King for a Day

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

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

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

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

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

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

Thanksgiving

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

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

Thanks for reading and Happy Thanksgiving!

Horrible news

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

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

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

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

Howdy Pardner!

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

Surprise surprise surprise!

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

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

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

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

Enter Eva

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

Sleep

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

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

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