Christmas

This was my first Christmas completely removed from the United States. It has been very different and wonderful.
The most obvious differences have been the weather and wonderful lack of commercialism. As anticipated, Lubutu’s Christmas weather is tropical. Christmas Eve was very hot, with the blazing Equatorial sun in a cloudless sky. Though I cannot say I enjoy sweating on Christmas, it has been nice to escape the West’s commercialism. No one has disposable income here and there is nothing to purchase anyway. Last week I spoke to Kurt and we talked about his anxieties of his yet unbought gifts for his parents and siblings. It was difficult to relate. In a different conversation, my mother asked if it was all right for us to exchange Christmas presents in February, after my return home. The question was so alien to my current situation that it took me a few moments to think and answer.
Though the contexts of weather and commercialism are different, I had an unforgettable holiday. On Christmas Eve I went to church at the cathedral directly opposite Couvent. Four of us entered into a crowd of about 600 people, all beautifully singing, swaying, and dancing. Ten altar boys danced in synchrony, surrounding a motionless singing priest. The interior walls of the church’s vaulted ceiling amplified the passionate voices. We initially joined the large group standing in the rear, dancing and clapping. When the hymn was over, several people offered us their seats. We initially refused but it was clear this was a losing battle. We eventually sat down on a backless wooden bench and listened to the service being conducted in Swahili.
In a forward corner of the church stood a crèche. The figures all had black skin and the manger lay under trees and a roof constructed of banana leaves. The only other decorations hung across the width of the sanctuary. Strings of thousands of packing peanuts criss-crossed over the congregation’s heads. Many more hymns followed with drums providing the only accompaniment. We clapped in time to the music as everyone sang passionately of the holiday.
It had a fantastic Christmas experience here in non-commercialized tropical Lubutu.

Bisoke

I planned to spend two days in Rwanda's Parc National de Volcans. Yesterday I satisfied my curiosity about the mountain gorillas. What next?
There are three choices of non-gorilla activities. The most popular is a short hike in the forest to spend time with golden monkeys. Like the gorillas, these small primates have been habituated to human contact. I asked several people about the experience and received reviews varying from "fantastic" to "they were up in the tree tops so don't waste your money." So no golden monkeys for me. Another possibility for a day trip is a hike to Diane Fossey's grave. She lived in these mountains, studying and educating the public about mountain gorillas. She was murdered in 1987 and is buried just outside the park boundaries. Not having read or seen "Gorillas in the Mist" I decided to forego this activity. The third possible choice is Bisoke.

Parc National de Volcans encompasses five extinct volcanoes. They form the border between Rwanda, Uganda, and the Democratic Republic of Congo. From the Rwandan side it is possible to climb two of these mountains. Karisimbi is a two day trip but Bisoke can be hiked in a day. To me, on a visit to Volcanoes National Park, isn't it logical to try to climb one of the volcanoes?
The National Park charges seventy-five dollars per person (including a guide) to climb the mountain. As I predicted, there were no other tourists wanting to go today. I had the guide to myself! I am sometimes a fast hiker and groups of varying abilities can be exasperating.
We began the trip by walking through beautiful fields of flowers resembling daisies, grown and harvested to produce a natural insecticide. After a gradual ascent through the flowers, we crossed a stone fence that encloses the national park, built to keep people out and wild animals in. The going got rough almost immediately. The path was steep and very muddy. Following each step forward I slid back a half step. The guide and I proceeded through several different vegetation zones and saw a lot of fresh droppings (including gorilla) and footprints, but no living animals. The path got steeper and I repeatedly thought "how are we going to go down this?" I considered calling it all off several times (40% of tourists do so) but 4 ½ hours after starting, we arrived. At the summit of 3711 meters (about 11,500 feet) lies a perfect crater lake. On the other side of the water lay Congo—home!

After a short break for lunch we started down. For me, this was much worse than ascending, though faster due to my innumerable falls and slides. My hiking boots were dirtier than I have ever seen them, likely due to hundreds of dunkings in 6 inch deep mud.
The path down took slightly under four hours. When we crossed the stone fence to exit the park I was exhausted, happy, and relieved to have stopped sliding and losing my footing.
Was it worth it? Definitely. Would I recommend it? Only for people who are very fit and have excellent hiking boots, rain gear, and lots of determination. And only in the dry season, though the guide told me there is mud even then, as the summit is usually in clouds. If descending steep muddy trails makes your ears burn with anticipation, it is perfect. I loved the experience and am pleased I persisted to the summit but tonight am hungry, tired, and sore!

Gorillas

It's only money, but 500 dollars is a lot. I debated about buying a permit to see the mountain gorillas in Rwanda for a long time. To me, 500 dollars is many days of sweat and toil. Permit holders spend only one hour with the gorillas. Is anything worth 500 dollars an hour?
Here in Rwanda's Volcanoes National Park there are eight groups of habituated mountain gorillas. Each day, seven people are allowed to visit each group. A typical gorilla group contains seven to twelve members headed by one or more male silverbacks. The other members are females, babies, and younger males called "blackbacks." Each gorilla group has a name. After arriving at park headquarters at 7 a.m. I was assigned to see the Susa Group. Susa has the most members but is also the most remote. Tourists wanting to see them must be willing and able to hike a long distance.
It was a hard trek of three hours straight up the side of a mountain, beginning at an altitude of 9000 feet. The path was toppled trees and trampled plants. My feet rarely made contact with solid ground. Without a walking stick to plunge down to the earth and use as a third leg, it would have been nearly impossible.
So at noon today I had my contact with the mountain gorilla. Susa has two silverbacks, the extremely large, 200 kilogram(440 pound)dominant males. There were approximately a dozen females and as many blackbacks and babies. Bigger gorillas lazed on the ground while the babies swung in the trees. National Park rules state that humans are to stay seven meters away but one especially friendly female came much closer to inspect us.
When we were halfway down the mountain, the wind picked up, clouds rolled in, the temperature dropped, and I was drenched from my first Rwandan rainstorm. By the time we drove back to town the sun was out. Our group celebrated our successful gorilla encounter with cold beer in the warm sun. There are approximately 710 mountain gorillas in the world, all threatened due to territorial encroachment. I spent part of today with a few of them and felt lucky to do so.

Trip to Rwanda-Kigali

This morning I woke up at my usual early hour, went for a run on Axe Kindu, and returned home for breakfast. There were new arrivals last night so for a nice change I had camembert with my usual horrible coffee.
At 11 a.m., a car brought me to Tingi Tingi, a widened section of pavement called an "airstrip", located 20 minutes outside Lubutu. Seconds after we arrived, a small plane landed. Out popped three expatriates and their baggage. In response, Kirstin (a Belgian expatriate leaving Lubutu) and I jumped in. The twelve seat plane took off over the thick jungle. Slightly over an hour later we landed in Goma, far eastern Congo.
After a few minutes at the MSF base, I was drivn to the border and crossed into Rwanda. What a change! The roads are well paved and have shoulders or sidewalks where people can walk. When I jump on a taxi motorcycle the driver hands me a helmet. There are stoplights and there is currency other than the US dollar.
Thankfully one of the drivers from the MSF base helped me cross the border, travel by taxi motorcycle to the nearest Rwandan bus station, change money, buy a bus ticket, and get seated on the next bus to Kigali. From the border this entire procedure took twenty minutes, unheard of in Congo.
Three and a half hours later the bus arrived. I took another "taxi moto" to the recommended but not very nice Hotel Okapi.
So many things are strange here. There is a lot of traffic. In contrast with the quiet of Lubutu, Kigali is deafening. No one stares at me or says "bonjour" even though I saw few other white people in town. There are sidewalks, lots of traffic signals and glass buildings taller than one story. There is almost everything except ice cream parlors and movie theatres. Of course these were the two things I most eagerly anticipated! Too bad.

The countryside is drastically different here. There are mostly big rolling hills, almost completely deforested of their native trees, every inch divided into square cultivated plots. No matter how steep, nearly all of Rwanda is being used to grow food.
It is overwhelming to be in this city after four months in Lubutu.
Kigali is a one day city. I have been here exactly twenty-four hours and feel I have done and seen it all. There isn't a lot her for the tourist, but what I did see was powerful and nearly had me crying in public.
Mention Rwanda to most people and they remember the genocide of 1994. For one hundred days the majority Hutus slaughtered the minority Tutsis. After it was over, one million people had been murdered. When recounting this story, Rwandans pause here and then invariably add "Rwanda was dead."
Perhaps not dead but badly hurt. To begin healing the national wound, dozens of genocide memorials have been opened around the country. Today I visited one of them, the Kigali Memorial Center.
The Center has two floors. On the first, rooms are arranged in two circles, one inside the other. The exhibits in the outer circle begin with photographs and commentary of the colonization of Rwanda, steadily leading up to the events of 1994. Video screens tell the tales of eyewitnesses and survivors. It was chilling as I remember those 3 1/2 months very well. I remember thinking "uh oh, this is not going to be good" when the president of Rwanda's plane was shot down on approach to Kigali airport. I remember the killing extensively covered in the press while no government intervened to stop the massacre. And I remember being relieved when it was over.
After finishing the outer circle of commentary, the inner circle of exhibits were even more chilling. One room was filled with carefully stacked skulls, many crushed by blows. Another held thousands of photographs of victims, submitted by their families for display.
That over, I ascended the stairs. To the left were huge photos of children. A plaque below listed their favorite toys and foods and the way in which they were murdered. The remainder of the second floor detailed other genocides throughout history-Armenian Turks, European Jews, and Cambodians, among others.
I exited the building and walked around the gardens encircling the Memorial Center. The flowers and fountains sit atop the mass grave of 250,000 Rwandans.
After an emotionally wrenching three hours, I spent the remainder of my day shopping and walking the streets of Kigali. I have ended my afternoon and now sit with a drink next to the swimming pool at the Hotel de Mille Collines, made famous in the film "Hotel Rwanda." Only fifteen years ago, hundreds of people sought refuge here, drinking the water from the pool to stay alive.
As with all genocides, the most puzzling question is "How could people do this to each other?" Not to strangers but to neighbors and friends. My one full day in Kigali was interesting and emotionally exhausting.

I woke up late this Sunday morning, brushed aside the mosquito net and swung my bare feet on the warm cement floor. Stumbling into the dining room, my eyes opened wide at a much welcome sight. René, a Belgian surgeon, sat at one end of the long dining table, an open can of French foie gras before him. Fortunately he was willing to share his little piece of culinary heaven with me. We both ate so much that we left the table contented and ill. During our breakfast conversation I had heard loud noises coming from the kitchen. Jana and Remo, German expatriates, were making coffee cake. Brushing aside any thoughts of satiety, I dug in. It was delicious. Finally free, I waddled out to the terrace where Maria poured me a tiny cup of ultra-strong Lebanese coffee.

As expatriates in Lubutu we eat very well, but the food is not varied. Breakfast is bread, butter, and jam, along with coffee or tea. The bread is tasteless and has the shape of a slightly elongated hot dog bun.
Lunch is at 1 p.m. and is the largest meal of the day. It is served as a buffet on a side board in the dining room. Several identical, covered serving dishes hold the food which varies little from day to day. The buffet starts with rice, potatoes (mashed and boiled) and badly overcooked pasta. Next are vegetables, usually one raw (sliced peeled cucumbers or whole cherry tomatoes) and two cooked. Spinach is a constant and the second is always poured directly from a can, usually corn or green beans. We always have two meats. The most likely is pork cut into little chunks prepared grilled or in a bland oily sauce. Chicken sometimes appears, but into pieces and floating in a mysterious brick red sauce. Once every 2 weeks there is terribly smelly fish that forces me to eat on the terrace. The cooks deep fry plantain slices to eat as slightly sweet chips. Dessert is usually pineapple chunks. Someone drags out a few bars of Belgian or French chocolate out of the refrigerator, breaks it into chunks, and we argue the merits of one brand over another.

Dinner is mostly lunch leftovers but often the cooks prepare two plain roasted chickens (plucked next door in the kitchen- watch out for feathers!) and either bread, pizza, or quiche. The last two are a bit different from what I am accustomed. The staff uses the same dough as to prepare bread, but they allow it to rise in the pizza or quiche pan before baking. The result is a delicious thin topping sitting atop a one inch thick crust, occasionally raw in the center. Pizza toppings are corn, tuna, chicken (with bones) or canned slimy mushrooms. The quiche is always leek.

It sounds delicious, right? It is but it is also repetitive. The staff who cook our food appear to have no knowledge of spices or variety. The spinach is prepared exactly the same way each day. There are dozens of bulbs of garlic in the pantry, all unpeeled and rotten.
Condiments have saved me. I slather virtually everything in either ketchup or Bertolli pesto. I do have one special treat I look forward to each day. Remember those deep fried plantain chips? I put several on a plate and microwave until they are viciously hot. I dip a fork into a jar of Nutella and apply the black paste onto the steaming chips. After a minute, this perfect combination is cool enough to eat. People here make fun of me because I eat this every day and am clearly in ecstasy with every bite.

On Sunday the kitchen staff departs at 1 p.m., leaving the afternoon for the expatriates to get creative in the kitchen. A few weeks ago I made Chicago-style stuffed spinach pizza which was a great hit. Other have created Javanese curries, Belgian rice pudding, French eclairs, and Algerian grilled chicken—all delicious. Today started with foie gras and German coffee cake. I wonder what’s for dinner?

King for a Day

This morning I was running around the hospital doing my usual morning preparations. Passing by the Pediatric Ward I saw a striking little boy. He waved and said "bonjour" like the other children. But he was wearing a necklace and wore a homemade crown. I stopped and took his picture and told him that today he was the King of Pediatrics.

The MSF hospital in Lubutu is likely one of the best in the Democratic Republic of Congo. It is a Hôpital Générale de Référence, a place where sicker patients can be referred from their primary care Centres de Santé. In the West, a general community hospital would be the closest equivalent. Most of the wards are the same—Internal Medicine, Pediatrics, Maternity, and Surgery. In addition, this hospital also has a cholera ward and isolation rooms for viral hemorrhagic fevers, like Ebola.
The patient experience is different than in the West. When hospitalized, patients are assigned to a metal bed with a plastic mattress, a single sheet, and an overhanging mosquito net. Almost everyone (including adults) has an accompaniant—a family member or relative who stays with them, does their laundry, cooks their food, and helps with care. All medical care is free of charge. That is a good thing because patients are in the hospital for a very long time.

Those who have encountered hospital care in the West know about Length of Stay. In the US, the government has determined the number of hospital days necessary to care for someone with nearly every medical diagnosis. Private insurance companies follow these anticipated Length of Stay rules. These rules have shortened in my medical career. For example, when I was in training, a woman giving birth stayed in the hospital for two or three nights. Now it is one night.
If a patient remains in the hospital longer than the anticipated Length of Stay, the physician must justify the patient's continued hospitalization to the government (Medicare and Medicaid) or the insurance company. Several times I have had to speak to someone at an insurance company daily in order to keep a sick child in the hospital.
There aren't any Length of Stay rules here in Lubutu. Patients are hospitalized for much longer than in the US or Europe. Why? There are several possibilities.
Perhaps here in Lubutu, by the time patients get to the hospital they are sicker than people in the West. Maybe the diseases are at a more advanced state before patients go to their neighbourhood Centre de Santé. Likely more important is the lack of follow-up for patients discharged from the hospital. At home, if a patient has severe pneumonia, they might be treated with intravenous antibiotics and oxygen for a few days, then switched to oral medicines. One day later they go home with a follow-up appointment with their primary care physician. The entire structure of having one's own health care provider is missing here. If someone is discharged from the Lubutu hospital remaining even slightly ill and told to see their neighbourhood Centre de Santé in follow-up the next day, it is very unlikely to go well. The patient likely has either no (or incomplete) medical records with them. They Consultant they see may not know them. There is no mechanism where the Consultant can contact someone at the hospital to see what occurred. Consequently, patients must remain in the hospital until they are 100 percent cured and back to normal. This makes for long hospitalizations.

Sunday morning. It had been 3 ½ months since I left the US and I badly needed a haircut. Where does one get this done in Lubutu? Sure there are barber shops and salons de beauté here, but I doubt anyone has much experience cutting thin, straight, blondish hair. Fortunately, Dominique Beels, a Belgian expatriate, assured me she is an expert in this area. She practiced cutting hair on her three brothers over the last several years and she is willing to help me, too.
So at 11 a.m., in the Equatorial sun, I sat outside in the back yard of Couvent wearing only a bathing suit. Dominique came bearing scissors and a comb, apologizing before she even began. At the first snip a big hunk of hair fell to the ground. No turning back! Thank goodness Dominique was able and willing to do this, as I would be doing the cutting myself if she were not. Still, I miss my regular barber and the chat we have every 6 weeks.

I like to think of myself as an adaptable person. I've travelled extensively, one time for a year continuously. I've never before felt the need to be homesick, but this time it is a little different. There are several things I miss about my life at home.
First, of course, is Kurt. I miss him terribly. He is my best friend and spouse. I miss talking and laughing with him. I even miss our "discussions." He's a classical musician and I love attending performance where he is playing. I miss our talking about classical music and learning an evening's program before he plays it.
Living in a group is difficult. I miss my lovely home and the privacy of its walls. In Albuquerque, I can shut the doors and curtains and all is quiet. No one bothers me. I can sit outside on the back porch and no one wants to talk or hear about my day. I can eat in peace. Living in Couvent, it is difficult to ever be alone. Even with my bedroom door and the window shut, noises intrude.
Concretely, there are several things I crave—ice cream, seeing a film in a movie theatre, yogurt, good coffee, walking and playing with our dogs, Indian food, frozen margaritas, garlic, good fresh fruit. None of these things are here.

After an hour in the blazing Congo sun, my haircut was almost complete. As Dominique cut away, I talked to her about all the things I missed while living here in Lubutu. She told me her own story. After a few months here, she scheduled a vacation in Belgium. Before leaving Congo, she swore she would eat ice cream every day once she got to Europe. She was home for 10 days and guess what? She ate it once. We all crave what we can't have, right?
I'm all grown up and I'll be fine but a chocolate sundae with a frozen margarita on the side would be perfect right now.

Thanksgiving

Thursday is Thanksgiving and it is looking like it will be quite a celebration here in Lubutu. Although every European living at Couvent is anxious to eat a traditional American Thanksgiving dinner, it looks unlikely to happen. Rather than think about what I might prepare (or, rather, have the cooks prepare) I have been making a list of the foods unavailable here, but necessary to prepare the traditional meal.
First is turkey. A fellow expatriate swore that last week they saw one "somewhere down by the river." After the sighting, I took several walks down to the river, approaching it from all known directions. I have talked to everyone I saw, drew a picture of a turkey (as no one knew what I was talking about), and been met only with amused puzzlement.
Even if we could delude ourselves into thinking that one of the scrawny chickens here was a turkey, nothing else is available either. Stuffing? Yes, there is white bread but no sage, pecans, or celery. Cranberries do not exist and neither do oranges. No sweet potatoes or yams, brown sugar, or marshmallows. No one has ever seen a pumpkin and none of the spices are available anyway. Yesterday I described the fabrication of gravy to the kitchen staff. In return they traded glances that subliminally said, "does he really want us to mix fat and flour together, whisking constantly over a low to medium heat, then slowly add preheated turkey stock (what is a turkey anyway?), continuing to whisk so as not to form lumps? Does anyone actually bother to do this and would anyone eat the results?"
So I think the gravy is out, too.
That leaves mashed potatoes. We have those here in Lubutu. We have them twice per day, every day, in fact. There is no milk or cream or butter to make them palatable, but we have plain mashed potatoes. From what I can tell, my Thanksgiving dinner is likely to be a huge pile of mashed potatoes covered with the ubiquitous Couvent tomato sauce.

Even though lacking in the culinary side of the holiday, I am still thankful for much in my life. I'm thankful to be healthy and able to improve the health of others. I'm thankful for my privileged background and the opportunities this life has afforded me. I'm thankful that I have known love, forgiveness, and friendship. And I am thankful to be here in Lubutu.

Thanks for reading and Happy Thanksgiving!

Horrible news

I travelled to Mungele this morning, as usual. Initially nothing seemed out of the ordinary. The staff greeted me with smiles, handshakes, and "bonjour"s, as they do each morning. The niceties, however, were followed by a gruesome and disturbing story. Last night a 4 year old local girl was murdered. The killers used machetes to cut off her arms, legs, and head. They carried away her internal organs and stuffed her disembowelled trunk into a cloth bag. Her remains were discovered 300 meters into the jungle, about 3 kilometers from Mungele. She was an albino.

Albinism is a hereditary disease. Inheritance is autosomal recessive, meaning if a person carries only one abnormal gene they are not affected. A person manifests the disease if they have both genes abnormal, one inherited from each parent. People with albinism lack melanin, the pigment that darkens our skin and protects it from sun damage. Their eyes also lack pigment. In animals with albinism, the blood vessels of the retina show through, making the eyes red. In humans, red eyes are more rarely seen. People with albinism have a higher incidence of problems with visual acuity and other ophthalmologic disorders as well as a higher susceptibility to sun damage. Otherwise they are generally as healthy as those who have normal pigment.
For several years there have been reports of witchcraft-related killings of albinos in Africa. Body parts of albinos are used to make potions, believed to confer wealth on those who ingest them. In late September 2009, three men in Tanzania were convicted and sentenced to hang for the murder of a 14 year old albino boy, his body mutilated by machetes.

As with most horrors, the locals of Mungele are quick to blame "others" for the local girl's murder. I've heard theories of "people from North Kivu" (the next province, 20 kilometers away) and "people from Tanzania." No one wants to entertain the thought that a local person could be capable of such horror, especially against their own neighbor, yet no strangers have been seen in the area. This is a tiny community and it is difficult to believe an outsider could infiltrate the village and abduct someone without notice. The police from Lubutu are investigating.

Unrelated to story, here are some photos of some local boys swimming, taken with underwater camera:

Howdy Pardner!

A wonderful, varied, and puzzling aspect of life here in Lubutu is the greetings. The Congolese are very polite. When passing me on the street, the vast majority smile and offer both a physical and verbal acknowledgement.
As in most parts of the world, the physical greetings are usually a wave or handshake. The one handed wave is the most common. A special treat is the two handed Congolese wave. Both palms outwards and a broad smile. It's enthusiastic and welcoming. A few people don't wave, but it is uncommon. Even this group makes some effort, smiling or nodding their heads instead. The extremely polite are more common; several men have tipped their hats as they pass.
Most physical gestures are coupled with verbal greetings, which are more varied. Most common are "bonjour" (before 1 p.m.), "bon après-midi" (1-2 p.m.) and "bonsoir" (after 2 p.m.). Less often I hear "jambo" (Swahili for "hello"). "Karibu" is nice, meaning "welcome."
Young children's verbal greetings are incredibly diverse. By far their most common way to say "hello" is to scream "MONUC!" Puzzling? The Mission de Organisation des Nations Unies en République Démocratique du Congo is the UN Peacekeeping force. It has been in this country for over a decade. In the minds of the local children, all white people logically work for the UN. There must be an assumption that these same white people wish to hear the name of their employer shouted by children, accompanied by jumping, smiling, and waving. It's cute but strange. Being in an MSF vehicle or wearing MSF t-shirts makes no difference. "MONUC" rules.
Stranger yet are the children screaming "Good MONUC!" This must have originally been "Good morning" and was merged with "MONUC!" The result is an approbation of international peacekeeping interventions shouted by innumerable Congolese kids.
Unlike most places in the world I have travelled, I never hear the word "hello." This, despite my American accented French betraying my anglophone origins.
Regardlesss of the specific nature of the greeting, it is the culture here to always acknowledge another person as one passes by. As I walk around town, I am continually saying "bonjour", waving, and nodding. I can't help but think how shocking it must be for a Congolese person who visits or immigrates to Europe or the US. In these places people rush past one another, sometimes bumping into one another, without any exchange whatsoever. For a Congolese, the silence would be deafening.

Surprise surprise surprise!

Life is full of unexpected turns.
Last night I spoke on the telephone with my employer in Albuquerque. We were scheduled to discuss my return to working at Presbyterian Medical Group (PMG), after finishing my work here in Lubutu.

As a physician, taking time off to do volunteer work is tricky. When I first started with PMG, my boss was Dr. Phyllis Floyd. Dr. Floyd was wonderful to me and everyone in the group. I had been doing some short term volunteering overseas but in 2007 I asked her if I might leave for 5 weeks to volunteer in Malawi. My neurologist co-worker was willing to pick up extra hours so that our patients wouldn't have to wait too long. Dr. Floyd agreed. I went to Malawi, did my teaching, and came home.
A year later I began to think about what it would be like to have a once-in-a lifetime long term volunteer experience. I had heard about Médecins Sans Frontières/ Doctors Without Borders and thought I might give it a try. I approached Dr. Floyd about taking a nine month leave of absence to volunteer with MSF. My neurology co-worker was again willing to put in extra hours. Dr. Floyd thought about it and then told me she was sure we could work something out. Great! I was set. I applied to MSF, got accepted, and am now a field volunteer here in Lubutu.
Except for one problem. A few months after my initial conversation with Dr. Floyd, she suddenly and unexpectedly resigned. Rumors flew that she had been forced out.
So a new administration of Presbyterian Medical Group took over. When I approached them about fulfilling the promises given to me by Dr. Floyd they initially balked. Finally after a lot of haranguing, I was told that for this nine month period I could switch from employed to "PRN" status. Being "PRN", a physician is an independent contractor. They receive a salary but no benefits. I met with Dr. Mark Epstein (Dr. Floyd's replacement) and discussed this at length. He encouraged me to keep in contact with him by email, letting him know when I would be returning. When I mentioned the possibility that I may be gone for only six months (instead of the nine planned) he brightened. I had been thinking that perhaps for my patient's sake (as well as my hard working co-worker) that if I were only gone for 6 months that might be easier. The medical group was considering interviewing someone to work temporarily in my absence but this person could not start until January 2010. If I were only gone until January, interviewing this temporary replacement wouldn't be necessary. Dr. Epstein was pleased, my practice administrator was pleased, my co-workers were happy, and I was happy. I signed the papers to switch to "PRN" status, got on the plane, and was off to Congo.
In retrospect, though, there were a couple of odd things that occurred long before I flew away. Several weeks before my departure, a letter was sent to all of the pediatric neurology patients at PMG informing that I was leaving to do humanitarian work. There was no return date given. I was puzzled and the patients were, too. Our office received many calls and visits from patients asking what they should do. We assured them I would be back at in early 2010 and not to worry. In my absence, their wait time to see my co-worker would be longer, but this would be only temporary.
Many physicians were puzzled that Presbyterian wasn't making more of a positive spin on my volunteering with MSF. Isn't doing something like this a good thing for the world? Wouldn't they want to publicize the fact that one of their employees was doing this?

So last night I was on the telephone with Dr. Epstein. He greeted me, asked me how I was, and fired me.
Wow! I really wasn't expecting that one! I was told that taking time off to do humanitarian work "is not compatible with the vision of PMG leadership."
Conveniently for the PMG leadership, I was switched from "employed" to "PRN" status before being discharged. Interesting that while I was still employed full time (and thus entitled to benefits and a severance package) that a letter was sent out to my patients detailing my departure and not giving a return date. Coincidence?

Like all events of this nature, this event is likely a blessing in disguise. Still it stings. I worked hard for them and thought I did a good job. I suppose if I have to be fired once in my life, it is good that the reason given is that I am doing humanitarian work.

Enter Eva

My life is very busy these days. Since Sophie left and Joseph is on vacation, I’m trying to juggle the work of three people. I’m stressed and very tired.
I arrive at the hospital at 6:30 a.m. having several tasks to attend to before the Centres de Santé can open and function for the day. I pick up boxes of vaccines stored inside cool boxes, retrieve the newly sterilized materials I deposited the evening before, grab any supplies I have ordered, and jump in the car to start my journey to work..
The first stop is Kalibatete, where I unlock 10 padlocks, drop off supplies or pharmaceuticals, and give instructions to the staff. The clinic has been very busy the last few weeks and there are usually several patient care or staff issues, all of which I solve at 7:15 a.m. Then back in the car, off to Mungele. I arrive between 9 and 9:30 a.m..
The first order of action is to greet the staff with a "bonjour" and handshake. I have only two to three hours to spend there, so I must organize my time wisely. I see patients with the Consultants and Sage Femme (midwife), help with immunizations, see babies being born, help take the inventory in the pharmacy, and make long lists of things to do, order, print, or photocopy, once I return to the hospital. I tell everyone I am returning to Lubutu at noon but it never happens. Patients needing further evaluation at the hospital are loaded into the car and the engine starts. Inevitably, a Consultant comes out running with another sick person needing transport to the hospital. No problem, as that is why we are here. We drive to their homes to get their personal belongings. Patients supply their own food and wash their own clothes, so we sometimes have to battle as they attempt to bring more luggage than the vehicle can accommodate.
Finally we're off! It's back to Lubutu, arriving about 2:30 p.m. I stumble back to Couvent with an aching back, starving for my first full meal of the day. Breakfast was a cup of bad coffee I drank at eight and a half hours previously.
Lunch, though the biggest meal of the day for the rest of the team, is small for me. There is often little left to eat after 22 other hungry stomachs have been filled. It is 3 p.m. and I generally have to attend meetings, to order items essential for both Centres de Santé, or document statistics. Oh yeah! Theoretically I am also supposed to pay attention to Kalibatete, the busy urban health center I am responsible for managing.
Unfortunately, due to this shift in my job description, I've been neglecting the place, spending between zero and thirty minutes there per day. After my daily obligatory and rushed evening visit, I return back to the office for more computer work, begging for supplies, and preparing for the next morning, eleven hours away.
With all this work, my mood has been bad the last few weeks.
That was the state of affairs when......enter Eva Goossens.
Eva works for MSF Base in Kinshasa that manages all the Belgian projects in Congo. We've been corresponding by email for several weeks, communicating mostly about training and education needs of the staff. Fortunately, Eva morphed into my personal management consultant. During the last two days she has visited both Mungele and Kalibatete, interviewed each staff member privately, and did a group exercise. Afterwards she and I discussed her findings. The people at Mungele are happy because I am there every day; those at Kalibatete feel abandoned. We talked about this unfortunate situation where there are not enough hours in the day to give the personnel at Kalibatete the attention they need. Even starting at 6:30 a.m. each day and finishing 12 hours later, I cannot do it all alone.
This new work schedule has been killing me leaving me physically and emotionally exhausted. Eva then gave me permission—virtually ordered me—to change the situation and especially decrease the travel. This is a great relief. With my new schedule, I'll be able to spend whole days at Kalibatete, more equally splitting my time between the two Centres de Santé. In addition, Eva helped m recognize that some of the education I have been doing has succeeded, some not. Yet even the less successful presentations were taking up a huge amount of my "free time" (Saturday nights and Sundays). No more. She helped me strategize on how to more effectively focus these educational efforts.
It has been wonderful to have Eva as a distant objective observer. She has helped me view my job in a new light. I cannot do it all and must stop trying. Eva made me realize how I can get so focused on one routine that I fail to realize there are alternatives. As an outside observer, she helped me “step out of the box”.
I am halfway finished here in Lubutu. I've done some things right, but a few wrong. Thanks to Eva's help, I have a second chance.

Sleep

Last week I was seeing patients with the Consultants, talking to and examining people with everything from muscle aches to malaria. A forty-five-year-old man and his family member appeared at the door. The patient had a blank look on his face and was being led by his younger brother. Our patient was staring, his eyes slowly wandering around the room. He visually fixed on objects, holding his gaze in one spot for 30 seconds, and then moving his eyes. He shuffled slowly and was settled by his brother into a chair.
Djogo, one of the Consultants, took the medical history. The brother did all of the talking. Two weeks ago the illness started with a change in personality. With further questions it became clear that symptoms dated from months earlier, with the patient becoming quieter and passive. When asked questions, it would take him several seconds to reply, if the answer came at all. His responses were only tangentially related to the questions asked. There had been nothing else—no fever, no seizures, no head trauma. Other than his passive staring state, his physical and neurological examinations were normal.
What was this?
The first thing that came to my mind was a chronic meningitis. Most people think of meningitis as an acute illness with high fever, a stiff neck, and quick death. But there are infections of the meninges (coverings of the brain) that are slower, so called chronic meningitides. Tuberculosis or Cryptococcus infection of the meninges can cause this. These infections are treatable but must be diagnosed by spinal tap. Or perhaps this was a brain tumor, likely in the frontal lobe, the seat of personality and motivation. But the patient didn't have other symptoms of a brain tumor like headaches, changes in eye movements, vomiting, or seizures. Maybe it was an unusual type of seizure, but for two or more weeks? That seemed unlikely.
So it was probably a chronic meningitis. As he needed a spinal tap and treatment, I brought him back with me to the hospital. When we arrived, I discussed the case with my fellow physicians. They agreed with my differential diagnosis but added another possibility I had not considered—maladie de sommeil or sleeping sickness.

African sleeping sickness is caused by infection with a parasite, Trypanasoma brucei. Transmission to humans is by the bite of tsetse flies. There are both acute and chronic types, caused by different subspecies. In my patient's case, it was would be Trypanasoma brucei gamiense, found in Central and Western Africa.
For the first two years after the infecting bite, the symptoms are mild. Slowly, behavioral changes appear. People who used to be fastidious become careless about their appearance. Tempers flare unpredictably. Even delusions or hallucinations can develop. Patients begins sleeping more, eventually spending little time awake. Finally, they stop eating.
The diagnosis of central nervous system disease is made by finding the organisms or white blood cells (a sign of infection) in the spinal fluid. Therapy is a real challenge. Older medications that treated the infection were very toxic. Between 1 and 5 percent of patients died from the therapy. Fortunately, a new drug (éflornithine) doesn't have as many associated deaths, but is still toxic and difficult to administer.

My patient with the personality changes had a spinal tap. It was completely normal. This makes both sleeping sickness and chronic meningitis (like tuberculosis) much less likely. The next phase in diagnosis is a scan of the brain (to look for tumor or other changes) and an EEG (to see if this is a seizure variation). Neither of these tests is available here in Lubutu.
After a few days in the hospital, my patient was sent home without diagnosis or treatment. The car carried the two brothers back to Mungele. They walked home, one silently staring at nothing in particular.

Ghosts of Belgian Congo

Since my Congolese counterpart is on vacation for the rest of October, I'm travelling to Mungele each day. It is 1 ¼ hours each way, giving me plenty of time to finish about a novel per week. This week I have been devouring Isabelle Allende's The House of the Spirits. The book is quasi-magical realism. The dead cross timelines, appearing in the present and then disappearing forever.
When I travel to places that have changed dramatically, I wonder what their past was like. Who lived here? What did it look like? I try to imagine the ghosts of the past coming back to life.


Lubutu has several Belgian colonial buildings. I see them each day as I walk or am driven through town. The most elegant ones are the present mayor's office and the OCPT, directly across the street from one another at the main crossroads of town. I've imagined that OCPT stood for Office Congolaise de Poste et Télécommunications or, maybe, it was Office Centrale de Poste et Télégraphe. The ruined building has steps leading up to a central porch. At the top of the stairs are three tellers windows where the mail or telegrams were dropped off. To the left are a hundred or so rotten wooden post office boxes, most missing their doors. There is no cornerstone or date anywhere on the building. To me it appears to have been built in the 1920s or 1930s, as the steps are rounded in the Art Deco style.
There are dozens of old homes in the city, all falling apart. Standing in their front yards and obscuring the view are ugly wooden shacks, one abutting the next. These are pharmacies or shops. But step behind them and one gets a glimpse of what Lubutu must have been like under the Belgians. Big brick single story houses, with pitched metal roofs, each with a huge front porch. Inside there are big rooms with high ceilings. The large yards, now filled with weeds, must have once held vegetable and flower gardens.
At the northern end of town stands the cathedral, red brick and bearing a date of 1929. Clustered around it are the convent (now Couvent, where I live), the church school, and the houses which most likely once held caretakers and gardeners. Except for the church and convent, all is slowly tumbling down.

The present Democratic Republic of Congo was first colonized by Europeans in 1885. Actually it was only one European, Leopold II, King of the Belgians. In February of that year, the European powers carved up Central Africa and established colonies. France got what is now Congo-Brazzaville and the Central African Republic. Portugal got Angola. And Leopold II got the Congo Free State. The king personally owned the colony, not the country of Belgium. He used his personal bank account to finance the construction of infrastructure, building roads and putting in a communication system. All money derived from mining and the rubber plantations went directly into the king's pocket. Initially the Congo Free State was immensely profitable. Unfortunately, the King's greed grew, resulting in brutal mistreatment of the population in order to increase revenues. Newspaper articles in Europe detailed the abuses. Two books published in the early 1900s created further scandal- Joseph Conrad's Heart of Darkness and Mark Twain's King Leopold's Soliloquy. In addition, the price of rubber collapsed rendering the Congo Free State financially unviable. At first Leopold II offered to reform the colony, but this was rejected by the European powers and public opinion. For two years, no country was willing to take over the Free State. But in November 1908 the government of Belgium annexed the territory, renaming it the Belgian Congo.
Conditions improved under the Belgian government. An educational system was started, run by the church. Proper physical treatment of all workers was legally guaranteed. Still, a system of de facto segregation separated the races; the center of town was inhabited by whites while the native Congolese lived on the outskirts.
As with most colonies, Belgium eventually grew weary of government from a distance. In the late 1950s there were riots in Léopoldville (now Kinshasa) as the Congolese demanded self-rule. In June 1960, they got their chance and independence followed.

I love to walk through the center of town, mentally erasing the shacks that now obscure the past. I imagine what Lubutu might have been like under Belgian rule. Was this a place where the colonists desired to live? Or was it punishment to be posted here, banished to the uncivilized end of the world?
Stay tuned. Thomas, one of the expatriates, knows a local elderly gentleman with a good memory. We have been promised an architectural and historical walk through Lubutu some time in the next few weeks. I hope to soon discover more about this corner of the Belgian Congo.

Silence

We all know that women are treated differently than men in this world. As a man, this usually slips by me unnoticed. People treat me a certain way so I assume everyone is treated equally. This morning, however, the difference struck me especially hard.
In order to keep myself from getting too fat, I’ve been exercising. Once a week I swim at Lac Vert. The remainder of the time I’ve been running. Two or three days per week, my alarm rings at 5:45 a.m., just before sunrise. I pull on a t-shirt, running shorts, and shoes. By the time I stumble outside, it is light. The guardians at Couvent sleepily say “Bonjour”, open the gate, and I’m off.
I cross in front of the main church in town and turn left onto a narrow path. It winds through a neighborhood of square mud houses with leaf roofs and bamboo fences. I’ve taught the children on the route my name and that I am working with MSF; they scream these words to me, mixed with “bonjour”s and ask how I am feeling. I run by, wave, smile, and try not to trip on the uneven dirt path.

Finally, I emerge on the road leading to Kindu (photo). It is dirt and gravel, brick red, and very hilly.
On my way out, there are few people awake and I concentrate on running. It is hot and humid and feels like New Orleans on a summer’s morning. Some days the mist is so heavy that I stop to wipe my glasses several times and I return home with wet hair. Eventually I get to turn around and head home. By now, the people living on the route are awake and outside. When I first began running there were a few stares, but that’s now stopped. People appear to have grown accustomed to the early morning sighting of a sweating, panting American trying to avoid middle aged spread. The trip home is filled with smiling, waving, and saying “bonjour.”
Two weeks ago another American joined the ex-pat team in Lubutu. Terra is a family practice doctor and works in the hospital. She’s forty, fun, and fit. Terra has been joining me on my runs and I love her company. We talk about our lives while trying to avoid brakeless bicycles hurtling down the steep hills. Terra is a good looking woman and in great physical condition. When I began exercising with her, my run changed. At first I couldn’t pinpoint the origin of this difference, other than I had someone to talk to. Now, in retrospect, I realize I wasn’t hearing as many “bonjour”s.
I didn’t figure it out why until this morning. We had a new arrival to the team yesterday. Jana, a Norwegian anaesthetist, joined the team. Like Terra she is good looking and physically fit. This morning Jana joined us on our jog out Axe Kindu. On the way home I ran a few meters behind the two of them. Compared to my previous runs, all was quiet. The three of us hardly got any “bonjour”s, waves or smiles. Why? Everyone was silently staring. One woman running with me had provoked a few stares and closed a few mouths. But with two women the route was silent. Men, women, and children stared as we wound our way home.

This got me thinking about the different ways men and women are treated. In general we are lucky to be expatriates. As white men and women, we are seen first as Mzungus (white skinned) and second as men or women. Both white men and women are subject to a combination of respect, puzzlement, curiosity, and derision. But white women are treated differently than men. If I had run with two white men this morning I doubt we would have provoked the same silent stares.
Women have it worse. I walk down the street alone and people smile and say “bonjour.” A woman walking down the same street, navigating through the same crowd of friendly faces, often encounters stares and unwelcome advances.
When we got home from our run, Terra and I discussed this. She told me a story that reinforced the point. Two years ago she was working in a small town in Peru and went to eat at a local restaurant. She sat down and ordered. A few minutes later she realized the remaining clientele had stopped eating. They were staring at her, the lone female alien. They watched as if at a sporting event until she was served, quickly ate her meal, and left. Would I have provoked the same reaction?
Sure this is true in Peru, but such a thing would never happen in “civilized” America right? Right. Think about when a man is seen eating alone in a nice restaurant. Most people assume he is on a business trip. Now think about a woman of the same age, eating alone in the same restaurant. Is the first thing that comes to mind a business trip? Probably not. Questions arise. Why is she alone? Why couldn’t she get a date? Perhaps she even evokes pity.
Here in Lubutu, despite their strangeness, female foreigners are actually treated with greater respect than women in the general population. They’re foreign and special. They’re “not really women,” partially exempting from the notion of what is or is not appropriate. This makes me wonder what kind of inequalities a Congolese woman encounters. Undoubtedly, many more than silent stares along the road to Kindu.

Ess Ess Pay (SSP)

My work life has changed dramatically in the last week.
My department is SSP (Soins de Santé Primarie, or Primary Care), the first line of patient care. SSP works through the Centres de Santé, improving access to the hospital, and through sensibilization (health promotion and education).
The head of our department is Sophie. She is Swedish and stereotypically so. Ever been to Sweden? Everything in our office is clean, absolutely on time (here where very little is ever on time), and efficient (in a place where everything is inefficient). She is strict and demands excellence. Not a bad boss in my book. In real life, Sophie is an Intensive Care nurse. She departs a week from today. I'll be sad to see her go.
Working side by side with Sophie is Alphonsine. She is being groomed to eventually take over Sophie's position. Together they are responsible for all of the Centres de Santé in the Lubutu health district, the sixteen run by the government and the two run by MSF.
Except the two run by MSF are my turf.
Sophie and Alphonsine go out to all of the government-run Centres de Santé and offer advice to their Consultants. They encourage the government-run clinics to refer patients to the hospital in Lubutu. They are also in charge of a huge team of sensibilateurs (pronounced sahn-see-beel-ah-tour, they are health educators) who daily disperse across the four main roads leading out of Lubutu. Sophie and Alphonsine help choose the educational topics. Recently we had an outbreak of monkey pox caused by eating undercooked simians. Thus recent messages have included tips on cultural preparation of monkeys. The gamut of topics is wide- basic hygiene, need for immunization, or contraception and family planning. This work is very important here where the level of health knowledge in the general population is low.
Me, I am in charge of the two MSF-run Centres de Santé, Kalibatete and Mungele. Analogous to Sophie's relationship with Alphonsine, I have Joseph Nyembo, a Congolese person working side by side with me. Only Joseph and I don't work together; we work in parallel. If I'm at Kalibatete, he is at Mungele, and vice-versa. This arrangement has been disappointing for both of us. I can't train Joseph to do my job as we never work together. We have to have one of us in both places each day. It's a challenge. With my time remaining, our geographical separation must change. Neither MSF nor I will be here forever and Joseph needs to learn how to manage a Centre de Santé.
The first two months I was here, I worked exclusively to improve the quality of care being given by everyone at Mungele and Kalibatete—the Consultants, the midwife, the people doing bandages and suturing, the staff taking vital signs and registering people, the guardians and the cleaning ladies. I have talked to and worked with them all. In addition I learned some administrative tasks ranging from management of the pharmacy to gathering and calculating statistics. I learned how to beg other departments to mend roofs, make photocopies, supply us with soap, or a myriad of other tasks necessary to keep the doors open.
October has been a shocker. Joseph is on vacation for the entire month. Sophie departs in seven days. Since the first of the month my work has transformed from 95% clinical to 95% administrative. I'm hardly seeing patients anymore. As a change, I suppose I don't mind being an administrator. If I wasn't here who would be crazed enough to run his butt off travelling daily between Mungele and Kalibatete, writing lectures and other teaching lessons, and begging for cleaning supplies? I volunteered knowing I would do some administrative work, just not quite this much.
Joseph will be back on November 1st. Why does October have to have thirty-one days?

Lac Vert

Have you ever had a place that is very special to you, where you feel you could spend hours and hours and perhaps forever? I know it is silly, but a tiny little lake just outside Lubutu is becoming my weekly psychotherapy session.
The worst thing about having my elbow torn up is that I haven’t been able to go to Lac Vert. When you think of volunteering to do overseas medical work, the natural questions are about the nature of the work. What exactly will I be doing? What is the population like? What is the security situation? Another very important question is how you will be spending free time. Can you go running or take long walks?
When I arrived in Brussels for my briefings, I was delighted hearing that we could go running and take long hikes. They also mentioned that there was access to a small lake near to Lubutu. Each weekend, the group takes a car to Lac Vert for swimming, communing with nature, and just to get away from it all. When I ripped up my elbow, my inability to go swimming was my worst restriction. I couldn’t eat well (had to hold the fork with my left hand), had to shower with one hand (sounds easy but just try it), and would get severe twinges of pain. But the worst of it all was that until everything was healed I couldn’t join the group to go to the lake.

Today, after thirty-four days of healing, I returned.
The trip out from Lubutu is twenty minutes of highway. The vehicle turns onto a jungle track and the real ride begins. Forty minutes of being thrown around the vehicle, traversing the worst driveable path I have ever seen.

All the windows must be closed as the jungle is so thick that any open window shears off plants and their accompanying insects. The truck is an oven by the time we reach the lake, but it is all worth it.
The Green Lake is small and surrounded by dense jungle, just like everything else around here. The banks are lined with ferns. The only animals we see are birds. Two ducks live on the lake. They are small russet shaped birds, six inches in length, and unafraid.

During the three hours we spend in the water, they swim with us, coming a meter away. Occasionally a hornbill flies over. When these huge birds fly their beating wings sound like slowly turning helicopter blades. There is the sound of frogs and insects, but nothing else. No traffic, no people.
When we arrive, the first thing I do is get some exercise in, swimming back and forth across the lake. Having fulfilled my exercise quota, I dog paddle, side stroke, and elementary backstroke around the perimeter, trying to see if this week one of the ducks will let me touch it. After I get out, someone has always brought along a carefully hoarded snack, something delicious from Belgium or France to share.
Dried off, it’s back to Couvent, the hospital, Lubutu, and real life. It’s OK, though. I got to visit this little bit of heaven and will daydream about it until next Sunday.

In Denial

This whole Neurologist in The Tropics concept is rather new. Most people assume that all the Developing World needs is a good dose of primary care doctors. Two years ago when I taught in Malawi, several ex-pats wondered what my function would be. How do you use specialty care in this setting?

Vladimir, the ex-pat in charge of pediatrics here in Lubutu, asked me for a neurology consult. Two weeks ago, an eleven year old boy was admitted to the hospital with cerebral malaria. He was comatose for a few days and had several short seizures. All that was successfully treated. Unfortunately, he retained some weakness in the left arm and leg. The parasites that had infected his brain had caused a stroke.
He was now awake, alert, and normal except for his mild left sided weakness. His mother and the nurses were helping him to walk and care for himself. But something was odd. The boy did not understand that he needed assistance. If he wanted to get out of bed he would not call for help. He would swing both legs over the side, stand up, and fall trying to take his first step. So Vladimir called me.
When I examined him, the boy was awake, alert, and spoke good French. We talked for a bit and then I did a neurological examination. His left sided weakness was moderately severe. There was no way he could walk unassisted. I talked to him about his weakness and told him he would likely get better with time, possibly even back to normal. Rather than smile, cry, or thank me, he gave me a puzzled look. He denied he was weak at all.
Anosognosia. I had never before made this diagnosis in a child. It is a disorder I learned about while studying Adult Neurology. If there is damage to the right frontal and parietal lobes of the brain, the left side of the body is weakened. Interestingly, some patients are unaware that the left side of their body is abnormal. Others are not only unaware of their weakness but deny it. Show them their abnormal arm and they deny it is weak. Even wilder are the patients who recognize the weakened limbs are present, but deny that the abnormal arm and leg they see are their own. The patient recognizes the limbs are paralyzed, but state that they belong to someone else. That is anosognosia—unawareness or denial of paralysis. It is usually a left sided weakness caused by a stroke on the right side of the brain. In this case, it was from cerebral malaria.

So, are specialists needed in a developing country? Trying to answer this question is confusing me, leading me in circles. Yes, places like Congo need good primary care doctors, and lots of them. That is the standard model here. Open lots of small Centres de Santé scattered in all the tiny villages, all doing primary care. As a model to try to change the overall health of a population (mortality rates, burden of disease) this model doesn't work very well. The project in Lubutu is a reaction to this failure. Yes, in the area there are primary care Centres de Santé, but now there is a central Hôpital Générale de Réference (referral hospital) to accept sicker people as inpatients. As a public health model for lowering mortality rates, it has been very successful.
Two years ago, when I worked in Malawi, I was teaching at a super referral hospital, likely the best hospital in the country. I diagnosed and treated lots of children with neurological disease. Many of these kids had been undiagnosed or misdiagnosed. I know I impacted the lives of the children I cared for . Hopefully by teaching others to care for neurology patients, my impact was longer lasting. But did I make a meaningful dent in the public health of the population of Malawi? I doubt it.
In this context, should we be only working for the health of the population doing preventive care (like immunizations) and primary health care? Does caring for rarer problems matter?
I would love to say that this hospital in Lubutu doesn't need a full time neurologist. But they do. Walking around the hospital, I am positive the burden of neurological disease and neurological complications of other diseases would keep me busy full time. But would my presence impact the overall health of the population of just this tiny slice with neurological problems? If I improved the diagnosis and treatment of epilepsy or here, would I lower mortality rates? I doubt it. I would certainly improve the quality of life for the people with epilepsy, though. Available resources are important, too. There's not enough primary care doctors willing to volunteer or work here, let alone neurologists.
So what do the people of Lubutu need? As a primary care doctor here, I'm a necessity. As a neurologist, am I a luxury? Not if your child has cerebral malaria.

Shifting Forms

What is it about teaching that is so irresistible?
One of the reasons I was recruited to the Lubutu project is that I have experience with teaching medical professionals. When I lived in New Orleans, I taught pediatric residents from Tulane University. I found the experience rewarding but exhausting. The fatigue was primarily my fault, as I taught a one month course over and over. By the time I got good and burned out, I had taught the same two dozen lessons about sixty times. Not smart.
I took a few years off from teaching but was eventually ready to dive back in. In 2007 I taught a one month course in pediatric neurology at Queen Elizabeth Central Hospital in Blantyre, Malawi. I took my old Tulane lesson plans and changed them to fit the context. With the topic of Acute Flaccid Paralysis, I added a large section on polio, something not needed when I discussed the topic in New Orleans. Malawi was my introduction to tropical medicine. Photo below, Doug with residents in Malawi in 2007.

When I sent my resumé to MSF, I emphasized my teaching experiences. The recruiter told me that this was one reason I was placed in Lubutu. There is a log of formation going on here. Formation (fohr-mah-syohn, accent on the final syllable) can be loosely translated as "teaching" but involves much more. It means to mold or form someone into someone else by imparting knowledge.
The goal of many non-governmental organization projects is to teach local (in this case, Congolese) staff. In Lubutu we are teaching them the work necessary to run both primary care (the Centres de Santé) and referral health facilities (the hospital). We do this through a series of formations and working side by side. I have three main targets of my teaching- the Consultants, a mid-wife, and a supervisor-trainee.
The Consultants have attended a four year course in the diagnosis and treatment of disease. There are six of them- two at Mungele and four at Kalibatete.
When my ex-pat predecessor was here, only Mungele was open, so he concentrated all his efforts there. In general, the results have been good. The Mungele Consultants are both intelligent and can follow the MSF primary care protocols.
At Kalibatete, three of the four consultants are ex-hospital employees. They have worked for MSF for years. I enjoy spending time with the three of them. We share interesting cases and discuss treatment options. They have all the protocols memorized. The fourth consultant was recruited from outside the MSF system. She worked for many years in government-run Centres de Santé before getting the job with MSF in Lubutu.

When I arrived, Soki(photo:above) was challenging. Her book knowledge was excellent. When I asked her the signs of tuberculosis, she could recite all eight. But she was terribly disorganized. In English-speaking medicine, we write SOAP notes. This stands for Subjective (what the patient tells you, the history), Objective (the physical exam and any laboratory tests), Assessment (the differential diagnosis- what are the possibilities here?) and Plan (therapy, including prescriptions). One learns to write SOAP notes early in medical school. Soki never learned this organization. Her physical exam skills were excellent in some areas (abdomen, pelvic exam) and poor in others. Her biggest challenge was thinking about the history and physical examination together and coming up with possible diagnoses. Initially , diagnosis and treatment were reflexive. Patients who complained of pain in the upper abdomen immediately received a prescription for antacids. No further questions ("what makes it worse?") and no physical exam. Chief complaint led to prescription.
I have spent dozens of hours working with Soki and she has dramatically improved. Patients now get a complete history and physical examination. She can follow the protocols we use in the Centres de Santé—everything from a cold to measles to whopping cough. She knows when she is beyond her limits of knowledge and needs help some someone with more experience.

Aside from the six Consultants, I also teach Kenimbe, the mid-wife at Mungele(photo). My predecessor in this position made sure that Kenimbe received lots of instruction in the MSF systems of prenatal and postnatal care as well as childbirth. Kenimbe is thrilled to have an ambulance to summon in case of a difficult delivery. Most of my formation with Kenimbe has been on family planning and care of pregnant women.
Of all the formations with which I am charged that of my assistant, the supervisor-trainee, has been the least successful. Part of this is structural. There are two Centres de Santé for the two of us to supervise. We are rarely in the same physical space. Joseph is being groomed to take my position when I leave. We have a lot of work to do.
Today, a new phase of my formation of the staff began. Every other week I am doing formal presentations on a selected clinical topic. This week schistosomiasis, next is family planning, after that typhoid fever. Preparing the lectures is a huge amount of work. I have to make a PowerPoint presentation (printed out as there is no electricity at the Centres de Santé), handouts, and a pre-test and post-test. Three weeks ago I sent all of this off to Kinshasa for approval, received their suggestions two days ago(!), and did the first presentation today. It went great. As usual, part was through I ran into a verbal wall. I did not know the verb "to hatch." We had a momentary diversion while I described chicks leaving eggs. I was rewarded with "éclore", the answer to my word search.
The educational level of my audience was a change for me. In the past I have usually taught physicians. The original PowerPoint presentation I created was inappropriately technical. Fortunately, the people in Kinshasa reformatted my slides. They added graphics and eliminated some complex wording. All the participants succeeded, with scores on the post-test perfect or nearly so. Afterwards we had a long discussion about schistosomiasis and public health, out of the boundaries of the lecture. They learned and then thought about the implications of this new information for their patients.
So why do I think that teaching is wonderful? Personally I love the moment when a student has an imaginary light bulb illuminated above their head. They've had information crammed into their brain. At an AH HA! moment it all comes together. They can think.

Worst. Day. Ever.

Ever have a day that just sucks?
It started before dawn. Last night was sleepless. Was it the handful of milk chocolate covered espresso beans I ate at 7 p.m.? Or that it is 80 humid degrees at night and for the last two weeks I have not stopped sweating? Or possibly the conversation outside my window at 11 p.m. extolling the virtues of a particular brand of dried Belgian sausage? I have to be at work at 7 a.m.. Since the world was conspiring against me and sleep was clearly not going to happen naturally, I did what any sane person would have and took a pill. Benadryl twenty-five milligrams. Just a mild sleep inducer. No big deal.
It worked. I slept well but when Couvent's workers began noisily cleaning the dining room at quarter till six in the morning, I was not happy. With a Benadryl hangover—mouth like Arizona and vision unable to focus—I stumbled into the bathroom, washed my face with cold water and dressed. I poured a cup of coffee and again wondered why. We are not far from Rwanda, where some of the best coffee beans in the world are grown. Why must I drink bitter lousy coffee to rouse myself from this hangover? I would happily trade the four kilograms of Belgian chocolate in the refrigerator right now for one Starbucks latte.
That settled, it was off for my 3 minute 24 second commute to the hospital. The day loomed especially loathsome. It was evaluation day at Mungele. I have no problem with evaluating people, but the MSF forms are extremely long and involved. I was still only fuzzily awake and couldn't yet focus on the written word. Though important, the process is painful for everyone. The person being evaluated fills out a section about their job, usually copied verbatim from their Profil de Poste. This very detailed document describes work duties and responsibilities, for each position in the organization. Employees are expected to comply with each word of their Profil. After I read aloud what the employee has written about their job duties, we get into the nitty-gritty. This is a discussion of several aspects of the job, like Autonomy and Accepting Responsibility. As an evaluator, I chat with the employee, come up with a quasi-mutually agreeable grade, and write everything down. It is a thorough evaluation and each one takes at least an hour. Since I had six evaluations, I had six straight hours of going over the same forms glowing in the distance. And my vision was so blurry I couldn't read anything.
But I'm way ahead of myself.
Almost exactly three and a half minutes after leaving Couvent, I arrived at the hospital to find I had no transportation to Mungele. The logistics/ transportation people know the SSP (Soins de Santé Primaire—Primary Care) team needs a car for Mungele each day. Once every two weeks, for some reason it does not happen. A 7 a.m. departure time sometimes happens much later, once a vehicle is found. I have learned that the best way to resolve this problem is to walk into the Radio/Transportation Room and demand that they do their job so that I can do my job. It wasn't actually as bad as usual, and we were off by 7:25 for the standard trip to Mungele. I still wave at kids and look at the incredibly green jungle, but mostly I use this time to read. As the Benadryl was lingering and my vision was still nuts, I held The Devil Wears Prada six inches from my nose, laughing like a maniac as the driver took me safely to EvaluationLand.
Mungele! Finally it could begin. But first I needed to get out of the truck and rip open my right elbow. You remember my right elbow? The one with the 5 inch gash from last month? The one that had twelve stitches, a surgical drain, and eighteen dressing changes? The one that finally healed two days ago?
I suppose the newly grown skin was thin and fragile. I bumped it or scraped it and off it came. Blood dripping down my arm I walked into the clinic for a wound dressing. I sat down and felt like crying. Only last night I was talking to someone about how much I was looking forward to returning to swimming at Lac Vert this weekend. For the last four Sundays I have patiently waved to the group as they depart to this little piece of heaven. Finally my elbow had healed and I could join the group on Sunday! Only now I couldn't because there was no skin left and it was bleeding like crazy.
Bandaged up, I plowed through the evaluations and survived. The exploits of Miranda Priestly entertained me on the drive back to Lubutu. I felt like I could be that mean today, no problem.
One unmemorable lunch later, I walked to the hospital to start the task of typing the evaluations into the computer. At 32 minutes each, it only took a little over three hours. Finally at 6 p.m. I turned the computer off and headed for home. On my way out, I was told that next week I get to do evaluations at Kalibatete, where there are twice as many employees. Yippee.
Dinner, beer, chocolate- my Holy Trinity tonight. I lay in bed writing and am listening to the humongous anvil-headed fruit bats make incredibly loud mating cries. You know the lovely relaxing sound of frogs? I'm hearing that, too. Just add a second layer or deeper, louder, and longer fruit bats into the mix. In Lubutu, nature is really loud.
I suppose one has to have days like this to appreciate the good things in life. Honestly, I can deal with the lousy coffee, begging for transportation, evaluating people, and the Benadryl-hangover lack of vision. But my elbow? I have to go through a day like this and then get to feel my elbow seep bodily fluids into the sheets all night? It's looking that way, Tonto.

Poliomyelitis

Photo: boy with "fish trap"

The ride from Lubutu to Mungele is through a series of small villages. Each is separated from its neighbor by 5 to 10 kilometers of dense jungle. As we leave the outskirts of Lubutu, we pass an area where several people are using one crutch to walk. One leg is small and positioned at an odd angle, unsuitable for weight bearing. For the next thirty minutes, there are no more one crutch walkers. Then a big clump of adults, adolescents, and children, using hand hewn wooden crutches appears. After a few kilometres of jungle is another village where people are again walking normally. What is this?

Poliomyelitis is caused by a virus, transmitted by the fecal-oral route. It is primarily a disease of children. Patients first develop a common cold- like illness (fever, headache, sore throat, drowsiness). In 2% of those infected the second, meningitic phase follows. Slightly over half of the children with meningitis go on to develop paralytic disease. This acute flaccid paralysis is usually in one leg.
When I was in medical training, I was told that soon polio would be only a medical memory, wiped out by vaccination. That did not happen. Polio is still endemic here in Congo, meaning that there is some disease almost every year. I have seen both young children and adults on one crutch and one normal leg. The paralyzed limb is smaller, as the nerves from the spinal cord leading to the limb have been killed by the infecting virus. Without nerve stimulation, the leg doesn't actually shrink, it simply doesn't grow normally.
There are two types of poliovirus vaccine. When I was training, OPV (oral poliovirus vaccine) was used. Children received a drop of pink liquid to swallow, containing millions of attenuated (weakened, but not killed) infecting virus particles. The weakened virus infected the child but produced no symptoms. The big advantage of oral vaccination was herd immunity. The vaccinated child excreted weakened poliovirus in their stool. Since children's fingers go everywhere, the vaccinated kids transmitted the weakened virus to everyone around them. The people in the surrounding area (the herd) become immunized secondary to contact with the child receiving the vaccination.
Attenuated live virus vaccine and its herd immunity was great. Unfortunately, even with weakened virus, some people got paralytic polio from the vaccine itself. Eventually, almost all cases of paralytic polio in the United States were due to vaccine. So a switch occurred. Now children in the US are immunized with an injected, killed polio vaccine. They cannot get disease from killed virus, but there is no herd immunity. Only the person receiving the injection is protected.
In Congo, children receive the oral vaccine, because here herd immunity remains important. I have been shocked at the low vaccination rates in the population we are serving. At birth children are issued a health record card. On the front is identifying information, in the middle a growth chart, and on the back is the vaccination schedule. Since my arrival, we have started dong weekly vaccination clinics at both Centres de Santé. Children in Congo are scheduled to receive oral poliovirus vaccine at birth, 6 weeks, 10 weeks, and 14 weeks. I am still searching to find a child who has a record of receiving all four doses. Without this vaccine, children get polio.

Photo: Boys on a pirogue, local way of crossing river
Why aren't people bringing their kids in for free vaccine? I did an unscientific survey by talking to my Congolese co-workers. They all listed parental ignorance of the necessity of vaccination as the most important factor. Parents in smaller villages may actively flee organized vaccine campaigns, fearing any kind or authority, governmental or otherwise. Years of war does that to people.
It's hard to know what is saddest about medical care here. Is it lack of resources that we have in the West? Or is it seeing people with conditions treatable in the West that must simply be tolerated because we are in Lubutu? My vote is for a disease like polio- a completely preventable condition with lifelong consequences.