Letters home

"Not all who wander are lost" JRR Tolkien

2006-05-20T11:06:00.000+01:00

One of my favorite quotes of all time.

Leaving this time around is still hard, but it's with a real sense of security that even in an extremely unpredictable part of the world - and with a population even more unpredictable still - that the programs started will continue and the knowledge taught and learned will not be wasted.

I fly out of Kigali tonight. Thanks to everyone (too many to list here individually) for all the support and love and encouragement this whole year! I definitely would not have been strong enough to have kept going without you all. I'm looking forward to catching up with everyone back home where I'll be planted for at least a year before off and wandering again...

lots of love,
Ann

Out of survival mode...

2006-05-08T09:23:00.000+01:00

One of the most gratifying things about returning this time around is that the sense of desperation that was my constant companion from July to December is notably absent. The problems are there, it is true - but things have stabilized - the Nyabiheke health center hospital had *3* patients total for most of last week - and two were chronic (femur fracture in traction and arm wound with daily dressing requirements). It's such a luxury to be thinking about things other then basic survival, things like nutritional supplementation, HIV prevention and treatment, Income Generating Projects, Schools, Vitamin A supplementation, mass de-worming...

Here are some of the scenes from the past two weeks:

Vitamin A / Mebendazole distribution:

Community health workers distributing Mebendazole & Vitamin A

Vitamin A deficiency is one of the 5 leading causes of blindness in the world - and preventable by a 10 cent capsule... Intestinal worms are endemic and can contribute to poor growth, decreased cognitive function and anemia ... and are also easily and inexpensively treated... things were going so smoothly at the health center that I went along with our community health workers house to house to find all children under 5 and help administer the Vitamin A & Mebendazole capsules

HIV Educational Campaign "Extravaganza"

One of the skits illustrating the importance of getting tested for HIV

As part of starting up a comprehensive prevention and treatment program for HIV/AIDS, community mobilization with educational activities especially focusing on decreasing stigma and encouraging testing are underway. Gihembe camp's anti-AIDS youth club who has been active for a few years now - came to visit and support Nyabiheke's fledgling club "New Hope" and jointly they put on an afternoon of dancing, skits and music for the kids and adults at Nyabiheke.

Dancers from the Gihembe anti-SIDA group performing to a crowd literally packed to the rafters

Income Generating Projects
I've mentioned it before but I have to say it again - the difference in the camps since Louise came and helped people start their own businesses is palpable. To have an occupation while in such a tough situation - not able to return home, not able to work in the regular local economy - it truly transforms people's lives and attitudes.

Our hospital was so empty that the IGP bagmaking group took over one of our wards! (Exactly the way it should be in my opinion)

Another group enjoying a reprise from the heavy rains on a sunny afternoon

People go to "work" each day at their tailor stations or bagmaking or soapmaking stations. For those of you in Boston who'd like a handmade nylon bag (they're selling for 5000 Rwandan Francs - roughly $10 US, materials cost about 2400 and it takes about 2 days to make each bag) let me know and I'll bring one back for you or put a bunch in the mail!

The local tailors' co-op sewing a tear in my overworked and shabbier-by-the day white coat (costing the equivalent of 50 cents which I thought was a pretty good deal, but one of my nurses informed me was "muzungu price" (white people's price) telling me she would have only paid the equivalent of 10 cents!)

Outdoor School
My version of outdoor school in elementary school was going to the woods for a day and learning about building shelters and making fires and basic survival. Here the children know all those things from an early age - their outdoor school is going on while they await the construction of proper schools with walls and roofs to attend.

At school finally, under the shade of the pine trees

The compromise made between the Rwandese Government and UNHCR is that there will be a preschool and K-3 school (plastic sheeting and poles) constructed in the camp, and extensions to 2 local schools will be built to accomodate the rest of the children grades 3 and up. It's not a perfect solution but at least the littlest ones won't be walking 2 km to get to school. Funding for these projects is jointly supplied by UNICEF and UNHCR and the materials the children are using as well as the blackboards are donated by UNICEF. The teachers are refugee volunteers, serving their own community.

A Morning for Art

Ryan and Ryan are two U Wisconsin Madison students studying in Kenya for the semester. Through a connection of a connection (as these things often happen here) they stumbled onto our doorstep in Nyabiheke for a few days last week eager to learn and help in any way possible.

After observing the Vitamin A distribution and HIV activities, and being instant favorites of all the camp kids - they wanted to design a project to bring back to Wisconsin with them to educate their campus about the ongoing humanitarian crisis in the Congo and the lives of the refugees it has caused.

The children took their tasks very seriously and there was little of the mugging for the camera or gawking at the 3 muzungus that I had been expecting

With just a half day of planning we were able to gather 30 children ages 6-17 together from all parts of the camp to spend a morning coloring pictures of their lives here, what they hope for, or what they want to be when they grow up. The morning was an incredible success (I just have to mention at this point that over 50% of the children said they wanted to be nurses or doctors!). Ryan and Ryan will be putting on an exhibit of the drawings at their campus in Madison sometime this fall.

This young man drew a picture of the camp and his life here (left) and on the right a picture of the Congolese flag and himself as a politician in the future. He wanted to be a politician to make Congo safe so that he and his family and all of the refugees can return home someday.

I've been reflecting on the difference between staying alive and living these past two weeks. It's the things like education, dance, drama and art and even yes having a job, being able to have an occuption - these are things which restore dignity and allow people to live - very different than the staying alive of airway, breathing and circulation we focus so much on in the medical world (yes without this there couldn't be the other) however the stuff of living, of diginity, it's happening slowly here even in a refugee camp even in the middle of Rwanda.

This last photo is of one of our other young artists. He drew a picture of a football player (soccer for us Americans) which he wanted to be when he grew up. But on the back of the page he wrote a message which at this point, given the situation in Congo may be even more difficult to achieve than becoming a star footballer...

"My hope is to be able to go home to the Congo someday, thank you."

We hope so too...

best,
Ann

Progress

2006-05-01T23:35:00.000+01:00

I'd somehow forgotten how beautiful Rwanda is - being back in the countryside at the camps this past week reminded me - especially now that it is rainy season - everything is so green and alive. It makes the grey of London seem very very far away!

I've forgotten my cable to download pictures so those are coming next time I get in email range, I promise. Being back at Nyabiheke, with the nonstop greetings from the children and their choruses of "Doc-tor An-na" and the elders with their more restrained "Mahoro" and the hugs and kisses from my staff - it feels like home. The health center is running without a glitch - the atmosphere is so calm, so organized, none of the desperation that I had remembered. Malaria cases are down 50% since net distribution in December, daily educational lectures have continued and I wandered into a mass Vitamin A and Mebendazole distribution being done by the Community Health workers from tent to tent for all children under 5 (Vitamin A being one of the leading causes of preventable blindness in the world) as well as a new startup anti-AIDS club meeting.

The IGP groups started by Louise have definitely had a profound impact on the atmosphere of the camp - the sewing group in one area, the soap makers, the handbag weavers - people are joking and laughing together while they work. Makeshift school have been set up under the trees so the children are occupied during the day and many adults are volunteering as teachers in these schools. Classrooms are being built, a nursery school and K-3 to stay in the camp, grades 4 and above will be attending the local schools as soon as extensions to them are built. Meanwhile they are doing what they can (and I happen to think it is quite a lot!)

The nice thing about having been here near the beginning, then being away for a bit - is the ability to see significant change - in a good direction. I am so happy to be back - and realizing that my time is far to short. I really only have 3 weeks left before headed back to Boston. The HIV paperwork draft is finished - will be reviewing it this week and even though it all can't possibly get done in the next 3 weeks - what I have seen of the programs that have started and continued in my absence gives me much confidence that this will hold true with the HIV programs as well.

Return to Rwanda

2006-04-17T19:26:00.000+01:00

Hello,

I wasn't actually sure that I would be "blogging" this trip - it's such a short one - but here I am after all.

I'll be here a little over month - to institute HIV programs into the camps - as best I can - in this short space of time. After sitting in a classroom for 3 months (a fantastic experience don't get me wrong, I recommend the DTM&H London program unreservedly to anyone interested in international health) it's easy to forget the realities of being on the ground. Things seem so neat, no untidy complications like institutional and governmental entanglements, no security issues, no infrastructure problems - just treat patients and institute public health programs the "best" way - the way all the studies say they should be done...

It's a rapid readjustment, and slightly bumpy but not anywhere near as difficult as I had been imagining. Seeing old friends always heartens the spirit and I recieved such a warm welcome from the Kigali office.

Louise is finishing up her 4 month stint as Income Generating Project coordinator for all 3 camps here - she has done an unbelievable job. In the health sector you can make or help keep people healthy- but she gives them back their dignity. They have started soapmaking, lotionmaking, ladies handbag making projects (if anyone wants to buy one let me know, the bags are woven with nylon fiber and from pictures I've seen are beautiful (see http://louiseruhr.blogspot.com for more info).

Meanwhile I have been dispatched first to Gihembe camp (the larger camp of 17,000) to do an assessment before returning to Nyabiheke "my" camp in a couple days...

I am reaching the end of the year of wandering - thanks for coming along! I'll try to post a few more times before I leave.

Happy (late) Easter and God Bless all,

Ann

Boston Globe Op-Ed

2006-03-12T19:08:00.000+01:00

Just a quick link to a recent op-ed I wrote about the experience in Rwanda for anyone who is interested...

http://www.iht.com/articles/2006/02/20/opinion/edkao.php

Time is going by so quickly in London... I'll be back in Rwanda before I know it!

best,
Ann

Hello from London!

2006-01-22T18:44:00.000+01:00

Happy New Year!

I'm here in London (worlds and worlds away from Rwanda) at the London School of Hygiene and Tropical Medicine taking a diploma course in Tropical Medicine. It's definitely a change and I miss Rwanda a lot, but it's also such a luxury to be back in school. I'll be here until April!

I'm not actually sure if anyone is still checking this site but I wanted to alert whoever is interested in following along with Nyabiheke Refugee Camp to Louise Ruhr's blog site. Louise's focus is microfinance and she will be in Rwanda the next 4 months implementing income generating projects in the camps. Please see http://louiseruhr.blogspot.com for updates from the camp.

I won't be posting much (or at all) over the next few months while here in London (pretty much just going to class and studying so it's not all that exciting) but visitors are welcome! Thanks again for everyone's support and well wishes over the past 5 months. I will update about future plans (back to Rwanda vs. Banda Aceh vs. location to be determined) as soon as I know myself!

best,
Ann

Leaving Rwanda... Coming Home

2005-12-21T10:48:00.000+01:00

So my plane leaves in a few hours here from Kigali. Even up until now I have been jetting around town to various stores, working on getting prices for equipment still needed for the health center that a donor has offered to fund... it's good to stay busy though - to be able to focus on something other than leaving. Saying goodbye has never been a strong point of mine (is *anyone* good at it?)

I have a 4 hour layover in Nairobi and another one of 10 hours in Amsterdam then finally back in the Sates on Thursday afternoon. I can't even imagine being in sub-freezing weather in Boston (T 29 at last check) but then there's Hawaii on Saturday! Thanks again so much to everyone who has been a part of this endeavor... all the emails, support, packages, prayers and well wishes from everyone at home were so important - along with such dedicated staff in Kigali and at the camp.

Some pictures from the going away party, and some final views of "my" camp....

Final few hours before the party ( me in African dress - another present from Theo) with my nurses

There is never a true party in Rwanda without singing and dancing

A view of "my camp" at a distance

Moving farther and farther away....

Merry Christmas to all...

love, Ann

Tourist for a day

2005-12-18T12:18:00.000+01:00

It's easy to see the origin of the title "Gorillas in the Mist"

I didn't come to Rwanda as a tourist - and have been so busy the past 5 months that tourism was far from my mind - but I really *did* want to see the mountain gorillas before I left, and yesterday finally had the chance to go. I had read “Gorillas in the Mist” and had seen the movie but nothing really prepared me for a face to face encounter with these creatures.

With such a scarcity of land in the country, fields of tobacco and permethrin continue right up to the border of the mountains

The Virunga mountains span 3 countries (Democratic Republic of Congo,Rwanda and Uganda) and are the home to the mountain gorillas, made famous by Diane Fossey’s research, book and subsequent movie about her life.

One of the young females who blissfully continued eating despite our arrival

In Rwanda, there are 3 semi-habituated groups of gorillas that people (eight people per group plus 2 trackers) are allowed to visit, 10-13 in each group for one hour each day. We left Kigali at 5AM to make it to the park by 7 AM where we were divided up into groups. The hike was about an hour to the edge of the forested mountain region then another 45 minutes of tracking through dense brush and undergrowth – thick bamboo groves, and stinging nettles - before we “found” our group. Each group consists of a silverback male (the fur on a male mountain gorillas back is black until it reaches sexual maturity at age 13 or 14 and then it turns silver) and 3 or 4 females, a handful of babies and juveniles.

The lead silverback (all 220 kg of him) kept close watch over his group *and* us visitors

The gorillas not only tolerated us but seemed interested at times – and it was hard to respect the 5 meter distance we were supposed to keep from them when the mischievous juveniles would come up to examine us which made us all laugh. On the other hand when the lead silverback decides to move in for a closer look it’s not a laughing matter. It’s hard to squelch the urge to turn and run when a 220 kg animal is moving quickly toward you – but you’re supposed to stay very still and try not to appear a threat (whatever that means)… something I did only with the help of our tracker holding me firmly by both shoulders as I instinctively wanted to get quickly out of the way when the massive silverback decided to give us more detailed inspection…

Our tracker/guide (who was taking the picture) kept saying "turn around, turn around!" but it's not so easy turning your back on a gorilla that weighs 4 times as much as you do... I could only manage a quarter turn....

The rest of my day was spent in Gisenyi a beautiful sleepy village on the shores of lake Kivu in the northwestern region of Rwanda and then crossing over the border (by foot) into Congo for a few hours – finally being able to see the country that the refugee populations I have been serving were from.

3 more days – back to camp later today, tying up loose ends tomorrow at camp, back to Kigali on Tuesday (will finally visit the genocide memorial, something that’s important to visit but not easy to stomach) – then the long flight home…

Pictures to go with the last post

2005-12-16T12:51:00.000+01:00

Pictures as promised (corresponding with the text of the last posting...)

Nicole (our head nurse) with our new white board!

The long awaited, much needed mosquito nets! (donated by Refugees International)

Ben, my medical coordinator supervising the distribution of the nets

Christian, one of my refugee nurses explaining the importance of tucking the nets under the sleeping surfaces to keep the mosquitoes out...

A mother and child watching their new bednet being installed.

Shelter to shelter installation was time and labor intensive, but a great way to educate the population and ensure the nets are being used properly... our nurses teamed with the animateurs (community health workers) going to each shelter and installing the nets. Unfortunately often there are two or three beds (dry grass on a plank of branches) per shelter and we could only provide one per house - (the children and pregnant women are the priority to sleep unde the nets). We should be able to provide an additional 1200 nets (another one for each shelter) mid January - thanks again Refugees International!!

The ever present crowd of children - the little boy on the right probably had a greenstick fracture of his distal humerus - I had put the splint on him the day before this picture was taken and I caught him running (and falling) again the very next day!

With the rainy season ongoing, even on this rocky hillside (with a lot of work and care) there are little gardens cropping up throughout the camp. This boy was extremely proud of of the result of this hard work with his sunflower towering over his shelter...

Little boys will like trucks everywhere in the world - and the children here are quite adept at making replicas of our trucks from plastic bottles and bits of wood and string.

One week remaining...

2005-12-14T14:59:00.000+01:00

I’m not sure I can describe all these contradicting emotions that continue to course through me. It’s hard to believe that it’s already the middle of December and I have essentially completed my time here. I am so so proud of my staff at the health center – I was in Kigali most of last week for meetings with UNHCR and other organizations and coming back the health center is running without a glitch– everything is in order, in fact improvements have been made, there are new educational posters up that they have requested from the local hospital and the medicines are newly organized and labeled in our emergency drug cabinet. The folders continue to be in order with the admission files, the community health workers and guards continue to efficiently triage the patients registering their names in the medical record books and taking their temperatures and weights, my nurses continue to give educational lectures each morning… and we finally have a white dry-erase board (after ordering one in July!) to track patients and schedules… I amuse my staff to no end with how excited I get over each new item – I was bouncing off the walls after the white board came in – and did cartwheels when we got our mosquito nets!! (literally)

I could just be feeling slightly sentimental (or more than slightly) but I was sitting in morning report yesterday… remembering my first few days when I started out back in July without anything!! No schedule, (start and finish times stretched well into the late mornings and evenings - I was even chided last week by Alphonse for being 5 minutes late one morning! He is one of my refugee staff - and previously one of the worse offenders holding to the "African Standard Time" method of punctuality - meaning up to 1-2 hours late is on time )- no system of hospital rounds, no triaging, weighing and taking temperatures and doing consultations ourselves, no cabinets for medications, no laboratory, no bed numbers, no admission notes, no medication records no OB department, no HIV testing no Family Planning materials… working straight through lunch into the evening, no one washing their hands, no one even examining patients most of the time, every patient being treated with 3 or 4 antibiotics unnecessarily… we have come such a long way. And I really feel like it’s true not just something I’m saying to convince myself – that my job is complete here… that while there never is an end to learning – these amazing nurses, Congolese refugee and Rwandese national alike have absorbed every detail of every aspect of medicine I have been able to convey – from administrative to fundraising, to medical record keeping to patient care… and have really taken an ownership and pride in their health center and hospital… our health center and hospital. It’s such and overwhelmingly joyous feeling I could explode at times…

And so I float around this last week trying to soak it all in – remembering where we started and the miles and miles we’ve traveled together in 5 short months. I am so grateful to Barry Wheeler, the amazing country director for ARC for Rwanda and to Larry Ronan and the rest of the Durant crew back in Boston for giving me this opportunity – it was such a perfect almost eerily too perfect combination of events – this new camp without a doctor – my being allowed to build something – to create a health center and hospital from the ground up, the uniquely talented and hardworking local staff and refugee staff alike with everyone working so well together as a team … the support from Barry who pretty much just let me run with anything I wanted to do… any idea I had was met with complete acceptance – “go for it” was the most common phrase I heard. And the blessings that came seemingly out of nowhere whenever I wanted to give up - whether from the MGH Chelsea Urgent Care crew at home, my family, UNICEF, Refugees International, EGPAF... I have been incredibly lucky.

I am almost certain I will return in April – depending on my funding – to help finish the last piece – the HIV program. Our PEPFAR funding was approved and I just found out we have received additional funding from OPEC nations through UNHCR (part of all those agonizing meetings last week) also for HIV activities – So my job largely in April (if I’m able to return) will be setting up a HIV testing and treatment center within the camp. We have been so fortunate to partner with EGPAF and the local hospital but only having testing available once a week and having to transport patients to get started on HIV treatment is problematic. I’m thankful we have the funds to start our own programs in the camp next year.

More thanks are due. After feeling completely and totally sorry for myself over Thanksgiving but then getting all those supplies from UNICEF – I received more care packages from home.. thanks again to Tim & Leigh Anne, mom and dad (as always), Tom & Kate Faber, and Johanna Cooper, First Presbyterian Church of Vancouver, Washington… Also Eileen and the rest of the Refugees International crew came through in a big way (see www.refugeesinternational.org) getting us the donation that allow us to purchase mosquito nets – for each household in the camp – actually there’s enough money for two for each household. Malaria continues so fiercely here – people are suffering so much and while we have become quite adept at treating it – it’s nice to have a little going for us on the prevention side.

So it’s with such pride and sorrow.. so bittersweet I can hardly breathe as the camp kids rush to me every morning, that I am preparing to leave. What I will miss the most is those smiles and voices greeting me every day. What I will not miss – at least not for a while is the feeling of desperation – every day being up against a wall – without a safety net – no panel of experts to rely on – and death being so much more a reality – especially children dying. Needlessly – really all such easy “saves” in the US, but we have done pretty well, no one has died of malaria (yet) – and no one really should die of malaria anywhere in the world - but I know the local hospital in the village has up to 5 deaths a day, most days, from malaria. It’s a testament to the hard work of my staff in education so people present early with symptoms and their skill at treating malaria that have allowed us to escape thus far without a death. I have become even more convinced that education is the essential building block of health (of course along with clean water, adequate nutrition, medicines…)

Pictures to come of our shelter to shelter installation of mosquito nets, and of course more of the children. I will be home so soon it’s hard to even imagine the reverse culture shock. I look forward to catching up with everyone when I drop out of the sky… More to come soon (yes, pictures I promise) …

All my best,
Ann

Thanksgiving thankfulness

2005-11-26T16:49:00.000+01:00

November 24, 2005 Thanksgiving.

I have to admit I was not in the best mood waking up Thanksgiving morning. I’m homesick, exhausted, temperatures are sweltering again inside the tent and because it’s an American Holiday and we are an American NGO it’s vacation staffing (only 2 nurses) which is really impossible to safely run the hospital and health center given that we are full of patients with malaria and the waiting room is full of new cases. So I am working on Thanksgiving – for the first time here I’m grudgingly working – I’m impatient with my nurses, impatient with my patients… tired of the onslaught of malaria that doesn’t seem to be ebbing at all, tired of all the things I can do little or nothing to change in these refugees’ lives, tired of working under these conditions without the proper staffing or medications… in short I’m a particularly bad version of myself. To make matters worse we are on our last bottle of quinine tablets without any way to get more for the next couple of days and I can just picture the scene of patients in rigors swamping the health center in the upcoming days. I really don’t know if I have the strength for it…

But grace comes in the most unexpected of times and places – (hence the word “grace”) and about 4PM a *huge* UNICEF truck comes roaring into the camp trailed by the requisite entourage of children running behind. I had written a letter to the UNICEF health division a few weeks back after their education staff had visited the camp. I hadn’t heard back so I tried emailing the same letter to the education staff member that had given me his card. Still no reply so I had pretty written them off as unable or unwilling to help… then in another moment of grace I was having lunch with Andria, a Canadian UNHCR intern (specifically in HIV concerns) at the Novetel when I was back in Kigali when lo and behold a UNICEF physician comes to our table to greet Andria. I am introduced and immediately (perhaps a little too enthusiastically) jump straight to business – asking her if she has seen my letter… she says no, but gives me her card and encourages me to email a copy to her so she can forward it to the head of the health division. I do later that night and invite the head of the division to come visit the camp.

Later that week, Kofi who is a Togolese physician – head of the Rwandese UNICEF health division shows up at the camp. He is a large man who speaks his mind directly and forcefully – it is refreshing after being frustrated with the Rwandese penchant for circular pronouncements. Although after his visit he said he couldn’t *promise* anything, UNICEF was shifting warehouses in Kigali and he stated that he should have some things that could help. The next weekend we are back in Kigali and Theo and I call Kofi and visit him at his residence – and he says he has signed a requisition for a huge amount of supplies – 4,500 blankets; 4,500 jerry cans, educational kits, recreation kits, health kits… and we should be expecting them early in the week.

As the week goes by I have to admit I had my doubts (I’ve become a little jaded with all the unkept promises I’ve been hearing) and Thursday arrived still without the truck. But come Thursday evening, Thanksgiving just when I am mired in self-pity and frustrations here comes this massive truck filled with supplies and suddenly I am thrilled.

The UNICEF truck drawing quite a crowd at the camp

Unloading the boxes with one of the refugee scout leaders

There are 2,000 tablets of quinine in addition to a huge amount of recreational equipment and school equipment for the children as well as medical / surgical supplies, It is a gift at just the right time for the refugees and just as quickly as the weather changes here – my spirits are lifted and I am energized enough to help unload the truck (which causes quite a stir among the refugees). I am constantly amazed at how and where help comes – just when I feel like despairing there always seems to be an opening that allows us to slide by again… *grace*.

Now if I were *really* African, I would have been able to balance the box without any hands!
***********************************************************************************

I hope everyone had wonderful Thanksgivings – mine turned out to be lovely after all. Thanks also goes out to singer-songwriter Ralston Bowles for sending me his CD “Carwreck Conversations” – all the way over here in Rwanda from all the way over there in Michigan. I had used a quote from his song “Fragile” in my quotes of the week and a friend of his saw it and told him about it… I had to admit that I had only ever heard other artists cover the song and hadn’t actually heard *him* sing it… something that has now been happily remedied… the CD is truly inspiring and thought provoking… visit www.ralstonbowles.com to get your own copy!! So I will leave with a quote from another of his songs…”Draper”

“I don’t believe that I’m a cynic, I don’t believe that I don’t believe
I don’t believe that any slogans are going to bring anyone relief
I just believe that I am moving toward learning how to fly
I just believe that life is more than rehearsing how to die…”

All my best,

Ann

The final month...

2005-11-19T03:32:00.000+01:00

“I don’t think you know what this is like… to have your love pinned to my life… like something I can’t hold onto and something I can not leave behind. Maybe you’re just not afraid of anything in this whole world… maybe you have never held nothing in your hands.. Heaven help me .. when I think I’m not enough for this world.. Heaven help me.. when I think I am…"

That’s a song quote in honor of my friend Brian Webb (an amazing singer-songwriter) who is playing in a few hours at Club Passim way back over there in what feels like a completely other life that a completely different person lived in Boston (although if I were back I’d be there at a front table in a flash!) . It’s from a yet unrecorded song “Strange way to Grieve” and happens to encapsulate all the swirling emotions I’m having as I enter my last month here in Rwanda –(my last month at least for this stretch- I can’t imagine *not* returning). He’s probably sold out but if you’re fortunate enough to get in (10PM Friday November 18) you won’t be disappointed.. although hmm.. as I’m recalculating the time difference I realize he might be actually playing now (the daylight savings time always confuses me, there is no springing forward or falling back in the tropics…).

I am awake at this hour (3AM) here in Kigali – for some reason an insomniac the past few weeks, desperately tired and more than a little homesick as the holidays approach. The health center and hospital at the camp is operating so smoothly now – I’ve been able to concentrate my efforts more on administration/fund raising and budget planning – things I have to say I don’t enjoy nearly as much – but I’ve been purposefully withdrawing myself from the day to day operations of the health center and hospital… slowly but steadily .. It’s perhaps like having a child and learning to let go – it hurts a little to not be there every minute helping and advising but I know that it’s time for them to fly on their own… and more importantly they are *able* to. I am so proud of my nurses and staff – when I follow up (probably more often than I should) everything is in order, admission notes, vital signs, medication records… Our family planning / prenatal clinic /minor surg clinics are running smoothly – we have weekly HIV testing where we regularly have far more than the 20 patients that can be tested each week (I am in the midst of hammering out an agreement for antiretroviral drug provision) – the monthly vaccination campaigns run like clockwork… our laboratory is fully functional (I am also in the midst of some wheeling and dealing to obtain the final two big pieces of equipment needed – a kerosene powered refrigerator and an autoclave), Counseling and physiotherapy has started.. . Ben (the medical coordinator) and my nurses have such an ownership and pride in their work as well as such dedication – the refugee and national staff are working together remarkably well, we have trained 5 new refugees in basic nursing skills who have become valuable members of the team, and I realize happily and a little sadly that I am rapidly becoming superfluous… which is the whole point after all “local capacity building” as the country director Barry puts it. I still see a fair share of patients – but the consultations are more perfunctory – more often than not I am just signing off on a plan of management that I could have written myself… I seem to have worked myself out of a job!

Our new lab with Leonia - our new lab tech!

Meanwhile there have been this string of visitors from various NGO’s “aid-gamers” as one book I read cynically put it.. as the year ends all agencies seem desperate to make their token visits so we can be some footnote in their annual report… so I’m perhaps sounding a little cynical myself… It’s just when you see the problems every day – when refugees come to you every day – when their children are hungry and they can’t provide enough food for them, when their children don’t have any clothes or shoes to wear, when their children are suffering every month with malaria because there are no mosquito nets… when their children are *still* not in school after 8 months because of some bureaucratic quagmire between UNHCR and the Rwandese Ministry of Education – and I’m seeing this and hearing this every day… when our old battered vehicles are constantly breaking down and we have to push them to get them started… in the midst of these daily struggles some immaculate white land cruiser pulls into the camp (most often unannounced) with some equally immaculately dressed “aid-gamer” from some cleverly titled NGO with a cute logo on the door of the SUV… and we are expected drop everything we are doing to greet them and show them around the camp and tell them about our programs… (almost like it’s a tourist site and these children and families are on display) … it’s hard to not get a little cynical.

Don’t get me wrong – some agencies have been wonderful. UNICEF in particular has promised real *tangible* help in the form of 2,000 blankets, nutritional supplement biscuits, delivery kits, educational kits… Refugees International has pledged $5,000 for malaria prevention, and USAID through PEPFAR has given a large amount of funding so we can start out own HIV testing in the camp…meanwhile EGPAF is funding the testing and treatment of our HIV patients currently… all these things are truly wonderful and make worlds of difference. It’s some of the other organizations that can be so frustrating (they will remain nameless for now).

One in particular – an agency dedicated to the welfare of children – came a month ago, and we detailed the needs, the very *basic* needs of the children in our camp (supplementary food, clothing, medicines etc..) they looked around and said with a straight face that they couldn’t really help us with those basic needs because “our mandate is really just advocacy for children’s rights” … What the heck does that even mean? What are the rights of children if not education, food, clothing and healthcare???? They came back again last week – having hired an “expert” to come work in the camp for the next few months giving lectures and “mobilizing the population” about the rights of children.

So that particular day I’m very tired from having been in a hot tent all morning taking care of yet another dozen children all having convulsions from temperatures over 104 from malaria – and I’m listening to this very nice French-Canadian country director of this organization introducing me to this woman who I’m sure is lovely and has great intentions but I can’t help getting a little angry. I say in my much improved French – and probably not very politely that I have never seen an “abused” child in this camp. Not in the western sense of the word. It’s not as if these parents don’t love their children or don’t know what their children need. The fact of the matter is that they do *not* have the resources… *we* do not have the resources to provide the things these children need. And listening to some self-professed expert on the rights of children talk all day and night is not going to give these parents the clothes, food, schools or medicine that they already know their children need. There are no sweatshops hiding in the bushes of this refugee camp – I can feel myself getting angry again just writing about it. So the inevitable result of this “mobilization of the population on children’s rights” is going to be parents being told that their children deserve to go to school, and deserve adequate food and adequate clothing (as if they didn’t know this already – I feel it’s demeaning and condescending) and then this expert will leave without providing any real assistance and the workers who were there before this expert and will be there after this expert will be left with an even more dissatisfied population and will be just as unable to provide for them… I feel like screaming “use this woman’s salary to buy some clothes for the kids.. or send her to lobby the Rwandese Ministry of Education for school for these kids… or come even to the health center and sponge down a baby with a 104 degree temperature.” Do *something* but don’t just talk… sigh. But this is the reality of aid work – or maybe just another reality of life – there will be “talkers” and there will be “doers” and I just happen to have come across too many “talkers” for my liking these past two weeks.

Speaking of “doers” thanks to Dr. Marjie Curran (pediatrician extraordinaire) from MGH for managing to send a case of Elimite, infants Tylenol and Motrin, something that will alleviate the suffering of these children far more than 2 months of lectures to their parents (OK, I realize I’m sounding bitter…I think it comes from being over tired). On to happier topics.

Soap making 101

To get a head start on the Income Generating Projects that Louise will be returning in January – April to head up – Theodore has begun soap-making training for the refugees. It’s an incredibly rewarding experience to teach a new skill and especially for this population where on this rocky mountainside agricultural possibilities are quite limited – these small IGPs are not only adding an influx of money but also industry and self respect into a demoralized population. Louise has been busy back home in Minnesota fundraising and will hit the ground running with small business loans. And it makes me realize more and more that this is *really* the biggest and most rewarding part of the job – giving a population skills that they will always have and be able to use – it’s true in the health sector as well as the IGP world…

The Soap Coming out of the Mold

Theo demonstrating the cutting technique

The happy group and the finished product

Newest and Oldest patients!

I think I mentioned in one of my last posts that we have started deliveries with the hiring of a midwife – and despite the fact that it still scares me a little (not having any resuscitation equipment for the babies) we have done half a dozen successful deliveries. We also have had a few more transfers from Congo - including this 100 year old woman (can you imagine being a refugee at 100 yrs old) who despite everything is so sharp and has a great if resigned attitude on her life here.

Ben with our newest mother & baby

After 100 years of living - now a Refugee

Thank you to everyone again for all of your support and well wishes. I can not express how much they mean to me - especially down the homestretch here when I am getting so tired and homesick and more than a little lonely at times. I'm hoping to see the mountain gorillas and a few other "touristy" sites before I go. I have found a flat in London - right in the center a few blooks from the London School of Tropical Medicine so thanks for those who have helped in the housing search as well - I do expect visitors in London! (and thanks to Danica for being so wonderful and flexible in facilitating the funding - I'll be sending more receipts your way!!) Happy Thanksgiving to everyone and God Bless,

I'll end with another quote which pretty much sums up life here... it's from Nigerian Booker Prize winning author Ben Okri's Book The Famished Road

"It was dark in the forest till we got to a clearing. In the middle of the clearing a solitary wooden pole had been stuck into the earth. The pole had burst into flower. Little buds had grown out along its length and some of the buds had opened into the beginnings of branches. Dad said: 'This is what you must be like. Grow wherever life puts you down.' "

Love,
Ann

News from the homefront

2005-11-07T07:47:00.000+01:00

So this isn't really Rwanda or Nyabiheke Refugee Camp news... but I am delighted to announce the birth of my 2nd niece - Charlotte Anne Kao on November 1st. She joins my adorable 3 yo niece Emily and her parents Tim & Leigh Anne in Kailua Hawaii where Tim is stationed as a US Marine currently... congrats!!!!

Emily happily taking on her new role as *big sis* feeding Charlotte

I am taking a bit of a breather here in Kigali for the next few days, catching up on paperwork, working on budgets, lunching with potential NGO partners/funders, trying to streamline the drug purchasing process... (*and* enjoying hot showers, electricity & running water and tracking down ice-cream at every available opportunity).

Charlotte Anne Kao - smiling away already!

I have settled my plans for Jan-April - I will be in London Jan5-April8 at the London School of Tropical Medicine & hygiene (getting a diploma in Tropical Medicine) after visiting Tim, Leigh Anne, Emily & Charlotte in Hawaii for 10 days. ( I'll be in Boston for about 36 hours from the evening of Dec 22nd to noon Dec 24th). If anyone has tips on housing or just coincidentally has an empty furnished flat near the London city center that needs a resident Jan-April please let me know! The London housing search isn't the easiest from Rwanda...

I hope everyone is well... Ann

Brief Update

2005-11-02T11:51:00.000+01:00

Hi everyone,

The post below ("what happened to October etc...") is finally finished (more medical details than the non-medical folks would ever want to know... although I happen to think it's interesting...)

N.S. with a rare smile enjoying her new presents...

– as promised here are pictures of a few of our kids coloring with the presents donated by the MGH Chelsea Urgent care staff. N.S. is an 11 yo with osteomyelitis of the R leg after falling on some rocks… I honestly had never seen her smile in 2 weeks until getting these crayons and coloring books.

I.K. has frequent smiles, but now has something to keep him busy when we're not around...

I.K. is the other boy – he has been hospitalized for nearly 2 months now – his house was struck by lightning 5 months ago in the Congo and he suffered severe burns to both knees. We had been treating him on an outpatient basis with daily dressing changes but even though he was getting better – his mother took him to a local “traditional doctor” and he came back with wide open sores on both knees and worsening contractures. He hasn’t been able to walk since the fire but we decided to keep him as an inpatient and slowly with twice a day dressing changes and physiotherapy – his is improving. I’m hoping he’ll be able to walk with some crutches before I leave in December

It's been busy but good - I will update more in Kigali - we have a Maternity ward and a midwife and are doing regular deliveries, a laboratory (although around 90% of the cases we suspect are malaria are confirmed now by laboratory - we're still saving 10% on medications that would have been given)...we've started weekly HIV testing (5 out of 43 tested are positive thus far)... and there have been meetings all week with UNHCR, UNICEF, Save the Children, EGPAF, JRS, Refugees International - trying mainly to figure out how to send these children to school but also trying to get help with funding some malaria prevention projects and getting a refrigerator and autoclave for our lab...

I miss you all!

Love,
Ann

What happened to October? (and sorry Sox fans.. Red Sox fans that is.)

2005-10-23T15:34:00.000+01:00

Post finally finished!

I know it's been such a long time - the past two weeks have been exhausting - malaria and more malaria...

I just wanted to post these pictures... Christmas came early this year for the children in Nyabiheke refugee camp in the form of such a generous flood of supplies from the staff at MGH Chelsea Urgent care... I received 4 huge boxes full of crayons and coloring books, medical supplies, *candy* and soap for the refugees. Thank you thank you thank you. You will all be happy to know that the post office gave me *NO* trouble. It was the same lady that I broke down in front of 2 months ago and she looked so afraid that I'd start crying again that she didn't even open the packages... :) The first two pictures are here at Top's place (the Senegalese finance administrator for ARC Rwanda, Theodore (camp manager) and I stay with him when we go to the BIG city !) We are in Kigali opening the packages - we got out of a meeting late Friday night so waited until the morning to open them... it was really like Christmas morning - all of us in our pajamas still opening the boxes. I am overwhelmed by all of your generosity ... will be posting pictures to show the supplies in good use. Thanks Mom & dad and Tim,Leigh Anne and Emily for your packages of goodies too - I got 6 packages on the same day and after such bone-numbing weariness it definitely injected some energy in me :)

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Signs of Life

Damiscen came nearly every day to the health center starting in July then most of August. He wanted to volunteer – to be trained in basic nursing skills. Too much on my hands already and warned by the staff to be a little wary of “volunteers” (ie at some point they may complain to UNHCR or others that they are being exploited and demand compensation). But his persistence finally won over and starting September he came with his friend Davota every day.

A veterinarian of sorts in his previous life in the Congo his tenacity and inquisitiveness sharpened all of us. Not afraid to ask why – about every little thing we were doing – showing up every day including weekends… showing an amazing capacity for learning and retaining material… I have worked with many med students and residents – but in terms of sheer curiosity – he easily surpasses them all (and myself for that matter). Learning for him was a hard fought for opportunity and he approaches each day at the health center as if his life depended on the knowledge he was obtaining (and perhaps it does). I am humbled constantly in my interactions with him – it’s another thing added to my list of things I take for granted… access to knowledge.

Our "med-student volunteer" Damiscen sporting his new white coat...

Professor Shayka teaching our full waiting room in the morning

We have started a daily education campaign with a morning lecture to the patients “waiting room” Shayka one of the refugee nurses has earned the nickname of “professor” because of his love of giving these lectures. Each week is a different topic, dysentery, malaria, skin infections – and Monday I give a short discourse to the nurses who then take turns each morning teaching the patients… It’s hard to quantify but I think small inroads in education are being made…
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A malaria mystery and miracle

“Something’s wrong with this quinine” It’s a comment I repeat over and over to Nicole our head nurse and pharmacist. Malaria has been a huge cause of morbitiy ever since I arrived in July, but these two weeks we are being inundated with treatment failures. We had switched from the government recommended Amodiaquine/Fansidar combination in September because of all the treatment failures we had been having with that combination… Patients coming back, swearing they had been taking their medicine – appropriately describing which pills they took when and how much … yet returning requiring intravenous therapy. That had diminished significantly since we switched to quinine. The quinine regimen is longer (7 days as opposed to 3) and has more side effects (tinnitus, vertigo) but we rarely had a patient return needing hospitalization if they were placed on oral quinine. The increase in cost (about $1.20 per adult patient per course as opposed to 70 cents) was well worth the price when the cost of IV therapy / inpatient hospitalization is considered with treatment failures from Amodiaquine/Fansidar.

With the start of the rainy season however – in full force in October – we were going into the 2^nd week of October and patients were being carried in every 10-15 minutes having previously been seen by me or another of my staff, diagnosed clinically with malaria, started on quinine, yet coming back even sicker. It’s disheartening to say the least. There was a “war zone” mentality – with 2/3 of my staff out with malaria themselves, it was all I could do to keep up with the skeleton staff I had and despite the rain, temperatures still reaching so high inside the radiant oven of a tent we were working in. I always caused a little bit of commotion from the surrounding patients and staff when hourly I would need to go to the water pump in back of the health tent to splash water over my entire head just to keep cool. We converted our pedi consultation ward into an ER, taught the guards how to take temperatures and stacked up patients wherever we could find room. It was an assembly line of IV D50 boluses and quinine infusions… but no deaths … I can’t imagine how no one possibly died.. I think we just got lucky given the patient numbers and lack of staff …

There seemed to be several possibilities for this surge in treatment failures…. 1) Patient noncompliance (but the pill count, and description of how they had been takiing their meds was correct) 2) Mistaken diagnosis (entirely possible without a laboratory but patients got dramatically better after their first infusion of intravenous quinine) 3) Quinine resistance (very rare but possible, but once again patients got better with IV quinine and oral has fairly good absorption ) or 4) Defective quinine tablets. Another of the articles I downloaded from the NEJM (what did we *ever* do without the internet) quoted a rate of almost 40% “fake” mediations in this part of the world and it’s true we had switched our supplier… from Congolese to Ugandan quinine tables. Supporting this hypothesis was the fact that it was largely adults that were coming in so sick. The quinine syrup and drops we gave to the children and infants were from the same supplier as we previously contracted with and seemed to be effective… So we switched back to Amodiaquine/Fansidar –which was not extremely effective but less *ineffective* than the defective quinine… and waited for Kigali to purchase another batch of tablets for us… It’s such a helpless feeling to know you don’t have effective medication.. Fortunately the new batch – (quite dramatically really) seemed effective – our hospital went from 100% occupancy to less than 10%.. within 3-4 days of the switch…

Micyo the day before discharge

My “favorite” malaria case of those crazy two weeks was this child you see pictured here. Each night I had been pouring over the articles on malaria I had stored on my laptop – trying to figure out the best way to treat the patients with the resources we had – (and it didn’t help in the midst of all this that I received a reply from the Red Cross of Rwanda that they would *not* be able to supply any bed nets for the camp… initially they had been so encouraging)… but I fell asleep on Wednesday night.. under *my* mosquito net reading about the manifestation in young children of focal seizure activity secondary to hypoglycemia as a presentation of malaria… I awoke at 4 AM with the sound of a vehicle pulling up to the house. It had to be an emergency … it’s the only reason a driver comes at that hour to our house.. so I wearily dragged myself out of bed and opened the door. My drivers are always surprised at how light a sleeper I am .. it comes from all those years of taking call …this ability to switch on and off so quickly… When I arrive at camp, Louise and Betty 2 of the nurses are around the bed of a 2 yo child who is unresponsive. They have been trying for nearly 2 hours to get an IV but have not been successful. The child has been unresponsive in total for about 4 hours. Looking at him I see immediately that he is having a focal seizure, his eyes are deviated to the right and there is faint twitching of his mouth… I try for an IV but by this point he is so cold (T 35 celcius) and has been stuck so many times… that it’s not an easy task. We give an IM injection of diazepam, then drop by drop under his tongue of 50% Glucose and within 15 minutes he stops seizing and starts calling for his mother. Call it karma or coincidence but I’d like to think it was pure grace… it’s nothing short of a miracle – that I had fallen asleep with that specific article just 5 hours before being collected for this emergencey and there wasn’t even a question in my mind what the diagnosis or proper treatment should be… It’s one of the most gratifying moments here to date when his mother takes my hand and says (as translated by Betty “If we were still in the Congo, my child would be dead” Micyo does well over the course of the next couple days in the hospital and cries only when he is told he has to leave because he is well enough to go home… (a welcome change from most children’s attitudes toward hospitals)

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Babies taking care of babies, and no school in sight...

The children here are all so beautiful – and I don’t mean that in a maudlin dewy eyed “every child is beautiful in their own way Hallmark card” kind of sentiment. They really are amazing – literally playing with rocks – prized possessions are empty plastic bottles from which they make toy cars.. we have over 1200 children less than five years old in this camp, and eighty households headed by children under 17. They face each day hungry, alternatingly drenched to the bone and frying in the extreme heat, the only clothes the rags on their back, chronically infested with scabies and worms – yet each day they run to me and grab my hands with smiling faces practicing the few bits of English they have picked up “good morning” (no matter what time of day it is) “Doctor Anna.”

Often an 11 year old brings in a 5 year old and a 2 year old for consultation having the responsibility of care for the younger ones. One 14 year old, when escaping from the rebels in the Congo – having lost her entire family, found two toddlers on the 50 mile walk to the border who had been orphaned themselves and is now taking care of them here in the camp. Many grandmothers are taking care of babies having lost their own children to war and AIDS.

Since the start of this camp in April all of these children (almost 2800 less than 18 yo) have not been in school. The Rwandan school system runs from January to September and April was right in the middle… money also ran out because the cost of drilling for water and setting up the camp exceeded the budget so that even though a piece of land had been designated for a school… it wasn’t able to be built initially… Then the Rwandese government ministry of education declared that the children would have to go to local Rwandese schools (the nearest of which is 2 km away), and would have to start at the beginning of the new year in January. (This despite the fact that education the other camps in Rwanda is handled by JRS – Jesuit Relief Services – who from my understanding are doing a wonderful job, and the schools are all within the camps). In the mean time it will be 8 months without school for these children and they are growing up in an already displaced and difficult situation … now they are growing up wild. It makes my heart sick to think of 4 and 5 year olds walking down steep terrain, alone 2km to get to school… already vulnerable they will be easy prey for anyone with less than benevolent motives. Also the local schools have nowhere near the capacity to take this influx of children… and that’s the kicker – the government wants money from UNHCR or ARC or whoever to rebuild and add on extensions to the local schools…before allowing the refugee children to enroll I understand that the local schools are in need of funding also – but it seems almost like blackmail… and negotiations are at an impasse for the moment and the more time these children are out of school, the harder it will be.

Theodore has started a scouts troup with the young boys that has added a little structure to their days… it’s these young girls who are shouldering so much of the responsibility of child care, water fetching and cooking that are the hardest to contemplate…

A young girl brings her younger sibling to our monthly immunization campaigns.

Halfway point!

2005-10-09T07:55:00.000+01:00

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

Two months in Rwanda and turning 30

2005-09-20T17:52:00.000+01:00

Hello all,

As you've probably assumed, I am still without regular internet access, but have been so busy in the past 2 weeks that I haven't missed it...well not *that* much anyhow. It is my 30th birthday today and I am at a loss to explain how September 20 has snuck up on me (and 2 months have gone by since I arrived in Rwanda) this year much less 30 years worth of September 20ths.

I have travelled to Byumba today for a meeting with my Rwandan counterpart Dr. Moses, and yes... to be able to be in touch with friends and family today is important to me.

I have hardly had time to breathe since finishing August's monthly report and have not been faithfully keeping up with my journal. It's been a hard couple of weeks, "growing pains" if you will - any organization will suffer from bumps in the road especially at the beginning and I suppose when starting up a health center at a refugee camp in the Rwandan countryside, I should allow for more turbulence than other endeavors. Still I get frustrated and impatient because of how I *want* things to be and how I see that they *can* be... and most days nothing is easy - one has to follow up on every detail - not just say it and trust that it will be done. There's also the constant vigilance against corruption and misuse of funds that is so rampant in this part of the world (well any part of the world - I suppose but I'm just running into it more here with my managerial hat on). Fortunately ARC and Theodore (camp manager) and Barry (country director) have an absolute zero tolerance policy for any kind or corruption or misappropriation of funds - but it is exhausting to always be checking invoices and payroll sheets over and over. It's been such good training for me though - I tend not to prefer conflict but here I have to stand my ground each and every minute... good for me but exhausting nonetheless.

I received a call from the USAID representative today (great birthday present!) that our PEPFAR proposal for HIV/AIDS funding was approved for FY '06 which is wonderful news and so there will be money to start HIV prevention, testing and treatment programs!

I only have a few minutes left at this internet cafe before having to go to dinner but I will leave you with some pictures of the birthday party that Theodore threw for me last night... about 50 people - complete with a huge dinner, cake and lots of traditional dancing. I was touched that it was refugee and Rwandan staff alike- and most of my staff from the guards at the health center to my nurses, to the cleaners and nutrition center staff along with my drivers were there. Theodore presented me with a traditional dress from his home country of Benin in West Africa which you can see me wearing during the dancing!

The day yesterday started in such sadness, I attended a burial of Adeline, a 4 month baby girl who I'm sure had AIDS who we had managed to see through pneumonias and gastroenteritis and fungal infections and fever after fever the past 2 months since my arrival. I was at her bedside all weekend as she struggled not to drown in her own secretions from yet another pneumonia and suctioned her (our suction is a feeding tube attached to a syringe) almost every 10 minutes but despite all the "tricks" I knew, broad spectrum antibiotics, diuretics, steroids... couldn't save her. All of my nurses and I attended the burial - this child had such a will to live we had hoped against hope that she would make it through this episode, but it wasn't to be. The graveyard of the camp is in one of the most beautiful spots I've seen, surrounded by pine trees atop a mountain, there are half a dozen rough wooden crosses now - those refugees who will not see their earthly home in the Congo again... But as healthcare goes we had to return to the clinic where malaria is in full force now that the rainy season has started and there are stagnant pools of water... we admit 10 patients over the course of the day and our little hospital is bursting at the seams.

But night comes and as I enter my house I am greeted by this huge raucous party and speech after speech of such warmth that my emotions swing from sadness and exhaustion to joy and celebration...it takes away that bit of homesickness that had been festering a little the past few weeks with too much work and too little sleep and struggle after struggle to get even the smallest tasks accomplished. Such emotional roller coasters each and every day here but it reminds me of how fortunate and truly blessed I am to be here on this earth at this moment in time doing this work that I find myself so engrossed in .. I am keenly aware and in awe of being *alive*.

All my best,
Ann

A monthly report and watching a refugee crisis unfold at home.

2005-09-07T04:18:00.000+01:00

Hi everyone,

Still no email access from Gituza - I'm back in Kigali for just 24 hours to submit my monthly report to UNHCR, so this will be short (for a change!) The medical coordinator we let go last month was in charge of these monthly reports and as we have not yet found a replacement guess who had to do this month's...? I HATE paperwork - and the UNHCR database requires the compiling of every imaginable data point. I can't see how putting all these numbers into little boxes saves any lives but as Theodore says - you can work all you want all month but if you don't put the report together it's like you've done nothing.... Well it's not to *me* or the *refugees* I've been taking care of that I've done nothing but to the ones who push the numbers around (and I know, I know they're very important too...) it might seem that way....

That plus our medical record keeping is good in the sense that we keep track of all the information *somewhere* whether it's this ledger book or that or the other - but it's not at all compiled so on top of working 12 hour days at the camp clinically this weekend I came home to compile all the data (nearly 2000 patient visits) by candlelight and paper as our generator works but all our lightbulbs are out and we can't replace them in this little village we live in ... sigh. So I can watch the food channel, MTV and BBC but by candlelight...

It's the least amount of fun I've had here - I can see patients all day and be happy... exhausted but happy - but sifting through records and putting numbers in little columns, just give me a pencil to stick in my eye!!!I am well though - it's really fun getting to create something - to build a medical center, hospital, laboratory - and to get to teach at every step of the way. Data collection is important... I know, I know - and so I'm doubling my efforts in that department - creating databases, weekly reports so that when I'm gone my staff will have an organized system of patient tracking. I've really been stretched in so many ways here, clinical medicine, I.T., administration, finance, nutrition, epidemiology, teaching, sanitation, hygeine... I don't think my head will ever stop spinning.

<>

On a more somber note - I've been watching in horror the unfolding refugee crisis in America. It's so strange to be overseas taking care of refugees and watching the kind of destruction that took place in Mississippi and Louisiana and hearing about the medical teams deploying there. In a strange and maybe a little warped way it makes me feel very connected - hearing about the threat of dysentery, cholera and typhoid - things I'm concerned about every day as well.

It reminds me that we are so fragile (hence the quote of the week)really no matter where we live... we are all a storm or earthquake or terrorist strike from being refugees ourselves. I think we have a false sense of security sometimes living in America - but suffering is universal. There's a lot of play here on BBC (my main news source) about the International response to Katrina and all the countries pledging aid to the US - even Sri Lanka - one of the poorest most devastated countries from the Tsunami made a "token" donation of $25,000 which isn't so token when you think about it.... Red Cross teams from France and Thailand, Norwegian water experts, Oil from Saudi Arabia and Kuwait - even an offer from Iran - and of course all the Americans who are helping their own fellow citizens. I'm not sure why it takes a disaster to bring out the best in us (and worse... I'm not forgetting about the looting and gang violence either) , but maybe it 's the fact that it is a reminder that "there, but for the grace of God, go I" it allows us to imagine ourselves in other's shoes for just a moment...and that's enough to mobilize compassion and action.

Thanks again for all the continued messages, support and packages. If any of you know an ophthamologist or dentist that wants to come visit a refugee camp in Rwanda... send them my way!!!

Much love,
Ann

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

2005-08-27T00:01:00.000+01:00

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

Only week three!! August 5-12

2005-08-12T07:52:00.000+01:00

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!!!

A Vaccination Campaign and Kigali for a day

2005-08-04T19:05:00.000+01:00

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

2005-08-04T13:40:00.000+01:00

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...

A few images and thoughts

2005-07-29T23:02:00.000+01:00

Everywhere in the camp are large gatherings of children...

There are some great pictures that I wanted to share - some taken by Louise out the "window' of the health center office - where she could remain relatively inconspicuous. There are so many children in Nyabaheke around 2,500 - and so many children taking care of children. No school organized for them yet, very few adults to supervise... how do we give some structure to their days? This question disturbs me every time I enter the camp and see the huge gathering of boys lingering about. The females in this society from a very young age shoulder the burden of the heavy work - I see so many little girls carrying huge cans of water, sticks, babies... while the little boys scamper about not infrequently in some mischief. "In Rwanda we still have the problem of gender inequality" says one of the community health workers to me when I ask why the boys aren't helping with the daily tasks.

A nine year old refugee boy looking in at Louise

All babies are carried wrapped snug on mom (or older child's back)

(Oh and Kate Hundley - in record time - identified the quote as from "Tobias" written and performed by Brian Webb. Brian & band are playing all the way back in Boston Sundays at Toad (across Mass Ave from the Porter T station) at 7PM - go see them if you have a chance!!) Kate is an actor in the DC area and has a play going up in the next few weeks too... (send me details Kate, I'll put up a link!)

Ngarama & Nyabeheke (or 4 days without an internet connection) July 24-27

2005-07-28T23:00:00.000+01:00

I'm finally back in Byumba... which actually seems like a *huge* city compared to where I was in Ngarame... the following (sorry for the length - it's 4 days worth of journaling) is only such a small portion of what I've been experiencing. Sorry to be out of touch.. I am well and *loving* my time here... Ann (oh and nice work on the song, Shan... )

July 24, 2005 Sunday

Ngarame & Nyabeheke

A view of the Rwandan countryside

It is a very bumpy rocky dirt road all the way from Byumba to Ngarame – I am tired and nauseated and far too foggy to attempt any French which is the only common language w/ my driver Ismael and I. We listen to African music until the radio goes out of range and Ismael fiddles with the radio in obvious dismay. I have the inspired idea of breaking out my ipod w/ radio transmitter and even have a South African gospel choir to put on Ismael perks up and says “blues, jazz?” And the universal language of music makes us both smile as I dial up Keb’ Mo.

The Rwandan countryside is so beautiful but I am not feeling well enough to appreciate the lush hillsides and tropical idyllic setting. Everywhere women clothed in bright colors are carrying loads on their heads – their ramrod straight posture putting even the most stylish of runway models to shame. They carry what must be 50 – 75 lb loads with such grace – barefoot – up slopes of such steepness.that I might only hope to scramble up using my hands to brace myself. Up up up they go without a missed step, their bundles secure on their heads.

A view of Nyabaheke camp above the bore-hole / water pump

The camp at Nyabeheke is truly a miracle. As Barry has explained – it was the only piece of land available for the ever burgeoning population of refugees coming from the Congo border region – those Tutsi’s fleeing the Interhamwe. The site had no water supply and through a remarkable combination of experience, skilled staff and just good intuition or grace as you might have it – a bore hole (the first one attempted) drilled hit water – enough to supply the entire camp. The water is pumped using a generator up the mountain to where the camp is situated and stored in huge reservoirs. They just had 3 months to prepare the entire camp from uninhabited uninviting steep stone slopes without water…

There are almost 5,000 refugees in the camp – most recently arrived in the past 2-3 months. The atmosphere in Nyabeheke is different than that of Gihembe. Maybe it’s because these are recent arrivals, but there doesn’t seem to be the inertia – the helplessness. Or maybe because of the way the camp is set up – with 5 structures surrounding a common kitchen area / 10 of those 5 units making up a neighborhood. We meet up with a group from the ARC board of directors who have been visiting all 3 camps and have a very warm welcome from the camp residents. The Mayor of Ngarame is here as well and he has been an essential partner in the building of the camp. Many villagers were hired to help build the camp and the mayor reminds us later that they can also use our help – the villagers that is, not just the refugees. Life is hard everywhere in Rwanda it is apparent.

A quick tour of the medical facilities shows a few patients with malaria and quinine infusions. Malaria is a huge problem in this camp and many of the staff have succumbed already. The camp leadership team are all a delight to meet: Theodore is from Benin and brought over personally by Barry where he had been working w/ Catholic Relief – Barry trained him 20 years back and called him in as a personal favor. The medical coordinator, Richard is from Kigali and has a cousin who is a nurse in Boston. Richard looks as if he could have stepped out of a Manhattan apartment. Clemens, Jean Marie and half a dozen other Rwandan staff – all are living in this little hotel at the bottom of the hill where I will be staying as well. The accommodations here are stark – I’m typing this under my mosquito netting – after having taken my “bucket” shower. There is no running water (in fact we get our water from the camp bringing it back in 20L containers) and electricity from our own generator runs for 3-4 hours at night.

Our local dance troupe

Tonight though I feel at home – to greet the board of directors there is a Rwandan traditional dance troupe and musicians and we dance under the bright starry African sky to the beat of the drums and the amazing voices raised high. African dance is so visceral there can be no thought of preserving any kind of dignity – you have to let yourself go and just move to the beating of the drums and clapping and singing. It’s beautiful and breathtaking and awe inspiring in a way so different than anything I have experienced before. There is such unabashed joyfulness in every move and sound.

Tomorrow will be more touring of the facilities – the mayor has expressed interest in my helping out at the local hospital which serves a population of almost 150,000 people and is staffed by only 2 doctors. The hospital receives the patients from the camp that are too ill to remain at the camp and I will be happy to oblige – although I once again get the feeling that I will be learning far more than I contribute.

There are a few things I would like to help get started – the HIV education / treatment at this camp, a health survey of children under 5 assessing nutritional status, growth parameters, continued basic hygiene issues… but these things will come – it’s still a delicate balance of not “taking over” but collaborating at every step of the way.

July 25, 2005 Monday, Ngarame

I have learned so much and seen so much in the past 5 days I feel like I might explode. I’m back under my mosquito netting, typing on my laptop. I’m not sure when I will be able to post these entries as the phone line has been disconnected and there is no way to obtain internet connection currently. Maybe tomorrow I’m told.

Today we started off in the Mayor’s office – a solid brick building just down the road from the “hotel” we are staying at. It’s his hotel in fact as well. It was hastily put together for the ARC team that was building the Nyabiheke refugee camp. The camp itself is truly *truly* a miracle – Put up in 3 months, exceeding W.H.O. Sphere standards in every respect.

The mayor is a little hard for me to read – but Barry and the ARC staff have nothing but good things to say about him and his participation in aiding ARC build this camp into the stone hills. He reveals that for 30 years of his life he in fact was a refugee himself – in Uganda and clearly identifies with those that are now forced from their homes.

He also reveals a bit about the “Gecaca” (pronounced Gachacha) process which is the reconciliation process Rwanda is going through from the 1994 genocide. I remember staring in horror at CNN as this was going on in 1994 and wondering why no one was stopping it. In much I have read since that time – we (we being the international community –those with the power in this world we live in). We *truly* failed the Rwandan people. This was not some remote tribal warfare that was too difficult for us to understand. This was a premeditated programmed extermination… a genocide – one which many swore to never allow happen again after WWII. Nearly one million dead…

But onward Rwanda must go and they have on their own set up these tribunals – made of 9 elected judges. Each week there are cases brought up from that time of the genocide and people testify on either side. If the perpetrators confess, their sentence is halved with half of that being done in community service. There is restitution made if possible, admission of guilt and the country acknowledges a painful history and finds a way to move forward. It is an obligation of all Rwandans to participate. Rulings must be by consensus of all 9 judges, not majority. It’s a process that the Rwandans are proud of – that they themselves are drawing on their own strength and determination to move forward - something that seems to be working at these early stages.

The mayor of Ngarame demonstrating the famous "hollow" rock

We then drive 100 meters (we are driven everywhere here…) down the street to the famous “rock” of the Ngarame area. The legend is that the King buried a drummer here – the center area of the large rocky mountain surface in a diameter of about 3 feet – when struck with another rock sounds hollow. Looking out at the mountainsides I can see where Rwanda got it’s name “land of 1000 hills” it’s so beautiful on top of this rocky slope, the air is crisp in the morning and the hillsides are still covered with trees in this area. I again get the distinct feeling of being at home.

Back up the bumpy dirt road to the camp where we attract such a crowd. The children all chant “muzungu” which means “white skin” at me and in a land where everyone is dark skinned there is no distinction between asian and caucasian – we are all just white skinned folk. There are more introductions and touring – so many formalities that must be followed. The camp is truly a wonder – very clean, the care in planning the camp and the pride in how it has come to fruition is evident on Barry’s face as he describes the water supply, latrine systems, cook stoves. The ARC headquarters is being built out of the stones dug from the ground – stone by stone, mortar mixed from cement and sand – it is the only non plastic sheeted building on the camp. “That’s where your office will be” says Barry…

The camp shelters: the plastic sheeting is what UNHCR provides, some of the refugees fortify this with mud/stick reinforcements which makes the inside much cooler.

2PM and it’s time to go back down to town where the mayor wants to introduce me to the physicians in the hospital. A cachement area of 150,000 plus people, 170 beds and 2 doctors – well one is largely an administrator so really only one clinician. The hospital facilities themselves are well built brick buildings and it is as clean as can be expected. It is bursting at the seams w/ malaria patients however – it has been a bad malaria season – the first room I am shown has 6 babies under 1 year old getting transfusions. On and on we see ward after ward of malaria with an occasional end stage AIDS, kwashiorkor, or TB thrown in for good measure. The doctor seems exhausted, in one ward 2 patients die as we are standing there rounding on the other patients…and 2 look very close to death.

I offer to help in any way I can but my French is still not strong enough for me to be too effective on my own. One nurse speaks English and it is perhaps with her I will be working. I don’t even know where to begin at this hospital – the method of practice is so foreign to what I am used to. There are laboratory facilities but pretty much everyone with a fever gets quinine infusion for malaria, and if the fever persists they next get hit with ampicillin and gentamicin or ciprofloxacin for good measure. I don’t really see a pattern of the reasoning but with 170 patients plus doing all deliveries and seeing consultations and 1 doctor I can’t say I can really fault their approach. There can be very little time for analytical thinking. I am exhausted by the time we finish our tour of the hospital. I offer to come back and round with him on Wednesday but I truly don’t know how much I can change in a place that is so overwhelmed and understaffed. The camp facilities seem a haven in contrast to this hospital.

Evening and there is time to absorb the setting sun on the porch of the hotel. I am reading and thinking and all the staff gathers for dinner where Theodore keeps us in stitches about the witchcraft / voodoo in his homeland of Benin – and promises to buy me a “love potion” when I visit him there, Henry the local governmental liason has stopped by for dinner and they begin a discussion of Rwanda and approaches to solving her problems. It is an inspiration and an honor to sit among 6 Africans (5 Rwandans and Theodore) and hear the love of their homeland and the hope in their voices as they try to plan a better future for their country, there is no talk of leaving for somewhere better it is talk of make there *here* better… it sends chills up my spine…

July 26, 2005 Tuesday Ngarame
3 days without internet access and I’m really starting to go through withdrawal. It’s funny how being here makes me realize the things I really absolutely rely on. I can go without running water easily – it’s amazing how clean you can really get with a very small amount of water… I’m not yet craving any particular food – even electricity I can go for the most part without, a phone I can take or leave – but an internet connection – a feeling like I am not alone “stranded” out here – that connection with my friends and family – not having that for the past three days has been ridiculously hard – it’s not something I thought I would miss this much…

the waiting room of the camp health center

I am exhausted tonight. It was a full day of clinic at the camp – starting with rounding on our inpatients. 9 in all, 6 of them children. It will take a lot of gentle nudging from my side and understanding from the nurses but I think we will all move to the center. I find that the prevailing way of practicing medicine here is shotgun approach so that every child with fever gets quinine infusion for malaria, plus a dose of chloramphenical in case it is meningitis, plus possibly one or two other antibiotics. I guess w/o lab facilities you try to treat for the things that will kill and falciparum malaria and meningitis are definitely two of those things. Richard and Ben the two head nurses are quick studies though and it’s fun to start reasoning out clinical decision making with them.

One of our many young patients (the camp is 55% children, there are 80 households headed by children <18)

I join Ben for the rest of the day in the pediatric consultation area – we see over 50 patients with the whole spectrum of disease – two of which we “admit” one for severe dehydration and one for likely malaria – failing outpatient treatment. No laboratory and no potassium even – so we make do with what we have – in the case of the severely dehydrated baby w/ ongoing diarrhea it means an NG tube with Oral Rehydration Solution. For the presumed malaria cases – it means adhering to the WHO clinical case definitions – and assuming all the malaria is plasmodium falciparum which is the most dangerous kind. We see two cases of what I am convinced is pertussis in babies and I cringe thinking about how quickly it will spread through the camp. We have no medical assistants so we do all the weighing and temperature taking ourselves and it really is a slow rather grueling process. Another thing to plan for – finding a few young people in the camp with some level of basic education and interest and training them to weigh, measure and take vital signs. It will be an invaluable contribution and cut our time needs in half. And it will give a skill back and be a lasting presence in the camp after I leave. Will need to talk to Theodore the camp manager about this. Also basic hygiene practices – getting the nurses to wash their hands between patients – granted that calstat is expensive but even a basin with some antiseptic solution to dip one’s hands in between patients should suffice.

My exam room / office @ the camp

There is so far to go – I can’t believe all that we are doing without even a microscope or ability to do any blood testing. The HIV proposal will be sent out in the next few days and depending on funding we may be able to have that project up and running. It’s hard to think about these huge global practice – shaping things when confronted with the rush of patients every day – some quite ill. I really want to carve out some time for teaching, but the patient load is such that we are all *exhausted* after getting home… I will give myself a little break though – it’s only my 3rd day in Nyabaheke.

Coming back to where we are staying a disturbing discovery – someone has stolen my sleeping bag, from right off the top of my bed. The door to my room has been locked most of the day – there was only a short time when it could have possibly even been taken – yet it’s definitely gone. I can’t imagine anyone taking it – but it is a desperately poor place and I can only suppose that the person who took it needed it more than I did – but I am still a little disappointed and sad especially after a long day. Tomorrow Clemence has said that I can use the phone line at the Mayor’s office – so I will end my internet drought and be able to post all of these messages… (probably longer and in far more detail than anyone wants to read…. But hey it’s *my* blog…)

July 27, 2005 Wednesday Ngarame
Arghhh… day #4 without internet access. I didn’t get back from the camp tonight in time to go to the mayor’s office. There was a glimmer of hope momentarily when Clemens told me that the phone line was working again – but while that was true – for whatever reason the dialup internet connection was *not* working. Well I know for sure I can get a connection tomorrow because I am going back to Byumba to liason with Dr. Moses and Kebe. I am chagrined and a little amused at how hard not having internet access is for me. As much as I feel like I have settled in – and as much as I am loving my time here- I really miss being in communication with everyone at home… and the internet makes it so easy to be away from home without losing touch…

Morning "sign-out" reviewing last night's cases

Anyhow – another busy day – but starting to settle into a pattern. Morning rounds at the camp – it is gratifying to see all of our children doing better – I couldn’t sleep well last night because I was worrying about the last little 2 month old baby with the severe dehydration that I had admitted – without any labs or any way of ascertaining IV fluid rates- with a NG tube and a nurse not experienced in using it – with no way of communicating with me except sending a vehicle down a unpaved very long dirt windy road to actually physically come get me – all these things made me worry about how she’d be doing. She is definitely clinically improved although still having a large amount of watery diarrhea. I get to teach a little and explain oral rehydration to the nurses as we round and the importance of electrolyte repletion and the need to be very careful of IV infusions in small babies. They are all so eager to learn and rounding with them is truly a joy.

Weighing a patient

I did go back to the hospital in town this afternoon – which frankly I was dreading a bit. I get a little overwhelmed at the hospital with all the needs that are clearly not being met – yet it’s not “my” hospital (because I am starting to feel like Nyabaheke is “my” camp) and I don’t know how to best contribute. I had gone back briefly in the morning but Dr. Benon had an emergency c-section then cervical tear to repair so we had arranged to meet in the afternoon. Dr. Benon seems under so much stress – he speaks in nearly flawless English to me about how overwhelming the needs of the hospital are and how all the responsibilities fall on him. He still personally feels responsible for the deaths of any patient in his hospital … and so many die every day… he knows that it’s not his “fault” he says, but it still gets to him.

Even so, it is evident that he loves caring for patients and it is clear that his patients are very fond of him – greeting him along the walkways as we make our rounds. He takes me to his most complicated patients and we discuss the management – most of these patients look like end stage AIDS or TB patients and while there’s not too much to do – I’m able to make a few suggestions, and I think he just enjoys having a colleague to reason through things with – given that he is under such stress and time constraints that he doesn’t often get to think through the more complicated patients. . We agree that I will do “consultation rounds” with him every Wednesday morning and I am happy with that arrangement. I wish I could do more but my first commitment is to ARC and the refugees in Nyabaheke camp.

There are baby steps being made – a laboratory set up – I am promised – is a few weeks away, we are identifying 5 young men and 5 young women with some literacy to train as medical assistants, I have arranged with the district health coordinator for a mass vaccination to take place next Wed-Fri to vaccinate all the children under 5 (900 + children that age in this camp!!) and Ben, Richard & I are discussing how best to standardize nursing documentation in our “inpatients” in the camp – as there are no med sheets or vitals sheets…the HIV grant proposal will be finalized & submitted tomorrow, and everyone is *washing* their hands… at least when I am watching!

Part of the Nyabaheke team. From L to R In back is Ben (assistant medical coordinator, nurse) then me, in front Clemens (assistant camp manager), Louise (Income Generation Project volunteer ARC), Theodore (camp manager), and Richard (medical coordinator, nurse)

I am sad that Louise is leaving to go back to Minnesota tomorrow. She’ll ride with me back to Byumba then will go on to Kigali. It’s been so nice having another American here – she’s so committed to the Income Generation Project and “my” camp Nyabaheke is so ready for it – so many women interested in starting their own businesses. Louise will have to go back to the states to fundraise a bit to start up the project but promises to return in November with *funding* for some small business loans and training. So, SO *SO* desperately needed. Without her I will be the only non-African working at the camp… in fact as far as I know – the only non-African living in this region as it’s fairly remote although nothing in Rwanda by distance is that far apart – it’s just that there are only dirt roads so getting anywhere takes a bit of time… Well I really will *post* this tomorrow unless Byumba’s connection is also down…

More from Gihembe

2005-07-23T21:40:00.000+01:00

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.

Day one - Gihembe

2005-07-22T04:23:00.000+01:00

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 …

Ann

and finally... Rwanda

2005-07-20T23:06:00.000+01:00

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.

Best,

Ann

4 hours in Kenya...

2005-07-20T14:05:00.000+01:00

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 :)

Ann

12 hours in Amsterdam

2005-07-20T00:37:00.000+01:00

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.

best,
Ann

Goodbyes and Thanks

2005-07-18T12:01:00.000+01:00

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
Africa

much love and many blessings,
Ann

On my way to Rwanda

2005-07-01T20:04:00.000+01:00

So I have an official departure date: July 18th. I'll be leaving from Boston and flying to Kigali, Rwanda via Amsterdam and Kenya. Thank you everyone for all of your support. Please do click on the comments area to leave me messages...
Love,
Ann

Tamalia's Thank you from the Indonesian People April 2005

2005-07-01T19:49:00.000+01:00

This is a speech from Tamalia - one of the translators aboard the USNS Mercy as the second wave of Project Hope Volunteers were departing, March 2005. She works as a curator for the Indonesian National Museum in Jakarta.

"I think that it was Sir Arthur Chesterfield who said something along the lines that the human species is happiest when it is of service to others. Well, I do not think that I shall ever be on a happier ship than this one.

You, doctors and nurses who have worked on this ship treating the wounded Acehnese tsunami survivors are extremely special people with an enormous compassion and empathy for others, especially for those who are suffering. You are truly good people - if you were not you would never have volunteered to be on this ship and I think that when a large group of truly good and caring people are collected together in one place like this - it creates a certain energy of its own which has far reaching effects.

I do not know if you are aware of it but when I left Jakarta to join the Mercy the front page article of one the newspapers in Jakarta was about how Indonesian public opinion towards America was taking a major turn. This happened after Indonesians started reading about and watching via the television the thousands of mercy missions flown by the helicopters of the USNS Abraham Lincoln off the coast of Aceh. Daily the helicopters dropped food, water and medical supplies to the survivors of the tsunami whom my government would never have been able to reach in time after the enormous destruction of roads, bridges and communications by the tsunami.

And later Indonesians witnessed the compassion of the doctors and nurses of the USNS Mercy as they treated over 19,500 Acehnese patients and performed over 250 operations. I do not think that any other government in the world would have been able to provide such an enormous quantity of aid so rapidly because no other government is equipped with the enormous war machine that the United States has and what happened is that in the last three months we have watched that great war machine being used for something totally different and in a way that was completely foreign to us. It was being used to save and heal thousands of lives and quite frankly, at first we Indonesians watched with suspicion and then in puzzlement but finally with gratitude and fondness.

During the last days before the departure of the ship many of the patients were returned to shore to finish their final recuperation at Indonesian hospitals many of which are just starting to fully function again. It was a very emotional time for me as I have had to translate for many of the patients and doctors and nurses as they bid each other farewell. Over and over again this is what the patients have been saying, "I do not know how to thank you. I cannot repay you for what you have done. I have nothing with which to repay you. It is only God who will be able to repay you for what you have done..."

It is one thing to heal people and to give them medical aid but I think that there is another element in all this that you may not be aware of. These people that you have been treating are the poorest of the poor. They eat chicken or meat perhaps once a year. If they eat fish twice a week that is already good. Normally, their meal will be a plate of rice with some chilly peppers and a bit of swamp spinach or other vegetable. There has been an insurgency going on here for many years. The military comes and extorts money out of them and burns their houses. Then the separatists come and kidnap them, extort money out of them and burn their houses.

They are frequently caught in the cross-fire between the military and the separatists and it doesn't matter because they are just garbage - people of no value. If they go to a hospital for help they are not kept waiting for hours - they are sometimes kept waiting for days and they are treated with arrogance and without care. Indifference is often the best they can expect. And then they came here. Here you not only healed their bodies but you treated them with such gentleness, such compassion and such great courtesy. For the first time in their lives they were treated as human beings who have worth. You see a man who has lost an arm, a patient who has lost a leg and yet when they leave the ship they are all smiling.

The joy in them is overwhelming. They are perhaps happier than they have ever been in their lives because for the first time they are aware of their worth as people - that their thoughts and feelings and lives count. When they leave here they know that they are valuable. They leave with self-esteem. This is something very special and very rare that you have given them.

In Indonesia the words for "thank you" are "terima kasih" which if you translate them literally mean "accept love" for what is it to give someone thanks other than to gave them a part of your love? So allow me on behalf of my country and my people to express to you our gratitude and to give you our love."

Reflections on coming home from Indonesia March 3, 2005 "Homecoming"

2005-07-01T19:43:00.000+01:00

I already miss the smell of the ocean and the thick heavy humidity of southeast Asia. It's something that hadn't happened to me before - this not being able to write or even describe a place or experience while I was there. I know I promised up-to-date emails of my activities but found myself at a complete loss for words every time I sat in front of monitor and keyboard.

Where to start now that the icy blue of the New England sky and the snow on the ground tell me irrefutably that I am home.

Should I start at the end with the last heartbreaking story of a month of numbing tragedies recounted for us - that of the 5 yo girl we put on the Indonesian military C-130 plane to Jakarta just as we were boarding our own US Marine C-130 to Singapore? How she lost her mother and siblings the day of the wave torn away from them and washed up on a mosque's steps a mile inland, brought to a hospital with a severe aspiration pneumonia - somehow found by her father who had been out of town - the two of them all each other had left in the world. How she was treated in three different hospitals, getting through skin grafts and the pneumonia how they finally were discharged from the 3rd hospital to an IDP camp nearly 6 weeks later to slowly begin their lives together again. She had a seizure and never regained full consciousness the day after her discharge and her father rushed her back to the hospital. How we found her on land in that decimated pediatric ward of the formerly proud Banda Aceh University Hospital in a corner crib unresponsive her father holding hand. Helicoptering her to our ship the might of America poured into a tertiary care floating hospital complete with CT scanner, Operating Rooms and ICUs. How the glimmer of hope in her father's eyes slipped back into despair as we discussed the CT and test findings with him. Massive hydrocephalus - from tuberculosis. The TB we could treat but we didn't have a neurosurgeon to relieve the hydrocephalus. So to Jakarta she was going as we were going home - her chances of survival and meaningful recovery meager - her father with the only thing he had left in the world still holding onto her hand as she continued to lay unresponsive on the stretcher. Still he pulled me close to him in a tight hug as we were leaving - thanking me in the only way he could - our differences in culture and religion shattered by love of this little girl. I will forever be haunted by the look in his eyes.

There are happier stories - particularly from Ward 1 our makeshift "family" ward which functioned as the social center of the ship. Colorful origami figures hung from the ceiling and former strangers clung to each other for support. A large crowd gathered as we would round each day - as opposed to the fierce American need for privacy the Aceh people desired community in a way that is foreign to our discrete disjointed western lives. The day's triumphs and setbacks made their way in murmurings throughout the ward on each patient - when asked if a patient wanted privacy for some delicate test result the answer would always be a quizzical expression as if the question was too absurd for a straight answer. I never became fully comfortable in the month of daily rounding with the crowds we would gather as we moved from one patient to another.

The benefit of the open bays - designed to house recovering wounded "subacute" soldiers, marines and sailors in a bygone era was that of dispersion of horror and grief. All had their own tragedy and for a short while on Ward one - no one had to go through it alone. The older women left without a family to care for took on the nurturing role for the young mother whose baby was recovering from extreme dehydration and electrolyte imbalance. A 15 year old girl whose arm was amputated because of an aggressive tumor took turns coloring with a 9 year old boy with a large mediastinal mass.

The play room - lined with drawings first of coffins and waves which made way to happier themes - was not just inhabited by the children - the adults were often found lounging on the cushions, deep in discussions. If ever a ward itself could be responsible for healing - Ward 1 had a power of transformation deeper than anything I can explain.

Elisa manifested this perhaps the best - she was our profoundly sad and withdrawn 17 yo girl with pneumonia and brain abscesses, paralyzed on her right side - having lost her mother and siblings in the tsunami - emerging from her cocooned grief to the warmth of Ward 1 and finally full of smiles as she found her voice again. The day of her transfer back to the ICRC field hospital when she was finally able to move her right leg for the first time in a month (the powerful IV antibiotics finally penetrating the abscesses in her brain) she burst out in giggles so loud that we couldn't believe they had come from her.

Flying in a helicopter over Aceh the dead brown earth where the saltwater had reached sometimes miles inland killing everything it touched was in stark contrast to the tropical greenness juxtaposed against all the death. Someone had described it to me as if a giant hand had come and scooped everything away in its path. Looking on it the first time the rendering was accurate. I couldn't stop myself from snapping pictures despite the determination not to fall prey to "disaster tourism." The magnitude of destruction was uncapturable in pictures however. Arriving on the scene nearly 5 weeks after the event, dead bodies were still being pulled from the mud. A school we visited was lined with flags in the schoolyard - each marking the spot a dead body had been found. The director of the university hospital had lost his wife and children and came back the same day to start digging out patients from the hospital. The heat and acridity of the air on land was accentuated because we were used to the clear saltwater breezes on the decks of our hospital.

There is so much more to tell - the Navy culture - the amazing doctors and nurses I was lucky beyond measure to have met and worked with, football on the flight deck, seeing the southern cross in the sky and the 4 moons of Jupiter - but this is my best attempt for a start. Thank you so much for your thoughts and prayers as I was gone - I'm looking forward to catching up with everyone in person.

much love,
Ann