A month gone by (and a record 11 days without the net!) August 14-26

Hello all!

I'm sorry for the long silence and even longer entry - but there are a few pictures this time around! I'm still without internet access although finally moved into a permanent home - so there's every hope that I'll have a connection in the coming weeks... (hope but not expectation) I am as always thrilled to hear from everyone at home - my last entry was really not a plea (hidden or otherwise) for packages, I promise :) But for all of you who have been so kind as to offer - things in short supply on this side of the world include hand sanitizer, chocolate and snack bars... although I've managed to brew up a makeshift sanitizer from isopropyl alcohol a little glycerin and water (not as friendly on the skin but does the trick and is cheap and uses locally available supplies!) For those who have also generously offered to donate money - it's tax deductible and you can either click on the link to the right to donate online or send a check to:

American Refugee Committee
430 Oak Grove Street, Suite 204
Minneapolis, MN 55403 USA

Just designate it to ARC Rwanda, Nyabiheke Refugee Camp Health Center, and let me know so I can make sure to chase it down. Most importantly though thanks for the continued well wishes and support!

August 14-15, 2005 Sunday - Monday
Goodbye to the hotel Ngarame / Rainy season comes early / Homeless again back in Kigali

I have been living in this “hotel” of sorts in Ngarame – the hotel belongs to the Mayor and it’s been perfectly adequate housing but it also doubles as a local tavern so people are coming in and out every night and it was hard not to be self conscious every time I stepped out of my room and was met by dozens of staring men.


Bedroom of the Hotel Ngarame

My room – picture enclosed and mosquito netting which I’ve become used to sleeping under, the bathroom – no running water so those yellow jerry cans we bring back from camp where the water is filled up. To flush the toilet you pour water into the red bucket then pour it down the toilet. To bathe more water in the red bucket – and if it’s at night for the 3 hours the generator is on – these wire coils go into the bucket to heat up the water. You then use a cup to pour the water over yourself to “shower.”


Bathroom of the Hotel Ngarame

We didn’t have access to any kitchen facilities and to get anything – a bottle of water – more toilet paper – anything, you had to find one of the hotel staff who may or may not be around. Meals were all cooked at the mayors house around the corner and brought over – and meal times were highly variable … (it seemed to get later and later every night… 7:30, 8:00… 8:30.) the food was fairly monotonous, don’t get me wrong – I am thankful for any food these days – but boiled bananas, boiled potatoes and boiled goat meat can get fairly repetitive. Breakfast is tea and eggs or some bread, lunch was from my cliff bar and luna bar stash ). I think about the refugees and their constant meal of corn meal and beans and I really have nothing to complain about at all.

All this to say that it’s been perfectly liveable conditions but I am so happy to finally moving into a house of our own. Theodore, the camp manager (from Benin) and I will share a house – it has been renovated the past week and will be in Gituza another tiny village closer to the camp. There is a decent sized yard and I have visions of starting a garden – Theodore wants to get goats and chickens – but I’m not feeling all that friendly of chickens as of late.

Monday comes and it’s pouring rain – I understand what monsoon means now – and I’m back in a hotel in Kigali. Goodbye to the hotel Ngarame last night – no power, no hot water – but it was the last night – and the house was to have been finished today – our new house. I awoke early to finish the final packing – arriving at the house in Gituza it is clear that it is nowhere near ready. The house itself is situated on a lovely strech of dirt road – water is plentiful by tap (no more jerry cans!!) and the view from the front window is onto a tree lined field with mountains in the background. It has a sturdy brick frame – 4 bedrooms, a large sitting area but the beds aren’t assembled the bathroom unuseable and no outhouse even, the water hasn’t been fully hooked up… we make a hasty retreat back to Kigali where we’re promised that things will be ready in a “few days.” I’m hoping it’s true – while I am somewhat of a wanderer by nature – not being fully settled nearly a month in makes me feel a little unsettled at work too…

August 18-19, 2005 Thursday-Friday
Homeless no more / management 101 / A precipitous delivery & coding a premie



Our house in Gituza!

We arrived back in Gituza last night – me with a rather heavy heart, fearing the worst – it’s really all about expectations because in fearing the worse I actually saw what we had as completely charming – we have beds with / mosquito nets and running water!!


View from the front door of our house

Within the past 3 days when Theodore and I have been “homeless”, the water supply ran dry in the camp– something wrong with the generator – and as just another example of how health and hygiene/water sanitation is irreversibly entwined – I returned to a mini-epidemic of dysentery. Diarrhea and diarrhea and more bloody diarrhea – the young children as always suffer the worse and our pedi unit overflowed into the women’s and men’s wards. My nurses have been working such long hours – I feel a little guilty thinking of the hours whittled away in Kigali while they were seeing such a rush of patients – in fact two of my nurses look a little green and admit that they themselves have succumbed to dysentery (I know it’s a little like hitting someone when they’re down but never one to pass up a teaching moment I once again impress the importance of hand hygiene!!).

Returning after not being at the camp for several days I am reminded of my “celebrity status” as the only regular “muzungo” – kids line the rocky path up the mountain waving and cheering me on – at first I was a bit uncomfortable with all the hullabaloo but it’s really become fun for me – hamming it up and waving to them all…


Some of my daily greeters (note the sunglasses!)

As medical director of the camp I’ve had to take on some of the not so fun duties – especially as pertains to administrative decisions. I mainly try to lead by example but as things go when someone is clearly not fulfilling the requirements of their job and is being detrimental the cohesiveness and functioning of the unit – that person has to go… (gosh I’m even *sounding* like an administrator, aren’t I?) So it was with one of our staff and despite the fact that I know it’s the right decision – it’s a wrenching one because he has become a friend even in this short time… and it leaves our already strapped health center minus a senior level nurse which means that I will be on radio call every other night and working every other weekend alternating with Ben. Still it’s the only decision to make but it leaves me with a heavy heart…


More of our camp children

Friday and on arrival at camp Ben tells me that a 8 month baby has just delivered – to one of the woman who was already an inpatient – hospitalized with dysentery or possibly malaria (so the assessment reads on the admission sheet) – nowhere in the note or physical examination is there any mention that the woman is 8 months pregnant. (note to self, review the history and physical exam with my staff – I have created an admission note template and daily record progress note sheets but apparently haven’t gone over all the elements in enough detail!) 33 weeks and the baby looks perfect, she is grunting and retracting and flaring really just a tiny bit and I’m hoping with mom’s recent stress that her lungs have matured and she is able to transition without too much trouble.


Giving our newest patient a bath

She is looking well enough that at mom’s request I give her a bath with water boiled from the nutrition center. It is the last happy moment I have with the child. The mother seems to have given up on the baby almost immediately (despite the request to bathe the child)– it is her 8th child and she seems so uninterested – although granted she is feeling sick herself, but she is so beautiful this baby and struggling to survive in the harshest of conditions that I want to give her the best chance possible.

We place an IV, start D10, place an NG tube, get hot water bottles and a cardboard box filled with soft gauze… and then we have to round on the rest of the inpatients– she seems to be stabilizing a bit – or perhaps it’s wishful thinking on my part


A makeshift incubator

I had numbered all the beds a few weeks ago with pieces of paper stuck to the beds but as these things happen – the beds themselves keep moving around. Today I write the numbers of the beds directly on our walls (the plastic sheeting of the tents) and I’m much happier with the permanence. I’ve been trying to convince the staff of the utility of being more organized - I actually don’t consider myself an extremely organized person – but I guess I am when it comes to efficiency and work – I hate wasting time and it’s something that I’ve been trying to pass on and will continue to try to teach while I am here. I was almost driven to distraction yesterday by how disorganized our sign out rounds were.

We check back in on the little baby after rounds and she has tired significantly. I listen for the heart rate and when I find it is 60 I am immediately sure that this child will die. We have no endotrachial tube or ventilator or oxygen – this seems to be a recurring theme and I can’t make her lungs mature faster – no surfactant either. I call Ben over and he to my surprise immediately starts CPR, I look at him struggling over this tiny child and despite my misgivings I bend over to help with compressions. The child does start spontaneously breathing again and we make the decision to transfer her to Ngarame hospital. In the ensuing 30 minutes she stops breathing twice more. We give atropine and hydrocortisone and boluses of D50 but everytime we get her started again she tuckers out. We load her with her mother into the land cruiser to race down to the hospital. With this tiny baby, her chest bruised from our compressions but spontaneously breathing, we race down to the hospital. Mom does not at all seem interested in the proceedings – she stares out the window with a face completely devoid of emotion.

I am amazed at Ben’s persistence – it seems like it would be me coming from western high tech medicine who would be the much more aggressive one, but I just don’t see any scenario in my mind’s eye where this baby lives. Ben gets an Ambu bag with baby face mask from one of the hospital staff and starts giving positive pressure breaths – we have coded the baby over the course of 3 hours, 6 times and in the hospital do 3 more rounds and yes we restore spontaneous breaths and circulation but it really is a futile endeavor. I finally have to take his arm as he is reaching for the Ambu bag yet again and say “enough.” I am in tears but it is time to let this child go. We ask mom if she wants to hold the baby as she takes her last agonal breaths but mom says no and waves the little bundle away. So she dies in my arms and Ben can’t bring himself to stay in the room. He has four children of his own, and his wife is 35 weeks pregnant so I think it is a little too close to home for him and why he was so aggressively attempting to resuscitate the child. On the way back up to camp Ben talks about getting oxygen tanks and resuscitation equipment in the camp. I don’t say to him but I think to myself that no amount of oxygen would have saved this baby here in Rwanda. The hardest part for me is that the child would have been an “easy” save in any NICU in America. She was almost twice the size as my niece was when she was born and Emily is the most beautiful and intelligent toddler in the world now (no I’m not biased at all)…. “where you live should not decide whether you live or whether you die…” but it does.

Returning to camp is hard – we instruct the construction crew to make a little coffin. But there are a waiting room full of patients to be seen – despite the fact that the dysentery epidemic has mostly been controlled now that the water supply is plentiful again. there remains the daily URIs, scabies, gastroenteritis and continued malaria patients. I spend most of the afternoon in minor-surg clinic removing this skin lesion or another and suturing the finger of a toddler – we only have 2.0 suture which is quite large – but as I’ve been learning you make do with what you have…I try not to think of how much I’m violating sterile procedure and just use a lot of betadaine and alcohol…

August 20, 2005 Saturday

Another weekend on call and I’m mainly working with one of the refugee nurses, Shaka – I have been so impressed with his quiet strength and uncomplaining attitude – he and his 10 year old sister share a tent – they lost their parents in the fighting in the Congo – he does his work efficiently and thoroughly and hears something once and puts it into practice immediately. We are only allowed to pay refugees 400 Rwandan Francs (about 80 cents) a day and a nurse makes the same amount as a cleaner if they’re both refugees and about 20 times less than my Rwandese national nurses. It doesn’t seem fair – as most things don’t in this world I’m discovering but I’ve never once heard a negative thing come out of Shaka’s mouth. Today though I discover his sense of humour – he has been somewhat reserved on rounds but today he teases mercilessly about my abuse of the French language.

Of course 5:30 PM brings an emergency (it’s funny how some things in medicine are truly universal ie the arrival of an emergency just at change of shift) and it’s an older man with malaria and depressed mental status rigoring on the table in front of me – I start the quinine infusion, and give a bolus of D50 without a moment’s hesitation (I laugh thinking back on my prior case record of one solitary patient I’d ever treated for malaria in my entire career before coming here). He gets dramatically better and as I’m packing up to leave we have a woman run into the center saying that a friend of hers is about to deliver a baby. It crosses my mind to deliver her in our health center and then I decide that’s absolutely insane because we have no delivery kits and no sterile instruments and no OB nurses… so we drive down the hill to pick up the woman from her tent who clambers into the land rover with two other women - her mother and a sister. The woman in labor is 19 and having her second child – which is not at all uncommon in this culture – I find myself hurtling down this mountain yet again in the dark – I think that Immanuel our young driver is taking advantage of this “emergency” by driving even faster than he normally does – the recent rain has made the dirt road very slick but he is an expert driver despite his youth and I don’t feel anxious at all about the ride.

The anxiety comes from the moans emanating forth from the rear of the land cruiser – the contractions are coming faster and I hear grunts starting and I say “DON’T PUSH” really loud in English which makes everyone laugh. Then in a completely surreal moment where time seems to freeze the other two women in the Land Rover start singing piercingly beautifully and clearly – “It is a hymn” says Immanuel my driver the words he struggles to translate but says are praising God and creation – and the 19 yo in labor ceases her grunting and slows her breathing to listen to the song. It’s yet another truly indescribable moment – careening down a mountain in pitch black surrounded by banana groves with 3 refugee woman – one nearing delivery and the soundtrack is this beautiful wild song being sung by 2 of them. I think if I die at this very moment going down this mountain – there wouldn’t be any other way I’d rather go.

We get to the hospital before the baby enters this world, but just, and a loudly screaming boy is delivered within minutes of entering the delivery room. Normally I would have stayed a little longer but I’m on emotional overload and want to see how the elderly man with malaria is doing. Back up the mountain in the pitch black – he is doing fine – has ceased rigoring completely and is speaking coherently…

August 21-23 (Sunday – Tuesday)
Humble beginnings/staff meeting

Sunday morning and the voices of singing from the church services echo throughout the health center of the camp. I work with Nicole the head nurse and pharmacy coordinator who is the model of efficiency and we see patients briskly. One of the refugee women has delivered last night at home in her tent her husband comes and tells us and we go for a house (tent) call to visit the new baby. It’s my first time in one of the tents and it’s as humble as it seems from the outside. Dirt floor a couple blankets for padding no furniture or beds to speak of. But there is this glowing mother and beautiful baby in her arms and two healthy babies in two days lessens somewhat the pain when I think of the small body buried in the coarse wooden coffin behind the health center.

Monday comes and I hold my first official staff meeting – there is an formal announcement of the nurse who has had to leave – I’d rather just have everything out in the open so we spend a few minutes discussing the issue. Thankfully we quickly move on to my goals for the health center which are 1) instituting a family planning clinic 2) getting the laboratory up and running 3) ditto with the OB/GYN department 3) HIV / TB programs 4) public health education program with the animateurs and 5) some kind of children’s / mental health efforts. One goal is immediately realized when a driver comes into the meeting announcing that the laboratory equipment has arrived! I ask for further suggestions from my nurses and Hannifah who has a special OB interest points out that we really need to start a prenatal clinic. “Great I say – how’d you like to be in charge of it – we can start on Thursday! (in two days)” She is a little taken aback I see but rises to the challenge and nods her acceptance.

While the house renovations are moving along slowly we still don’t have a phone line and I had planned to go to Byumba today (Tuesday) to meet with Dr. Moses and be able to have internet access but as things happen, logistically ttraveling to Byumba today was impossible. I am disappointed but my dependency on email is slightly lessening – we get out satellite TV dish today and not having had cable really ever in the states I now have access to 80 some channels including the Food network, MTV and MTV2… I’d trade it all in an instant for a phone line though…I just have to be patient I know it’s coming…

Wednesday-Friday August 24-26, 2005
Moments of pride / Visitors / The face of AIDS


Morning signout rounds with my nurses

Wednesday starts as any other day – signout then morning rounds – we have become such a picture of efficiency – by the time I arrive in camp at 8:30 everyone is waiting – the evening nurse ready to give report – the admission sheets ordered by bed numbers in a separate folder – 7 smiling faces greet me as I say Marimutze meza (good morning!) while walking to the tent. I am touched because the 2 evening nurses who have been working since 5 PM the previous day have all started staying throughout morning rounds – this despite the fact that I try to tell them to go home and get sleep. I don’t think they’re staying just to humour me – at least I hope they’re not – and more and more they are active participants in rounds asking questions of the patients – jumping in to do the exam – anticipating my questions and answering them before I even ask. I feel like a proud mother!


The little girl standing was a patient hospitalized with malaria - she would pretend to be asleep each time we came to round except after hearing us say she could be discharged she jumped up from the bed and gave us a smile

More malaria, less dysentery – a few cases of pneumonia - one of which is a man who I’m sure is in the late stages of HIV/AIDS and who despite our financial restrictions I can not help but decide transfer the 20 km to the nearest counseling and testing center and also to refer for CXR / sputum analysis for TB. He is only 40, married with 4 children the youngest of whom is 2 yo. Talking to him I get the sense that he is fully aware of his diagnosis although he says he hasn’t been tested. In the Congo where he used to live, he says, the only thing a person thinks about doing when they get a positive test result is committing suicide. He says his wife will leave him if he tests positive and she finds out. I can not honestly guarantee him that we will be able to provide antiretroviral treatment at this point – but he does still agree to go for testing after being reassured that the result will be completely confidential.

A woman in late stages of liver failure with massive ascites who we are treating with the only diuretic we have – furosemide is slowly slowly diuresing but seems to know that this is just palliation – she tells me that she is afraid of dying this morning… all I can do is hold her hand and assure her the best I can that she really is as likely to die as any of the rest of us today at any rate (which is mostly true.)

Thursday and we have visitors from USAID and Family Health International who are doing a site assessment to determine needs (and FUNDING!!) for Family planning and Gender Based Violence education and training. We meet with a group of refugee women who candidly discuss their lives – from awaking early to start grinding the corn to taking care of multiple children (their own and other orphans) without much help or support from the men – I can tell our visitors are affected by the stories they are hearing – I just hope it translates into practical help which is so desperately needed.


The women's focus group with our NGO visitors

Another moment of feeling like a proud mother – Hannifah has completely taken off with this idea of a prenatal clinic and along with Matilda and Louise (2 other of my nurses) there are almost 50 pregnant women waiting to be seen! It’s a good “show” for the visitors – she meticulously weighs, takes BPs and measures fundal heights of all the women. After finishing all the exams (working straight through the lunch hour) she holds an impromptu education session in our still unstocked unsupplied maternity ward – everyone seated on the floor - educating on nutrition, safe delivery practices, and even family planning – I am bursting with pride as I sit back and take it all in – the women are so eager to learn and Hannifah has definitely connected with them. When she asks how many would like to be tested for HIV I only see 2 or 3 out of the 50 that do *not* raise their hands…

Hannifah giving prenatal education to the expectant mothers in the camp

Friday and another visitor, this one from EGPAF (Elisabeth Glaser Pediatric Aids Foundation) Dr. Jeroen is actually a Dutch HIV expert working for yet another American NGO, who has been funded by USAID to institute HIV programs in the Ngarame area – he is very much open to trying to help us institute an HIV program in the camp and it’s too perfect that he is present when the man that we had sent down to be tested a few days previously returns to us after finding out his result (which unsurprisingly is positive – it has taken him 3 days to get the result however between transportation issues and staffing issues at the Ngarame clinic). He is still resistant to telling his wife and children and becomes upset at any further efforts to persuade him. He looks emaciated and is clearly dying – (with a wife and four children to leave behind) and I will have to find one way or another to get him started on ARV treatment (which will equal life for this man) funding or no… It hammers home the urgency of the issue in a way that no proposal or numbers could ever do.

I am going to have internet access (11 DAYS now without!) as it’s finally a weekend off and to Kigali… so I will be posting this lengthy installment shortly… I am well – and leaving you with a picture of sunset over “my” camp – because it really has become my camp now… I am tired to the bone but this is the most rewarding work I have ever done. I’ve had several bouts of homesickness – which lessen so much when reading all of your messages and well wishes so thank you so much for all of your continued support – I couldn’t keep doing what I’m doing without it!



All my best,
Ann