Ghosts of Belgian Congo

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


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

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

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

Silence

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

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

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

Ess Ess Pay (SSP)

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

Lac Vert

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

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

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

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

In Denial

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

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

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

Shifting Forms

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

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

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

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

Worst. Day. Ever.

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

Poliomyelitis

Photo: boy with "fish trap"

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

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

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

Overview of my project here in Congo

Where are the patients?
Access to health care is a big issue here in Lubutu. Congo is divided into Health Districts. Our district is centered on Lubutu, its largest town. The ability for a population to access health care can be measured several ways. One is to determine the difference between the expected number of patients who reach a health facility with a particular diagnosis versus the actual number of cases seen. In an emergency health situation, the average person makes four visits to a primary health care facility (Centre de Santé) per year. If the target population is 10,000 people, you would expect 40,000 visits per year. If there are only 10,000 visits per year, you have a problem. That problem can either be that you have an incredibly healthy population (unlikely), your census was wrong (perhaps only 2500 people live in the area, so the 10,000 visits experienced is right on target) or there is a problem with access to care. The sick cannot reach a health care facility.
Beginnings of the project
The MSF project in Lubutu started three years ago. An inquiry at the time revealed that mortality rates in this area of Congo were extraordinarily high. One measures mortality rates as the number of deaths per 10,000 population per day. In an emergency (refugee or displaced person) setting, this number should be under 2 deaths per 10,000 people per day. At the time of the inquiry in Lubutu, the mortality rate was about 5 per 10,000 per day. Even though this was not an emergency situation (no war, famine, or natural disaster) MSF chose to intervene. At the time there were twenty-one Centres de Santé in the Lubutu Health District, all run by the Congolese government with the aid of Merlin, a British NGO (non-governmental organization). If there was a complicated case in one of these primary care Centres de Santé, there was no place where more intensive care could be provided. There was no referral hospital.
So the first thing MSF did was take an old government owned hospital, completely rehabbed it, and opened it as a Hôpital Générale du Référence. They let the word out to all of the Merlin/Congolese government Centres de Santé that the referral hospital was open for business and would happily accept their patients. Patients are cared for completely free of charge at the MSF hospital so there was no financial barrier to referral.
At the same time, MSF decided to take over four of the Merlin/Congolese government Centres de Santé and reopen them as MSF facilities. Two are open already, Kalibabete and Mungele. These are where I work. Merlin/Congolese government facilities charge a fee to see the Consultant and for medications. All care and medicines are free of charge at MSF facilities. This was done in order to try to remove any financial barriers to access.
Still too few patients
Unfortunately, the number of patients referred to the hospital remained low, possibility indicating an access gap. In order to increase referrals, a free ambulance service was set up. Consultants at any of the Merlin/ Congolese government Centres de Santé can radio this service at any hour. Transportation for non-emergency cases is on an availability basis. If an MSF vehicle (like the car that takes us to Mungele each day) is travelling by a Centre de Santé and there is a non-emergency patient who needs a ride to the hospital, we give them one.

The results of these efforts are mixed. In the three years since the Lubutu project opened, mortality rates have decreased eighty percent in this Health District. This is amazing. It is likely due to a number of factors including the absence of war and the economic stimulus of having a large NGO-funded hospital in a small town. Whatever the cause, the decrease is wonderful news. At the same time, outside of the immediate area around Lubutu town, access to care remains a problem. The rate of hospitalizations and procedures (such as Caeserian sections) remains much lower than expected. This problem is not symmetrical across the district. Along the two Axes with the best roads, access to care is better. The biggest gap lies along Axe Maiko, heading north.
Lubutu sits at a crossroads, with four routes leading to the cardinal directions. These roads are called “Axe” (axis) followed by the name of the town at their termination. Thus Axe Walikale is the road loading out from Lubutu to Walikale . This is the paved road I take to the Centre de Santé at Mungele. Two of the Axes are good paved roads, one is a passable dirt road, but the fourth is terrible. This is Axe Maiko.
How to improve access further?
Patients at the non-MSF Centres de Santé pay for services and medication. How about asking everyone to stop charging for care? Surprisingly, it is unclear if this would help. At Mungele, most of the patients live close to the Centre de Santé. The majority of those living two villages away choose to get their primary care from the nearer government run clinic. Patients prefer to stay in their own village and pay a fee rather than travel (by foot, bicycle, or motorbike) to Mungele, where services and medications are free of charge. So if we eliminated charges everywhere, would that improve access?
How about starting a patient bus service along the three Axes where the roads are decent? That might help. Statistics show that access along Axe Walikale, the road we take to Mungele, is best. One or two MSF vehicles drive on Axe Walikale each day, picking up and dropping off patients from all of the Centres de Santé . Patient transportation appears to have helped. But MSF is not a public transportation company. Who is going to start a bus service here?
The biggest gap in access lies along Axe Maiko, the road leading north out of Lubutu. It's infamous as being difficult, full of deep potholes. MSF's Toyota Landcruisers cannot traverse it. The obvious thing to do is make Axe Maiko into a real road, right? Right, except that MSF doesn't build roads. Currently the only way that patients living along this route can get to Lubutu for care is to walk, pedal a bicycle, or ride on the back of a motorcycle.

Last weekend I took a long walk up Axe Maiko. It is not a road. In many spots it is little more than a footpath through the bamboo jungle. When there are two parallel tracks they are often at different elevations, one two feet higher than the other. No wonder access stinks. If patients have an illness requiring hospitalization they must either have the money to pay for a motocycle ride or get to Lubutu on their own power. Not likely if you need a Caeserian section.
This all came together today. Before clinic was open, one of the people working in triage came to see me.

A man was seated in the waiting area with two bandages on his leg. A dozen flies circled the gauze. The smell was horrible and the other patients were complaining. We took him into an exam room, cut off the bandages, and cleaned his wounds.

Above his left ankle was a deep infected hole, the bone clearly visible. A tract of infection led all the way up to his knee. This man lived on Axe Maiko, sixty kilometres from Lubutu. The original injury was a year ago, a cut from a machete. It got infected. He went to the local Centre de Santé where antibiotics were prescribed. They didn't help. The wound became deeper and the sinus tract appeared. Even if the Centre de Santé phoned the ambulance, the vehicle could not traverse Axe Maiko. The patient could not walk or pedal a bicycle. His family could not pay for a motorcycle ride. So he sat in his village until he got the worst infection I have ever seen.