Only week three!! August 5-12

Hi everyone. It's been quite a week but I'm back in Kigali and able to post. This is a warning to proceed at your own risk... there are no pictures (I've gotten out of the habit of carrying my camera everywhere but I will try to do better next week)... also it's very lengthy so only for those truly interested in the details :)

Also - any guesses on the song quote? (Sandra?)

Last note - for those in DC - go see my friend Kate's play which is up right now, details at http://www.naturaltheatricals.com/herakles.html


August 5-6 Friday – Saturday (Ngarama)
A camp meeting / The grass is greener across the border / Part politician part preacher / did you know you were a refugee? In case you forgot / A very sick 4 y.o. and a questionable transfer

Friday afternoon, back from Kigali – headed back to the camp to see some patients. There is apparently a camp meeting though – much of the entire camp are gathered in a clearing – something is up – I’ve obviously missed something very important since being in Kigali. I am requested to come sit up front – on the side – the front 5 chairs are for VIPs… (not the latrine VIP – ventilator improved piping – I say which makes Ben laugh) there is a loudspeaker setup with bullhorn tied to a tree branch..

Ben fills me in – apparently in the past 2 nights 600 refugees have attempted to leave (about 1/3 of them successfully) to Uganda. There are rumors that the World Food program distribution in the refugee camps in Uganda are giving their refugees rice and milk, everyone gets mattresses and there is plenty of firewood and plots of land to cultivate. The meeting is to dispel these rumors – not that Rwanda is a prison – it doesn’t really matter where they go- but a lot of parents have left their children behind – on their own – as if we didn’t already have a surplus of unsupervised children.

The VIPs are the UNHCR (United Nations High Commissioner of Refugees) Africa coordinator and camp coordinator& MINALOG (ministry of local government) Local coordinator and the Mayor of Ngarama and the local Police commissioner… They arrive a full hour late. It’s a tough crowd anyways – life has been hard here and apparently many promises have not been kept. The Mayor gets up to speak first – Ben sitting next to me acts as translator. The mayor is a master politician – he first notes that all food provided to all refugee camps is from the World Food Program and that the rations of maize (unground cornmeal) and beans is the same everywhere – he also notes that the people who perpetrated the genocide – many escaped to Uganda and are waiting to kill them there once they cross the border – and perhaps the rumors are being started by these same people who want the opportunity to finish them off. He reminds them over and over that they are Refugees (in case they had forgotten somehow) and it is their job to be patient and wait until the time comes that the Congo is stabilized and they can go home. Looking at all the faces staring at us – staring at the mayor in his fine clothes and burgeoning belly – I don’t see a lot of agreement or acceptance there. He tries another tactic – how many of you are Christians, he asks? Most hands are raised. He goes full-out gospel quoting Matthew’s beatitudes “Blessed are the poor in spirit for theirs is the kingdom of heaven…” He finishes with a little Old Testament Exodus – “the people of God wandered for 40 years in the desert – you haven’t been here but 4 months and already are panicking – things will get better – just remember you are refugees and it’s your job to be patient…”

The UNHCR officials go next –and nothing much different is said – finally the refugees line up for a turn at the loudspeaker to air their grievances – they all seem quite legitimate – not enough fuel for cooking and they’re not allowed to cut down trees – no cooking materials, no blankets, no mosquito nets… the UNHCR officials are looking more and more uncomfortable – Nothing is said about the quality of healthcare fortunately and I grab Ben because it’s getting late and I want to do a final evening rounds. Also the crowd is starting to sound slightly hostile and despite the police presence – I’d rather not be in the middle of a riot (not that I think this will happen but one can never be too sure)

The minute we get back to the health center Theodore the camp manager radios Ben to come back to the meeting because one elderly lady claims she was refused treatment at our health center. I don’t see how this can be possible – we don’t deny anyone treatment – but there you have it and we both go back. Neither Ben nor I have seen this woman before – and Theodore takes the opportunity of my arrival to push me in front of the crowd and say to them that even a doctor from the United States has come to help take care of them … The crowd does nod politely and smile and there are even a few scattered spurts of applause – but I can’t bring them rice and vegetables and blankets and fuel and plots of land for gardens and mattresses and schools for the children to attend… I can’t even get them more soap.. I’m feeling so foolish and inadequate as I’m standing in front of these thousands of refugees so I take the opportunity to grab the elderly woman by the hand and walk her back with me to the health center. This produces the loudest applause of the night.

In the health center apparently one of the other providers – not Ben or I – I can’t imagine Ben saying an unkind word to anyone – was somewhat rude to the old lady – I tell her I will have a word with that person and we proceed to hear her complaints (which are many).

Saturday comes, my first weekend on call and the minute I arrive at camp there is an extremely ill 4 yo to greet me – the child came in with severe vomiting and has received fluid resuscitation (probably too much for his weight) but still has altered mental status. The child is breathing about 80 times a minute very shallowly, is lethargic and weak, and I once again miss things that were routine like say oxygen an endotracheal tube and ventilator. We give IV ampicillin and gentamycin and quinine for good measure (yes this is exactly the kind of practice pattern that I have been railing against – but faced with a critically ill child and no laboratory of radiology facilities… I have to treat for cerebral malaria and systemic sepsis) The child improves slightly with antibiotics on board but 4 hours later it is obvious that he is failing our treatment. He is still extremely lethargic has a temperature of 40 degrees centigrade and I only have one nurse on weekend nights… and a dozen other patients. I know that the local hospital at least has better staffing and oxygen – not that I think that oxygen alone will save this child but given that I barely hear any breath sounds anywhere anymore I don’t really have a choice…

We race down the dirt road with the child and mom and show up at the hospital where the nurse in the ER takes the history … Vous n’avez pas oxygen? I just assumed the hospital had oxygen – they do surgeries there for goodness sake. I will have to stop making assumptions. The physician isn’t even in the hospital. An Xray I say hopefully – maybe an effusion I can tap? No XR on weekends, how about a blood count and electrolytes – maybe a metabolic problem that can be resolved… and the lab is closed. I might as well have kept the child to die at the camp… Life is so hard here and so unfair… but I leave the child and mother in the hospital on the 3 antimicrobials he had already been started on… I feel like taking him right back up to my camp at least mom has friends there – but it would be rude – and there are more nurses in the hospital.

This is one of the days I feel so inadequate – so unable to help in any meaningful way – between yesterday’s “town hall” meeting and all the unmet promises from the UNHCR to these people and this 4 year old who shouldn’t have to die – it’s hard to swallow. I understand more Dr. Benon’s “stress” and feeling of responsibility – no matter how often you see this – it doesn’t make it right or OK… and I do feel responsible for this child’s welfare…

August 7-10 (Sunday – Wednesday) Ngarama --> Byumba
A happy ending / camp church choir / adding more windows / Back to byumba and learning to be a pharmacist / Is it time to kill the rooster?

I sleep fitfully Saturday night thinking about the child in Ngarame Hospital – the one I left under the watchful eye of a nurse but without much to offer. On awakening Sunday morning the first thing I do is go check in on the child – fully expecting to walk into the hospital and see a body wrapped in a sheet… Instead a smiling mother and alert child sitting up staring at me is what I find and I am really quite overwhelmed with relief and joy. He’s still breathing quite quickly but has definitely turned the corner – I think it’s nothing short of a miracle – I know that “kids get better fast” some of my colleagues in Indonesia, February got a little tired of hearing that mantra from me – but somehow I had forgotten it in the middle of Africa.

Next stop up the dirt road to camp to make rounds and from the tent across the way – the tent that we used for vaccinations, the tent that is used for food distribution – a church service is underway. I stand a ways off not wanting to cause any distraction – and hundreds of voices in perfect unison and 7 or 8 part harmony sing hymn after hymn – a leader sings the simple chorus first and in unison all join in. I wonder when I will stop being surprised at how resilient humans are. After all they’ve been through and are going through and all that is lacking – there’s this Sunday morning (and it really is beautiful here up on this mountain) and there’s a song of praise to be sung – and there’s still joy even in the most trodden down of hearts – and maybe the mayor had a little bit of it right Friday night– even if he was using it to illustrate a point that was misdirected – “Blessed are the poor in spirit… for theirs is the Kingdom of Heaven.”

Monday and everyone has returned from Kigali. I’m glad to have everyone back – it’s a bit lonely on weekends here. It’s the dry season and the tent I do consultations in turns into an oven by mid day – there are a few windows cut out of the plastic sheeting but only on one side and there is no air circulation. Ben and I are wilting by noon each day and the thermometer we use to check patients for fever already reads 38.5 (over 100 degrees) as the ambient air temperature. It is the dry season and the top layer of dirt and dust sticks to the sweat pouring down our patients’ and providers’ faces alike. It’s my third week of this and I know rainy season is coming in September but doubt I’ll make it to the rainy season if this continues. I ask Pierre the construction manager for the camp to “make us some new windows” on each side of the structure and the next morning (Tuesday) workmen with blades and scissors have made 3 new windows (there are some advantages of working in a tent). It’s the quickest construction I’ve seen and it definitely makes the working day more tolerable for us… I hope I won’t be regretting this come rainy season – but we’ll just have to deal with that when it comes.

We travel to Byumba Tuesday evening because there is a pharmacy training there and Theodore brings along a live rooster as a present which rides in the back of the jeep. I am feeling a little sorry for the rooster on the ride over to Byumba – it looks so miserable hunched to the floor of the back as we go over bump after bump of the unpaved road.

Wednesday and the damn rooster crows at 4AM, 4:10 AM, 4:20AM (you get the picture) right outside my window (I am feeling much less sympathetic with it) and I give up on sleep and take advantage of the running water for my second shower in 8 hours. It is a full day of a meeting on proper pharmacy management and inventory and ordering and storage and selection and how to recognize smuggled drugs– Nicole is our official camp pharmacist and I am there because as the “director” these are all things I’m supposed to know as well… there are so many things I haven’t fully appreciated having been so used to just writing a prescription and not worrying about the pharmacy aspect of it in the states…

Thursday morning begins the same as Wednesday with the rooster at 4AM and I actually ask Kebe later in the morning when we’re going to kill and eat the darn thing. He is laughing at me (I had been pleading for its life when I arrived in Byumba Tuesday) and says he likes that it crows that early because it awakens him to pray (he’s a devout Muslim). It’s an early start on to Kigali for Dr. Moses and I for more meetings….


August 11 Thursday Kigali
UNHCR & Intrahealth (NGO alphabet soup) / Meltdown at the post office / From HIV to w32.pn

Kigali (back in Internet range!! – actually was in internet range back in Byumba but my laptop was acting a little strange… more on this later) and a meeting at the UNHCR headquarters to discuss HIV testing / treatment implementation in the camps. So all Refugees in the entire world are under the jurisdiction of UNHCR which partners with other NGOs (non-governmental organizations) to manage the camps ie ARC (American Refugee Committee). Everyone up to speed here? The partnering NGO can be in charge of some of the camp activities or all of them ie ARC is in charge of the health, sanitation, construction etc at the two main camps I’ve been talking about: Gihembe (outside Byumba – Kebe’s camp) and Nyabiheke (outside Ngarame – Theodore’s camp… and my main camp). ARC runs everything *but* health care at another camp Kiziba outside Kibuye in the west, but AHA (African Health Associations) runs the medical part of that camp.

To make things even more confusing in the process of writing for this PEPFAR funding (comes from USAID, CDC, State Dept) we found out that USAID had given a large sum of money to another NGO Intrahealth (US NGO based in S. Carolina) to implement VCT (voluntary counseling and testing) and PMTCT (prevention of mother to child transmission) in Kiziba and Gihembe for FiscalYear (FY) ’05 but Intrahealth had not as yet done anything about it. No money was allocated for Nyabiheke because it didn’t exist yet. The meeting today was with UNHCR, USAID and Intrahealth and us (ARC) – (I’m not making this stuff up I swear – I couldn’t if I tried) to figure out what was going on with all this money and how it was going to be used. My ulterior motive was to get some of it siphoned off to Nyabiheke, because Gihembe already has VCT implemented. Pshew – deep breath I’m rounding the homestretch here. TRAC (treatment research aids committee) part of the Rwandan government oversees all HIV treatment in the country and needs to approve every site for VCT or PMTCT programs as well as ARV (antretroviral treatment). To approve a site, certain things must be met ie a laboratory, refrigerator, trained personnel etc… things which are still lacking in Nyabiheke. The meeting is highly informative for me because it really clarifies the lay of the land – as much as can be clarified with so many organizations. It’s almost a different kind of colonialism – well the inverse of it really – you have all these foreigners with money scrambling to spend it on helping the African people – it’s a very good thing but pretty darn confusing. TRAC designates each district’s HIV activities to be under the auspices of a certain NGO effectively dividing up the country into fiefdoms of HIV care run by various international NGOs although the vast majority are American. To have some kind of equivalence there are standardized protocols and training sessions that must be realized to be a TRAC approved site. Although as you can imagine, the quality of care being delivered is probably quite disparate.

Refugee camps have been included to an extent (ie Intrahealth given jurisdiction for the two I had previously mentioned) but because Nyabiheke is new it wasn’t on anyone’s ’05 budget. It all makes sense while drinking tea and sitting round this very nice UN conference room (real chairs… with cushions! And a table without splinters!) but it’s hard to explain this to the mother of the baby that I’m sure has HIV and the adults that come in seeking testing and care. I would love to find the means to become a TRAC approved site for at very least VCT and PMTCT by the end of the year. Of course this all takes money…

Anyhow after the meeting I am back at ARC headquarters and get notice that my package from my parents has finally arrived (my replacement sleeping bag … well two according to my mom, candy, hand sanitizer) – it’s very exciting (hey, these are the things that are exciting when you’re eating boiled bananas and boiled potatoes and boiled goat meat every night) and I’m looking forward to picking it up. The notice came in one post office where the box is, the package we go to pick up in another location “office for express mail” where the woman says I have to go to customs to get it cleared because it was sealed and listed at a value of $200. We head off to yet another office where another government official opens the box and inspects each item. Yes it’s a sleeping bag – yes it’s another sleeping bag, yes it’s 4 bottles of hand sanitizer – I demonstrate the pump action for her – yes it’s camp towels, they dry awfully quick – oh yes and soft too – cliff bars, twizzlers… nothing too dangerous here. I pick up the box to leave but she motions me to another office and begins punching numbers into a calculator.

It is very hot, I am very tired and thanks to the rooster haven’t slept much in a couple nights. I’ve been working for 11 straight days in a hundred degree tent without electricity or running water (I know boohoo poor me – I’m having a little pity party here) and then this official tells me that there is a tax on my package of gifts from my parents… the main item sent to replace something that was stolen. It’s a little too much to bear. Fine, how much? $130. US dollars? US dollars. WHAT???? That’s like 60% of the value… Yes nods the official, Rwandan taxes are quite high. I don’t have $130 dollars. I don’t even have 50 dollars. All I have on me is 10,000 Rwandan Francs (equivalent 20 USD). I am so tired and hot and frustrated at this point (and I really want my twizzlers) that I actually burst into tears in front of this woman. I am mortified to find myself crying – I try to explain all of this to her in french – I empty out my pockets so she can see I only have 10,000 Rwandan Francs I tell her I’m not selling these items, they’re a gift … I’m so distracted that it takes me a while to notice that she is even more mortified than I am that I’m crying. Please don’t cry… don’t cry she says over and over in French… if only your parents had written that this was a gift and that there was no commercial value – it’s OK, we’ll just change it – it’ll be all right – here … and in record time she takes the 10,000 francs and gives me a receipt, picks up the box herself and carries it to the waiting car. Please, please just be happy, OK, just be happy, are you OK now? I am able to let her know I’m fine and that I’m grateful for her help… and I do feel a little silly about the whole thing now… but I guess the moral of the story is that crying can get you out of traffic tickets in the US (never actually tried this one out) and high custom fees in Subsaharan Africa… (n=1 in a nonrandomized study – well I guess it’s more of a case report)

Back to ARC headquarters, package safely in hand and trying to open any file on my computer – have to revise the budget numbers for the PEPFAR proposal when everything freezes. I apparantly have quite a robust virus circulating among all my files including main execution files. NOTHING is easy today…. NOTHING I’ve evidently not been practicing safe internet / file sharing and a virus (w32.pn) has infiltrated all of my files and systems. Thankfully another guardian angel has alighted and Francis the IT guy for ARC happens to be in the office today – so now I have a French version of Microsoft office installed but my computer has been de-virused (is that a word?) and is back to it’s USOH (Usual State Of Health - sorry couldn't resist). If only one could download a patch for HIV.

Once again this is all probably more information that you needed or wanted to know – blame it on the days without internet. Thanks again for all of your support and messages, it really makes my day everytime I read them. Oh and I do welcome packages, but if sending them please write US value less than 10 dollars and no commercial value!!!