Postels Blog: Lubutu, Congo

The End

2010-01-24T18:50:00.000-08:00

(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

2010-01-18T07:58:00.000-08:00

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

2010-01-13T06:51:00.000-08:00

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.

Christmas

2009-12-29T09:00:00.000-08:00

This was my first Christmas completely removed from the United States. It has been very different and wonderful.
The most obvious differences have been the weather and wonderful lack of commercialism. As anticipated, Lubutu’s Christmas weather is tropical. Christmas Eve was very hot, with the blazing Equatorial sun in a cloudless sky. Though I cannot say I enjoy sweating on Christmas, it has been nice to escape the West’s commercialism. No one has disposable income here and there is nothing to purchase anyway. Last week I spoke to Kurt and we talked about his anxieties of his yet unbought gifts for his parents and siblings. It was difficult to relate. In a different conversation, my mother asked if it was all right for us to exchange Christmas presents in February, after my return home. The question was so alien to my current situation that it took me a few moments to think and answer.
Though the contexts of weather and commercialism are different, I had an unforgettable holiday. On Christmas Eve I went to church at the cathedral directly opposite Couvent. Four of us entered into a crowd of about 600 people, all beautifully singing, swaying, and dancing. Ten altar boys danced in synchrony, surrounding a motionless singing priest. The interior walls of the church’s vaulted ceiling amplified the passionate voices. We initially joined the large group standing in the rear, dancing and clapping. When the hymn was over, several people offered us their seats. We initially refused but it was clear this was a losing battle. We eventually sat down on a backless wooden bench and listened to the service being conducted in Swahili.
In a forward corner of the church stood a crèche. The figures all had black skin and the manger lay under trees and a roof constructed of banana leaves. The only other decorations hung across the width of the sanctuary. Strings of thousands of packing peanuts criss-crossed over the congregation’s heads. Many more hymns followed with drums providing the only accompaniment. We clapped in time to the music as everyone sang passionately of the holiday.
It had a fantastic Christmas experience here in non-commercialized tropical Lubutu.

Bisoke

2009-12-16T10:57:00.000-08:00

I planned to spend two days in Rwanda's Parc National de Volcans. Yesterday I satisfied my curiosity about the mountain gorillas. What next?
There are three choices of non-gorilla activities. The most popular is a short hike in the forest to spend time with golden monkeys. Like the gorillas, these small primates have been habituated to human contact. I asked several people about the experience and received reviews varying from "fantastic" to "they were up in the tree tops so don't waste your money." So no golden monkeys for me. Another possibility for a day trip is a hike to Diane Fossey's grave. She lived in these mountains, studying and educating the public about mountain gorillas. She was murdered in 1987 and is buried just outside the park boundaries. Not having read or seen "Gorillas in the Mist" I decided to forego this activity. The third possible choice is Bisoke.

Parc National de Volcans encompasses five extinct volcanoes. They form the border between Rwanda, Uganda, and the Democratic Republic of Congo. From the Rwandan side it is possible to climb two of these mountains. Karisimbi is a two day trip but Bisoke can be hiked in a day. To me, on a visit to Volcanoes National Park, isn't it logical to try to climb one of the volcanoes?
The National Park charges seventy-five dollars per person (including a guide) to climb the mountain. As I predicted, there were no other tourists wanting to go today. I had the guide to myself! I am sometimes a fast hiker and groups of varying abilities can be exasperating.
We began the trip by walking through beautiful fields of flowers resembling daisies, grown and harvested to produce a natural insecticide. After a gradual ascent through the flowers, we crossed a stone fence that encloses the national park, built to keep people out and wild animals in. The going got rough almost immediately. The path was steep and very muddy. Following each step forward I slid back a half step. The guide and I proceeded through several different vegetation zones and saw a lot of fresh droppings (including gorilla) and footprints, but no living animals. The path got steeper and I repeatedly thought "how are we going to go down this?" I considered calling it all off several times (40% of tourists do so) but 4 ½ hours after starting, we arrived. At the summit of 3711 meters (about 11,500 feet) lies a perfect crater lake. On the other side of the water lay Congo—home!

After a short break for lunch we started down. For me, this was much worse than ascending, though faster due to my innumerable falls and slides. My hiking boots were dirtier than I have ever seen them, likely due to hundreds of dunkings in 6 inch deep mud.
The path down took slightly under four hours. When we crossed the stone fence to exit the park I was exhausted, happy, and relieved to have stopped sliding and losing my footing.
Was it worth it? Definitely. Would I recommend it? Only for people who are very fit and have excellent hiking boots, rain gear, and lots of determination. And only in the dry season, though the guide told me there is mud even then, as the summit is usually in clouds. If descending steep muddy trails makes your ears burn with anticipation, it is perfect. I loved the experience and am pleased I persisted to the summit but tonight am hungry, tired, and sore!

Gorillas

2009-12-13T12:27:00.000-08:00

It's only money, but 500 dollars is a lot. I debated about buying a permit to see the mountain gorillas in Rwanda for a long time. To me, 500 dollars is many days of sweat and toil. Permit holders spend only one hour with the gorillas. Is anything worth 500 dollars an hour?
Here in Rwanda's Volcanoes National Park there are eight groups of habituated mountain gorillas. Each day, seven people are allowed to visit each group. A typical gorilla group contains seven to twelve members headed by one or more male silverbacks. The other members are females, babies, and younger males called "blackbacks." Each gorilla group has a name. After arriving at park headquarters at 7 a.m. I was assigned to see the Susa Group. Susa has the most members but is also the most remote. Tourists wanting to see them must be willing and able to hike a long distance.
It was a hard trek of three hours straight up the side of a mountain, beginning at an altitude of 9000 feet. The path was toppled trees and trampled plants. My feet rarely made contact with solid ground. Without a walking stick to plunge down to the earth and use as a third leg, it would have been nearly impossible.
So at noon today I had my contact with the mountain gorilla. Susa has two silverbacks, the extremely large, 200 kilogram(440 pound)dominant males. There were approximately a dozen females and as many blackbacks and babies. Bigger gorillas lazed on the ground while the babies swung in the trees. National Park rules state that humans are to stay seven meters away but one especially friendly female came much closer to inspect us.
When we were halfway down the mountain, the wind picked up, clouds rolled in, the temperature dropped, and I was drenched from my first Rwandan rainstorm. By the time we drove back to town the sun was out. Our group celebrated our successful gorilla encounter with cold beer in the warm sun. There are approximately 710 mountain gorillas in the world, all threatened due to territorial encroachment. I spent part of today with a few of them and felt lucky to do so.

Trip to Rwanda-Kigali

2009-12-10T08:48:00.000-08:00

This morning I woke up at my usual early hour, went for a run on Axe Kindu, and returned home for breakfast. There were new arrivals last night so for a nice change I had camembert with my usual horrible coffee.
At 11 a.m., a car brought me to Tingi Tingi, a widened section of pavement called an "airstrip", located 20 minutes outside Lubutu. Seconds after we arrived, a small plane landed. Out popped three expatriates and their baggage. In response, Kirstin (a Belgian expatriate leaving Lubutu) and I jumped in. The twelve seat plane took off over the thick jungle. Slightly over an hour later we landed in Goma, far eastern Congo.
After a few minutes at the MSF base, I was drivn to the border and crossed into Rwanda. What a change! The roads are well paved and have shoulders or sidewalks where people can walk. When I jump on a taxi motorcycle the driver hands me a helmet. There are stoplights and there is currency other than the US dollar.
Thankfully one of the drivers from the MSF base helped me cross the border, travel by taxi motorcycle to the nearest Rwandan bus station, change money, buy a bus ticket, and get seated on the next bus to Kigali. From the border this entire procedure took twenty minutes, unheard of in Congo.
Three and a half hours later the bus arrived. I took another "taxi moto" to the recommended but not very nice Hotel Okapi.
So many things are strange here. There is a lot of traffic. In contrast with the quiet of Lubutu, Kigali is deafening. No one stares at me or says "bonjour" even though I saw few other white people in town. There are sidewalks, lots of traffic signals and glass buildings taller than one story. There is almost everything except ice cream parlors and movie theatres. Of course these were the two things I most eagerly anticipated! Too bad.

The countryside is drastically different here. There are mostly big rolling hills, almost completely deforested of their native trees, every inch divided into square cultivated plots. No matter how steep, nearly all of Rwanda is being used to grow food.
It is overwhelming to be in this city after four months in Lubutu.
Kigali is a one day city. I have been here exactly twenty-four hours and feel I have done and seen it all. There isn't a lot her for the tourist, but what I did see was powerful and nearly had me crying in public.
Mention Rwanda to most people and they remember the genocide of 1994. For one hundred days the majority Hutus slaughtered the minority Tutsis. After it was over, one million people had been murdered. When recounting this story, Rwandans pause here and then invariably add "Rwanda was dead."
Perhaps not dead but badly hurt. To begin healing the national wound, dozens of genocide memorials have been opened around the country. Today I visited one of them, the Kigali Memorial Center.
The Center has two floors. On the first, rooms are arranged in two circles, one inside the other. The exhibits in the outer circle begin with photographs and commentary of the colonization of Rwanda, steadily leading up to the events of 1994. Video screens tell the tales of eyewitnesses and survivors. It was chilling as I remember those 3 1/2 months very well. I remember thinking "uh oh, this is not going to be good" when the president of Rwanda's plane was shot down on approach to Kigali airport. I remember the killing extensively covered in the press while no government intervened to stop the massacre. And I remember being relieved when it was over.
After finishing the outer circle of commentary, the inner circle of exhibits were even more chilling. One room was filled with carefully stacked skulls, many crushed by blows. Another held thousands of photographs of victims, submitted by their families for display.
That over, I ascended the stairs. To the left were huge photos of children. A plaque below listed their favorite toys and foods and the way in which they were murdered. The remainder of the second floor detailed other genocides throughout history-Armenian Turks, European Jews, and Cambodians, among others.
I exited the building and walked around the gardens encircling the Memorial Center. The flowers and fountains sit atop the mass grave of 250,000 Rwandans.
After an emotionally wrenching three hours, I spent the remainder of my day shopping and walking the streets of Kigali. I have ended my afternoon and now sit with a drink next to the swimming pool at the Hotel de Mille Collines, made famous in the film "Hotel Rwanda." Only fifteen years ago, hundreds of people sought refuge here, drinking the water from the pool to stay alive.
As with all genocides, the most puzzling question is "How could people do this to each other?" Not to strangers but to neighbors and friends. My one full day in Kigali was interesting and emotionally exhausting.

2009-12-05T07:39:00.000-08:00

I woke up late this Sunday morning, brushed aside the mosquito net and swung my bare feet on the warm cement floor. Stumbling into the dining room, my eyes opened wide at a much welcome sight. René, a Belgian surgeon, sat at one end of the long dining table, an open can of French foie gras before him. Fortunately he was willing to share his little piece of culinary heaven with me. We both ate so much that we left the table contented and ill. During our breakfast conversation I had heard loud noises coming from the kitchen. Jana and Remo, German expatriates, were making coffee cake. Brushing aside any thoughts of satiety, I dug in. It was delicious. Finally free, I waddled out to the terrace where Maria poured me a tiny cup of ultra-strong Lebanese coffee.

As expatriates in Lubutu we eat very well, but the food is not varied. Breakfast is bread, butter, and jam, along with coffee or tea. The bread is tasteless and has the shape of a slightly elongated hot dog bun.
Lunch is at 1 p.m. and is the largest meal of the day. It is served as a buffet on a side board in the dining room. Several identical, covered serving dishes hold the food which varies little from day to day. The buffet starts with rice, potatoes (mashed and boiled) and badly overcooked pasta. Next are vegetables, usually one raw (sliced peeled cucumbers or whole cherry tomatoes) and two cooked. Spinach is a constant and the second is always poured directly from a can, usually corn or green beans. We always have two meats. The most likely is pork cut into little chunks prepared grilled or in a bland oily sauce. Chicken sometimes appears, but into pieces and floating in a mysterious brick red sauce. Once every 2 weeks there is terribly smelly fish that forces me to eat on the terrace. The cooks deep fry plantain slices to eat as slightly sweet chips. Dessert is usually pineapple chunks. Someone drags out a few bars of Belgian or French chocolate out of the refrigerator, breaks it into chunks, and we argue the merits of one brand over another.

Dinner is mostly lunch leftovers but often the cooks prepare two plain roasted chickens (plucked next door in the kitchen- watch out for feathers!) and either bread, pizza, or quiche. The last two are a bit different from what I am accustomed. The staff uses the same dough as to prepare bread, but they allow it to rise in the pizza or quiche pan before baking. The result is a delicious thin topping sitting atop a one inch thick crust, occasionally raw in the center. Pizza toppings are corn, tuna, chicken (with bones) or canned slimy mushrooms. The quiche is always leek.

It sounds delicious, right? It is but it is also repetitive. The staff who cook our food appear to have no knowledge of spices or variety. The spinach is prepared exactly the same way each day. There are dozens of bulbs of garlic in the pantry, all unpeeled and rotten.
Condiments have saved me. I slather virtually everything in either ketchup or Bertolli pesto. I do have one special treat I look forward to each day. Remember those deep fried plantain chips? I put several on a plate and microwave until they are viciously hot. I dip a fork into a jar of Nutella and apply the black paste onto the steaming chips. After a minute, this perfect combination is cool enough to eat. People here make fun of me because I eat this every day and am clearly in ecstasy with every bite.

On Sunday the kitchen staff departs at 1 p.m., leaving the afternoon for the expatriates to get creative in the kitchen. A few weeks ago I made Chicago-style stuffed spinach pizza which was a great hit. Other have created Javanese curries, Belgian rice pudding, French eclairs, and Algerian grilled chicken—all delicious. Today started with foie gras and German coffee cake. I wonder what’s for dinner?

King for a Day

2009-11-30T09:33:00.001-08:00

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.

2009-11-29T08:19:00.000-08:00

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

2009-11-26T10:03:00.000-08:00

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

2009-11-17T13:14:00.001-08:00

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!

2009-11-14T07:31:00.000-08:00

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!

2009-11-12T07:17:00.000-08:00

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

2009-11-08T07:00:00.000-08:00

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

2009-11-02T16:32:00.000-08:00

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.

Ghosts of Belgian Congo

2009-10-29T15:03:00.000-07:00

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

2009-10-23T06:46:00.000-07:00

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)

2009-10-19T17:08:00.000-07:00

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

2009-10-16T17:34:00.000-07:00

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

2009-10-14T21:27:00.000-07:00

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

2009-10-11T08:13:00.001-07:00

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.

2009-10-06T21:53:00.000-07:00

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

2009-10-06T08:49:00.000-07:00

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

2009-10-01T20:28:00.000-07:00

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.

Searching

2009-09-28T09:21:00.001-07:00

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

2009-09-23T14:53:00.000-07:00

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

2009-09-20T19:45:00.000-07:00

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

2009-09-17T12:42:00.000-07:00

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'

2009-09-14T11:50:00.000-07:00

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

2009-09-12T09:17:00.000-07:00

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

2009-09-11T07:09:00.000-07:00

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!

2009-09-07T13:23:00.000-07:00

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

2009-09-06T10:41:00.000-07:00

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

2009-09-05T12:26:00.000-07:00

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

2009-09-03T09:16:00.000-07:00

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.

Shocks

2009-08-31T12:15:00.000-07:00

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

26 August 2009

Shocks

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

Those Crazy Relations(hips)

2009-08-29T08:07:00.001-07:00

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

Luxuries?

2009-08-28T09:37:00.000-07:00

23 August 2009

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

Mind the Gap!

2009-08-26T07:50:00.000-07:00

21 August 2009

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

Commuting

2009-08-24T16:46:00.000-07:00

18 August 2009

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

2009-08-23T16:57:00.000-07:00

2009-08-23T16:53:00.000-07:00

16 August 2009

Gifts

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

2009-08-21T19:09:00.000-07:00

15 August 2009

Heartbreaks

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

2009-08-17T09:25:00.000-07:00

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

2009-08-16T17:24:00.000-07:00

2009-08-16T17:02:00.000-07:00

12 August 2009

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

2009-08-14T14:03:00.000-07:00

10 August 2009

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

2009-08-11T12:42:00.000-07:00

Finally at my assignment location: Lubutu

8 August 2009- Lubutu, DRC

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

But I'll do it.

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

The Big Leap

2009-08-09T15:47:00.000-07:00

30 July 2009

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

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