always ready to help you.

gratuitous pregnancy picture completely unrelated to post (but for the abundance of the banana tree behind me)

The beginning of the end fills you with nostalgia so that you look at everyday moments and try to burn them into your brain. Today I rode a taxi to Banakoro to assure that the construction supplies for the clinic waiting area had been delivered and to meet with a local doctor who will be helping to train the community health workers. On the walk to find a taxi and on the ride there I kept staring out at the world. The women walking with buckets of giant mangoes balanced on their heads stopping to readjust their pagnes before tromping on. The skinny little boys in ripped clothing holding big tomato paste cans and waiting on traffic medians for the opportunity to scamper amongst the cars and beg for spare change. Men sitting in delapidated lawn chairs around a tiny brazier with a pot of tea on it, enjoying shade, companionship and repose. A slender boy of ten riding his bike along a street at top speed with a look of total determination and purpose. Little children moving independently in the world in ways that are hard to describe to my own American mind. For example, a person less than three feet tall striding along carrying a bag of something recently purchased with no supervising adult in sight. Where could this small person be going, all on their own, full of purpose? Most beautifully, it is safe. You needn’t be afraid to ask your four year old to get something at the boutique on the corner because everyone on your street knows them and they know everyone and life is outside and public so children are safe from other people, if not from infectious disease and horrible accidents.

I was talking with my friend Posie, an American working with the Mali Health Organizing Project, about what we were looking forward to in America and what we would miss so badly about Mali. Greetings are the thing to be missed. I was at a Rotaract meeting on Saturday and a woman strolled in 40 minutes late. The president of the club was talking but she said, “Hello everyone!” (in French, of course). And everyone said hello to her. I tried to imagine myself strolling into a meeting late and interrupting things to greet everyone, and laughed at the idea. But here the rudest thing is not to be late or to interrupt, but to fail to acknowledge other people with a greeting. How hard it can be for we Westerners to get it!! I still launch straight into business and then have to backpedal three sentences into my agenda to greet people and ask after their families. Especially with my Malian friends who are most Westernized.

This isn’t to say that I don’t look forward to many aspects of life in America. Most of all, how easy things are. By that I mean that I can buy a week’s worth of groceries and put them in a giant refrigerator instead of walking for half an hour in burning heat every other day to buy fruits and vegetables. That I can drive places instead of taking sotramas or haggling to exhaustion with taxi drivers. That I can see my beloved friends and family any time I want instead of scheduling poor quality Skype calls and trading emails. But I miss the shouts of playing children and the joking cousins and the beauty of colorful fabric and babies everywhere and joyful connection and the slow life already.

Pizza Night!

Just a brief note on the wildness of the separation between toubab and Malian worlds at times. My friend Assata lives with her daughter Mai across the street from Pizza Da Guido’s, a pizza restaurant just down the street from me. They’re both awesome – just extremely sweet, open-hearted, open-minded women with a lot of energy and good senses of humor. And they’re not poor at all, they’re middle class Malians. But they have never been to the pizza restaurant despite a strong interest in eating pizza.

Mai, Assata, Me and Paul enjoying wood-fired pizza

This is because the price of one pizza (5000 cfa or about $10) is the same price as a month of admission at the preschool where Assata is a teacher. There are definitely two economies at work in this town.  So, last night Paul and I along with our friend Alys (a university student who is living with us for a few weeks as she wraps up her study abroad program here in Bamako) took pizza to Assata and Mai.

It was all so cute. They were bustling all around getting plates together and all of the neighbors kids came to check out the new food.

The Butterfly Effect

The butterfly effect is the idea that minor initiating actions have ramifications that our puny human minds cannot comprehend due to the intense unfurling of chaos that is the nature of the universe. A butterfly flaps its wings in South America and this sets the steps into motion to start a hurricane in the Atlantic Ocean. In my case, the desire to make a donation to the CSCom at Banakoro and support their material needs led to questions about management – how could we be sure that supplies donated by Duke and Rotary were well-managed and didn’t profit some one individual. These management questions in turn prompted a movement in the village (led by a schoolteacher and friend, Assana, pictured here) to have a management committee for the CSCom at their level. Because the mayor of the entire commune (whose office is located in a neighboring town) funds the CSCom, the management committee has been located there and has done a very poor job of overseeing the health center. The results have been abuses of power by the healthcare workers that were unknown both to me and to the mayor until our first community meeting on the topic last week.

Assana with his little ones - he is exactly as kind as he looks in this photo

Further revelations about bad behavior and corruption came out at this Thursday’s meeting. The midwife leveled harsh accusations at the pharmacist: namely, that the health center pharmacist has been selling medications from her own supply for her own profit rather than managing the med supply at the CSCom, and that she frequently refuses to come to the health center to open the pharmacy and supply medications even when there are patients in need of help who come to find her at her home. The abuses of power by the pharmacist were particularly sad because she was the one healthcare worker at the CSCom who was actually born and raised in the village. Her bad behavior had been going on for over a year, but since the oversight of the CSCom has been so bad, the mayor who has the power of hiring and firing had no idea. The people were really passionate at our meeting, shouting and arm waving and finger-pointing. The village chief stood up and demanded that all of the health center staff be replaced. Several people voiced their accord. In the end, the mayor seemed completely swayed and stated that this was the only solution – to replace the entire staff of the CSCom. (The staff are all women and it was noted that “Once women don’t get along, it’s over. You can never repair it.”) The demands for a village-level management committee were also heard and the mayor stated that all financial statements from the CSCom would be reviewed by the village from that point forth. The chef de poste medicale left in tears, and my lack of Bambara skills left me unsure as to whether this was because she had just been fired, because she felt that the accusations against her were false, or for some other reason.

The shift in management and staff is probably good, but it is problematic for me. I have been working with the staff at the CSCom for several months to assess community needs and plan the community health worker (CHW) program. Now, with their absence imminent, I feel unsure as to whether the CHW program can go forward. Although all of the supplies that I have donated are still at the CSCom, I have this paranoia that when the staff leaves someone might take the stethoscopes and penlights that a Duke physician so kindly donated with them. Everything feels like a big question mark now. The CSCom will continue, but who will lead it and how? Strangely, I don’t feel angry or frustrated. My plans for a health worker project are nothing in the face of this movement for local control of the health center, which is much more important. I feel happy to have helped to spark it, even if my intentions were simply to meet the material needs of an under-supplied clinic.

Physician Pay on Two Continents

Who’s going to take care of them?

I saw yesterday’s NY Times article which quoted Obama commenting on the shortage of primary care physicians and detailed the coming storm over Medicare reimbursement. Essentially, the government is talking about redistributing physician pay so that specialists get less and primary care doctors get more. The specialists are up in arms, of course. They acknowledge that primary care doctors should get paid more, but the specialists clearly shouldn’t give up any of their compensation to make it so. I didn’t actually know how much money doctors made when I went to medical school. I thought maybe a primary care doc made around $100,000 and a specialist made $200,000. My highest salary prior to starting this process was $27,000 a year as a community organizer (on which I was able to live quite comfortably) so I figured anything thereafter was likely going to be an improvement of some sort!

Imagine my shock today when I went to the website http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm and found out what enormous amounts of money people I know will be making in the very near future. About 20% of my graduating medical school class at Duke (class of 2009 – coming to Mali put me into class of 2010 now) went into ophthalmology – average salary $305,000 per year. Why would anyone want to care for poor diabetic people with ulcerated feet or help aging AIDS patients manage their 25 different medications when you could do lens replacements, call it a day at 5 pm, spend more time with your kids and make twice as much money?

Everyone comes to medicine for different reasons and I understand the desire for extreme wealth in combination with interesting and helpful work (in the case of ophthalmologists, making the blind see) that isn’t overly stressful. I can’t say why I feel this very strong, almost visceral rejection of the lifestyle specialties to which many people for whom I have a lot of respect seem inexorably drawn. I think that it is mainly because it seems like an unfair twist of government reimbursement plans that a radiologist should make three times as much money as a family practice doctor when they have training of similar duration and are similarly intelligent. My mother is a gastroenterologist, so she is in the category of hugely compensated procedurists. She still thinks it’s crazy to get paid 10 times as much for your time when you do a colonoscopy versus the same amount of time spent in clinic thinking through illness and managing medications. The worst part of this is the way that some medical students begin to talk about and conceptualize primary care. They talk about it as though it is for dumb people, because obviously how much you are paid and your intelligence are so very closely correlated. I have heard people say, “I mean, why would you go to Duke med if you just wanted to do primary care?” I agree with the interventional cardiology fellow who, after flawlessly snaking a catheter into a patient’s heart, told me, “A monkey could be trained to do this. The hard part is thinking about people’s problems and using cognitive abilities to solve them.”

The ophthalmology equivalent here in Mali, ironically, is public health. If you specialize in public health by pursuing post-graduate medical education in Benin or France then you have the potential to work with those unstoppable cash-cows, the NGOs. Nobody aspires to take care of patients because it is time-consuming, depressing, and doesn’t pay at all (a chef de poste medicale at a community health center earns 150,000 cfa or $300 a month!). People even reject surgery as being too low-paying. The outcome is the same as in the U.S. Primary care physicians get paid less and less as people flock to areas where they are better compensated and have a better lifestyle. Oh, and all of the public health specialists live in Bamako whereas the people who need care are spread throughout the bush. And then if you do a bad job taking care of poor, powerless people there are no consequences for your failure just as the rewards for heroic efforts are non-existent. It’s extremely sad.

I think this is all a bunch of crap. I believe that there should be a redistribution of pay, because it isn’t as though a rational and thoughtful process was undertaken to decide current reimbursement schemes! As usual, when it comes to getting government money, it has a lot to do with who has the best lobbyists and connections. Using pay to try to steer people to needed disciplines within medicine would be a very appropriate manifestation of the free market. Is it not generally the case that when there is a shortage of something (say, primary care physicians) that thing becomes more expensive and highly valued? And if people chose something they didn’t feel passionate about doing because of the money, they should realize that that decision was poorly made. Too bad for them. It’s not as if anyone would be poor their salary were reduced from $300,000 to $200,000 a year – it is all so very much more money than 99.9% of people on the planet could dream of having. When asked about the salary issue at a presentation to our first year class, one of the Duke family practice doctors sighed and said, “I am so tired of people complaining about money. Doctors make more money than any other professional group in the U.S. and somehow people still think that it isn’t enough.”

Nowhere else in the world are doctors so much richer than everyone else, nor do they have to work as hard in other parts of the world as in the US. For me, our job is to be enthusiastic and competent at taking care of people and to realize that there are different ways of providing this care but that none is superior to the others. My colleagues doing neurosurgery aren’t better or smarter than my colleagues doing family medicine, they just have different priorities and interests. Everyone needs to be nurtured and appreciated in their work, as we cannot function if any part of our system is missing. And we need more doctors so that we can take care of everyone and still have time to take care of ourselves. So I think we should do what it takes to have enough primary care docs and we should appreciate those who have chosen that path! Right now I am planning to pursue a residency in internal medicine, and I’m not sure what will come next. But I haven’t ruled out being an internist or a hospitalist. I always felt that my future was in Africa, but hearing of the physician shortage in the U.S. makes me remember the myriad issues of justice and access to care that continue to plague my home, the richest country in the world.

A Whole New World

A new era has begun in Paul and my life. Today we saw an ultrasound of our son or daughter-to-be at 12 weeks of age. I was more moved than I had expected to be. There had been a nagging fear in my mind that at this ultrasound I would learn that the baby was either dead or horribly malformed (like it had no head or something). When I voiced these fears to one Malian friend he looked at me accusingly and said, “Don’t say that!” as though saying it was bad luck.

What was hardest for me was that the dice had been cast. If the baby was missing a bunch of chromosomes and was not going to make it, then it was decided and I just had to wait until the end of the first trimester to know what had been determined in the first few days of cell division, gastrulation, etc. So, seeing something that looked roughly like a baby wiggling around simply awed me. It worked! The ultrasound tech was saying fairly obvious things like, “It has two legs.” And I repeated, “Two legs!” and grinned from ear to ear. It’s nuchal translucency was normal. It’s femur was 7 mm long (so tiny!) and it appeared at one moment to put its hand in its mouth. Honestly, I fell in love and couldn’t stop smiling all day, and Paul looked like he was in shock. This is definitely something new, I am beginning understand this kind of love, the parent’s love for a child, from the perspective of the giver rather than the receiver. I can only say that it has to be one of the top three most powerful forces in the history of our universe.

After a the ultrasound and a doctor’s appointment (where I was scolded for losing weight during the first trimester… what can I say – 100 degree heat and nausea aren’t the best formula for plumping a person up) I went to Banakoro for a village meeting. Talk about intense. The village leaders were meeting with the mayor about the health center. Things got heated, which was great, but issues came up that nobody knew about before. Such as the accusation that the health care workers are price gouging for medicines and demanding extra payment to refer people. That they are charging more than the governments fixed price of 2000 cfa for deliveries. That they are arrogant and treat the village people like dirt. The mayor was very diplomatic, and there are more meetings planned to get to the bottom of things and shift the balance of power so that the health workers see the villagers as their bosses. It was a very emotional time, but I felt really gratified when I spoke about the community health worker program, which would train villagers as lay health educators. I suggested that these lay health educators could also serve as witnesses and write down instances where villagers were mistreated to create an advocacy system. This idea was very well-received. The next 7 weeks are going to be so very busy as I work with Rotary to train the health workers, and finish up my research. But who knows when I’ll be back in Mali, so carpe diem.

Coffee tables and Elections

my coffee table, my life

I mention the coffee table only because at certain times some household space becomes utterly reflective of our priorities and our life. So, my coffee table, my life. My time is consumed by qualitative research, practicing French (since I don’t have as many French-based social interactions now that I am in data analysis mode), working on a study on maternal mortality at Point G (hence the thesis on the topic) and

planning things (hence the planner). The flowers were a sweet gift from some young girls in my neighborhood and are the proof that I have not descended into hermit-hood!

When the six foot tall speakers are set up in the street in front of our house and the little orange metal chairs are arranged in a circle around them, then the music starts playing and the under-12 crowd convenes from all around (running towards the music in flip flops or bare feet) it can only mean one thing: election season!

One of the big wigs of the ADEMA PASJ party lives across the street from us, and he is the cause of the continual pediatric dance parties that are the root of my insomnia. There have also been motorcycle rallies, parades with horses, cars and people on foot, and lots of yelling and frenzy until all hours. I was completely baffled by why the political parties have so many activities for kids, who cannot vote. Apparently they also give tea and milk to old people, but the main activity seems to be focused on children. There is a lot of yelling. I asked my friend Assita about it and she explained that, “If nobody will yell for you, the people cannot have confidence.” Basically, inciting frenzied support (yelling, dancing, chanting, whistles) shows people that you have something awesome going for your political party. And nobody has more energy or has more demographic sway in Mali than children (the under 15s comprise something close to 50% of the population).

The political party behind my sleepless nights. They look so happy.

Motorcycle rally for adema anyone?

No political parade is complete without a caped horseman.

The ADEMAmobile

The loudest motorcycle, ridden by a ten year old who pops wheelies.

my coffee table, my life

Last night I was a good sport about the dance party in front of the house. Paul and I watched and I danced a little on the sidelines. You can’t do anything here as a toubab without people noticing. So today several of the neighbors’ kids commented that Nana danced, could dance, or should dance at that very moment. But it is better to be known as a dancer than a grump (or not to be known at all in this very social place).

Easter Monday Musings

My last sewing project!

I love Easter, even though I don’t consider myself Christian and generally believe death to be a permanent condition in the absence of immediate cardioversion (heart shocking). But I find the idea of re-birth at a personal level and dialogue of sacrifice and forgiveness extremely pleasing to ponder. I love New Year’s resolutions for the same reason – start over, reset button, etc. I knew it was time to take a break tonight when I found myself Googling “Medical Supplies Audit Form” at 9pm. The form is very necessary for a little non-profit that I am helping get their monitoring and evaluation system in order (www.malihealth.org, for anyone interested in learning more about the Mali Health Organizing Project), but my brain needs to stretch away from the confines of its logical, rational, planning zone wherein it has been fenced ALL DAY.

I have long been pondering how to bring creativity back into my life. Going to med school cut short several of my earlier hobbies including sewing (see the wedding dress pic), batik (I used to sell my work at a few little craft fairs and make presents for loved ones), drawing, and jewelry making. I wasn’t particularly talented at any of these things, but I found them pleasant and calming and loved having my own creations all around me, decorating my space. I remember during one of my med school rotations looking at this massive batik of a dragonfly in a spider’s web that I made during a morose moment of my sophomore year of college and thinking, “How the heck did I possibly have time to do that??” Then I ran out the door because I was late for something.

It's easier than it looks

Teaching yoga replaced art for me during my first and third years of med school because it was social, but I could play with words and create imagery and a practice for people to enjoy. In some ways it felt like the perfect balance – I could guide my students and it was social and humorous, but I was also helping them with their health. This Friday I am leading a yoga class here in Mali – my first time teaching since last May!

Sometimes when I ponder the idea of re-birth and re-creating ourselves, I wonder at the choices we make and the things that we give up unconsciously. The infinite beauty of the human mind is its ability to imagine that which has not yet come to pass, and guide us to a more beautiful life if we so choose. I have seen many awesome examples of people who chose creativity, kindness and compassion late in life, who chose to live on a path of noticing the little sweetnesses in life and sharing them with others. To me that is re-birth in its most poignant form. Every day we can choose to notice, to share, to breathe and to enjoy. So, having spent the whole day at a computer making conceptual models and looking up articles and creating audit forms, I think I’ll go do yoga in the hot darkness of a Bamako Monday and look forward to a good night’s sleep and a tomorrow with a bright, hot sky and the sound of children laughing.

When things seem papery thin and about to fall apart, the moment is ripe for transformation

Senegal and Updates

Right now I’m listening to children singing and playing outside. It is one of the enduring beauties of Mali – the enthusiastic presence of children everywhere. Paul and I spent the last week in Senegal with his sister Claire. It was so wonderful to have a visitor from home! My hope had been to visit a Rotary Club during my time there, but the chosen club (Rotary Millennium Dakar) somehow didn’t meet on the day that I attended. Paul and I sat patiently by a Rotary sign at a lovely hotel for about 20 minutes before a kind employee informed us that the meeting was apparently cancelled.

The sunset at Toubab Diallo

A pirogue on the beach at N'gor

Sara and Baba post-successful visa interview

Senegal was so fresh and beautiful. I think that it was a little hard to be there because I knew that I could have to come back to the 115 degree heat of Bamako soon and I kept comparing Bamako to Dakar. There really is no comparison. Dakar is like Europe practically – closed sewers, modern buildings, highways, cars instead of motos, people in Western clothing talking on their cell phones. I found myself wondering why I had chosen Mali over Senegal, given the comfortable familiarity of Dakar. When I got back to Mali I remembered instantly why I love it here. The people. Everyone says it, and it’s true. There are not nicer people anywhere in the world. Thus I am happy to be in the Bamako heat even in my current delicate condition (which will be elaborated in a few weeks).

Paul and Moonmoon clean our overpriced mussels

At Toubab Diallo

I got into several verbal scuffles in Senegal that were so unexpected. The most potent example took place in Popenguine. Paul, Claire and I were staying at a campement run by a women’s collective. I bought some mussels on the beach and took them to the kitchen of the collective where an awesome woman named Maïmouna helped us clean them up for eating. While we were working on the mussels she asked how much I paid for them. My answer, 1500 cfa, led to joyful peals of laughter. She told everyone how much I had overpaid and everyone had a good laugh about it. I overpay for things in Mali all the time, so the next time that I saw the mussel salesman I jokingly told him that the game was up – I knew that I had paid too much. The reaction was rage rather than humor – accusations that the women’s collective was ruining his business, etc. I was so used to the Malian perspective on things (laughter, gotcha, etc.) that I didn’t know what to say, but managed to be as snappy and uninhibited in French as I would have been in English, for better or for worse.

Otherwise, the journey was pretty pleasant and uneventful. We met up with some of our best friends from Mali (Sara and Baba) in Dakar. They had just received a visa for Baba to join Sara in America this summer, so there was much to be joyful and grateful about. When we landed in Bamako on yesterday it was still 102 degrees at 6:20 pm. But greeting people in Bambara and just feeling the way of things here made me ecstatic. This is home. I ♥ Mali.

Claire and I with a canine friend at Popenguine

Little boys on the beach at N'gor

In ambassadorial and research activity updates, we installed the solar panels at Banakoro just before I went to Senegal and the grant application for a Community Prenatal Care Strengthening Program is coming along great guns (due April 24). I am still working on coding my data from the community health worker project (please Lord let us have a manuscript by June) and have begun working on a few papers on maternal morbidity and mortality at the Gabriel Touré Hospital with the ebullient Dr. Tekete, whose dataset of 19,253 patients is pretty awesome if you are impressed by such things. Paul and I are also collaborating with a few colleagues on a survey to look at access to healthcare in a nearby low-resource neighborhood of Bamako and help a community health project with monitoring and evaluation. Last of all, I just got an email from Steven Fear of the Passback Program and they are sending seven boxes of equipment for the soccer teams of Banakoro. I’m so psyched! Now that I write it all down it seems an outrageous number of commitments. Par for the course of my life… By the way, the children singing morphed into a techno-hip-hop block party. There are six foot high speakers in the middle of our street and a ton of little kids dancing the night away.

P.S. We did not escape Senegal unscathed. An anonymous member of our party of three was infected by larvae of the tumbu fly and had a worm implanted in his/her thigh. The worm emerged in an unsightly matter at a disturbing time.

The solar panel on the roof!