Searching

Walking down the street in Lubutu, local people dress in one of two ways.
Women, being wiser, wear lovely printed fabrics. These are purchased in the market as large pieces of cloth called pagne (pronounced “pahn-yah”, accent on the first syllable).

Out of the pagne is cut and sewn a top. The remainder encircles the waist, tucked into itself after one and half turns around the body. Generally the fabrics on the top and skirt are the same, but sometimes not. The clashes in color and pattern are fun.

In contrast, men’s clothing is boring, mostly used articles from the US. Every time I walk down the street I am amazed at the t-shirts—Suffolk County Athletic Department, Cincinnati Reds, souvenirs from Midwestern marathons, University of Texas. Men wear old Boy Scout shirts with all the patches still sewn on.
What about pants? How do the skinny Congolese men fit into the average American’s pants? They wear two or three pairs, one on top of the other. The whole package is tied with a piece of twine or rope. I complain about the heat wearing one pair of khakis. How do they tolerate it?

Today I stopped in the Lubutu market, looked around, and chatted with the vendors. I saw Gap shorts, Snoopy t-shirts, and Abercrombie and Fitch baseball caps. Some things were badly frayed but most were in decent condition. How did this stuff get here?
The vendors told me they buy in Kinshasa. Huge bundles of clothing containing mixtures of used pants, shirts, dresses, skirts, socks and underwear, are unloaded off boats. These bundles cost $150 US, a huge amount of money here. The buyer examines the exterior of the untied bundle and makes a purchase. From there the clothes take a 5 hour flight to Goma and change planes for Kisangani. From there it is four hours to Lubutu by truck. Placed in piles in the Lubutu market, they are sold to the local populace.
Unfortunately, a lot is still unknown. Were these clothes donated to charities? Are they things that resale shops could not sell in the US and are now being bought in Lubutu? How did these things get from Austin, San Francisco, or New York to Kinshasa? Who paid to ship them across the Atlantic? Why are the things for sale in Lubutu only from the US?
I still haven’t seen anyone wearing my old Boy Scout uniform, but I look for it every day.

Changes

16 September 2009
Change is good, but change is hard. Things are changing, both outside and inside of me.
My body is different. Back in New Mexico, I woke up early each morning to exercise. I eat a lot but try to choose wisely. I'm in good physical condition. When I arrived in Lubutu my diet went to hell. There is a culture of chocolate here next to none. Every person coming to visit the project is laden with kilograms of Belgian chocolates. Each week, when the guests arrive, we feast. I ate more chocolate the first month here than in the rest of my life combined.
This has led to shiftiness. My swimmer's back and shoulders have shifted down to my waistline. All the pants I brought are tight. The buckles are using the last hole in my belts. Is this "normal" aging? If so, it's not doing great things for my psyche.
After my fall and injury two weeks ago, I stopped exercising. I couldn't swim because I had a big hole in my elbow. I wore a large bandage and my arm hurt. This morning I returned to running. My route is still out the road to Kindu but I don't go up the big steep hill anymore. Oddly, this morning at 5:45 a.m., the alarm rang, and I thought: "do you really need to do this?" Why is that odd? To those not suffering from exercise obsessive-compulsive disorder, the question is logical. But to me who works out each morning without fail, it's a revelation. Yes, you too can become less neurotic! If I can, anyone can.
The language is changing for me. French is coming easier. When I arrived, before saying anything I had to think and plan my words in advance. No more. With chit-chat conversations I now just talk, no thinking required. This is not to give the impression that I am developing anything near verbal fluency. I often run into Great Walls of Incomprehension. I backtrack, describe something (rather than name it), or flip into English. But often the words come without thinking.
One change is not working out so well. The novelty of Lubutu has worn off. Yes it is still lovely and fun.

I walked home tonight and the beautiful sunset reminded me how lucky I am to be here. But things have changed. The commute to Mungele does not fly by anymore. It now feels like an hour, sometimes a long hour. My walk to Kalibatete is 16 sweating minutes each way. I still occasionally discover new things on this route.

Yesterday I ran across a beauty parlor where the clients sit outdoors on the ground and have colored threads braided into their hair. I walk this route 12 times per week and it feels like it.
How to overcome the beginnings of boredom? The logical answer is to look for things that are different- patients with new diseases, the arrangement of fabrics for sale in the market, the people I greet and who sometimes walk with me. I still have many remaining goals and challenges here. It's just not fresh and new anymore. Perhaps I should go running, eat some chocolate and count my blessings. In French.

Photo: Something different-"traveling salesman" with his wares

Paix - Peace

13 September 2009 - Paix

Go onto Google Earth and find me. I am southeast of Kisangani, the third largest city in Congo. When I first received this assignment from MSF, I did the same search. Lubutu was visible very early as I zoomed in. This is amazing as the town is comprised of a crossroads, a market, and lots of square houses (see photo below).
As you electronically swoop down, you will notice two airports southeast of the city. I knew the Congolese roads were awful and assumed I would be flying into the Lubutu airport. But why would this tiny town have two airports?

Both airports are the route of my one hour commute to Mungele. They are actually in the villages of Tingi Tingi and Amisi. They have airport codes like any other. The first time we drove to Mungele, I missed them. The road widens to about twice its normal size in these two villages. I figured I was excited by the jungle and waving at all of the children. Perhaps the terminals and runways were a bit off the main road, hidden by the vegetation. Oddly, there wasn’t any visible village of Tingi Tingi, just the widened road. What was this all about?

Congolese Petrol station I pass every day

When I was growing up in Indiana, Congo was called Zaire. Shortly after independence from Belgium, the country was taken over by a military strongman, Mobutu Sese Seko. He was an eccentric figure in my youth- a friend of apartheid-era South Africa, host of a boxing match featuring Muhammed Ali, and a plunderer of the national treasury. Eventually people grew weary of President Mobutu and a rebellion was launch in the east of the country. He was deposed and exiled. The country was renamed République Democratique du Congo (RDC). What follows is confusing. In eastern RDC there have been a series of armed rebellions and wars, some autonomous, others supported by foreign powers. These ongoing conflicts are centered in North and South Kivu Provinces. I am next door in Maniema province.

Tingi Tingi and Amisi were the scene of two huge refugee camps. They were the temporary home of people fleeing the war in the east. It appears that these camps were farthest west that many refugees reached before returning to the Kivus or Rwanda. The airports are these widened strips of blacktop. They were used by international aid organizations to fly in supplies. As the security situation deteriorated, the roads could no longer be used. This pavement allowed food and medicine to reach over 100,000 people.

There is ongoing conflict in the Kivus. Fortunately, Maniema province has recently been beyond the reach of major military activity. I’ve asked many Congolese what they want most for their country and the answer is unanimous. Peace.

Wise Woman - Midwifery in Congo

The Wise Woman

I can't remember the saying exactly. Is it "With age comes wisdom"? My 47th birthday was today and I spent it getting wiser.
When we refer patients who live in Mungele to the hospital in Lubutu, we give them a ride. When they are done with their hospital care, we take them home. I enjoy seeing the same people go both ways—sick towards Lubutu, healthy going home. The vehicles can carry a maximum of eight passengers, other than myself and the driver.
This morning was normal. It was a Mungele day. I went to the waiting area and announced that the car for Mungele was leaving. Carrying huge tied-up bundles of their belongings, fourteen patients and parents made a mad dash for the truck. The person in charge of giving out the tickets for the rides home had miscounted.
Fourteen officially signed and stamped white slips were waved at the unhappy driver. How could he choose? Some of these people had been in the hospital for a long time and wanted to get home. After a few minutes in crisis mode, we discovered that another truck was headed the same direction. They had plenty of room. Crisis averted.
The trip was uneventful- rolling hills, jungle, little villages, waving screaming kids, goats and chickens and pigs in the road. Normal.
I decided for a change I would work with the midwife today. She was doing prenatal care. Before we introduce her, we need some background.
Four weeks before departing the US, I met with David, a physician who had done lots of overseas work. We talked about his experiences and what I might expect. I asked him what I should pack. On his list was the book "Obstetrics in Situations of Isolation." David said that this subject terrified him more than any other. I thought there was no way I'd be doing obstetrics in Lubutu, so I didn't buy the book. Guess what I was doing on my birthday? Obstetrics in a situation of isolation.
The majority of pregnancies in Congo are delivered at home of by midwives in the Centres de Santé. Kenimbe (photo) is the sage femme (pronounced "sahj fuhm, literally "wise woman") at Mungele. She does prenatal and postnatal visits, delivers babies at all hours, and immunizes mothers and newborns. She is intelligent, works hard, wears elegant clothing, and speaks beautiful slow, enunciated French. Today she was doing prenatal checks. I joined her in the mud-walled, banana-leaf-roofed maternity department.
Women get pregnant younger and more often in Congo than in the US or Europe. Kenimbe told me she rarely sees a first pregnancy later than age 19. Four to six children are average. Some women start prenatal visits very late. Two of the five new patients today were nearing term.
At their first visit, Kenimbe takes a long history of the women's previous pregnancies and medical conditions. All the usual vital signs are taken- temperature, blood pressure, weight. Urine is checked for protein. Even if asymptomatic, each woman has a blood test for malaria and syphilis. If positive, they are treated. If the malaria test negative, the women receive oral malaria prophylaxis. Everyone gets folic acid for the baby and albendazole for mama's intestinal worms. Each new patient carries home a mosquito net for malaria prevention.
Kenimbe then examined each woman in the room next door. To estimate delivery date, she measured uterine fundal height. She feet the baby's position to make sure the head is pointed down. Next out came a cornet acoustique ("kor-nay ah-koo-steek"), a tubular metal instrument with rounded ends. One end was placed on the mother's abdomen, the other on Kenimbe's ear. She gently pushed with the weight of her head until she hears the infant's heartbeat. That done, the mother received a tetanus shot and appointment slip for her next visit.
The place ran like a factory. The ladies waited outside in a small covered area. For 2 to 3 hours they were verbally given information about maternal and childhood health topics. Kenimbe called the patients in turn, having to only slightly raise her voice as there is no glass in the windows.
After clinic, we chatted. Kenimbe is a strong advocate for women's reproductive rights. She knows all about contraception and family planning. She called the current situation in Congo "catastrophique."
I had a great birthday with this very wise woman. But what about my Mungele birthday present? As I was leaving to return to Lubutu, I walked through the area where patients wait to see the Consultants.
A small boy had been brought in for vomiting and diarrhea. He was sitting on his mother's lap. I was four feet away when the poor child vomited again. As the mother took the child to the wash basin to clean him, I noticed movement in the wet spot on the ground. A fifteen centimetre white roundworm wiggled. Ascaris. Happy Birthday!

Chez Nous - 'Our Place'

9 September 2009

Chez Nous
I live in Couvent, one of two houses for MSF ex-pats here in Lubutu. Since I keep talking about the place in many of my posts, we should go on a tour.
From the outside, the building is surrounded by a high bamboo fence. Guardians are continually on duty to pull the gate open and greet us. The front yard is completely shaded. The only lawn ornament is an unused badminton net. The building has a brick exterior with a high metal peaked roof. All of the floors and walls are concrete for easy cleaning.
There are 14 single bedrooms in the main building and three individual banana leaf roofed houses in the back yard. When I arrived I was offered one of these cute little rondavels; it sounded tempting until I heard stories of bats, mice, and lizards living in the roofs. So I'm in the main building, which is U-shaped. We'll start at one end on the terrace and walk through.

We sit on the terrace most evenings to talk, read, or play games. The furniture is wooden with cushions covered in wild Congolese patterns. There are two coffee tables which double as dining tables if people want to eat en plein air.
The first indoor space is the Game Room, home to a ping pong table, some broken couches, and a non-functioning television, the victim of lightening. Two or three times per week we project movies onto one of the walls. Since arrival I've seen "Slumdog Millionaire"; "The Reader" and "The Duchess", both dubbed in French; weird films from Serbia and China, and several French movies.
Entering the main hallway, there are bedrooms on either side. At the far end, lined up one after the other, are the dining room, kitchen, bathroom, pantry, and laundry. The only decoration in the otherwise austere hallway is several shallow round baskets set between the doorways. These are receptacles for our dirty laundry.
My bedroom is in this main hall. It's quite small, with a concrete floor and walls. I have a big window with metal casing and screens. Inside there is room for only a single bed with mosquito net, a desk and uncomfortable chair, and a set of shelves for books and clothing.
After the bedrooms we come to the shelves where our clean pressed laundry magically reappears, two days after it is deposited in the hall. The clothes are sorted by type- t-shirts in one stack, pants in another, a small hillock of socks. One evening ritual is to sort through the clean clothes to find your own. Almost directly across from this cabinet is the door to the dining room.
Our dining room contains a single long communal table, seating twelve. All the food is served on a side buffet made of rough hewn darkened wood. A third table holds the condiments (pesto, Nutella, honey, ketchup, among dozens) that we use to spice up our meals. There are also two "hot weather" refrigerators in the room. Only one even partially functions. The other deceased fridge was the victim of a lightening strike.
Next door, with a pass-through to the dining room, is the kitchen. Although there are two four-burner electric ranges and ovens, the staff prefers to cook on an open fire. The walls, ceiling, and preparation areas are black with soot.
Our communal bathroom has a central hall with three showers and three toilets. The showers are cold water and deliver slightly more than a trickle. The weather is so warm that the lack of hot water is inconsequential. We have three Western style toilets. Each stall has buckets or water that are used to flush. There is no water inflow to the toilet tanks, so after you've finished your business, you pour water in the bowl till it is clean.
Next door is the pantry. It has two large institutional freezers containing mostly cheese, beer, and soft drinks. As we have no functioning refrigerators, we have to cool drinks in the freezer. This often leads to a huge mess when someone forgets.
I love the laundry. It's a long narrow room with three large built in concrete wash basins. These basins, several clothes lines, and a lot of work, get our clothes cleaned. The pressing irons are metal and hot coals are used for heating them up.
Back outside, we come to the three rondavels. Couvent has a large back yard with an herb garden, vegetable garden (eggplant, tomatoes, onions, pineapple), and several papaya trees (for breakfast). There are two loudish generators. There is also a cabana containing some furniture and a hammock. No one has set foot in there since my arrival due to rumors of "big green snakes". There are beautiful birds here. Sitting on the terrace I've seen bee eaters, hornbills, and owls. Insects are minimal, but once per month there is a Mass Suicide. One early evening each four weeks, large black flies swarm around the artificial lights for an hour. They die almost simultaneously and it is impossible to walk without stepping on a crunchy carcass. How sad I only get to experience this a few more times!
Currently the inhabitants of Couvent are 7 Belgians and one person from each of the following: Burundi, Germany, Sierra Leone, Sweden, Taiwan, Burkina Faso, Lebanon, Norway, and the USA. Maison Rouge, the other MSF ex-pat residence in Lubutu, houses one Belgian, one French, one Swiss, and one Gabonese. Conversations flip quickly between English and French, though not everyone speaks the former.
As far as I can tell, in MSF you either work in medicine (doctors and nurses), medical support (pharmacy, laboratory), logistics (getting supplies, supervising and planning construction, assuring clean water, supervising vehicle movement), or administration. The Lubutu project is apparently heavily medically weighted. Among the 21 ex-pats we are 13 medical personnel, 2 medical support, 4 logisticians, and 2 administrators. Five of the six people doing logistics and administration had no particular training in these areas before starting with MSF. They applied, went to a two week training course, and were off. So those of you thinking you'd like to do some overseas volunteer work but aren't medically inclined, le voilà!
I like Couvent a lot. The people I live with are very nice, diverse, and interesting. It's a great place to hang out for six months. Below, typical East Congo Jungle landscape.

Sundaze

Photo: Lac Vert, where we usually swim on Sundays

Sundaze
I was dreading today. My usual Sunday morning routine is to get up late, drink coffee on the terrace, and perhaps go for a bike ride. Lunch is served at noon and then the group is off to Lac Vert for a long swim. We arrive home just before sunset, eat dinner, do a little more reading, and fall into bed early. Perfect.
But my elbow is cut up and I can’t go swimming. So what else is there to do in Lubutu on a Sunday? I was going to find out.
I woke up to discover some recently departed ex-pat Saint had left behind an Italian coffee maker and some Ethiopian roast. Things were looking up. I escaped Couvent coffee for the day. Coffee in hand I debated whether to read Agatha Christie or an MSF tuberculosis textbook. Ms. Christie won.
At 10 a.m., Marie-Aude ("mahree-ode", a Belgian physical therapist) asked if I would go with her on a long walk to the cascades ("kah-skahdz", accent on the second syllable). These waterfalls/rapids were a bit outside of town, just off the road leading from Lubutu to Kindu. This road was the scene of my fall and injury five days ago. The walk to the cascades was the only Sunday alternative to Lac Vert or just doing nothing. Since I’m not very good at just doing nothing, I was delighted to go explore. The only problem? Someone described the route and it was very complicated. The directions were: "Take the road to Kindu. After you go down the second big hill, turn onto a jungle path a little before the bridge. Go about 20 minutes into the jungle and don’t get lost." With my recent luck on the road to Kindu, I decided the two of us needed company. I asked Dominique (Belgian laboratory supervisor) if she would join us. She had gone previously and knew the way. With her "oui" we were set.

I’ve been chatting a lot with Dominique lately. She is 26, a laboratory scientist, and an expert on HIV. Marie-Aude is mid-30ish and is on loan to MSF from Handicap International. She is in Lubutu teaching inpatient physical therapy techniques to the national hospital staff. We three are all on our first MSF missions. We’ve each got our complaints, but we’re enjoying the experience. Dominique is returning to Belgium tomorrow for vacation. She has a long shopping list for Couvent’s residents, including me. Nothing is available here. As I did not bring a 6 month’s supply of shampoo and toothpaste with me, I’ve placed my order and gladly handed her some Euros!
The three of us exited Couvent and took a narrow path leading through a quaint neighborhood of Swahili houses. After 10 minutes we emerged on the red dirt Kindu Road. Each time I had gone this way it had been early morning and I was running. Now I could take the time to appreciate the beauty around me. Going up the second big hill, we held a Moment of Silence for my right elbow, exactly at the spot of the accident.
One and a half hours after departing, we turned off the road onto a well hidden jungle path. Immediately an entourage of children joined us.

They had been hunting caterpillars in the forest, but we were much more interesting. After twenty minutes the kids brought us to the roaring water.
The cascades were nice.

Better was getting to play with the children and caterpillars. We sat around for awhile, took a lot of photos, and shared some French cookies with our new friends. On our walk home, Dominique remarked that as tourists we would have paid a lot of money to walk through the jungle, hang out with kids, and play with orange caterpillars. She’s right, but this was something that is very difficult to experience as a tourist passing through. No the cascades weren’t just nice, they were great.

To Arms

6

Photo: Remo, a German MSF non-medical volunteer, bastes birthday pig

6 September 2009
To arms!
Birthday time! To celebrate three birthdays in September (Vladimir's, Chen's, and mine) we're having a pig roast. We've used some of the Couvent food kitty money to buy a live pig. Porky was living in the front yard for the last couple of days, feeding on scraps from our meals. This morning the butcher made a house call, cut the pig's throat, and scooped out its organs. Vladimir, a Norwegian ex-pat, has experience in All Things Pig Roast. He took charge and stuck a long pole all the way through the animal, built a fire, and has been roasting it for nine hours. It's become a beautiful honey color.
What follows the pig is even better. Sophie (my boss and co-worker, from Sweden) spent four hours this afternoon making us a birthday pankekentorten. She first cooked dozens of thin crepes. She then layered them with chocolate cream and banana slices. It's beautiful, huge, and heavy. I saw the cake when I went to the refrigerator to get a drink. Dominique (from Belgium) made a wonderful concoction of blended pineapple, orange, lime, banana, and papaya. It's a lovely mauve-yellow color. Two hours ago we started drinking it with Cuban rum or Absolut vodka. Yum.
Clouding this for me is the talk of some of the ex-pats. Like me, they've been injured of gotten ill while working for MSF. Some of them got better in the field. Some of them left their projects to seek medical care in a larger African city or Europe. They all warned me not to wait too long before leaving the project (at least temporarily) to get to a larger hospital.
Since my fall three days ago, I've been doing okay. Martine changed my massive dressing again today. As usual, the gauze was stuck to the wound and stitches by dried blood and serum. She carefully removed everything and then inspected her handiwork. Today she pronounced it healing but red and inflamed. So is it infected? She pressed the entire length of the suture line and got no pus. She stuck a forceps into the last small remaining hole, probed around, and got no pus. So it's probably inflammation "but stay on antibiotics a few more days."
This crazed brain of mine knows other facts. Martine leaves in four days. What then? I have become medically and emotionally dependent on her. If all goes well, no problem. But what if she leaves and things don't go well? If I am going to get to a bigger city for care, I need to leave Lubutu on Monday morning to catch a flight to Kinshasa. But leave for an uninfected cut? And what happens when I get to Kinshasa? They certainly aren't going to put me in the hospital for an uninfected cut. Do I go to Brussels? Do I just go home? For something that might go wrong?
I don't want to leave, at least right now. Of course, on one level I always want to go home, but just not right now. I'm finally getting into the groove of this place. I like what I am doing professionally. I like the people I'm doing it with. I like Lubutu. Throw away all of the anticipation, preparation, travel, and adjustment right now? Go home because of a big uninfected gash on your right elbow? It sounds unreasonable but several people are encouraging me to do exactly that.
I wonder if it is easier or harder to approach medical problems from inside the system. Is it easier to be knowledgeable or blind to the possibilities? I have to believe it is the former. The few times I've faced the medical system as an outsider, it has been paternalistic and functioned poorly.
I simply want someone to hug me and tell me what to do.

Oops!

Photo:Doug with lifesaver surgeon Martine at the scene of the fall

3 September 2009

Oops!
Life is like playing in the surf. Standing in waist deep water, the waves hit. They are fun because it is the little variations that give life interest. Less often, a big wave hits and you jump to keep your head above water. If you see it in advance, you hold your breath and it passes. Once in awhile, you're caught off guard and come up with a head full of salt water.
I've gone running three times per week since I've arrived in Lubutu. Exiting Couvent, I run on a small trail before appearing on one of the main gravel roads leading out of town. >
The soil is brick red here. My shoes, socks, and legs, are covered with red dust each time I finish. It's a lovely run, 25 minutes in each direction. The most distant point is a long steep hill topped with a large brick church. From there I can see miles of hills and jungle, as well as the red ball of the sun rising.
Yesterday was typical. I got up before sunrise, put on my running gear, and off I went. I was happy to reach the top of the hill, as I knew I was halfway done. Once at the church, I turned around, admired the view, and smiled. On the way home the first 10 minutes is steeply downhill. I get to take a bit of a break, relax, and say "bonjour" to dozens of people, as I let gravity carry me along.
I don't know how it happened. Somehow my right foot got caught. On the steepest part and at the highest speed, I tripped. I landed on my right elbow and left outstretched palm. They were shredded. Blood began running down my right arm and red dust and rocks were ground into both wounds.
What could I do? I stood up, noticed that I had a big bleeding hole in my right elbow, and started running again. I had no other option. I couldn't phone anyone. I had to get home.
Many things passed through my mind. I was in a great deal of pain and didn't know if I had broken my arm. If I had, I needed to get to Nairobi or Europe for medical care. Even if the elbow wasn't fractured, the wound might be open to the joint. If that were the case I would be in serious medical trouble. Even if neither of these options were true, I had a big hole in the skin over my elbow and there were a lot of dirt and rocks in the wound. The flesh was gone- full thickness absence, not just skinned. In this best case scenario, if I didn't get an infection, I was probably going to end up with a big scar. I thought about Martine (pronounced "mahr-teen", accent on second syllable) our Belgian surgeon. She was my good buddy and had better be a good surgeon.
Twenty-five minutes after the fall, I arrived at Couvent. My first action was to wake up Martine, whose bedroom is right next to my own. In the hallway with most of the bedrooms, there is a sink. I turned on the water and stuck my right arm under. I started using my skinned left hand to clean the dirt, rocks, and dried blood, off my right forearm. By this time, Martine was up. Once I reached my right elbow, my left index finger entered the large hole in the skin. I had a vasovagal reaction. I was lowered to the floor pale, sweating, and nauseous.
That over, the two of us walked to the hospital and went directly to the operating room. She numbed me up and washed out the wound. The joint was not involved. She didn't think there was anything broken. After suturing she inserted a surgical drain. Drains are temporary conduits for blood, pus, or fluid, to reach the exterior of a wound. If a surgeon expects a large accumulation, they insert a drain to prevent the wound from swelling and the sutures being pulled apart. Washed out, sutured up, and with a piece of rubber hanging out of my arm, the whole thing was covered with a large sterile dressing.
From the operating room I went to the recovery room. Fifteen minutes later I walked home. I spent the remainder of the afternoon reading and relaxing. Early in the evening someone remarked that my dressing was dripping blood and serum. So it was back to Martine I went. Fourteen hours after she had first helped me, she was still in the operating room. After finishing her last patient, she changed my blood soaked dressing and inserted another drain. This was one of those life experiences best forgotten.
Last night I slept poorly. Each time I rolled over I was reminded of the accident. I'm lucky this happened here in Lubutu. If I was on a remote MSF posting with no hospital or surgeon, things would have been much more complicated. Here I knew I could count on sterile technique and I slept in the bedroom next to the surgeon. It could have been much worse.
I had dragged Martine out of bed and kept her in the operating room even later than she had planned. What could I do to thank her? I can't take her out to dinner, as there are no restaurants. I can't buy her a gift as there is nothing to buy. I can only thank her for pulling me out when an unexpected wave crashed over my head.

Unmentionables

Photos: Swahili building techniques, Central square in Lubutu

1 September 2009
Unmentionables
There are many bad contagious diseases floating around here. The three most common things I see each day are also the three biggest killers: malaria, diarrhea, and pneumonia. I've got the protocols for these three diseases memorized. The threshold for treatment of these conditions is very low. If patients come into an MSF clinic with one day of diarrhea and aren't clinically dehydrated, we still prescribe rehydration salts. We make them a follow-up appointment in 1-2 days. If they look even minimally dehydrated (dry mouth, sunken eyes) they drink rehydration solution in the clinic. They wait around several hours to make sure things don't worsen. Diarrhea kills people here so the threshold for diagnosis and treatment is low.
In contrast, mental illness is hardly recognized and rarely treated. Since my arrival, I've seen major depression, panic attacks, post-traumatic stress disorder, adjustment disorder with depressed mood, and psychosis. I fear I'm the only one paying attention.
Early this afternoon I was at Kalibatete seeing patients with the Consultants. It's always fun because the four of them share interesting patients. If one room has an unusual case or physical finding, we all go see it. I am constantly moving from one exam room to another to help out and learn. So when I got a call to come to the end room, I wasn't surprised. I was surprised at the tone of panic in the Consultant's voice.
Flopping (literally) on the exam table was a young woman. Was this a seizure? It didn't look right. I examined her and realized this crise (pronounced "kreez") was a conversion reaction. Subconsciously, she had turned anxiety or stress into a physical manifestation. Fifteen seconds later, every person who works at Kalibatete was in the exam room with me. Four Consultants, two pharmacists, the security guard, the cleaning lady, two people who register patients, two people who take vital signs, and the guy who does crowd control. That's fourteen people and me watching a fake seizure in a room about 6 by 8 feet. Two hundred curious onlookers were trying to peek in. Yikes.
I explained that this was not a crise epileptique but a crise anxietique. The family of this poor young woman were dragged in and quizzed. This 17 year old was pregnant. Her partner was in Kisangani, 4 hours away. He was unfaithful. She had been seen in the Centre de Santé that morning for a sexually transmitted disease. It was Ramadan and she hadn't eaten since sunrise. So guess what the crowd decided was the origin of her crise anxietique? Yep, they decided it was because she was hungry.
The Consultants are receptive to the concept of mental illness. It simply does not occur to them as a diagnostic possibility. Even if they think about it, they discount its importance. A patient at Mungele with major depression was initially counselled that he'd stop crying and start sleeping again if he didn't work so hard. Many people in Western developed countries have experience (personal, family, or friends) with mental illness. We know the disability brought by depression or anxiety. It can kill. That personal experience with mental illness is lacking here.
Without diagnosis, medical treatment for mood and anxiety problems is not possible. Fluoxetine (the generic of Prozac) is available, but has rarely been prescribed in the three years this hospital has been open. Why? Clearly most importantly is underdiagnosis/misdiagnosis and unfamiliarity.
A second big problem is the way people are prescribed medicines. In our Centres de Santé patients are given a prescription for 5-7 days, no matter how long their anticipated treatment. At their initial appointment, if they have an infection that requires 4 weeks of antibiotics, they get a prescription for 7 days. After that time they come back to the Centre de Santé and wait in line for another 4 to 6 hours. Then they get another 7 days of therapy. Why? My predecessors were worried that if people were given too many pills, they would sell them. People who are depressed or anxious need medicine for 6 to 12 months, if not forever. If you're feeling depressed or anxious enough to need medicine, are you going to put up with waiting for hours once per week? I doubt it.
So now that I planted the concept of mental illness in the minds of the Consultants I tackled some of these prescribing habits. Now when we see a therapeutic response we give people 2 weeks of therapy. Not a major victory but a start. But we still had another problem. Patient who take antidepressants need to take the medicine for up to 6 weeks before they see a therapeutic effect. Unfortunately, the side effects sometimes don't wait that long; patients temporarily feel worse before they feel better. To the Consultants, the concept of taking a medicine that might temporarily make you feel worse was met with a mixture of disbelief and "even if that's true, why would anyone take the stuff?"
We Westerners also deny and discount the importance of mental illness. I've had many patients with conversion reactions or pseudoseizures whose family deny the possibility of a psychiatric problem. They ask for a second opinion. When they don't like that answer, they ask for a third opinion. When that's unsatisfactory, it's off to Mayo Clinic where they are sure they'll get a "real" diagnosis.
People with mental illness also pay more for their care than those with "real" sickness. If they see a doctor for hypertension or heart disease, they likely owe a low co-payment. Go to a psychiatrist (who is an MD) and they probably pay the same amount. But if they need psychotherapy, the co-payment is significantly higher. After all, the therapist isn't really doing anything, at least in the mind of the insurance company.
Is there a solution here in Lubutu? I don't know. When I do my one on one teaching, I try to discuss mental illness at least once per day. I've started some formal lecture presentations and will add Mood and Anxiety Disorders to the list of upcoming topics. Yes, I know that depression isn't as likely to kill you as malaria. I can't change the culture here. But perhaps I can help a few people with mental illness get it diagnosed and treated in this corner of Congo

Tidbits

29 August 2009
Even in this country where children are malnourished, people have pets. I don't see them so much in town, but each time we drive to Mungele, we pass three or four dogs. They look about the same-sandy brown mutts, long pointy ears, and skinny. No matter what they look like, you know their family loves them and gets lots in return. It's nice to see this bit of "love luxury".
We have a pet at Kalibatete. It's a duckling. When I first arrived it was very tiny but is now adolescent duck sized. All day it walks around the clinic, circling the waiting area, the pharmacy, and the four exam rooms. If you leave a door open he'll walk in, take a look around, peck the hard dirt floor a couple of times, and waddle out. After it rains he's in heaven. There are puddles everywhere to explores and splash around. Though bold he stays slightly more than one arm's length away. I've tried to coax him into eating from my hand, but still no luck.
Greetings are interesting here. Since most people speak Swahili as a primary language, they say "jambo" to each other at any time of the day. As a white person, I am always greeted in French. As expected, in the morning that involves "Bonjour." People generally work from 8 a.m. until 1 p.m. and then take a break, called "le repos." (pronounced rah-poe, accent on the second syllable). Here le repos is only one hour but it's a very special hour. Until 2 p.m., people greet each other with "bon après-midi". Although to my knowledge this salutation exists in neither France nor Belgium, it is ingrained in French-speaking Africa. When le repos is over at 2 p.m., everyone switches to "bonsoir" (good evening). This is a bit hard to believe as the sun his still very hot and high in the sky. Yet at 2:01 p.m., I walk down the street, sweat profusely, get sunburnt, and tell everyone "bonsoir."
Truthfully, it's not quite as strict as that. I have heard a few radicals saying "Bonjour" even later than 2 p.m.
You know how you go to a nice restaurant and on the menu they usually have some permutation of a free range chicken breast wrapped around something fattening and delicious? You order it and the meat is thick and juicy and flavourful?
Real live Congolese free range chickens are none of these things. The breast meat on a chicken here is ¼ inch thick, challenging to get off the bone, and sometimes difficult to chew. The remainder of the chicken is even leaner. Chicken legs served at Couvent are the size of quail legs served in the US. The wings are laughable.
So what is free range chicken in the US? I'm thinking that probably even organic free range chickens in the US are restricted in activity and have been bred for generations to have really thick breast meat. I know they aren't allowed to be pumped full of hormones, but they are not chicken in its natural state.

Wild Ride

Photo: Above, local worker Soki with Doug; Below: portrait of hunger

28 August 2009

When you're in primary care you don't really think about death. Sure, it's there. I see people with malaria every day and they look awful. You know that if you treat enough people, even with seemingly minor problems, some of them aren't going to make it. For the most part, that happens outside of your direct vision. The only people you see in the clinic are alive. If they look bad you send them to the hospital and they disappear.
Remember the little girl I wrote about last week? The one from Mungele who had encephalitis and a seizure? The one who was lucky to have a pediatric neurologist around? She died. No one can tell me much. She was admitted to Intensive Care and died two days later. She looked sick but not that sick.

Yesterday I had a typical Mungele day. It was a beautiful drive out and I saw patients with the consultants all day. I even taught my first formal class in French, so was feeling pretty good. About 10 minutes before we were to head back to Lubutu, an 8 month old boy arrived. He was breathing 60 times per minute and had a little "tugging" below his ribs. But he was breastfeeding moderately well and comfortable, despite his high breathing rate. His malaria test was negative and his lung examination sounded awful. Easy enough. It's pneumonia, of course. He got a shot of antibiotics and a ride to the hospital to stay a few days. It crossed my mind to call an ambulance, but that would have taken longer.
So we packed the baby and his mother up in the car for the one hour trip. We had a driver who insisted on obeying the MSF speed rules, which are crazy-slow, so the trip was looking like it would take twice that long. We slowed to almost a halt for each group of goats or pigs or chickens, which are plentiful on the roads here.
Fifteen minutes after departure, the baby intermittently started sighing with expiration. That's a bad sign and means that breathing is getting labored. Great. I was still calm as I thought perhaps the injection of antibiotics hadn't yet been absorbed. The sighs were now coming with every expiration and I was starting to sweat. Shortly thereafter, the child's mother opened the window, leaned out, and barfed at 35 miles per hour. She's never ridden in a car before. Great. The kid now began grunting with every single exhalation. With pneumonia, grunting is what patients do right before things go rapidly downhill. As if they weren't going downhill fast enough!
As the grunts get louder, I kept waiting for each one, to let me know the child was still breathing. At this point, I was scared that the grunts and the breathing were both going to soon stop. I was in the middle of nowhere with little more than a first aid kit in the back seat.
I told the driver to speed up, and he seemed relieved to be given permission to do so. Two minutes later, the mother started yelling. The driver put on the brakes and I was about to break I was so tense. Rather than show me her dead child, the mother handed me the still breathing baby and continued to barf. The sight of a vomiting woman was never so welcome. The remainder of the trip was divided into periods of incredible speed and slamming on the brakes for the mother to get out and do her thing .
After this mid-day adventure, I was exhausted. I went back to Couvent and chatted with Gerome, the new big boss over everyone. I explained how vulnerable and exposed I felt in the truck with this very sick child. The only other alternative would have been to radio and ambulance, which would have taken even longer. So had I done the right thing by just bringing the kid with me?
Gerome thought I had. This led to a conversation about the Congolese view of death. He said that here each person is mourned and their death is regretted. But to many Congolese, the performance CPR and rescue breathing are not appropriate. There is an acceptance that for each of us there is a time for death. This should not be fought.
That got me thinking about all the brain injured children I see when working in the US. Every year I take care of children who drown. Well, they don't actually drown, which means they die from submersion. They nearly drown which means they don't die. An ambulance is summoned, the kid's heart isn't beating, and someone does CPR for 45 minutes. The ambulance shocks the kid a few times and gives him powerful drugs to restart his yet unbeating heart. But then someone feels a pulse. The child gets admitted to the pediatric intensive care unit. If he doesn't die (which he usually does) he ends up profoundly brain injured: unable to communicate, blind, and without any evidence of perceiving his surroundings. With children submerged in warm water who have no pulse when pulled out, the outcome is universally bad.
What if the parents of these unfortunate near drowned children took the Congolese view and accepted that the time for their child's death had come? Or do the Congolese hold this fatalistic view only because they have no experience with a Western medical system that can occasionally work miracles?
It's something to think about after a wild ride home.