Halfway point!

October 9, 2005

I have just realized that I am already (or only depending on how you look at it) halfway through my time in Rwanda and I am back in Kigali – we actually do finally have a telephone line in Gituza, the tiny village I am living in right outside the camp – but the system is solar based, and it is the rainy season so the times that the line is actually functional is mainly when I am at the camp.

I apologize for the long *long* silence- things have been so busy - malaria continues to be a huge cause of morbidity… children are coming in with the highest temperatures I’ve ever seen (I had 3 with Axillary temperatures of 107! … taken with two different thermometers – but the temperature inside the tent is 102 so I guess it’s not so hard to believe. Even though it is the rainy season the temperatures have not abated – the thunderstorms come with the rapidity of a pouncing lioness and are over just as quickly - leaving us all soggy (the plastic sheeting is leaking in multiple places – the biggest problem is keeping the medications dry as they are dispensed in paper envelopes). But just as suddenly the temperature is up over a hundred again and we dry out quickly.

I have not been able to resume my regular journaling so this entry will just be a jumble of impressions from the past 3 weeks and no pictures this time around but I will try to be better again I promise.


Meanwhile at this halfway point … a few tabulations

7,238 patient consultations

214 inpatient hospitalizations at our hospital

15 births

5 deaths

0 deaths from malaria (…yet)

>4,000 vaccinations given to children and pregnant mothers

1 PEPFAR grant approved for HIV programs

2 “students” acquired along the way (volunteers)

94 the age of the oldest refugee patient I have seen

20 different standardized forms created for patient records/ databases / vitals

3 new clinics started (prenatal, family planning and minor surgery)

1200 bed nets requested from the Red Cross (and tentatively promised)

On a more personal note:

<>62 consecutive days without ice-cream (I finally found some this weekend in Kigali!)

21 cold “bucket” showers taken (I’ve gotten tired of constantly heating water)

1 live snake found in the living room

1 live rat found in the bathroom

1 live scorpion found in my laptop computer

1 African swallow who makes me laugh every morning because he thinks that the bird he sees when he looks in the rearview mirror of the land- cruiser parked in front of my house is an intruder and spends the entire morning attacking his own reflection

What I miss most about home is all of you… of course. I’ve said it before but I am truly overwhelmed with the amount of support I’ve been getting from everyone. Thanks so much to the staff at Chelsea Urgent Care for those packages of supplies and goodies that are coming and all the constant well wishes!! Thanks to Marjie for getting the donations of Ceftriaxone from the drug reps and to Henry for carrying them back from Boston, thank you to my family for their constant support even though I know it’s been so hard for my parents they’re holding up well too… and to friends old and new and some I haven’t even met who have taken the time to leave encouraging messages I am so grateful.

I have grown accustomed to the climate and people here but I miss seeing the variety of faces one sees daily in America – it makes me rethink all of my preformed notions of race and ethnicity – having never really considered myself “white” and certainly not being in that category in America – here I am undeniably a “muzungu” or white person – and the only one regularly present in probably a 40 kilometer radius. Any latent rock-star or celebrity tendencies have been quickly uprooted – it’s hard not to have the freedom of movement I’d been accustomed to at home – that freedom of anonymity - I attract such a crowd of gawkers and onlookers anytime I go anywhere… I know people are just curious but it’s hard not to feel self-conscious. But the natural wildness of this landscape is becoming a part of me – the rolling green hills, the unbelievable myriad colored sunrises and sunsets and the tapestry of stars that put me to sleep every night intermingled with the sudden powerful thunder and lightning storms that happen daily all are constant reminders of how removed from the natural world we are in Boston. I already know I will be missing all this when it is time to return home. <>
So a few more jumbled thoughts and it is soon time to return to Gituza. Pictures are coming at the next post I promise…

Cassava poisoning

There has been nearly a dozen cases of cassava poisoning – mainly in women and children the past few weeks. Children come in with acute onset of severe vomiting and altered mental status after eating the roots or leaves of improperly prepared cassava. It actually is a cyanide compound in the plant that causes this when it is not soaked and washed properly… we’ve been able to manage the cases with antiemetics and IV fluids and we’ve started a public education campaign about the dangers of improperly prepared cassava but still cases trickle in. I guess if my diet was only maize and beans for months on end I would want to find some other source of food for myself and my children but the toxic effects are quite impressive – no one with permanent neurological damage or deaths… yet.

More on HIV/AIDS…

He’s hard to recognize even though I had spent almost an hour in conversation with him just a few weeks ago, or was it just last week… time is playing tricks on me. He is emaciated and lying on the bed looking at me muttering words that I know are nonsensical despite not knowing the language. I had wondered what happened to him – this is the same 40 year old who was diagnosed with HIV and who had been refusing adamantly to let his wife or five children know. His wife who is 2 months pregnant is sitting at the foot of his bed and his youngest child – 2 years old is twirling mischieviously at his bedside unaware of the drama unfolding around her. Ironic that we had just gotten news of the PEPFAR funding, Ironic that I had received word that a regional hospital would accept him as a patient and start him on antiretrovirals and ironic that he is wearing a Tshirt that boldly proclaims “world AIDS day… ” Part of me wants desperately to take his picture – with his skeletal features and vacant expression, contrasted against the cheerful directness of the message proclaimed on his shirt there would have been no need for a caption… but it seems too disrespectful. He is dying – his neighbors had to bring him in when he was no longer able to refuse – his wife says that ever since he came back from the health center and our conversation 2 weeks ago it’s as if he has given up on living. I wonder how we could have better encouraged him or counseled him. I couldn’t at the time honestly guarantee that we would be able to provide ARVs… and despite all of our best efforts to encourage and counsel him, the fact is that here in Subsaharan Africa even in the year 2005, a diagnosis of HIV + is an automatic death sentence. I don’t ask her if she knows what he is dying of – Shaka one of the refugee nurses takes me aside and says he’s sure she knows by now. I’m not so sure but it’s not the time or place to bring it up. This week is destined by be bookended by deaths – with my birthday in the middle and once again – knowing in my heart that it is a futile endeavor during rounds we sit and discuss HIV, opportunisitic infections, and which antibiotics we will give. His 2 year old girl goes on twirling and spinning smiling all the while…

He dies at 4AM – I find out the next morning and the carpenters are already at work sawing and hammering a coffin. Later that week his wife brings their 6 year old in for consultation – just a normal skin rash but she asks me quietly why her husband died. Did he talk to you at all? Yes she says – she knows that he went to Ngarama hospital for a blood test – but she says he told her everything was “fine” and showed her a paper that he said proved that he was HIV negative. She can’t read… Matilda one of my nurses – just 20 years old – and fresh from a week long training in HIV education in Kigali – offers to take her aside and counsel her. I am torn because I don’t’ know where I stand ethically – he is dead and his wife and children have a chance at life. But his express wishes were that they not know… does my obligation to him extend beyond the grave? I don’t have any idea. I ask Matilda what she is planning on telling her… she says she doesn’t plan on revealing that the late husband had AIDS but she will try to impress upon her the importance of getting tested… it seems like a really easy inference for the wife to make if she is having a nurse encourage her to get tested for HIV that the husband had it but we are respecting the actual “letter” directives of her late husband… if not the true spirit of his wishes. I imagine that he would want his family cared for however…

The next week his wife goes for testing – accompanied by Matilda…. She is negative! – she will be tested again in 6 weeks but for now there is some relief for her in the midst of all this sadness.

Politics Congo style

There was a large murmuring outside of our health center – a large transport truck had rolled up outside. It wasn’t time for food distribution, it wasn’t a World Food Program or UNHCR or ARC truck. A crowd of refugees were clamoring about outside. I ask one of the refugee nurses what is going on. He sighs and says… “politicians” I ask him to elaborate… Evidently there are elections coming up in Congo next April, one of the large political parties is made up of Kinyarwandan speakers (ethnic Tutsis mainly but others who were originally part of the area of Congo that was all one country before colonialization – Congo, Rwanda, part of Uganda and Burundi were all one land) – people are required to register to vote 6 months in advance – and so this political party has been sending trucks to the refugee camps in Rwanda with all of their “natural constituents” to bring them back to Congo so that they can register to vote. Never mind that the situation is still not safe for repatriation and that this is not a UNHCR or ARC or Rwandese sponsored activity, never mind that the Interhamwe who perpetrated the mass genocide in Rwanda in 1994 have as recently as a month ago attacked families in Southern Congo … people are getting on these trucks, lured by false promises of land and money and security – and what is worse they’re bring their children with them. My nurse says they are all foolish and predicts that they’ll be back within two to three weeks. But over the course of 3 days nearly 300 refugees depart for the Congo. I am worried about them but there is not much to do but wave sadly to the children who are screaming their goodbyes to me… Representative Democracy still has a ways to go in this part of the world…

Thank you again to everyone … I miss you all so much – pictures are coming I promise!!

All my love,
Ann