Saturday, July 23, 2005

More from Gihembe

A view of Gihembe camp

Saturday and I have slept almost 12 hours straight. All the rush of packing and moving and traveling has caught up with me. Yesterday was spent getting a feel of the health care activities going on in Gihembe – the nurses see around 100 patients a day in “consultation” asking for help from the physician if any complaints are more complex. There is a small laboratory with ability to do blood counts and HIV testing, a small pharmacy with a fairly good list of medicines on paper although many are out currently and awaiting the next shipment. There are community health workers and traditional birth attendants.

A maternity nurse listening for the fetal heart rate

One woman has been in labor for the past day and the nurse asks me to come take a look at her. I go in and another nurse is listening to the baby’s heartbeat with a silver cone pressed to the mom’s belly. I try her way and don’t hear a thing but with my stethoscope can make out a heart rate of 140. The woman looks exhausted and on exam there has been very little descent of the baby (I of course am feeling woefully inadequate as my OB training was in medical school 7 yrs ago). Looking at the concern on the traditional birth attendant & maternity nurses faces however I realize that this is a formality and what they really need me to do is authorize a transfer. It is humbling but I know I have said the right thing when their faces show relief as I share my thought that I think the mother is too tired and the labor is not progressing appropriately and that we do not have the means to care for her at the camp facilities.

The rest of my day is spent rounding on the patients in the camp infirmary separated into a female, pediatric and mens' ward. There are 8 cots in each ward, and most are full. There are a lot of skin infections, febrile illnesses (all of whom are being treated as malaria) and diarrheal illnesses. There are also 3-4 psychiatric patients who are being given some mixture of phenobarbitol and valium,

Looking out onto the camp, I can’t let myself dwell too long on what a hard life these people have had – sometimes for almost 10 years – because it just makes me too sad. The children who are growing up in this place get to me the most and I try not to think about the learned helplessness being here must foster. The refugees are allowed to leave – it’s not a prison and there are no armed guards- but without proper papers they are exploited – can only take jobs with the most menial of wages and are at risk of detainment any time they are discovered. It’s a brutal existence.

A girl at the water pump

All water must be brought back to their dwellings in large plastic 5 gallon containers (it’s often the little girls I see carrying these). The ration of soap is one bar per person per month to do all personal cleaning as well as washing of clothes. Most of these refugees fled Rwanda or lived on the border areas in the Congo when the genocide took place in 1994 – then they were brutalized by the Interhamwe (the remnant militia that was pushed out of Rwanda into Congo) and are refugees in a sense back in their own country. It isn’t safe for them to repatriate to Congo and the Rwandan government – doesn’t see a financially viable way of settling them in Rwanda. It’s a problem that I can’t think of any solution to... all I know that there are 15,000 lives in front of me that are being kept in a state of limbo…

Louise teaching an IGP (Income Generating Project) Seminar

Still there continue to be signs of life – I finally was able to sit in on the Income Generation Project that Louise has been giving seminars on all month. She is a dynamic teacher and the room is full of adults whose hands shoot in the air with every question asked. They are so eager to learn – and it’s very basic business principles that Louise is teaching.. start-up capital, resource management, profit, investment, collaboration – but you can see from how excited and attentive the students are that this is more of what is needed – an option for them to take control of their own existences.

Dr. Moses returned from Kigali last night and was able to come over for a quick meeting. He is Rwandan and has been the Gihembe camp physician for several years now. He’s very sharp and energetic and so clearly cares deeply about what he is doing. Barry has asked me to put together a grant proposal for additional HIV education / treatment funding and Moses and I sketch the outline before he has to leave for another meeting.

I will be traveling to Ngarame tomorrow to see the “new” camp Nyabiheke where I will likely be spending more of my time as the medical care in that facility is in its infancy. Today I have my post-Mefloquine haziness and will be glad to spend time exploring Byumba and resting.

Friday, July 22, 2005

Day one - Gihembe

The road to Byumba from Kigali winds along green hillsides where steppes are carved into the hills for cultivation. Everywhere there are goats and cows being herded by scampering children. I’m still fighting jet lag and despite all of the amazing sight I am fast asleep in the careening SUV.

Gihembe – the camp right outside Byumba houses 15,000 refugees and is set at the top of a hillside. The shelters are simple wood frame with plastic sheeting for roof and walls, some have crafted supporting walls of earthen bricks, but most just have the plastic sheeting.

We go first to where I will be staying – with Kebe a Senegalese who is camp manager and have lunch. Then given the option to settle in and rest or go along with Louise (an American who has been here the past month doing seminars on income generation and starting small businesses) to see one of her workshops in the camp – decide to accompany Louise. The children run alongside our SUV as we enter the camp – waving and smiling and saying things in Kinyarwanda (the local dialect) that I don’t understand. But kids are kids anywhere and a smile and wave or a surreptitious tongue stuck out at them will make them laugh in no time.

When we arrive in the camp, thinking I will be accompanying Louise to see her seminar – I am immediately pulled away by one of the nurses for an “emergency.” The clinic is fairly bare – a few benches, an exam / consultation table and a cabinet with a few medicines. In the farthest corner in a carboard box piled high w/ rags is my emergency – an IV bottle hanging on a hook above. The little girl looks like she’s maybe 32-33 weeks gestation, the nurse says she is 10 days old and she is grunting flaring and retracting w/ thick brown mucous coming out of her nose. When I go to feel her head she feels so cold to me, her skin is mottled. She is 1,060 grams and I immediately feel the absence of my 1st world supplies. We have no incubator, warming lights or oxygen. My French is not coming back as fast as I would like and when a thermometer is finally located – it doesn’t work. Still just feeling her, she is so cold and I ask for anything that can warm her – boiled water in bottles to tuck around her rags. Once I have gotten the French words for cold and hot sorted out someone is sent to fetch the water. About 20 minutes later 3 glass bottles w/o covers, filled with boiling water arrive. We tuck them around her as well as we can, use a manual suction w/ foot pump to suction her nose out. We are out of ampicillin but to have gentamicin, the IV is running OK w/ D10 NS going in and a gavage tube has been placed (which is really quite advanced given that the camp doctor, Dr. Moses has been away and this was all done by the nursing staff).

She is getting sicker as I watch her over the next 45 minutes and I hate to think that I will lose the first patient I see in Rwanda. I tell the nurse that I am very worried about her breathing (in my broken French) and the nurse looks at me and says maybe we should transfer her to the hospital. I am *thrilled* to find that the town of Byumba has a hospital that has an agreement w/ the camp to take all ill patients. A cell phone call later (technology is truly amazing) an ambulance of sorts pulls up the dirt road and we pile the baby into the back (cardboard box and hot water bottles and all) w/ many other passengers going to town .

The hospital is several different wards – seems fairly clean – and the Rwandan physician takes the history from the nurse, writes his notes and orders without speaking at all to me. I hold back not wanting overstep my place, but am relieved when after he finishes – says to me – “neonatal infection, bronchopneumonia, hypothermia.” He has ordered an incubator (the only one I think they have) to come over from the birthing area, Ampicillin and Gentamicin and oxygen therapy.

The rest of the afternoon I spend having attracted a large contingent of children playing with them – learning to count in Kinyarwandan and allowing them each in turn to listen to their own heartbeats with my stethoscope.

Tomorrow will be my first full day of clinic … I have a feeling I will never be bored here. Thanks for all of your messages – I love reading them …


Wednesday, July 20, 2005

and finally... Rwanda

The view from my window in the Hotel Novatel, Kigali, Rwanda

2 days of travel, 4 airports, 7 time zones and I am in need of a change of clothes, bleary – eyed, tired beyond belief and I am also, finally *home*. At least my home for this little stretch of my life.

My baggage and I are all intact – which is really such a surprise to me – having had rather awful experiences with customs in Vietnam (complete with confiscated passport, dingy back room with a splintered chair, bare light bulb and a screaming guard - ask me for the whole story sometime) and Romania (just a few siphoned off items to the guards) I was expecting the worse but really had such smooth travels – for which I am exceedingly grateful.

Kigali on the outside has none of the dingy, overcrowded feeling present in a lot of “underdeveloped” areas I have been to. The small part I have seen – the roads are in excellent repair (better than Boston I have to admit) and traffic flows freely, although the aggressiveness of the drivers is reminiscent of other foreign capitals (and also exceeds Boston in that capacity as well). The ministry of justice however still has imprints of the war 10 years ago, what must have been mortar rounds that dug holes out of the brick building have intentionally not been repaired (per Barry the ARC country director who picked me up at the airport) – a sort of monument to the horrors that had happened. People go about their business here – there’s a hurried guardedness that is also similar to most big cities I have been in. There is a reconciliation process ongoing that started within the past year – with those who perpetrated the genocide being brought before local tribunals… it’s something that I don’t know how any people can recover and move forward from… so many dead and the killers were friends and neighbors.

I am staying in another quite nice hotel for the night – and on to the Gihembe camp which is outside the city of Byumba about a 40 minute drive north of Kigali. There are 15,000 refugees in that camp – mostly Congolese Tutsi’s ( I’m still sorting out the whole political situation so will clarify as I get a little more understanding). There is a newer camp to the east near the city of Ngarame – the camp name is Nyabaheke and it is literally built into the stone hills inch by inch of manual labor by hired villagers. That is where I will likely spend most of my time as the medical care is just starting and there is no physician there. The camp initially was planned for 1,000 but has close to 5000 now and is still expanding. Fortunately there is a water source – drilled straight down into the rock 80 meters. Funding is very limited and while we do have essential medications – medical supplies and office supplies (I will be trying to create a medical record system that will make sense and is sustainable ) will be scarce. There are a large number of children in the camp somewhere around 30% and concurrent malnutrition given the harshness of their time in the transit camps on the Congo border.

I am so thankful to be here and so excited to start working – there is much to be done… So many have expressed a desire to help and I will let you know when I get more details but given the cutbacks in funding from the UN for Africa projects – any help would be useful – and I have the added ability to be on the ground and can make sure it gets directly to those who have the most need… more on this also later. Now to get some rest. I do have a cell phone – not going to post the number here for obvious reasons – but it accepts international calls and I would love to hear friendly voices on the other end. Email me if you would like the number and I’ll forward it to you.



4 hours in Kenya...

The airport in Nairobi is pretty sleepy at this early hour - I had been expecting so much activity and chaos, but it's a few internet/fax shops open and a lot of closed shops. BBC news is playing on the TV in this little corner "business center." There are clocks with a leapord drawn on them that say "Hakuna Matata" (where would we be without Disney?) that post the time around the world: NY, Mumbai, UK, Tokyo - and occasional loudspeaker announcements are broadcast in Swahili, English & French successively. Thankfully the airline was able to arrange for transfer of my bags so I don't have to go out and collect them myself. I haven't received the claim tags back yet... but trust that all will work out.

It's still dark outside so I haven't gotten my first official glimpse of the African landscape. Flying into Nairobi in the dark was like any other city in the world, a lot of brightly lit buildings.

I've gone through so many emotions the past 24 hours that right now I'm just *really* tired. It will be nice to finally get to Rwanda and yes, to start working. Off to check on those luggage claim tags...

Next stop: Rwanda :)


12 hours in Amsterdam

I'm sitting here in a very modern hotel room in Amsterdam, using my own laptop w/ wireless T-Mobile connection, staring out into a green courtyard with a large evergreen tree - and I don't feel like I'm even a minute away from home. The flight was uneventful to Amsterdam - I managed to stay awake the whole time and read the new Harry Potter cover to cover (thanks Sharon) - so instead of exploring the city I crashed in a hotel "day room" considerately reserved for me by ARC. I arrived at around 8 AM local time and am leaving tonight at 8P to take a "red eye" (if that's what they're called from Europe to Africa) to Kenya (I get in to Nairobi at 6AM).

I'm a little nervous about going through Nairobi - the agents in Boston were unable to check my luggage all the way through to Rwanda (although when I told the attendants in Amsterdam they were incredulous and said it was a simple process and should have been done... but they couldn't do b/c the luggage was sealed until geting to Kenya)anyhow struggling to recover my bags and maybe even having to go through customs then recheck them while making my connection should be an adventure :)

Really not much more to report - thank you again for all your well wishes and prayers, they do mean a lot to me.


Monday, July 18, 2005

Goodbyes and Thanks

Med-Peds gang

The Fantail gang on Renee's rooftop

My Chelsea family!

It's 4AM and I am packing away still, time has run away from me so quickly and I am actually leaving this afternoon...

I have alternating moments of such excitement and sheer terror, and after all these goodbyes there's more than a little sadness mixed in there as well. I wish I could personally thank every one who has been so supportive, the fantail / Hope gang - thanks so much for the Leatherman (already used to remove the license plates from my car!) the headlamp (now that I've figured out what it is) the iPod radio tuner, and all the candy and care products.

To all my coworkers at Chelsea - I will *miss* having you to bounce questions off of - not just about patient care but life the universe and everything. I could not imagine having better people to work with. Thanks especially Kathy & Ursula for moving and storing all my *stuff* pshew, who knew I had so MUCH!! Thanks for all of the presents, boxes,laughter and support.

And to the med-peds gang, what is there to say? I think you should all come out and do a rotation with me (or Peter!).

I am continually amazed by how blessed I am to have such tremendous people in my life. Knowing you are all here supporting me makes it so much easier to go, although I miss everyone so much already. I will do my best in keeping this blog updated. Please leave messages or email...

My address in Rwanda (for those who had asked):
c/o American Refugee Committee, Kigali Office
B.P. 2680
Kigali, Rwanda

much love and many blessings,