Shocks

Photos: Doug with MSF vehicles; Little girl carrying a seat on her head

26 August 2009

Shocks

Couvent has a steady stream of visitors, people staying between 3 days and 2 weeks. They come from Kinshasa or Brussels, look around a bit, write a lot of reports, and enjoy the quiet of Lubutu. Morgan (pronounced mohr-gahn, with the accent on the first syllable) just left today after a 2 week visit. She's an electricity expert.
There's no electricity here except what is supplied by generators. The hospital has power 24 hours per day, of course, and Couvent gets electricity from 6 a.m. until 10 p.m. daily. Our electrical problems have two main origins: the generators themselves and the orages (pronounced "oh-raj") that come through.
Generators don't supply consistent current, at least these generators don't. The lights dim pretty frequently. Less often, the whole thing turns off if there are too many lights on or we have the microwave and toaster oven and everyone's computer running at the same time. There are kick-your-butt electrical storms (the orages) that come through two or three times per week. The lightning, thunder, and rain are intense, which can't do great things for the electrical system.
The brownouts and power surges wreak havoc on things. Two weeks before I got here, the television at Couvent was destroyed during a storm. The week I arrived one of our two refrigerators died after a lightning strike. In Lubutu, you can't go out and buy a new TV or refrigerator. You fill out a requisition and get it signed by several people. Then you send it to Kisangani. If the stuff isn't at Kisangani, your request goes onto Kinshasa. No luck there and it's forwarded onto Brussels. If they don't have it in the warehouse, someone goes shopping. You can imagine why we haven't received the new refrigerator.
This is a source for of anxiety as the remaining fridge doesn't work well, either, being just one more lightning strike away from oblivion. But since we lack all electricity from 10 p.m. until 6 a.m., nothing is particularly cold in the dying refrigerator anyway.
So what do you do when your major appliances keep exploding? You call in an electricity expert. That's Morgan. She has no formal training in engineering and isn't an electrician. She started working for MSF a few years ago, expressed an interest in this electricity stuff, and is now Ms. Electricity Fixit for MSF-Belgium.
Her Lubutu discoveries were amazing. It seems that when the hospital and Couvent were wired, no one took the orages into account. No one thought about a master fuse or lightning rods. This master fuse was described to me as a surge protector for complex electrical systems. When lightning strikes any part of the system, the surge protector trips. These things cost about 100 euro each. Morgan thought that MSF would need two, one for Couvent and one for the hospital. Lots cheaper than shipping a refrigerator from Brussels every few months.
Morgan has a special place in my heart because she proved that my French is improving. When she arrived two weeks ago, I couldn't understand a word she said. She is from France, doesn't enunciate well, speaks crazy-fast, and doesn't pause between sentences. At first it was not clear to me she was even speaking French! But something happened during her two week visit. Either she slowed down or my brain speeded up. I still only understand 50-75%, depending on ambient noise, her caffeine intake, and my fatigue. But that's a shocking improvement from two weeks ago.
Thanks, Morgan, for figuring out why our refrigerators keep exploding. And thanks for the boost in my confidence in speaking your language.

Those Crazy Relations(hips)

25 August 2009
Those Crazy Relations(hips)
At first the changes in the names and faces at the dinner table were hardly perceptible. An ex-pat would leave for a few days on vacation but they'd be back after a week. Last night something new happened and it was a big shock. It got me thinking about relationships.
Since my arrival in Lubutu, we've had a couple of long term workers join the group. No biggie. They folded right in. But last night something different occurred. Someone new arrived and the group dynamic changed instantly and dramatically. Earlier in 2009, Chang (our new anaesthesiologist) had been working with MSF here in Lubutu for a few months. After his assignment was over, he left for several weeks. He liked it so much he decided to apply for another assignment and is now back. Great! A new face and someone new to talk to!
Weirdly, the moment Chang arrived, I started to hear a lot of English. Sophie, my boss and co-worker, tells me his French is pretty lousy. As he is an anaesthesiologist, he doesn't do a lot of talking to patients anyway. So now there are four (and maybe five) of us who prefer speaking English. Before Chang arrived, the rest of us just limped along in French. But now there's no need as our little group can actually have real conversations, rather than just speaking in weird sentence fragments and gestures. To me, this is good and bad, as one reason for doing MSF in Congo was to improve my French, right?
Chang is also gregarious and that changed the group dynamic, too. He's returning to a place and people he knew previously and he's doing it by choice. Although not from the US, he's very "American"- kind of loud, instantly friendly, and you like him. Before his arrival, our group was a pretty sedate lot, but not any more! He's also a career MSFer (like the majority of the people here) so he knows how this world works. Unlike me, he wasn't initially awkward or ill at ease.
This started me thinking about the interpersonal relationships in this world of humanitarian work. By definition friendships here are temporary. The ex-pats are all transient, usually staying in one assignment for six to twelve months. The career MSF people (those who do assignments back to back for years) all list their ability to travel as one reason to do long term humanitarian work. They don't get bored as their job changes with each change in geography. On one mission they may be in charge of setting up an HIV program; On the next they're working in general medicine in a refugee camp. The people who do this long-term make friends easily, love being part of a group, and enjoy the challenges of their changing work. But don't they miss those life-long friends we all tend to make in our twenties and thirties? Or do they make them and just keep in touch by email and text messages?
Hardly anyone does this for their entire medical career. Most of the ex-pat staff are younger than me, mid-20s to mid-30s. They finished school and went directly into the MSF world. Martine, my Belgian surgeon buddy, and I are the only ex-pats older then 40. Sophie (my Swedish boss) and I are the only two in the group who are married. Perhaps that's why hardly anyone can do this forever. You get ready for a long-term relationship (either friendship or romantic) and this ever changing remote field work isn't compatible. I think most couples can live apart temporarily, but after too long the relationship will likely suffer.
To me, making friends with people for a few months and probably never seeing them again is a difficult proposition. But perhaps that's because I'm at a different life stage.
Some of the older career field humanitarian workers have relationships earlier in life, turn 40ish, have their midlife crisis, get divorced or whatever, and off they go to Congo or Cambodia for a few years. These people are rarer out here in the field. I've met two since arrival, in contrast with the dozens of younger people.
Personally, neither scenario fits. I worked in the world for several years before starting this 6 month mission with MSF. I don't think I'm having a mid-life crisis. I was just curious about this world of humanitarian work and thought I'd try it out. Maybe I'll continue and maybe I won't. But if I don't, the deal breaker is the relationships in my life, which mean more to me than any work.

Luxuries?

23 August 2009

As you have probably guessed, there are a great deal of differences between medical care here in Congo and the US. At first glance, it's the technology differences that strike you, but then you start to think, which is becoming increasingly difficult to do.
In Lubutu, we don't have much in the way of laboratory testing. We can get a blood count, blood smear for parasites, and dipstick for urinalysis. There is no microbiology here, which is striking. In this place full of weird bacteria and invasive parasites, there is no way to culture blood or urine or spinal fluid to definitively diagnose an infecting organism. As we can't culture anything, we can't test the sensitivity of bacteria against different antibiotics. Instead, we use protocols.
If someone has pneumonia, they get an antibiotic that kills the most common organisms causing pneumonia in Congo. If they get better, great. If not, the protocol says to give 10 days of a different antibiotic. If that doesn't work we are to search for tuberculosis using chest x ray and a sputum smear. But if we get to this point and they don't have TB, there is nowhere to go, diagnostically or therapeutically. There is no way to culture the sputum to try to figure out if your patient has something treatable (and you've just been giving the wrong antibiotic) or untreatable. Without technology, the protocol stops. There are no further suggested diagnostic tests or treatment. The patient just keeps coughing.
This came to mind last week at Mungele. A 30 year old man came in two weeks ago with a bad middle ear infection. Per the protocol, we gave him amoxicillin. When he didn't get any better, we began daily injections of different antibiotic to try to clear the pus behind his eardrum. It didn't work. So what next? Unfortunately, nothing. In the US, I would have stuck a needle into the pus, sucked it out, and sent it off to the microbiology lab. The lab would culture it and send me a report identifying the organism. That report would also tell me which antibiotic to use to cure my patient. But here I had to tell this man that unfortunately I had done all I could for him. That's difficult when you know that if this person were in the US, you could easily help him.
Another big difference between medical systems is the lack of focus on chronic disease in the developing world. In the US, as a pediatric neurologist, I deal with chronic disease daily. Half of my patients have epilepsy, a condition that persists for years. Here chronic disease is often not treated.
Last week I saw an adolescent with muscular dystrophy. He was in the hospital for pneumonia, which was being treated. The hospital medical staff asked me to talk to the patient and his family about prognosis and the genetics of the condition. So we had a long chat in Swahili and French. But then I thought….why isn't this poor boy getting physical therapy and chest percussion, to keep him mobile and free of illness as long as possible?
Most cases like this don't affect me (except emotionally) on a daily basis. Working in the Centres de Santé I am in the front line of primary care. People usually come to see us when they are acutely ill. Still there are issues that come up, like the chronic aches and pains we aren't treating.
People here do a lot of hard physical labor. If they have a heavy load, it is carried on the back. A strap is tied around the load and this is looped around the forehead. So guess what at least half the population lists as one of their medical complaints? Yep- headache and back pain. In the West, similar complaints get oral pain relievers, local therapies (heat or cold), massage, or even physical therapy. Here we tell people they need to rest. I'm fine with that, but when they come back after a couple of weeks rest and their knees are still stiff and achy, then what? Well then…..nothing. We don't hand out a month's supply of ibuprofen or give them physical therapy. We shrug our shoulders and say we're sorry and that there's nothing we can do.
Or perhaps in this place where most people die of malaria, pneumonia, or diarrhea, treatment of chronic conditions is a luxury that few people can access or afford. I hear health care spoken of as a basic human right, but is it only health care for acute conditions that it is basic human right, or all conditions?

Mind the Gap!

21 August 2009

Culturally, Lubutu is superficially easy to figure out. Look a little deeper, though, and the challenge begins.
As I've written before, the Congolese people are extremely polite. When passing on the street, strangers frequently greet each other with "Jambo" or "Bonjour." Toward me it is even more noticeable. Anywhere I go I am treated like a celebrity. The vast majority of people greet me verbally, smile, wave, or do all three. Kids run out of their houses to stare and their parents hold them up to wave. When I go running, all this happens at high speed. I get groups of kids running with me for short intervals, then falling behind with a laugh. Men stand on the roadside, wave, smile, and yell "courage!" But then the word "mzungu" appears. It's the Swahili way to express "white skinned" and I don't like it.
For the most part, the word is confined to small children. But when the little ones run and point and scream "mzungu!", their parents laugh and encourage them. No, I don't think that children here in Congo are innately racist, but I do think their parent's attitude makes them see race before any other character in a person.
For me this is difficult to understand. My country has a long history of racism. When children cry "mzungu!", my mind flashes to the treatment of African-Americans in the US in the 1960s, with racial epithets being used as succinct descriptors. For example, in those times a physician who was married with children and a prominent community member, but who was also African-American would likely be succinctly referred to as "that black doctor" or something even less politically correct. Today, most Americans would describe this same person perhaps by profession, marital status, where they live, etc. If race is mentioned at all (and in my world, it usually isn't), it's at the end of the story, as an afterthought. Like most Americans of my age or older, I've worked to overcome the tendency to classify people primarily by race.
So why do people here find it funny and cute when their kids point at me and scream "whitey!"?
I asked the national (Congolese) MSF staff. They couldn't answer because I don't think they understood the question. To them, calling someone "mzungu" is not impolite. It is just a descriptor of a person; of course children will say it.
I asked the ex-pat MSF staff their opinions. Like me, most of them were very unsettled by the word after they arrived. After awhile, though, "you'll get used to it." One person told me a story of a lighter skinned West African who came to Congo to work and was called "mzungu" like the rest of the caucasians.
I know these children mean no insult, but I cannot help but make the mental leap to racist America of the 1960s. I'm trying to overcome this cultural gap, but am having some difficulty with this one. Hopefully time will heal.

Commuting

18 August 2009

Some of the other ex-pats here have said they envy my freedom. They rarely have the opportunity to venture farther than the short distance between Couvent and the hospital. I get to walk to Kalibatete or be driven to Mungele every day.
I love the commute to Kalibatete. It's 15 minutes on foot and I say "Bonjour" at least 100 times each time I make the trip. At first, the Congolese staff were puzzled as to why I would want to walk. They see Lubutu every day and to them it's not interesting. I think it's full or new, fun things to discover.
On my way home tonight, I walked out the dirt lane connecting the Centre de Santé with the main road. There were two games taking place, one on either side of my path. To the right; kids were playing the Congolese version of kickball. On the left, smaller children chased a duckling, screaming as the animal stayed just out of reach.
As usual, the moment I appeared, everything stopped. Everyone stared, some kids smiled; and most of them waved. Smaller children sometimes scream "Mzungu" (literally "white skinned") while older kids love to say "Bonjour" and hear me repeat it back. As quickly as I had stopped all the fun; it restarted once I had passed.
I turned right on the main paved road and walked downhill towards the bridge, currently under construction. There's a few businesses on this side of town, but the main attraction are the mosque, a couple of churches, and the MSF clinic.
The best part of the walk is watching the people. The Congolese are well dressed and unfailingly polite. Women wear beautiful dresses made of yards of cotton printed fabric, all strikingly patterned. Men hold things in their hands, but women usually carry objects on their heads. No matter how many times I see it, I am amazed at their balance carrying heavy loads on uneven pathways. They glide rather than walk.
A new bridge is being built over the waterway that the roadway is crossing. Despite the physical presence of a backhoe, I think it's all being done by hand--digging, mixing cement, and the rest. There are always lots of men working no matter what time I walk past. Today I saw an ex-pat working with them. He was busy and didn't seem particularly interested in chatting, so I just kept going.
Walking uphill from the river, I got to the main commercial part of town. The stores here include lots of poorly-stocked pharmacies, shacks selling mobile phone credits, and a couple of stores to pick up the odd bar of abrasive, wildly colored soap. Finally I arrived at the main square of town. There is a pole in the center, with a faded and slightly tattered Congolese flag flying. Every day at 7 a.m. and 6 p.m. the flag goes up or down. An official walks out to the pole, blows a whistle, and the world stops. Everyone on foot, people on bikes and motorcycles, and every single car (in the cities)—they all stop. On my way home today I hit it exactly right. I got to watch the man whistle, salute the flag, lower it, and whistle again. Only then could I continue.
After Main Square, I hit the market. Lubutu's market is divided like most into food and non-food sections. The foods available are surprisingly limited. Today I saw dried fish, spinach, avocados, red caterpillars the size of a finger (served deep fried), raw rock salt, beautiful multicoloured beans, onions, garlic, cherry tomatoes, and an occasional papaya. As there are no grocery stores here, how do people get variety in their diet? Does everyone just grow food at home? Perhaps it's just seasonal.
The non-food section of the market is equally limited. Somehow a pipeline has been created between poorly made goods from throughout the world and the Lubutu market. There are garishly colored flip-flops for sale in almost every stand; I've heard they usually break within a week. "BIC" pens work for one or two days before drying up. But the market is also where women come to buy the fabric for their dresses. These stands are eye-popping with crazy juxtapositions of color and pattern.
Once past the market, there is a branch of red earth road to the hospital and Couvent. I like to continue straight ahead, even though it's a bit farther to home. Tonight I took the long way again and passed the only multi-story building in town, the cathedral. Since I'm living in the ex-convent for the nuns, I feel a special affinity.
As an extra special treat today, a 9 year old boy walked with me from the cathedral to my front door. He sang as we walked, the same tune over and over.
Tonight there was another lovely sunset. As I pushed open the front gate; I marvelled at my luck in being here.

16 August 2009

Gifts

Something wonderful happened today.
Today was the first day I did Mungele alone. It is the more rural of the two Centres de Santé where I am working. Though an hour away by car, the commute is beautiful.
This part of Maniema province is hilly. The entire way, the road is lined with thick jungle. Every ten minutes or so a small village appears. People wave or shout (nicely!) along the way and we often have to slow down for goats or pigs or chickens in the road.
This morning we arrived to the waves and "Bonjour!"s of the staff. As usual, there was a patient waiting for me to see in the small observation room. The night before, this man had been up in the treetops hunting monkeys. He had fallen 25 feet and was unhurt except for the ¼ inch diameter stick that entered the bottom of his foot and exited the top. He had tried to pull the stick out, but unfortunately it had broken. Not good for him but easy for me; he got antibiotics and a ride back to the hospital with me.
I saw patients with the Consultants for the remainder of the morning, and a bit later a 1 year old came in with fever, cough, and breathing fast. He looked very ill so he got antibiotics and a ride back to the hospital with me, too. At this point I felt good that I was managing this place and its staff alone.
Then the cool thing happened.
The Chief of the largest clan in Mungele came for a call. We shook hands and sat down for a chat. Using an interpreter, he thanks MSF and me for coming to his village. He said that the community felt our presence every day. They no longer had to worry about access to good medical care. But he wondered why MSF hadn't started construction on the permanent Centre de Santé. We'd been open for 3 months and were still in temporary mud buildings. Smart Chief. He knew that until the permanent building went up, MSF could leave as fast as they had appeared.
And then he gave me the eggs. As a gift to welcome me, he handed me four chicken eggs, wrapped in a piece of cellophane, and tied with a string.
I felt very special today. On the ride back to Lubutu I waved to every person we passed. I arrived at Couvent and I told everyone my story. They agreed this whole Lubutu experience was very "chouette", very cool. Yes the people here are lucky to have MSF, but we're lucky, too.

15 August 2009

Heartbreaks

Plumpy Nut. I never thought fortified peanut butter could bother me so much.
Last week I wrote about the malnutrition clinic (called CNTA) at Mungele. There are basically two levels of malnutrition care here: inpatient (called CNT for "Centre Nutritionelle Therapeutique") and outpatient (CNTA- the same but with "Ambulatoire" at the end). In order to get cared for as an inpatient (the CNT in the central hospital in Lubutu) a child must have Moderate or Severe malnutrition and have some other symptom or medical complication: anorexia, severe anemia, severe infection, of just look apathetic and exhausted.
The criteria for the CNTA, however, are different. Kids have to be Severely malnourished but free of those other medical issues. They are basically starving to death but not really "sick".
To get some perspective on this, even if a child is only Moderately malnourished, they look very skinny. Their arms are tiny and their ribs are easily visible. They do not look healthy.
Unfortunately, if you are "well" but only Moderately Malnourished, you don't qualify for CNTA. The Consultants and I take your history, examine you, and probably end up giving you some vitamins and some albendazole for intestinal parasites. We sit down with your parent and tell them that they should try to feed you more.
Why aren't we treating everyone with malnutrition (mild, moderate, severe) to the full extent possible? Apparently, for the general population here, obtaining food is not such a big challenge. Things grow easily. The jungle is apparently full of stuff to eat (both animal and vegetable), and there is no drought or war or anything else in the way of people getting food. Studies have been done in this geographical area that demonstrate only one planting/harvesting season per calendar year. This is amazing to me as plants here appear to visibly grow by the minute.
In other MSF projects where people are hindered from finding food by famine or war, access to food is obviously harder. In these other places, even Moderately malnourished "well" children qualify for the CNTA with free food supplements, a mosquito net, and a cocktail of medicines to help them get fatter.
The other confounding factor in the equation is that apparently mortality rates are not much higher for Moderately malnourished children than for normal kids. Since MSF resources are limited and the average person here isn't really prevented from obtaining food, it is harder to get help for your moderately Malnourished kid in Lubutu than it might be elsewhere in Africa, even within MSF. If it is true that Moderately malnourished children are not more likely to die than normally fed children, perhaps resources should be concentrated only on curing Severely Malnourished children (who do have a higher mortality) and encourage programs (non-MSF) that help people find food. Like how about two or three plantings/harvestings per year instead of just one?
Today we saw the CNTA patients back after their first week enrolled in the program. One kid stayed the same, but the rest of them gained weight. A lot of weight. Plumpy Nut is 500 calories per package. Since the children get 2 or 3 packages per day, they quickly pack on the pounds. After only one week they looked chunkier and healthier. But we still have to turn those Moderately malnourished kids away hoping they would gain some weight in the next month. Perhaps some kids will have miraculously improved. But without good education about agricultural practices in place, I worry that we might not be doing the right thing by asking these Moderately malnourished kids to wait.
I was initially outraged that we aren't handing out free food to every child here, no matter what their level or malnutrition. Researching this topic, I learned about limited resources and wellness education for communities. I know I'm being idealistic and unrealistic and simplistic. I understand all of this, but I'm here and it is breaking my heart to not give every malnourished kid a big handful of Plumpy Nut.
　
　
　

13 August 2009
　
Language Hell
Silly me. I thought I would be speaking and hearing French all day. After all, isn't French the official language of central and western Africa? Nope.
When I wake up in the morning in the convent, I speak French with the other ex-pats and the Congolese staff. I walk 200 yards to the hospital, pass about 40 people, and say "Bonjour" to every one. I walk into the hospital and am greeted over and over with "Bonjour, Dooglas!" (not a misprint) or "Bonjour, Doctor!" When I get to the office, my ex-pat co-worker and I speak French to each other, even though Sophie is from Sweden. Then we drive or walk to the Centres de Santé and Language Hell breaks out.
The patients only speak Swahili! So the Consultants take a history in Swahili, and we talk about it in French. We do the physical exam in Swahili and discuss it in French. After we arrive at a diagnosis in French, the Consultant explains to the patient in Swahili. The medical records and prescriptions are written in French and explained in Swahili.
If all this wasn't enough, some of the Consultants speak with such a strong accent that I strain to understand them. This is actually the hardest part of my language day.
After the daytime language nuttiness, I return home to Couvent and speak French to French people. Except they aren't really French. They're Belgian. Amazingly, I can now easily detect the difference in accents.
Couvent is actually home to an international staff. Other than the Belgian Horde, there are two Germans, a Swede, a Finn, a Lebanese, a Mauritanean, a Gabonese, a Sierra Leonean, and me, Mr. America. Crazier are our visitors. Last week had someone from Italy staying with us. Heavily Italian-accented French is both hilarious and nearly impossible for me to understand.
All in all, the language issue is not as bad as I had feared. The scary part is I believe my French is getting worse with time. The Congolese staff are too polite to ever correct me; they nod wisely as I utter nonsense. The ex-pats appear to understand when I'm saying and never correct me. If I had to guess, I would say I am getting less conversant in French the more I speak it. Perhaps if I stay mute for 6 months I'll be fluent when I return home.

12 August 2009

Weird Stuff
Clinically, this place is a tropical medicine gold mine.
In the last two days I have been working pretty intensively with the Consultants. When you are faced with a dearth of diagnostic tools (no lab tests other than a rapid test for malaria), you develop really great physical exam skills and you work with protocols. MSF is crazy about protocols and the organization is determined that everyone follow them exactly.
What's a protocol? Basically, it is an algorithm or flow-chart (boxes and arrows) that is used to diagnose and treat someone with a specific complaint. These protocols have been designed for lots of very common complaints here: pneumonia (first you try one antibiotic, then another, then you get a diagnostic test for tuberculosis); sexually transmitted diseases (broken down by sex of patient and their chief complaint into separate algorithms for: women with vaginal discharge, men with urethral discharge, genital ulcers, swelling of the lymph nodes in the genital region, or lower abdominal pain in a sexually active woman); malaria treatment (child versus adult, pregnant woman, patient appears relatively well versus patient appears gravely ill). Honestly, it takes a bit of the fun out of medicine but make treating common compaints a lot easier.
Of course, lots of patients fall out of the algorithms because they come in with Weird Stuff.
I saw a 10 year old boy today with a chief complaint of restriction of spinal movement that had been gradually getting worse for the last year. It wasn't painful but he was now at the point where he could not bend over at the waist at all. There was a bony hump slightly to the side of one of the normal spinous processes in the middle of his back. What was this? I hadn't a clue, but one of my experienced consultants let me know it was almost certainly "Maladie de Pott" (Pott's Disease) or tuberculosis of the spine.
A six year old girl came in with a 3 day history of painful edema of both legs along with swelling of the lymph nodes in the groin. She had no fever nor any other signs of illness. What was this? This time it was my turn to shine as I had seen a similar case a couple of years ago. It was likely lymphatic filariasis, a parasitic disease transmitted by mosquito bites. It is diagnosed by doing a blood smear to look for the organism, but you must draw the patient's blood between 10 p.m. and 2 a.m., when the worms are making their way around the bloodstream.
Malaria is a constant presence. Any child under 5 years with a fever and any adult with fever and one other symptom (chills, headache, acute back pain, anorexia, vomiting, or abdominal pain) gets a malaria blood test before they even see the Consultant. Even with this pre-screening we end up sending patients back out to be tested—it is usually positive.
Yesterday the pediatric neurologist in me got to shine. I arrived at the more distant Centre de Santé. Waiting for me was a worried Consultant. A 9 year old had been seen the day before with headache but no other symptoms. Her malaria test was negative. The child had had a rough night with little sleep; in the morning the girl had begun to talk nonsense so the family returned to the Centre de Santé. When I saw her, the child was very uncomfortable and the translator told me she was speaking correctly (she knew her name and mother, etc.) but was making strange grammatical errors. This likely encephalitis was way out of my league to treat in a Centre de Santé, so we made plans to bring her back to the hospital with us a few hours later. I continued seeing patients with the Consultant and we peeked in on the child and her mother; things were stable. Two hours later she had a seizure. As she almost certainly had encephalitis and was now seizing, I radioed the hospital in Lubutu for them to send out an ambulance. Fortunately, her seizure stopped after a couple of minutes and didn't require treatment. The ambulance arrived 25 minutes later and whisked her off. What did she end up having? Why schistosomiasis, of course, with eggs travelling up to her brain! Not the first organism that came to my mind, as in the US this is almost certainly viral and not treatable. Here there is a treatment (praziquantel) as long as you think of this parasite as a possible cause.
My job description is all about teaching these Consultants how to diagnose and treat common diseases in the Centres de Santé. Four of the six people I am charged with helping actually need the training, but the other two are teaching me! It is wonderful.

10 August 2009

Food, glorious food.
I’m not starving. Not even close. After five days here in Lubutu, the biggest issue for me is not weight loss but weight gain.
The days start early. The staff who take care of our temporary home arrive a bit before 6 a.m. They cook the food, wash the dirty dishes, cook more food, clean and iron our clothes, cook a little more, clean out bedrooms and communal bathroom, and finish their day by cooking. Their headquarters, obviously, is the kitchen, a large open room with a few provisions, two big wooden counters stained black from smoke, an open fire hearth for cooking, and an electric oven for baking.
Breakfast is very simple: bread and coffee or tea. Lunch is the main meal of the day and is a feast. Served at 1 p.m., there are invariably three starches- rice, potatoes, and pasta. For carnivores there are two meats; chicken is roasted or stewed and goat is invariably braised. A tomato-based sauce can smother the taste of these very free-range meats.
The standouts are the vegetables: green beans pan fried with onions and garlic, mustard greens cooked with herbs in a light cream sauce, or one of the myriad uses of eggplant.
Yes, the staff are masters of eggplant. It is grilled and tossed with fresh herbs, cherry tomatoes, braised sweet onions, and garlic. It is stuffed with breadcrumbs, cheese, and oregano. It is sliced thin, salted and rinsed, layered with tomatoes and cheese, and baked with a cream sauce on top.
The condiments available here are striking- fresh honey, pesto, Nutella, Dijon mustard, Heinz ketchup, olive oil, Speculoos (a kind of hyper-sweetened Belgian peanut butter) and strawberry jam.
But the best part is the cheese. By local legend, an Italian cheese maker immigrated to Goma several decades ago. Though deceased, he dispersed his knowledge of cheese production around eastern Congo. In consequence, we eat cheese one would expect to find in Tuscany.
Compared with the early afternoon foodfest, dinner is rather subdued. The staff often will bake bread or make quiche. We eat the leftovers from lunch. Mostly we sit around drinking bottles of Coke, Fanta, or local beer. If an expat has recently arrived in Lubutu, there is a chocolate bar to divide into twenty pieces for dessert.
We don’t have fresh milk. We don’t have hot water and the generator stops running at 10 p.m. But we eat like MSF royalty.
　

Finally at my assignment location: Lubutu

8 August 2009- Lubutu, DRC

Yikes. For the last several months I wondered what I was getting myself into. Now I know.
After two days travel, I have finally arrived yesterday in Lubutu. Yep, it is as advertised. Very Africa. The drive here from Kinsangani was four hours and beautiful. The jungle was thick thick thick and all I could think about was—How did the early explorers possibly get here? To me, it looks as if it would take a day go to 100 meters in that forest, but for hundreds of years people have explored this territory and its beauty.
We arrived mid-afternoon and after a short break in my new home (an ex-convent!) it was off to the hospital and the office for an extended tour.
The Médicins Sans Frontières project here is impressive. The hospital is a rehabilitated government facility, staffed exclusively by MSF. There is everything I have seen in hospitals of reference in Africa: inpatient adult and pediatric wards, an excellent laboratory, radiology, intensive care, an extensive pharmacy, and everything incredibly clean. Of course, there are a couple of things lacking in most hospitals familiar to people in US-a cholera ward and anisolation area for hemorrhagic fevers (such as Ebola) for example.
This morning, it was up early to go to one of my two assigned Centres de Santé (Health Centers). Mungule, situated two hours away by car, was opened in May, 2009. Kalibatate, within spitting distance of Lubutu's town center, opened four days ago. Both are staffed by national (Congolese) staff who provide primary care to the population. Both Centres de Santé do primary care, malnutrition screening, wound care, treatment for sexually transmitted disease, and health promotion. Mungule, the more distant, also has obstetrics.
Today we went to Kalibatate; tomorrow we go to Mungule.
The job ahead is formidable to say the least. Most health care providers in the Democratic Republic of Congo are not trained physicians. They are not nurses. They have little formal education compared to a western physician. My job is to train these providers to diagnose and treat disease. In French.
Fortunately, it appears I have a savior named Joseph. My predecessor in this position (who did excellent work here but departed the day I arrived) left me a thirteen page "passation", a description of my duties, obstacles, and assets. Chief among the last assets is Joseph, an "infermier", literally translated as "nurse" but more like a physician's assistant or clinical nurse practitioner. Joseph is to work beside me to improve the diagnostic and treatment skills of the local health care providers. My other savior is Sophie, my boss. An intensive care nurse from Sweden, she is kind and understanding and really smart.
I'm honestly kind of freaking out.
OK calm down. I know I can do this. I've kind of, sort of, done it before, and I'll hopefully do it again and I know I'll do a good job, but wow……this is bigger than any educational challenge I've faced before.

But I'll do it.

Mungele- written 8 August 2009
Yesterday, it was up early in the morning to take the one hour drive to Mungele, the second of the Centres de Santé that I will be supervising. Along the way we passed small villages, each with 20 or 30 houses, the houses of the people who would be our patients.
The houses here are square, in comparison with the round houses seen in most other parts of the continent. When under construction, the lathe, made of large sheets of criss-crossed pieces of split wood; is erected first. These large sheets (as big as the walls they will become) are lashed together at the corners, and then laid over with mud mixed with straw or grass. Windows are usually made by simply not putting any mud in a square space in the wall; the horizontal and vertical supports show through, forming tiny panes. Doors are usually open, occasionally covered by a piece of cloth. The entire building is capped by a peaked roof made of large leaves, laid on bamboo trusses. The leaves each overlap the one below, trying to keep out the rain.
There is no electricity here. There is no running water here. And this is how the people in this part of the DR of Congo live.
After an hour on the road, I saw the MSF sign, indicating we had arrived. We pulled off the pavement onto a rutted mud route, ascended a small hill, and came to Mungele.
The building itself was exactly as we had seen along the way, with the exception that our Centre de Santé had a completely waterproof roof and several rooms, each which could be closed by a wooden door. As both of the Infermière-Consultants (the people I am going to be primarily working with) were temporarily on leave, I decided to spend my day working in the adjacent Centre Therapeutique Nutritionelle-Ambulatoire (CNTA), an outpatient clinic for children with severe malnutrition but without medical complications. I was opening today.
Malnutrition is rampant here, due to poverty, other chronic diseases (malaria, intestinal worms, neurological conditions), and the fact that this area is so geographically isolated. Every child seen in an MSF clinic is screened for malnutrition by checking height and weight, measuring upper arm circumference (called "MUAC"), looking for edema, and then checking all of this against norms. Children are classified as Normal, At Risk, or Mild, Moderate, or Severely malnourished. Only children who are Severely Malnourished and are free of medical complications (they are alert and interactive, have no fever, and are not otherwise ill) can participate in the CNT-A.
And when I say "severely" malnourished I mean exactly that. We screened several children as Moderately Malnourished whose ribs were visible. In the US or Europe they would be considered extremely ill. They didn't qualify for the CNT-A but parents were instead given information about proper nutrition. If a child was acutely ill, however, they were looked after. One child, found to fall into the Moderate category, but who had a high fever and looked ill, was taken immediately to the Lubutu hospital by an MSF car.
Patients who qualified for the CNT-A were given a one week supply of Plumpy Nut, a fortified food, as well as a mosquito net. At program enrolment, all children are vaccinated, given a short course of antibiotics (shown to decrease complications), take a big oral dose of folic acid, and are given medicine for intestinal worms. The CNT-A patients come back every Friday. They are continued in the program (living on Plumpy Nut and whatever else they will eat) until they are out of the Severely Malnourished range. If they come back for their weekly visits and have gotten worse, they go into the hospital.
I had worked for a short time in an inpatient setting with malnourished children, but hadn't participated in an outpatient clinic. It was interesting. The local staff working in the clinic had all been trained by MSF at other locations. They met for the first time in Mungele, and quickly went to work implementing the protocols. They all knew their duties and responsibilities and did it right the first time. The beauty of standardization!
After 6 ½ hours of this, we packed it all up, jumped back into the MSF car, and headed back to Lubutu. I was light headed with hunger, but quickly realized that this was nothing compared to the starvation of the people we were working to help.

The Big Leap

30 July 2009

Sixteen months.
That's how long it took me to get here.
In March 2008, I submitted my application to Médicins Sans Frontières/ Doctors Without Borders (MSF). I wanted to work as a field volunteer, to be placed somewhere in the world to better the healthcare of people less fortunate than myself. I had done some shorter term overseas volunteer work before, but this would be The Big Leap. Six to nine months doing something somewhere for someone who was not lucky enough to be born into a middle class educated American family.
I got my answer from MSF quickly. They were interested in talking to me in person in their New York City headquarters. I had a three hour meeting with Human Resources; who explained some of the structure and function of the organization, but also tried to get to know me, my experiences, and how I might best work within this huge group of like-minded people. My interviewer also tried to get a grasp of my knowledge of French, a language I had studied thirty years ago.
Successfully concluded, I told MSF I could not commit to start working with them until 2009. I had to extricate myself from my job (head of the department of neurology at a private hospital in Albuquerque, New Mexico), convince my spouse that this was a good thing (very easy), and try to better my level of spoken French (not so easy working full time and concurrently learning to speak Spanish).
But I did it.
Almost exactly a year after my interview, I was back in New York for Information ("Info") Days, a busy three day indoctrination into all things MSF. The best part were the returned volunteers who spoke to us at the end of each day; all enthusiastic and helping us to place ourselves in some far off corner of the world, idealistically working away.
Info Days concluded, I went back to my rather contented life in New Mexico to wait for The Email that would announce my field placement.
I am a trained pediatric neurologist, happily married with no children, two dogs, and a nice home. I get to travel a lot, and am overall healthy and happy and lead a contented life.
Fortunately I also have this well developed compassion for others. Two years previously I had been sponsored by the World Federation of Neurology to teach and do clinical work in Malawi. I saw cerebral malaria and malnutrition and AIDS and untreated epilepsy and meningitis and rabies and I was not happy. Why , simply because you are born in a poorer country are you virtually condemned to a life of ill health? And with that ill health you have little chance of being able to succeed in school or better the life of your family?
It is chance, a big roll of the dice, and a big chunk of the world has come up losing.
Enough white middle class liberal guilt.
Two months after Info Days, I got The Email. They had found me a spot . It was exciting and frightening to read what I would be doing and where I would be going. They wanted me to work in a project in Lubutu, Democratic Republic of Congo.
In 2007, MSF had done an investigation into mortality rates in the Democratic Republic of Congo (DRC). They found dramatically elevated mortality in five areas, the highest around Lubutu. Most health care work in the developing world is aimed solely at primary care in small health centers. Although slightly helpful in reducing disease burden, mortality rates stay elevated. MSF was trying a different approach this time. First they had quickly opened a large 160 bed referral hospital and now were setting up small primary care clinics called "Centres de Santé." These Centres de Santé would do primary care but have the ability to refer complicated or sicker patients to a central hospital. It was this ability to refer patients for more intensive inpatient care that had been missing from past projects.
Would the newer vision of a central hospital with several Centres de Santé be successful in Africa?
My job was to work in one of these Centres de Santé. I would be part of an international staff of about 20 expatriates working with over 200 national (Congolese) staff, all of us working in the central hospital or the Centres de Santé.
Yikes.
Although I had done something similar in northern India several years before; I had not done it in Africa and I had not done it in French:
But why not? The people in New York thought I was qualified and I thought I was qualified. So I said "yes." I would go.
I would take The Big Leap.

4 August 2009
Kinshasa
After endless briefings in New York and Brussels, it was an early morning taxi ride that brought me to the airport for my flight to the Democratic Republic of Congo. Nine hours later, I arrived.
Kinshasa. In hindsight, a truly unpleasant city.
The city is MSF-Brussels headquarters for all of its operations in the DRC. The international staff are housed in basic concrete homes scattered around the city, all surrounded by high walls, razor wire, and twenty four hour guardians. Upon arrival at the chaotic airport, I am handed a detailed security memo, detailing the many prohibitions for MSF staff posted here.
At our first briefing the next morning, I am cautioned to be especially careful when walking in the streets during the rain. Despite the fact that it would be incredibly muddy, one risks one's life. It seems that in order to access the underground electric lines, people have resorted to digging up the streets. After their job is done, they cover the hole but not quite well enough. The rains come, the street collapses, and some unlucky pedestrian is electrocuted. So no walking the streets in the rain.
Not that I can walk the streets when it is not raining, mind you. Small sections of Kinshasa are deemed safe for walking. Want to go anywhere else? You must be driven in MSF vehicles.
I know it is for my safety and am glad of it, but feel sorry for the local population and the MSF staff who work here. The organization has a large HIV project in town and for month after month my fellow volunteers must follow these rules. Fortunately for me it is only temporary.
My fellow MSF volunteers, each one friendlier than the next, recount to me the glories of Lubutu, my eventual destination- small town, nice local population beautiful hospital, collegial co-workers. But that is four days from now. I have to survive Kinshasa for four days.
So I make friends. We go out to dinner, play soccer, go running together, go walking in the embassy quarter, eat Italian gelato (!), and talk and talk and talk. My fellow expats are mostly 30-somethings and the majority in Kinshasa have worked with MSF before. They are physicians, nurses, logisticians, and administrators and come from a huge variety of backgrounds. They are all deeply committed to humanitarian work and their jobs with MSF.
So I survived Kinshasa.
This morning I got up at 5 a.m., got ready, and some really nice person whisked me off to the airport. Along the way we passed dozens of women balancing large colourful plastic containers on their heads. Inside each container were dozens of loaves of freshly baked French bread, vertically arranged. The women would go back to their neighborhoods to sell the loaves, making a little money on each one purchased. Enough money to live for another day in Kinshasa.