Thursday, August 04, 2005

A Vaccination Campaign and Kigali for a day

Wednesday morning (Aug 3rd) rolls around and I am still nervous about the vaccinations that are supposed to happen today. We get to camp early 7:30 AM to round on our patients before meeting up with the local district health coordinator who is bringing supplies and nurses to start vaccinating at 9:00.

All of our patients are recovering, asthmatics (who I'm treating with aminophylline drips - we have no albuterol!), malaria, a child with a septic hip, a severely dehydrated 2 kg baby (who I'm sure has HIV but we don't have the money or the laboratory for testing --> I'm working on it though..) who is doing better. The nurses are now asking questions left and right and rounds is quickly becoming my favorite part of the day. We talk about logical antibiotic choices today and stepping back and assessing the clinical condition of the patient before shotgunning with 8 million different antibiotics. Even in the past week I can see a difference in practice patterns, the new admits don't have 4 antibiotics written for.. there are less IV's and more Oral Rehydration Packets being prescribed. It's a slow process but so gratifying.

After finishing rounds we make our way out to the tent where there ostensibly were supposed to be stations set up, corridors roped off and lines and lines of children w/ parents waiting to be vaccinated. It's 8:45 and the district health supervisor and nurses will be coming in 15 minutes. The tent is completely empty. There are no chairs or tables... there are no community health workers... there are no patients to be vaccinated... As hard as I pushed for the vaccinations to happen this quickly - I definitely feel like it's an embarrassment to me and the camp if things don't go well.

I am as frustrated as I have yet been in Africa - and I let it show... which causes consternation of the nurses and a flurry of activity around me (none of which is very productive). I think that while men in this society often are stern and show when they are not happy - the women do not and so everyone is surprised. I manage to take a deep breath and start delegating specific tasks to specific people.. I should have a little more faith because once directed - in a relatively short amount of time we are set up. The vaccines arrive and so do flocks of people and we are underway...

There is very little for me to do once the lines start moving and the nurses do the vaccinations - I sneak away to the nutrition center to check in on the inpatients there and see the large noon-time supplemental feed and 3 of the most angelic little girls, two with the largest smiles I have seen on children since coming here. They must like their porridge. I tasted a bit and can't say I cared for it too much...

The three feeding center muses

I feel badly that I almost lost my temper and as Ben and I debrief later that night he told me he had a meeting with the Community health Workers (CHWs)who are all refugees - they were chosen because they could speak French and read and write a little, not because they have any medical background and they weren't clear as to the urgency and importance of vaccinations. In three weeks since they were appointed they have had no training at all. As with most things here it is not deliberate laziness or insubordination, it's just lack of instruction. We draw up a lecture schedule of basic health topics (hygiene, prevention of spread of infection, malaria etc) and I ask Ben to bring this back to the C.H.W.s and ask for anything else they would like to learn about. They are delighted - and also want to help with the weighing of patients and taking vital signs!! Which I'm glad of because we did not have any money in our budget to hire any new workers... Around 500 children were vaccinated Wednesday and about that many tomorrow (1200 kids < 5 yo here) and they received *all* vaccinations which I am very impressed by: BCG, Polio, Diphtheria, Pertussis, Tetanus, H. flu, Hep B and Measles!

Thursday (Aug 4th) and I am back in Kigali after seeing the 2nd day of vaccinations start *incredibly* smoothly - everything is completely set up by the time I get to camp at 8:00 AM! (Oh ye of little faith!!) I meet with Barry (the country director) and two U.S. State Department /BPRM (Bureau of Population, Refugee and Migration)folk who are helping us with a proposal for funding to start-up HIV education / treatment in our camps. There is a lot of paperwork and numbers involved (two things I'm not fond of) but it is so important and even though the amount of money they *think* they can give us is less than 10% of what we need, any bit helps and we'll see where this goes. In the meantime I will dig around for other potential funding sources (Clinton fund, Does anyone have Bono's address or phone number?)

It's hard because refugees fall between the cracks and aren't written into anyone's specific plan when it comes to HIV education and care for Africa. We've spent so much money on just getting clean water, latrines and dwellings built (all of which are *absolute* essentials) that there really is very little left over for anything else. Even the medications are coming from money pulled from other parts of the budget. The UNHCR is supposed to provide satchels of "essential meds" but have not yet sent *ANY* - once again I don't think it's a lack of will - as Barry says if they *had* them they would send them - their budget has been slashed as well. So I'm becoming an expert in creative management of medical problems...

Anyhow I'm in an internet cafe in Kigali tonight after making an excursion to the "Chinese Store" run by a family from Shanghai who came 7 years ago to Rwanda - I didn't have enough time to ask their history as my cab had its meter running outside - but I'm sure it's fascinating, maybe on my next excursion... I even got to speak a little Chinese to the owner which with the recent Spanish to French / bits of Kinyarwandan transistions is really quite comical but she does understand most of what I'm saying. The Chinese Store is famous in Kigali for having everything from volleyballs (yes I bought one) to thermoses to Irons and every kind of paper or dishware product you could ever imagine - and yes.. it's all made in China.

Thank you all for your messages - I have read them all and love reading them (Maggie, Jackie, Paula, Kate, Janet, James, Louise, Nii, Don, Karon, Kate, Shan, Syd, Sharon, Anna, Melissa, Joyce, Tim, Amy, Byron, Tim & Leigh Anne, of course Mom & Dad.. sorry if I left out anyone - it's getting late and the cafe owners are glancing daggers at me...)

Back to Ngarame first thing tomorrow where I will spend the weekend on "call" - I've been warned it's deathly boring *and* still no internet access, but I'll read and catch up on sleep, plan my lectures and hit the volleyball around with the kids... I'm sure it'll be a nice pace compared to the last few days. I will post whenever I get in internet range - thanks for all your well wishes. Lotsa love, Ann

Thursday July 28- Tuesday August 2

Byumba and an internet fix/ Kigali Chinese Restaurants and never leaving the Novatel / “yes, it's really only me”/a staff meeting/ back to Ngarame / skeptical about tomorrow’s immunizations

Reading the U2 Documentary (U2- at the end of the world - thanks Shan) has made me a big fan of the divided title line as above. This past weekend I was finally back to Byumba which seemed like the cradle of civilization after Ngarame – staying with Kebe (the Senegalese camp manager of Gihembe camp) was like a reunion with an old friend. My room still had my stuff in it given that I wasn’t sure how much time I would be splitting back and forth and it was nice to come “home” again. Back on the internet was probably the closest I’ll get to a drug high given my aversion to mind altering substances. But the speed of the land line was so distressingly slow that I ventured into town to the internet café. Now when I say “town” it really is a town compared to Ngarame but I don’t want to mislead anyone – still with dirt roads, plywood construction… but there is an internet café and I am not ogled too too much there.

Louise has an extra room at the Novatel – well it’s her room but she’s going to a wedding on Saturday in Butare (south) and says I can stay there if I decide to go on to Kigali. It’s settled when Kebe says he will go Saturday morning to see a friend of his in Kigali and I can catch a lift with him – so off we go Saturday morning. The Novatel is this very very nice hotel in the middle of downtown Kigali – it’s complete with pristine swimming pool, patio dining, minigolf, tennis and volleyball courts out back. It’s where I stayed the first night I was in Kigali – interestingly Louise has the exact same room 216 – I wonder if it’s an ARC special… I don’t think I was fully appreciative of just how nice the Novatel was the first time around coming right from the first world. After my four days at the “hotel ngarame” it is in fact as close to heavenly as accommodations can get.

Kebe drops me off and we agree to go to an Ethiopian restaurant for dinner later that evening. Kebe’s not a big fan of Rwandan food (can’t say I blame him) and says there are no good Senegalese restaurants in Kigali. I adore Ethiopian food and I figure as long as I’m in Africa … (even though we’re really nowhere near Ethiopia) – it’s like someone saying that as long as they’re in France they might as well have Polish food…

Oh and wireless internet access… the Novatel has wireless access and I catch up on the Mariners (unfortunately) and the rest of the news, surf the web at high speed and generally become glassy-eyed, which isn’t quite as sad as it sounds given it is accompanied by a cold beverage lounging next to a pristine swimming pool surrounded by tropical foliage.

Kebe calls and says he’s on the way and I realize I’ve managed to exhaust 7 hours without leaving my poolside locale. I drag myself up to my room to change and meet Kebe in the lobby. A week of Africa has made me a little langourous in my timing – everything takes longer here – as Thedore pointed out “In America Time is Money – in Africa time is time” and Kebe is one of the only people I have met who is ultra ultra punctual – well to his schedule – like when he says he wants to go he means *NOW* where everyone and everywhere else the past two weeks it is really a gentle suggestion or even an abstract idea when someone says “let’s go”

Kebe’s friend works as a criminal investigator for the international tribunal (United Nations - can you imagine a job that would shake your faith in humanity so much - he investigated Serb atrocities in Bosnia and for the past 7 years, Rwanda) and is driving the largest minivan / sport utility gold monstronsity I have ever seen. It’s wider than a Humvee and up higher, it’s bigger than my apartment was in Boston… Kebe announces that there is a “small problem” with going to the Ethiopian Restaurant. “Oh” I say – disappointed, “was it closed.” Well no, well yes “the owner was shot.” I don’t really want details. He and his friend have the brilliant idea of going to Chinese food. I am very skeptical about Chinese restaurants (have grown up in one) even in the states but to go to one in Rwanda – well it’s an opportunity that really can’t be duplicated. It’s true that anywhere in the world that there is money to be made – there you will find a Chinese Restaurant. Kebe and Assama (his friend) say the same thing about the Senegalese (minus the restaurant bit).

The restaurant sits on the top floor of an office bulding (go figure) that among other things houses Rwanda Telecom (I’m disappointed they’re closed so I can’t personally go in and lobby for a line to connect me to the internet at Ngarama). It’s the oddest thing to me to see the classic Chinese décor complete with red hanging paper lanterns, red table cloths, the doublehappiness sign on the chair cushions – but all the waitstaff are black Rwandese. It’s a little mind numbing and I get such a sense of dislocation – like I am floating around a little above where the experiences are going on – I can’t unite all of the worlds I have been in the past few days – it’s been too fast-paced and the rapidity of changes makes my head spin. The food is perfectly adequate Chinese though – about a middle of the road restaurant in anywheresville America. Kebe and his friend get such a big kick out of bringing me there that it’s completely worth it for that aspect alone.

Louise has unexpectedly returned to the Novatel instead of staying the night in Butare – she has had quite an adventure with the Rwandan wedding planning – which as everything here never goes exactly as planned. And she has had to come home in the dark = something we are advised *never* NEVER *NEVER to do = don’t travel in the dark is like a mantra – unless you really want to tempt fate. We meet up with her on the patio and she is obviously harried but glad to be back in one piece.

Sunday comes and I was planning to go to the Genocide memorial having finished a book on the Genocide but I can’t bring myself to leave the Novotel. Henry calls – my friend from Partners in Health who is instituting Antiretroviral treatment for HIV patients in southeastern Rwanda and says he’ll spring me from the hotel since he has his own vehicle. I really don’t want to leave I say – it’s very nice poolside. Henry and his colleague – a recent pediatric grad from Dartmouth and a visiting 1st year Dartmouth student walk openmouthed into the lobby of the Novatel and out to the back patio. I think they’re getting an idea of why I’m having such a hard time going anywhere in Kigali – to set them straight I feel obliged to tell them that I am living most of the time in much less posh accomodations in Hotel Ngarame to the tune of no electricity, running water or internet. I’m telling Henry and his colleagues about my first week at the camp and they keep commenting on the fact that I’m “alone” you mean there’s no one else? They are coming from a place with abundant funding having been taken in hand by the Clinton foundation and have multiple American doctors now working together. It’s funny but I really don’t feel that alone.. not yet anyhow ... we discuss collaboration and funding options... Henry knows people who "know everyone" - it's nice that he's around.

The second of 2 Chinese meals in Kigali in two nights, Louise's last night in Rwanda, this time around (from left around back to me, half of Kebe, Samassa, Louise, Top (from Kigali ARC office, finance) and me

Sunday night and we go back to the same Chinese restaurant - this time with Louise - it's her last night in Kigali and as if that isn't disorienting enough - why not a Chinese restaurant?

Monday and a meeting of the camp managers w/ headquarters in Kigali. I fall asleep several times before discovering the ARC office has wireless internet. There’s lots of talk about budgets and such – things that I'm just not very good at paying attention to, (although I need to goet better. I turn on my computer in pretense of checking HIV proposal stuff and spend most of the rest of the time instant messaging with Tim who happens to be logged on in Hawaii – his Web cam is working too so I actually get to see him! We forego trying the voice conversation b/c it would be a little too obvious in the middle of the meeting.

Sunset on the way back to Ngarame

Finally we head back to Ngarame where on the road the sun setting behind the green hills makes me feel like there's nowhere else I'd rather be in the world right now. I check in on a few patients at the camp - who are all doing well on the way back to our lodgings. Tuesday and a full day of consultations, but baby steps – I have numbered all the beds and booklets so we can find patients easily. Now all we need is the whiteboard where we can sit and discuss the patients… I’m tired by the end of Tuesday – I think I will always be tired by the end of my consultation days. Ben laughs and says it's because when the camp hears the "Muzungu" doctor is working they line up with any and all complaints.

I have told Richard he is in charge of getting the vaccination logistics set up – we are supposed to have the mass vaccination take place Wed – Friday. We confirm with the hospital coordinator that there is in fact vaccine that is being driven back from Kigali. I had met with the district health supervisor as one of the first things when I had arrived - after finding that no immunizations had yet been given - we hammered out a deal and he said that if we provided him a list of children with the vaccinations needed by Friday (which we did) - by the next Wednesday (tomorrow) he would come up to the camp with the vaccine and supplies and a few extra nurses

Richard, Ben and I pick a site at the camp where normally the food distribution takes place – and discuss forming five lines, needing chairs and tables, and needing the community health workers to go out to the refugees' dwellings and inform everyone to bring their children. Richard says “no problem” but I’m not all that convinced that things will be as organized or – even organized at all. I can only hope for the best as I drift off to sleep under my mosquito net at 9PM...