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.