The End

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

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

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

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

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

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

Back in Business

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

Maiko Too

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

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

Christmas

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

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

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

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.