The End

(Photo: local mode of water transport, the pirogue)
MSF's involvement in health care in Lubutu is going to end. Phasing out of a large project such as this is a lengthy process and so plans are being made now to end the organization's activities here. It is likely to be a bumpy transition.
The intervention in Lubutu grew out of past failures. Years ago, and in other parts of Congo, MSF had a wide network of primary care Centres de Santé. Analysis of public health indicators (death rates, for instance) before and after the presence of these primary care services was disappointing. Without a hospital to refer more complicated and severe cases, the Centres de Santé alone did little to lower mortality or morbidity. Thus a new model emerged…. the Lubutu project. It was a risk and a new paradigm for MSF. Go into an area with a very high death rate and quickly open up a referral hospital. Try to get the existing government-run Centres de Santé to refer appropriate patients to that hospital. Finally, take over a couple of the existing Centres de Santé, in order to make them examples of high quality primary care clinics.

(Local consultant Tychique)
It appeared to work. Death rates fell dramatically, up to 80 percent. The result was likely due to a combination of factors (the end of war, an improving economy) but certainly the hospital's opening had an impact. Good for everyone.
But all good things must come to an end. MSF's charter is to respond short term to emergency situations. The organization does not generally engage in long term development. At one time the death rates here were so high that this area did qualify as an emergency environment, but no more. Lubutu was planned as a five year intervention. Three years have passed, two to go.

(Ex-pat Guillaume with palm nuts)
For those of us working here, thoughts of an MSF exit are difficult to imagine. Yes, possibly another non-governmental organization (NGO) can be found to take it all over. Perhaps they will have the resourced to employ all the doctors, nurses, cleaners, orderlies, drivers, pharmacists, operating room assistants, laboratory technicians, and people who cut the grass. Maybe they will be able to maintain the high quality of health care being provided here. But how many other NGOs exist that have 4 million Euro per year to spend on a single project and the organization to manage it all? If no one can be found to take over, then what? What happens to all of the local people who get malaria and can't afford medicine? How about all the malnourished children? And the people with chronic disease who now receive care and medicines for free? Or the women who need emergency caeserian sections?

How do you exit gracefully from the only business in the area that provides referral health care? There are many points to consider. In the best case scenario, MSF quickly finds a partner who can take charge. Then train as many local (Congolese) people to do the jobs that the expatriates are currently doing and concentrate on the present high quality of care.
If no suitable partner can be found, the situation is more problematic. Is it better to work maximally until the end and abruptly withdraw? Or is it smarter to pull out of programs slowly while trying to maintain the health of the population? Should the hospital in Lubutu suffer a slow decline or drop dead?

Our team discussed a few options MSF might have in the remaining two years. One idea I found interesting was to see if eliminating selected hospital services would impact quality of care. For example, how about if the hospital continued working exactly as it does now, but eliminated radiology? It is an expensive part of the system. Does an x-ray really add much to a good clinical examination? Alternatively, what if we eliminated certain expensive medicines? Does doing so increase death rates or the burden of disease in the population? At first these questions sound harsh and morally dubious. But wouldn't it be a good thing to know the minimum requirements needed in a hospital that makes a significant positive impact in the health of a community? That minimum would likely be a less expensive hospital than this one. If it were less expensive, perhaps these "pared down" hospitals which could still continue to positively impact public health would be a good idea for places like Lubutu. Retaining the same positive effects but at lower cost. More hospitals could be opened for the same costs.

MSF has spent a lot of time, money, and effort to develop and expand this project . To have the hospital return to its pre-MSF days of insufficient supplies, unavailable medicines, and turning away patients who could not pay, is a difficult concept to accept. Like me, I am sure that everyone who has participated in the success of this project is hoping that a solution can be found and that the people of Lubutu can continue to enjoy high quality health care.

Back in Business

For the last several weeks there has been low intensity military trouble around Mungele. Two groups have been intermittently shooting at each other, creating anxiety in the general population. Unfortunately, the people here are accustomed to shootings, battles, and war. They have grown used to armed men entering their homes, stealing animals and other belongings. When military activity gets too “hot”, the population flees into the jungle, sleeping in the dense forest until things calm down.
Seven days ago, I took the early morning car to Mungele for my usual Saturday trip. Nearby there had been some military activity a few days previously so there were not many patients. At 10:30 a.m. I departed to return home.
One hour later a battle began in the village and continued for hours. Soldiers from both sides were injured. When a truck transporting cargo and passengers passed by, it was stopped and the wounded from the Congolese army were loaded on for transport to the hospital in Lubutu. Shortly thereafter, bullets sprayed the truck. Miraculously, no one was killed, but seven of the civilians were struck. The truck rolled on to Lubutu. Since there is no mobile phone coverage outside Lubutu town, the injured arrived in the Emergency Room without warning. At 10 p.m., the hospital personnel heard the roar of the truck’s engine, lots of shouting and moans, and then eleven bleeding, gravely ill people arrived. Almost all of the injuries were severe and it is still unclear whether all the patients will leave the hospital.
The staff of the Centre de Santé and the population of Mungele and nearby communities had fled their homes and were encamped in the jungle. Virtually every home was pillaged, burnt, or both. In the Centre de Santé, all the doors was broken down and many items were stolen. Fortunately, though all of them were living in the insect-filled jungle, the staff of Mungele’s Centre de Santé were thought to be all alive and unhurt. All total, they spent five days in the intermittent torrential rains before most of them reached Lubutu. I was worried for their safety and was relieved to hear no one had been physically injured.
Today, seven days later, I went back to reopen the Centre de Santé. All was well until the car reached Amisi, the village 5 kilometers before Mungele. In the two towns, the only humans I saw were looters, leisurely stealing everyone’s possessions. With me came the two consultants, the pharmacist, and our receptionist. We cleaned for one hour and then opened for business. Magically patients appeared. They were examined and given treatment before hiding again. It is in no way safe for them to return home.
Clearly the local population was happy we were back. So was I.

Maiko Too

Today for something completely different I stepped out of my shell and went up Axe Maiko on the back of a motorcycle. I'm glad I did it but I will never do it again.
Lying in the four cardinal directions are four major roads leading away from Lubutu. These are named "Axe" followed by what lies at the other end. I have extensively explored Axes Kindu (dirt, my running route and the way to the cascades), Kisangani (paved, the road to the second largest city in Congo), and Walikale (paved, the road to Mungele’s clinic). Axe Maiko is the road leading straight north and ends at a huge national park. It is really nothing more than a path, not a road. Its rolling hills lead through thick jungle with each shallow valley containing a small creek. Four or five tree trunks haphazardly thrown across these waterways serve as makeshift bridges.

The route is extremely rough, impassable by even 4 wheel drive truck. Four times per month, two people from SSP (Soins de Santé Primaire, my department) ascend Axe Maiko on the back of motorcycles. MSF has professional motorcycle drivers who take medical staff and health educators to areas unreachable by the normal MSF Toyota Landcruiser. Today it was my turn to brave the journey.
But there was one other small complication. Friday is Eid el Kebir, a major Muslim holiday. On this day, Muslims ritually slaughter a goat in honor of Abraham’s obedient willingness to sacrifice his son Isaac, though a goat was substituted at the last minute. After slaughtering the animal, they cook it, eat a tiny bit, then distribute the remainder to those less fortunate. Thus, in places with sizable Muslim populations, goats are in short supply this time of year. Lubutu's Muslim population is not huge, but big enough to make live goats unavailable in town. Three of the expatriates living in Couvent are Muslim and wanted to share in the festivities. So they asked me if I would bring back a live goat from Axe Maiko on the back of my motorcycle. Sure, no problem.
At 7 a.m. this morning, the two motorcycle driver, my SSP co-worker, and I left for the two closest Centres de Santé. We were doing nutritional screening and follow-up, measuring and weighing children while giving their parents advice about feeding them. The 32 kilometer (20 mile) trip (one way) lasted 3 hours. I was outfitted in big white rubber boots and knee, shin, elbow, and forearm guards. The boots were crucial as several times I was forced to get off the motorcycle and walk through deep mud, through streams, or across logs. The professional driver proceeded through the difficult sections alone, the wheels of the motorbike often sinking in the mud above their axles.
Finally, after one hundred eighty minutes of bone jarring, butt shattering, yet scenically beautiful ride, we arrived at Centre de Santé Mundo. After weighing and measuring the children, we sang songs about nutrition, distributed handouts to the parents about constructing balanced diets using local foods, and gave hints about food hygiene.
Meanwhile the two drivers found and negotiated the purchase of a goat. They piled the radio, first aid kit, my backpack, and a mysterious nylon sack on the back of one motorcycle. On the other they constructed a bamboo frame that held one furtively bleating male goat.
A goat's cry sounds like a woman screaming. Our goat in particular was not excited about being strapped onto a wooden frame on the back of a motorcycle and his cries were especially loud.
To complicate matters further, a half hour into the return trip, the wind picked up, the sky darkened, and we heard thunder. Shortly thereafter, the skies opened with rain. We sought refuge in someone's home (people don’t hesitate to invite strangers into their homes here), opened the mysterious nylon bag, and pulled out four yellow rain suits. Perfect, I thought! Perfect except for a very agitated goat. Goats apparently hate to get wet, especially when tied down on the back of motorcycles. He began protesting wildly, crying continuously and kicking. And we were only two and a half hours from home.
At the halfway point, we stopped at Centre de Santé Twabinga and did more nutritional follow-up. By this time I was lame with stiff painful legs, sore muscles, and an aching back and butt.
At 5 p.m. we arrived at the hospital covered in mud and sweat. I led the goat to the Couvent on an improvised leash. Both of us were trembling, me from muscle fatigue and him from Post Motorcycle Stress Disorder.
All in all, it was an experience that, in hindsight, I’m glad I did despite the challenges. I wouldn't mind doing it again, but next time........ I'll go goatless.