Masks

The R&R and its Lubumbashi shopping spree for my Congolese friends at the hospital has come and gone already. Yet the fatigue stays – we have been tackling so many epidemics lately, and the measles is now a thorn on my side, as some of you know.

Vaccination campaigns in the Congo are traditionally supported by the big NGO’s and UN offices. The vaccines are donated by UNICEF and significant sums are provided to the Ministry of Health to carry out the campaign. Unfortunately, most campaigns in DRC see their funds deviated towards a few, deep, pockets. Children in rural, less accessible areas miss all the routine immunizations. Here in Shamwana, the coverage has been at best episodic for the last decade. Hence the epicentres of measles shaking up here and there. But the Ministry of Health is often reluctant to start emergency vaccinations because it would implicitly suggest that its previous, well-funded campaigns, were not effective.

When the first cases of measles happened a month ago, we started vaccinating in the affected villages, according to our MSF protocols, using the Ministry’s vaccines. In the context of an epidemic, MSF widens the age of immunization up to 15 years whereas the routine government vaccination is only until 18 months old. We made the mistake to inform our Lubumbashi office about our extended coverage right away. Because they were trying to get provincial Ministry of Health approval for our extended emergency campaign, everything had to come to a halt to show the goodwill of MSF to cooperate with the Ministry. We were told to stop all vaccinations at once. The negotiations on our side, in the field, with the local Médecins Chefs de Zone, were successful – it helped that both came by motorbike and saw the extent of the measles epidemic, with the extra tents and set-up already overwhelmed. But at the higher capital level, where the MSF Lubumbashi people were also lobbying, the approval for the emergency coverage was not obtained. Instead, we were instructed by the Médecin d’Inspection Provinciale not to do an emergency extended campaign, because the International Rescue Committee was to support another provincial Campagne de Rattrapage in January, with the associated funds. With, I mumble, the expectation to be as ineffective as the last one. So even if we have the approval of our local Bureau Central de Zone, they were forced to bend to the capricious decision of the provincial authorities.

Simply put, 4600 doses of unused vaccines from the previous mass routine campaign held in August are now sitting in our fridge in Shamwana and waiting for their expiry date. In the meantime, we have had 164 cases of measles in six different villages, and new cases keep on coming on a daily basis. To say the least, out here in the field, we are... rabid. Had we not informed the MSF capital office so swiftly initially, and simply gone through our regular channels through the Bureau Central, there might have been a window whereby we could still have gone forward with the extended vaccination. Because the local MoH was in agreement with us; and with the Congolese context of delays in communication and habits of long political discussions, the provincial level might have been informed much later, thus giving us a window of opportunity. Our Bureau Central people now think that the carpet was pulled from under their feet because of the prompt intrusion of the provincial authorities inadvertently facilitated by our Lubumbashi MSF office. Moreover, to vaccinate the measles-affected villages is feasible here with the current logistical equipment. The provincial Ministry of Health in Lubumbashi is de facto taking the children hostages by refusing to authorize our emergency vaccination, which does not cost anything. All this because it does not bring any supplementary funds to his office – I mean pockets, of course... We have to watch helplessly the measles spread and use up material and human resources, all the while knowing that the epidemic was altogether avoidable. The principle of international aid can be a pretty mask hiding an ugly reality when there is not much follow-up in the field. One must take into account the corrupted, tribal, ego-driven political infrastructures that are rampant on this continent. Ah, the arcaneness of dealing with Congolese officials and African realities! The road to hell is certainly paved with good intentions...

I now know next time to play dumb and to take advantage of the slowness of bicycle-driven messages used by the Ministry of Health to communicate with its hierarchy. We are all having fantasies of hiding in the night to go secretly vaccinate all these villages against measles. Historically, MSF had been known to defy Ministry of Health decisions or inertia, but there have been consequences. MoH’s have been known to denounce MSF on public radio, or even, we have been kicked out of some countries. With more experience and chaos in the humanitarian world, we are aiming for a better collaboration with the local medical authorities, but it can be a delicate issue that is difficult to take on.



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Parading on AIDS day in Shamwana on December 1st...


My absolutely fantastic medical team




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Sur ce, j’aimerais quand même tous vous souhaiter une bonne saison des Fêtes et une bonne année 2008! Que la joie et la paix soient dans votre coeur et que le nouvel an vous amène tous les souhaits auxquels vous aspirez!

Best wishes of health, warmth, luck, happiness and love for the holiday season! May 2008 bring you joy and fulfillment!

Masques

When I feel like contemplating, I read James Maskalyk’s blog on his mission in Sudan earlier this year, and my friend DC’s mass e-mails on her mission in Côte d’Ivoire at the halfway mark. It is an easy game, to compare experiences with other first missioners, to see if we all go through the same phases. James talks about a woman with retained placenta who dies of overwhelming sepsis and anaemia. He says: “No death is easy, if it starts to become that way, one should change professions.“ A colleague pronounced the exact same sentence earlier this year at home when I reacted with great passion to a young woman’s death. But somehow, tonight, such noble sayings make me express cynicism. Some deaths are easier than others. In the business of managing sickness, repetitive pattern recognition shows us that some deaths are sought for if not, even, deserved. We have a case of fulminant hepatitis. I was scratching my head about the reasons why – until he vomited a large amount of strong-smelling palm wine. The same happens back home, when the cirrhotic alcoholic comes in for the umpteenth time with bloody vomiting after a drinking binge. “What a waste of time and resources”, emergency room workers think but don’t say. “He looked for it.” Whether in the Canadian emergency department or in the Congolese bush hospital, doctors and nurses can’t help but express judgment at self-inflicted morbidities. The judgments offer an explanation to the unexplainable, and yes, some deaths sure feel easier than others. It is not a truth that we healthcare workers will admit publicly because it is so politically incorrect. But it would be preposterous to deny that we become more callous with time. Still, when death and sickness hit the innocent and the destitute – then, I certainly hope to always react with great passion.

This blunt political incorrectness is the product of a lot of fatigue... multiple apologies. The rainy season and its corollary of logistical nightmares have arrived in full force. For seven days last week, I was designated the acting project coordinator and logistician, because both were gone. And my bipolar karma went into a manic phase and spilled over to the non-medical responsibilities. The interim position, meant for a week-end, stretched to a week due to plane delays. And trucks got stuck in mud and decisions had to be taken with regards to immobilized precious fuel on the road, as well as significant plane delays. Challenges in communication with our capital team and a tense exchange with the local Ministry of Health were the cherries on top. The upcoming R&R this week-end will bring back my cheery self, I hope.

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Bébé Kalobwa, the one who was born at 900 g, being carried by her half-sister. Kalobwa is now 6 months old and... urmh... 3500 g, which still isn’t much. But at least she is holding her head that is now full of nice thick hair!






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Notre psychologue est partie, à ma grande tristesse. Pour son départ, on avait préparé en catimini l’invitation d’une troupe folklorique locale. La fête a été un franc succès. Les danseurs, vêtus de costumes de paille et de masques un peu effrayants, ont performé pendant une heure et demie. Leurs musiciens étaient aux tams-tams, en continu, sans arrêter. Le bidon d’alcool de palme et le chanvre parfumé partagés par les musiciens ont clairement contribué à l’atmosphère de transe et de magie noire qui flottait.



On a su par la suite que les Bifwebe, tels qu’ils s’appellent, sont aussi considérés sorciers et n’étaient pas venu à Shamwana depuis avant la guerre en 1999. La population les révère et les craint à la fois à cause de leurs soi-disant pouvoirs de magie noire. Ils sont les gardiens des vieilles traditions de brousse. Chaque danse performée racontait une histoire mythique: chasse, querelle de famille, apprentissage. Lors des danses, un des leurs ramassait sans faute chaque miette de paille tombée des costumes. A certains moments, les danseurs se fouettaient avec des branches de feuilles. A mes questions perplexes, notre watsan congolais a répondu que les brindilles tombés se faisaient transformer en gri-gris (amulettes traditionnelles de cuir, portées à la ceinture), ce qui, tout comme les flagellations, a pour but de préserver force et énergie vitale. Observer les faciès de nos employés congolais lors du spectacle relevait de l’expérience anthropologique. Selon leurs origines soit rurales soit urbaines, certains étaient effrayés ou du moins inconfortables, alors que d’autres se joignaient à la danse en rigolant et en prenant des photos. Quelle belle illustration du schisme entre le Congo païen tribal précolonial et le Congo éduqué chrétien (mais tout aussi tribal sous le vernis)... Devinez qui étaient les inconfortables? Pas les gens d’ici, habitués aux Bifwebe et à la magie noire! C’étaient les gens éduqués de Lubumbashi. Pour la peine, tout le village de Shamwana s’était regroupé à nos portes et notre palissade de paille a été complètement détruite par les attroupés qui voulaient voir le spectacle. Disons que le départ de notre psychologue s’est fait en grand et aura été inoubliable – il a laissé ses traces de destruction à la base!

Epi

Arrivée

Il aura fallu trois mois pour que je m’extirpe de ma bulle de voyageuse et que je me pose vraiment ici, à Shamwana. Le sentiment d’être ici, de me sentir chez moi, que ça devienne mon familier, vient d’atterrir doucement. Je reconnais chaque membre du staff national à sa démarche, son timbre de voix, voire même son ombre. Distinguer un Congolais la nuit n’est pas tâche facile - pourtant maintenant je reconnais chacun d’entre eux quelle que soit la pénombre. Lorsque je suis partie en réunion médicale à Dubié la semaine dernière pour discuter avec les collègues de l’avancement de nos projets respectifs, je me suis sentie en terrain complètement étranger. Shamwana, c’est vraiment mon quotidien maintenant. Je me suis attachée à ce petit morceau de terre africaine comme je n’y aurais pas cru. C’est difficile à admettre pour quelqu’un qui a activement cultivé le nomadisme pendant les quatre dernières années. Mais ça fait tout chaud au coeur, tout simplement, finalement.

Nyombo, notre patient le plus malade de l’épidémie de choléra de Kishale, maintenant admis chez nous pour malnutrition. C’est l’enfant le plus bavard et le plus mignon qu’il m’est venu de voir. Même complètement déshydraté, en choc hypovolémique, il multipliait les sourires, enterrés sous ses cernes oculaires de choléra. Maintenant, c’est mon petit pot de colle, il m’appelle "Muzungu!!!" et me suit partout à l’hôpital, entre les tentes. Je caresse secrètement des fantaisies de l’adopter, mais sa mère protesterait, sans doute...


Inauguration de notre nouvelle salle d’op juste à temps pour la visite du chirurgien expat. Les murs sont émeraude, bien agencés aux draps et aux tuniques...




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Of epilepsy and fires


Apolline, whom I had mentioned a few months ago, tragically died in Lubumbashi. She did not survive the skin grafting procedure. In developing countries, burns and epilepsy come hand-in-hand: the twinkling lights of cooking fires trigger the seizures that make children fall into the flames.

J looks around ten years old although his father states that he is past fifteen. He fell into a fire during an epileptic fit two weeks ago. He suffered extensive second and third degree burns to his arms, legs and trunk, but fortunately not to his face. He was brought to Shamwana by the outreach team a few days after the event. His burns were still seeping and by the time he arrived, were producing a greenish exsudate. Thanks to those who have responded with regards to the vinegar dressings for Pseudomonas aeruginosa. In the end, a few days of oral cipro did the trick, but we are preciously keeping the vinegar for the next one.

I helped out with a dressing change of J last week. While we were taking off the dressings, he was crying in pain, calling “Kaka” (big sister in Kiluba), and begging any sorcerer to enchant him to not have to go through the procedure. Through the tears, he was still answering "Présent!" to his name when I gently called. But once the dressings were off, while we doctors were inspecting his wounds, something strange happened. All of a sudden, he became silent, grabbed my wrist and stretched stiffly. His eyes emptied and took the colour of terror; his breath shortened. Only when he started walking on all fours in circles on the bed, on his exposed burns, did I realize that he was having an atypical seizure in front of us. I had only seen the classical generalized tonic-clonic kind. J’s fit really looked like possession: panicked eyes, fixed face, erratic, animal-like behaviour. We had to hold him tightly and softly call his name. Finally, after a few minutes, he came to, as if nothing had happened. The crying started right back on the note where it was interrupted, and he continued calling for his mother and sister and answering "Présent!" to his name again. Witnessing such an odd event made me reflect on the notions of black spells and possession that are rampant in African lore. It is hard not to believe in it when one sees the absence in the eyes of an epileptic during a fit, when one has no medical understanding of the disease.


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Of Shamwana, epicentre of epidemics


We seem to be collecting field experience straight out of Manson’s Tropical Diseases textbook. Apparently, with us Canadians, all sorts of adrenaline-charged events landed in a previously sleepy Shamwana. Since September, we’ve had an influx of tuberculosis cases, the bane of cholera in Kishale, an outburst of twin pregnancies, threats of a meningitis outbreak, and now... measles has arrived. I make sick jokes that the only diseases missing are the bubonic plague or, God help us, Ebola. (No worries for those back home, I would get evacuated pronto if Ebola was to appear here. People much more capable than me would handle it.) It’s truly the full MSF experience, complete with all epidemics!

Measles spreads like bushfire. If national vaccination programs were carried out properly, it would not be an issue. Unfortunately, our remoteness does not allow the Ministry of Health to deliver the vaccines with the appropriate cold chain, so children have not been vaccinated for a long time. Measles is extremely infectious. Once there is a confirmed case, we must declare an outbreak. It is a clinical diagnosis: fever, rash (hard to distinguish on ebony skin), conjunctivitis, and coryza. Young children are usually affected, and the older they are when they catch it, the worse it is. The complications can be severe: malnutrition, blindness, severe respiratory disease, death. The children look miserable, burning with fever, sunlight hurting their wincing, swollen, purulent eyes. The measled, the miserabled. Measles spreads faster than lightning. One child can infect 17-20 others. During my four-day absence to Dubie, an outbreak of 29 cases of measles exploded in Monga, one of our villages. Isolation is key in handling a measles outbreak. We have sent a tent, medications, heaps of vitamin A, and a nurse to Monga in order to isolate them all. The numbers seem to have reached a plateau at 41. I’ve now seen a handful of Koplik’s spots, the pathognomic blue or white spot on the palate or buccal mucosa which I’d only seen in books. Overall, a measles outbreak isn’t as resource-intensive as a cholera outbreak, but it spreads more rapidly so fast action is still required. Vaccination is key to the containment of measles. However, with our limited resources, it hasn’t been possible, and the red-tape filled response from the Ministry of Health has been reticent and yet capital told us to respect it. So for now, we just have to sit back and see what happens...



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Pictures from a little week-end in Dubie, where I arrived atop a massive truck called a Unimog...


Children in Dubie on giant termite mounds




Doing the laundry under the bridge in Dubie

Little pleasures, little treasures

Un arc-en-ciel parfait
dans son demi-cercle
entre les nuages de plomb
et un ciel éclatant
a accompagné la première écoute
qui a été à la hauteur de l’attente.

Mes proches me sauront profonde inconditionnelle de Radiohead. Leur dernier album In Rainbows vient de sortir sur Internet et on a réussi à l’obtenir (via la France et une nouvelle capital-log efficace) un mois plus tard. C’est un plaisir que le logisticien français et moi partageons, même s’il les a découverts une décennie plus tard que moi. Jusqu’à la fin de nos missions respectives, nous serons branchés sur la même musique sur nos Ipod Shuffle.

Au début de mon séjour à Shamwana, je ruminais sur la paucité matérielle comme remède au malaise existentiel inhérent à la vie moderne – une des raisons inavouées pour lesquelles on s’engage dans une mission MSF. A l’arrivée, l’écriture et la réflexion distillées ont sainement occupé l’espace vacant laissé par l’adrénaline familière (à l’urgence, toujours dans un avion, sous l’eau) et la techno-dépendance. Contempler de la musique, sentir les paysages de brousse en courant le matin, et jongler avec les mots sont revenus comme plaisirs tout simples et vrais à savourer. Tout cela a aussi aidé à réaccorder un peu d’harmonies intérieures.

Mais maintenant la paucité gastronomique nous pèse. Nos réserves de bouffe fraîche ont tari et on mange des saucisses hot-dog en conserve sauce tomate avec du riz mal cuit depuis une semi-éternité. La gastrono-gourmande que je suis se surprend à presque sauter des soûpers par manque d’appétit. Une autre raison inavouée de partir en mission, en tout cas pour une fille, c’est de perdre quelques kilos sans effort. J’espère que ça va m’arriver, car le prix d’inappétance est déjà payé! Les conversations de table, autrefois épicées et amusantes, tergiversent présentement autour de la nourriture. Lorsque je regarde des épisodes de Six Feet Under, je remarque avec envie les rosbifs maison de Mrs. F ou le take-out sushi de Brenda. Même les métaphores des discussions quotidiennes semblent vaguement alimentaires. “C’est grrrave”, diraient les Congolais en roulant joliment leurs ‘r’.

En tout cas, les mangues ne manquent pas...


Pont typique de la région et les problèmes qui s'ensuivent





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Work is sinning by its abundance in contrast to our bleak food choices and means of distraction. Our hospital admissions for the month of October have jumped up by 60%. I practice hunting and fishing at the base for patient materials. Mattresses, wooden bed bases, bednets and blankets. Pills and injectables, in constant rupture. The cholera epidemic in Kishale has thankfully abated, giving a little bit of rest to our nurses. However, cholera reared its ugly head “chez nous ici à Shamwana” with a single case in Kabusonji, the village next door, so we have to dedicate one of our tents as a Cholera Treatment Unit just in case. Moreover, the expat surgeon is here and monopolizing my Congolese colleague (who loves to cut) and needing an extra tent for post-op patients, so I am rounding alone on the busy ward. Hence the tardiness in my monthly statistical reports and bimonthly e-mails, apologies.

My latest butt-in with an ancient disease was dramatic. In Western folktales, one should not walk in horse dung or on rusty nails because of tetanus. We now know that the spores of Clostridium tetanii are heat-resistant and can be found in most soils – nothing to do with metal or horses. Back home, people are vaccinated against tetanus in childhood and whenever they end up having to go to the hospital for wounds or sutures. Here, oh well, here... “c’est le Congo”, with dismal rates of vaccination and wound infections, which is really one catches tetanus. The tetanus toxin binds to nerve endings and stimulates muscle contraction spasmodically. It was a seven-year old boy who was referred from a village. The story will never be clear: the parents said that they brought him to the traditional guérisseur after the signs started, but traditional practices usually consist of herbs and scarring, which could have constituted the point of entry. The child came with generalized stiff spasms, crying between episodes. The image of the nurse placing him on the bed, rigid as a wood plank, is embedded in my mind. Straight from Harrison’s Textbook of Internal Medicine once again: the spine curving abnormally backwards ie. opisthotonos, the taut facial spasms ie. risus sardonicus, the impressive lockjaw ie. trismus. I had seen a case in Cameroun, but not nearly as severe. I learned that any stimulus, sound or light or voice, can trigger the dreaded spectacular spasms. One can only imagine the suffering behind a body that has gone out of control. Without batting an eyelid, the excellent nurses knew to place him in isolation, in a dark and quiet room away from the noisy paediatric ward. Poor child. We emptied our stock of tetanus immunoglobulin and were generous with the muscle relaxants. A day later, he was finally eating mango and fufu, a respite after four days of lockjaw-induced starvation.


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Earlier this year, there was a BBC news clip from Congo-Brazzaville where a concert of music from all local ethnic groups was held. Pygmies were invited, but instead of hotel rooms, they were offered huts at the zoo. Throughout Africa, pygmies exist in most countries at this latitude. They are widely segregated against and viewed as only semi-human. In Rwanda and Burundi, during the conflict between the Tutsi and the Hutu, because they belonged to neither group, they were spared by the génocidaires. Here in Katanga, the Mai-Mai rebels hunted them like animals because they were thought to have collaborated with the government army.

Yesterday, along with the expat surgeon, we went to meet our local pygmies. In the village of Nsangwa, a mere kilometer North of Shamwana, lives a pygmy group of about 13 families. They call themselves Semi-Bantu or Batembo, and have their own language, Kitembo. Longstanding mixing with the not-so-tall local Baluba made them taller than expected – but still slightly shorter than the Baluba. Nonetheless, their physionomy is definitely distinct. And their way of life is completely different from the Baluba. Most pygmies throughout the continent are hunter-gatherers and experts in the bush – which is why the Mai-Mai accused them of helping the army in our region. They are nomadic and travel in groups of a few families. In Katanga, where they are few, they form their own quartier of a few houses right outside of an established village and stay there for a few months or years, until there is no more bushmeat to hunt. They work the fields for the villagers, getting paid with a few handfuls of manioc flour or clothes. The poverty they live in is staggering: they had absolutely nothing but the rags that they were wearing. Children played in sand. Babies were naked. Men wore torn shirts the colour of dirt. Huts appeared fragile and overcrowded. Because of the segregation, they are reticent to send their children to school or to benefit from the free MSF-supported health care. Yesterday, we discussed with their leader how shy they are to send their children to the school in Nsangwa. He said, word for word, that he did not know if the teacher would allow his children to class because they are Batembo. Moreover, teachers must be paid by parents because the government salaries haven’t been delivered in years, so poorer families have less of a chance. Yet, because the chief of Nsangwa insisted on it, all men of the village, including the Batembo, are to contribute voluntarily to the building of the new school, supported by the materials of Concern our neighbouring NGO. It leads to the paradoxical situation whereby the pygmy families worked on the school building but cannot send their children there. I’ll go speak to the people at Concern about that. And maybe we should somehow create a Save the Pygmy Fund...(Ah, for once I just wish that this last statement wasn’t just irreverence...)

Batembo family


Papa Chef Batembo

Sueurs

Notre coordonnatrice de projet a dit: “Ces médicaux, ils sont malades. Ils ne sont heureux que lorsqu’il y a une crise ou un désastre.”

En effet, ces derniers temps, c’est le délire absolu. Des conditions parfaites pour que je m’épanouisse tout en maudissant les maux d’estomac causés par les excès d’adrénaline et le manque de sommeil. Tout d’abord, à Shamwana, l’hôpital est débordé. 37 patients dans un hôpital prévu pour 20: l’engorgement – une situation bien familière au bercail. Il y a plus de patients admis qu’il n’y a de lits! On a eu au moins une naissance par jour, dont des triplés, et au moins six paires de jumeaux. Malheureusement, nous ne sommes pas équipés pour traiter les enfants prématurés ou à faible poids donc on en a aussi beaucoup perdu. Les paroles d’un collègue montréalais résonnent dans ma tête: ‘I could never deal with the death of a child’. Oulà, s’il savait ce qu’on vit ici. J’ai vu des trucs qu’on ne voit que dans les livres: une syphilis congénitale sur une paire de jumeaux, des naissances par siège à gogo, des déshydratations ‘au plan C’, ie. plus de 15%. On a opéré sur une grossesse ectopique alors que la patiente n’était que sous kétamine – pas recommandé pour garder un beau champ opératoire puisque les anses intestinales ont toutes débordé lorsqu’on a ouvert, une vraie éventration. Pour la première fois de ma vie, j’ai manqué perdre connaissance lors d’une chirurgie. Il faut dire que c’était dans une salle d’op surchauffée, à deux heures du matin après une grosse journée de travail au camp de choléra, totalisant cinq heures de Land Cruiser. Mon excellent collègue congolais, que j’assistais à opérer, a eu la gentillesse d’être patient. On a été en salle d’op pendant cinq heures au beau milieu de la nuit. C’est la vie! En tout cas, c’est “l’MSF”, comme ils disent ici!

En plus il y a l’urgence choléra à Kishale depuis trois semaines maintenant. Depuis le début de l’unité le mois dernier, ma compatriote l’infirmière de cliniques mobiles et moi en avons assuré la supervision. Or, le grand total de nos connaissances sur la gestion d’une épidémie de choléra se résume à une soirée où on a imprimé les ‘guidelines MSF’ sur le choléra et on les a potassés: “Cholera for Dummies”. Un vrai mode d’instruction, tout y était: tableau clinique, diagnostic et traitement, épidémiologie du choléra en région rurale, construction d’une unité de choléra, mobilisation et sensibilisation de la population, investigation des sources d’eau et du mode de transmission. Nous sommes devenues des borgnes dans un monde d’aveugles. Chez les expats, ni notre watsan, ni notre logisticien n’avaient de l’expérience choléra non plus. On a tous appris et improvisé: c’est ça, “l’MSF”. Heureusement, il y avait quelques infirmiers congolais de l’hôpital de Shamwana qui avaient travaillé pour MSF-France aux urgences choléra: ils ont constitué notre nouvelle expertise. Depuis une semaine, l’unité choléra a pris forme, une deuxième tente est apparue, les seaux de chlore à différentes concentrations sont utilisés correctement, les procédures d’isolement sont en place, et tout le matériel est là. L’épidémie suit le cours prédit: 2 à 3 nouveaux cas par jour, 24 cas totaux en date d’aujourd’hui, troisième semaine maintenant, pic des admissions prévu la semaine prochaine. Et, preuve que “Cholera for Dummies” a été bien appliqué et que nos experts travaillent fort, on n’a eu aucun décès dans les hospitalisations. On écrit des rapports à la capitale, on nous envoie du renfort, on espère avoir 5 nouveaux patients par jour, ce qui nous qualifierait pour le ‘kit d’urgence choléra MSF’. La PC a raison: ils sont malades, ces médicaux :).

Tentes, seaux de chlore et hygiénistes – résultats de la lecture de "Cholera for Dummies"


Un lit de choléra – trou pédiatrique de 12 cm par 12 cm, selon nos nouvelles instructions ... les enfants tombaient dans les trop grands trous des derniers lits!


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In February of next year, be on the watch for Bill Moyers' journals on PBS. I was just filmed and interviewed by the crew today in Kishale. They were mostly here to film Concern and the topic of the show is "How to deliver humanitarian aid in remote settings". They stumbled upon us and our little cholera camp. I do expect that they will edit me out or make me sound much sillier than I already am. But if you do catch it on TV, let me know, and please try to tape it ;)

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A friend requested the following as input for a presentation. He may have done his talk to medical students by now, but I figured that I might as well share the thoughts already written, to the risk of sounding pedantic.

Top ten things it takes to be an MSF doctor, fresh off the cuff, live from Shamwana.

1) A sense of humor. It’s never enough. In situations of stress, or in front of medical and moral challenges – one must be able to compensate by being light and putting things into perspective. The ability to laugh at oneself is precious out here. And a good, hearty laugh eases communication in all languages.

2) A sense of adventure. Self explanatory. Comfort creatures such as myself must forgo the warm baths, the soft beds, the air conditioning or even the fans, the 24 hour electricity and even basic hygienic work conditions. But living in the Congolese bush has its perks: wonderful sunsets, beautiful children’s songs and laughter, nightly tam-tams, and miraculous recoveries defying any of Harrison’s or Nelson’s predictions.

3) Flexibility. We do not decide who our fellow expatriate teammates are. Yet they become as close as family, for better and for worse. MSF life pushes camaraderie, territoriality and rivalry to the extreme. We get to know each other to the level of discomfort, and the crises situations distill out the worse and the best traits in each of us. And generally speaking, MSF life attracts the strongheaded kind, which predictably leads to sparks and tension.

4) The ability to think outside of the box. Nobody teaches us the medicine that is practiced in MSF settings, not even tropical medicine courses. Every mission has different tools and technologies. There is quite a bit of improvisation involved. One must suddenly become creative out of lack of means!

5) Open-mindedness. Cross-cultural understanding is key in our settings; the teams are international, but also, working with national staff requires a lot of sensitivity to cultural issues and perceptions.

6) Communication skills. To speak to patients, to connect with sick children, to be understood by the national staff whom we supervise, and to talk to teammates and report to capital team...

7) Endurance. MSF life is hard. It’s been described by a colleague as “treading water, one day bleeding into another”... The initial excitement and sense of exoticism wear off quickly and give way to hard, long days with not much means of distraction.

8) Common sense. Paramount and yet not always there. Emotional stability and being reasonable go a long, long way.

9) Introspection. Most of us have an idea why we want to do this work – there are, of course, both conscious and unconscious reasons. But the challenges that we face and the situations that we participate in take us to places and headspaces that we had never thought of. The injustice, the inequalities, the unfairness, the teamwork, the deaths – MSF work changes one’s view on life and humanity and there is no return after that.

10) Humility. MSF work can make one feel powerless and angry in front of inevitable medical outcomes that would be correctable elsewhere. My count of dead children, a medical near-impossibility back home, has multiplied since my arrival. One had no say in where or when he was born, yet that is the only difference between the expat and the Congolese staff, or even worse, between the expat and the victim of trauma. And one comes to admire the living conditions and the discipline of the locals who can plow through long days of hard work with incredibly few tools and a meager pay, if any at all. It is easy for the expat to fall into the trap of neo-colonialism, complacently allowed by a lighter skin tone. The superiority complex of the Muzungu (White Person) is tempting and one should assiduously avoid it.


Ordinary day for a local


Happy to be sent home, less malnourished, and on tuberculosis medications.
Not so happy about leaving the Muzungu and not giving her the daily hug.


Saison des mangues

Traversées

Traversées verticales

On est entre la saison des papayes et celle des mangues (en plus de celle des serpents, des scorpions et des pluies). Le mois dernier, le papayer sur le terrain de la base nous a donné quelques beaux fruits. Le hic, c’est d’aller les chercher. Les papayes, sans doute de 1 à 2 kg, sont perchées à environ 10 m du sol, confortablement haut dans leur arbre. Il faut prendre une longue tige de bambou et les décrocher, au risque de se taper une bonne commotion cérébrale. Notre gentil log-forage anglais s’était mis à la tâche pour nous dénicher du dessert. Après deux papayes un peu vertes qu’il a agilement attrapées manière rugby, une papaye bien mûre lui a éclaté dans les mains, le couvrant de jus visqueux et odorant. Nous n’avons pas pu retenir les esclaffades de rire. Quel sacrifice quand même! Disons que la salade de papaye verte a été excellente ce jour-là.

Maintenant ce sont les mangues qui jouent à Sir Isaac Newton. Dans nos pérégrinations en Land Cruiser, j’admire les lourdes branches de manguiers qui se penchent au-dessus de la route. Les chauffeurs les évitent avec soin. A ma perplexité, on m’a répondu qu’une mangue verte qui tombe est un dangereux projectile auquel les pare-brise ne résistent pas. Il faut donc faire attention, car remplacer un pare-brise nous coûterait de précieux délais en visites de village.

Lourdes mangues


En termes d’autres fruits, on vient de découvrir que les grands arbres à l’entrée de la base sont des goyaviers. Tous les jours, des enfants y sont grimpés et se pourlèchent les doigts; pourtant, pas l’ombre d’une goyave au grand marché du centre-ville shamwanais. Il semblerait obligatoire de défier les lois de la gravité pour profiter des goyaves roses et parfumées. Avec un peu de chance, j’arriverais peut-être à fabriquer un bon petit sorbet de goyave, comme je les aime tant l’été à Montréal sur le Plateau... Il faut bien pouvoir rêver un peu ;)


* * *

Traversées horizontales


Every week brings new challenges. The approaching wet season is acquainting us with another old disease. Just like tuberculosis, cholera has been living with humankind for a long time. But unlike tuberculosis, it does not have a protracted course of chronicity. Rather, it uses the method of killing by numbers to spread fast. The cholera bacterium, Vibrio cholerae, is found in bodies of stillwater. In small quantities, it produces a nondescript gastroenteritis. But if the bacteria are ingested in large amounts, cholera kills very rapidly by producing a toxin that adheres to the intestinal wall and makes a human lose all its water from both ends. People die of dehydration and hypovolemic shock within a matter of a few hours: it’s typically a ‘rice-water diarrhea’. The incubation period can be anywhere from a few hours to five days, and the human secretions produced are highly infectious. Hence the potential for epidemics. The bacteria is known to have originated from the Indian subcontinent, where there is enough human density to sustain ongoing epidemics and mutations. The last world pandemic started in Bengal in 1991 and was carried all the way to Latin America. I vaguely remember the story of people dying after eating oysters on a South American airline crossing the continent. In Africa, where the water supply is generally unsafe, cholera epidemics are chronic.

In our region, the cholera usually comes from lake Mwero where Kilwa sits, a few hundred kilometers away. The way to deal with cholera is simple: the patient must be given back all the water that he is losing. If treated in time, recovery is close to 100%. But the disease moves fast. As soon as there is a case of cholera, we must set up cholera treatment centres. CTCs consist of a building with individual rooms, each with a cholera bed. The principle of the cholera bed is that it has a hole in the middle to gather the secretions that fall into a bucket right underneath. Patients are so sick that they cannot make it to the latrine. It is not unusual to give over 10 liters of intravenous fluid per day to a cholera patient. And the watsan (water-sanitation) people play a large role in the management of a cholera outbreak: large amounts of chlorine are used to disinfect the secretions, corpses if any, and to ensure isolation. The MSF protocol is complex and involves three concentrations of chlorine with specific uses.

Last week, our outreach team was flagged down from the road and brought a cholera patient to the health centre in Kishale, where we had set up a cholera treatment centre after a single case earlier in the year. However, more patients appeared this week. I was dispatched with the outreach team to investigate the new cases and report whether an epidemic was starting. The objectives were to contain the outbreak, verify the functioning of the cholera treatment centre, and to trace the contacts or contamination.

Arrived in Kishale, we looked at the cholera treatment centre and followed up on the patients. Both were now doing well. The centre consisted of a simple tent with dividers and cholera beds inside; our cholera beds are simply metal foldable bedframes and plastic tarp with the hole right over the bucket underneath. Basins with chlorinated solution were placed at all entrances of the tent, for shoe soaks. The nurse was reasonably well trained. Then, we investigated the movements and possible contacts of both patients, and visited their originating villages, as well as the road that they travelled. Quite the Sherlock Holmes enquiry, to research a cholera outbreak. We looked at the water sources, the river and the traditional wells used by the villages. It was quite interesting, as people move quite a bit, and it is virtually impossible to trace all contacts.

After much questioning and discussing with the chefs de village, the family members of the patients, and the Croix-Rouges, the local health workers, the puzzle solution slowly emerged. The index case had brought the cholera from lake Mwero at the village of Pweto, where he had gone to sell palm oil last week. He had had diarrhea the whole way back on the road to Kishale. Case number two probably travelled the same road around the same time and must have come in contact with his secretions. He died on the way to the health centre a few days later. Case number three crossed the same village as case number two on the same day, on her way to get some salt in another village. She then became sick on her way back home two days after. Case number four is a household contact of case number four. Crisscrossing paths in time and place, village after village, along roads and rivers – and cholera spreads. For the time being, we do not think that the water sources have been contaminated. But since the traditional wells are unprotected shallow spring water holes in the middle of the bush, it would be easy. Then we would have to teach all families to do bucket chlorination, which is a logistical watsan nightmare in our context. Let’s just hope that it doesn’t have to go that way. So for now, we remain on cholera watch.

Shamwana-in-the-bush



Little girl with mortar, pestle and manioc. Girls start working at a very young age. When I took this picture and filmed her earlier today, boys her age who were running around gathered around me and wanted to look at the footage. They were all laughing, at which point I reminded them that she was working and they weren’t. They sheepishly answered: “Ah, c’est vrai...”

Eaux Libres

La saison des pluies se pointe petit à petit, pole pole, en Swahili. On a reçu vendredi un orage diluvien, où plein de petits torrents se sont formés sur le terrain de la base. Il y a même eu de la grêle, qui a ruiné la toiture fragile du centre de santé de Kampangwe. Avec la pluie, les bestioles apparaissent. Voici mon collègue congolais arborant fièrement l’intrus qui a osé déranger les patientes de la tente-maternité pendant la nuit suivant l’orage.

(Ce n’est pas un bâton, c’est un serpent!)

Parlant de bestioles, on nous a ramené de Kisele, à 30 km d’ici, un être étrange dénommé pangolin. Un expat quelconque de Shamwana en aurait réquisitionné un, et on lui en a ramené deux. C’est une forme de tapir ou de fourmilier, ou aardvark en anglais – le premier mot du dictionnaire, me dit l’infirmière de Nouvelle-Ecosse. Ça se roule en boule défensivement, c’est couvert d’écailles mais c’est un mammifère, ça se nourrit de fourmis et de termites, et ça se mange ici au Congo. Probablement de la famille des porcs-épics. “En tout cas vraiment”, comme ils disent si bien ici, ce n’est pas un de nous qui a demandé la bête puisque j’ai fait le tour de la base avec la question; de toute façon, c’eût été clairement contre les règles strictes de MSF-Hollande. Sans doute une idée étrange de nos voisins, les gens de Concern. Hmm... après réflexion, pas si étrange que ça. La famille Pangolin aurait pu remédier à notre problème de termites – deux pangolins familiers au lieu de la vague odeur d’huile de vidange qui flotte encore dans la maison et dans ma chambre...


Pangolin = a kind of aardvark = kibembe en kiluba

Pauvre petits pangolins – j’ai bien peur qu’il ne finissent dans les estomacs des gardiens de Concern. En tout cas, ils ne reviendront pas chez eux à Kisele...

C’est à Kisele que j’ai trouvé la maison la plus poétique qu’il m’est venu de voir:


C’est la maison de notre agent focal, toute neuve, avec une belle bâche. J’irai lui demander un jour quelle inspiration l’a piqué d’inscrire ces jolis vers libres sur son mur.


* * *


There isn’t much free water in this area, or in the region in general; we are not near the Congo river at all. In most villages, to obey MSF standards, the drilling and watsan teams have dug handpumps such as this one behind the health centre in Kisele.


The Congo is a poor old man sitting on a mound of gold. I had heard that expression about Peru when I was there for a project in 1994, but this country takes the saying to a different, exponential level. DRC is incredibly rich in mineral resources, well ahead of most African countries. This arises the concupiscence of neighbouring countries such as Rwanda, Uganda and Angola, which all have informally encouraged guerillas on Congolese soil. The mineral wealth has contributed to the foreign-supported strife that has been plaguing this land and impoverished it. The current conflict with the renegade Laurent Nkunda in the Eastern provinces, the Kivus, is said to be supported by Rwanda – although that has been officially denied. The simmering conflicts allow the neighbours to regularly raid the mineral riches of this underdeveloped country without any infrastructures to defend itself; and they create the vicious cycle of worsening poverty and violence that has been the history of the Congo of the last few decades. The movie Blood Diamonds was about Sierra Leone, but it could have been about DRC. Many external interests, and not the least, companies from rich countries such as Australia, the States, China and... Canada, exploit mines with minimal labor law. In the Southwestern part of Katanga, there is copper. The uranium used for the American nuclear bombs dropped on Hiroshima and Nagasaki came from the Belgian Gécamine mines in South Katanga. The South African soldiers of the MONUC UN forces are known to seek out mining opportunities as a sideline in the Kivus. In conflicted North Kivu, there are diamonds and gold. Lately, the rage is all about this Coltan metal alloy, used in microchips and Sony Playstation machines, which is found in the Kivus and probably here in Katanga as well.

Possessing such rich soil also has consequences on the water tables. I’ve had interesting conversations with our British drilling officer. His team and the watsan team have analyzed the water from the handpumps. The mineral water contents include lithium, cadmium, manganese, copper and other metals. Twice or more the 500 ppm acceptable for human consumption by WHO standards. “Maybe we should make batteries out of the water”, he said jokingly... So much that the water from the hospital handpump has been deemed too minerally rich for expat use.

Hence, our domestic water comes from the small river that runs behind Shamwana. Two days ago, I walked over there for the first time. It was a nice half-hour walk through the bush, with a few green hills as backdrop, strange bird sounds and crickets all around. At the river, people were doing their wash and kids were going for a swim, in an altogether muddy water. Young girls were carrying back clean dishes to the village.


Three times a day, local ladies are hired to hike down to the river to supply our washbasins, our shower and our cooking water (twice filtered and boiled). Here they are, crossing past the expat tukuls to fill our shower bucket on a Sunday afternoon:




Seeing so many people work for us at a minimal wages sits uncomfortably with my conscience. I realize how much energy and financial resources we expats use just to live and work here, compared to the locals. Even if by Western standards, we are leading a Spartan life. The water for our daily usage has to be brought from the river. The petrol feeding our vehicles and our generator, thus supplying the electricity to our computers, as well as the kerosene for our refrigerator and our lanterns – all must be driven here from Lubumbashi. At the same time, we are bringing health care and basic infrastructures to a region long forgotten and scarred by conflict. Children have not been vaccinated for over a decade. People are accustomed to use the services of the traditional healers and birth attendants, with disastrous consequences on morbidity and neonatal mortality. Moreover, the NGO’s are kickstarting the local economy by bringing employment and locally trading goods. It is a two-way street, this development business.

Angels and insects

La brousse fourmille de vie. Tous les matins, dans le seau qui nous sert de lavabo, on retrouve noyées quelques grandes mantes religieuses de 10 cm, copies conformes de fines tiges d’arbre sèches. Notre nouvelle sage-femme zétazunienne est fascinée par la quantité de mantes religieuses ici. Il est vrai que chez nous, elles sont rares et, me dit-elle, c’est une espèce protégée. Ici, elles pullulent. Et sont de toutes les couleurs, formes et mimétismes. Feuilles vert émeraude, brins de foin jaunes, branches marron. Toutes volent ou sautent, mais ne piquent pas, heureusement. Sylvester le chat s’amuse à les chasser au soûper tous les soirs à notre réfectoire et parfois en fait une collation.


Au soûper, on est attaqués par des espèces de fourmis volantes au derrière allongé frétillant qu’on ne voit à nulle autre heure de la journée. Dans ma chambre vit mon araignée familière de 5 cm, toute plate, qui parfois se cache derrière mon coffre, ou sous mon bureau. Heureusement, ma moustiquaire me protège et elle ne m’embête pas la nuit. Depuis le Cameroun, j’ai appris que les araignées sont serviables et mangent les moucherons et les moustiques. Celle-ci ne m’effraie pas malgré mon arachnophobie notable. Au moins ce n’est pas une grosse et poilue tarantule. Il faudrait lui trouver un prénom – auriez-vous des suggestions? “Sam the spider” me semblait bien...

Le mois dernier, la maison a été envahie de petites fourmis qui curieusement produisaient un peu partout des tas de poussière de la dimension d’une tasse en moins d’une demi-journée. J’ai finalement réalisé que c’étaient des termites, et que la poussière en question était... de la fine sciure de bois, résultant de leur digestion des planches de fondation. Horreur! La maison va nous tomber dessus et il va falloir que j’emménage dans un tukul! La solution? Simple et toute congolaise en sa débrouillardise: verser de l’huile de vidange dans les orifices du sol. Ma chambre a senti le garage pendant deux jours; mais le stratagème a fonctionné puisque les envahisseurs ont disparu.

Il y a quelques semaines, après le seul gros orage qu’on a eu, quatre scorpions ont fait leur apparition sur le terrain MSF en moins de vingt-quatre heures. Deux en plein soûper au réfectoire, et un devant l’entrée. Le quatrième a fait sursauter mon collègue congolais lors de sa visite de la tente-maternité. Les gardiens les gèrent avec un clou au bout d’une planche de bois, un tue-scorpions congolais ma foi. Je n’ai pas eu de réponse claire quant à leur venin, mais comme il n’y a pas eu de présentations critiques de piqûres de scorpion à l’hôpital, on va présumer qu’ils ne sont pas mortels...


* * *

L’équipe médicale a changé. C’est un bol d’air. Je m’étais habituée au néo-colonialisme et à l’autorité de l’ancienne équipe en m’en isolant tranquillement et en faisant usage de silences judicieux. Les nouvelles arrivées sont plus expérimentées et bien plus humbles. De par nos origines communes du Nouveau Continent, nous avons le même esprit de collégialité, que ce soit avec les expatriés ou le staff national. La communication est plus fluide. C’est rafraîchissant de ne plus s’engoncer dans la hiérarchie. Au PPD, ils nous avaient prévenus que c’était l’équipe qui marquait le plus une mission, et c’est foncièrement vrai. J’en soupire de soulagement.


* * *


We are visiting the village of Kabala quite a bit lately. Monday, it was my turn to accompany the mobile clinic team there, on one of the Land Cruisers, the T-32. On the road, the “agent focal”, the local MSF community worker, signalled us from his bike. Earlier in the morning, he had tried to bring a woman from Kabala to the Monga clinic after she had spent the night in labour. However, strapping a pregnant woman with active contractions on a bike and riding on Congolese roads is no small feat. He ended up dropping her off in Beela, halfway to Monga. So we stopped there and I investigated the scene. The lady, primiparous, was alone in a hut the size of a queen-size bed, in full-blown labour. She was fully dilated but there was so much cephalhematoma that I couldn’t tell the head position. Membranes had been ruptured for a while. The birth canal felt so small, and with the history of prolonged labour, I could not take a chance. In Africa, my stethoscope’s bell morphs into an excellent fetoscope: good fetal heart. So off we strapped her in the back bench of T-32 and back we headed towards Shamwana, a good forty-five minute ride. The nice, capable national nurse and I sat next to her on the opposite bench, while the Canadian nurse went back to the front seat.

In the car, she was lying silently, asking only “are we there yet?” in Kiluba. I was deeply, deeply sorry for not carrying around my obstetrics textbook at all times. The contractions barely extracted a wince from her face. We had pulled gloves, a dressing tray of three basic surgical instruments, and a few rolls of gauze kling: the only relevant stuff available from the mobile clinic equipment. All of us sweating buckets in the car.

At thirty minutes, I examined her and tried to convince myself that she hadn’t progressed – but she had. Still all caput though: the head felt so tight in that canal, I could not feel the skull. Sweat started pouring down my back. The last delivery I ran was in February up North, and it was an easy one, with expeditious labour – a small baby and a large birth canal. If anything, this was the opposite. But after a few contractions, the head started moving down and the caput was slowly crowning. The nurse went “Euh Docteur, je crois que ça y est!”. He was right. I yelled to the driver to stop the car. Still incredulous, I held the scissors and was contemplating an episiotomy à froid. But then I was too terrified to go through with it. I thought sheepishly: “People who actually know what they’re doing will deal with the tear when we get back to Shamwana. I just can’t do this, I just can’t, it’s been too long. “

Resisting the head so that it would not be pushed out too quickly, I helped it out gently during the next four contractions, praying that the tear would be fixable. The nurse was assisting me by giving constant uterine pressure. The head took forever to come out, an elongated, eggplant-shaped ball of humid black hair. Occiput anterior, face downwards, thank God. No cord around the neck. The baby restituted quickly to my right and was out before I could take the next breath. Loads of baby poo in the amniotic fluid, both the pea soup and the dark green kinds. A few squeaks from a blue baby boy, but not much else. We clamped the cord with the only hemostat from the dressing tray, then tied the rest with torn gauze, then cut it. The kid still wasn’t breathing much... No oxygen, no suction, not even a rubber pear – we’re in the middle of the road in the Congolese bush after all. Sweating buckets. Too bad; it came as a reflex, the old school thing that I’d never done before but had seen on TV: I grabbed the limp baby by the feet, head down, and then administered a few solid slaps on his back. And it worked! He spat out green meconium onto the beige khakis of the Canadian nurse who had come to help from the front seat. Finally, he let out a good scream and pinked up. The newborn scream is a familiar sound to me by now; yet, every time, it still is the best sound ever! I could feel the relief evaporate from my body while I was wrapping the baby in one of the mother’s two pagnes. Off we drove, back to Shamwana. The umbilical cord was still dangling between mommy’s legs, but hey, I’m of the ‘scoop and run’ school and I thought that it was best to bring her back to the appropriate facility as soon as possible.

Fifteen minutes later, on our arrival to Shamwana, the pilot and the FinCo from Lubumbashi happened to be visiting the hospital grounds. Apparently they got quite the scene: the national nurse and I drenched in sweat, hair matted on our foreheads, meconium stains on the expat nurse, all of us with bloody gloves, and a woman barely covered by her pagne being ushered away to the maternity on a stretcher. A delirious smile was plastered on my face while I was holding Baby Conehead like a trophy. The bench and the floor of the Land Cruiser T-32 were stained with a mix of poo, urine, meconium, amniotic fluid and blood. Quite the scene, I must say. Unfortunately we were too rushed to take a picture. But our visitors certainly got quite the glimpse of the true MSF Congolese deep bush experience...

The new, experienced midwife examined the baby and reassured me that it had been a difficult labour, that the baby was occiput posterior (sunny side up) from the position of the cephalhematoma and somehow, he rotated along the way, either on the bike ride or during the car transport. I am incredibly thankful that the outcome was good. There were many opportunities where everything could have gone wrong – we had no equipment at all to deal with any complications. But her delivering in the car was still better than in that dark hut in Beela on a dust floor. We are joking that while we are waiting for the ventouse to arrive, we should simply attach all our ladies in difficult labour on a bike and ride around town for the babies to rotate: it might save a few caesarians... And mommy didn’t tear at all, in the end, except for the very small nick that I inflicted before deciding not to go forward with the episiotomy.

Congolese women are so accustomed to a high neonatal mortality rate that babies born at the hospital do not have a name until they leave. So for now we are referring to this little one as Bébé T-Trente-Deux, referring to the car where he decided to be born. He only weighs 2.5 kg, but then again, Mom is no taller than 4 foot 3.

Now I am afraid to see what else MSF has in store for me... what’s next, a cricoidectomy with my Leatherman on the road?


Bébé T-Trente-Deux aka Conehead, happily breastfeeding, a few moments after arriving in Shamwana. I am still tachycardic on this picture.

"The horror, the horror!"

(Joseph Conrad, Heart of Darkness )

For the last three weeks, I’ve been replacing the expat psychologist during her well-deserved vacation. She has trained a team of six local counsellors to practice active listening and detect signs of serious psychological illness in their clients. Mental health is probably the most important dimension of our project, as our population lived through horrific traumas during the war that just ended in 2005. I yet have to understand what this war was really about. The Mai-Mai were rebels who decided to uprise in this part of the country and took the population hostage. Different groups of Mai-Mai rose and created havoc throughout the country. Most Mai-Mai were young local boys who enrolled themselves under a local commander. It is said that sorcery and strange rites were used to maintain loyalty; more likely, addictive substances were involved. The war happened when the national government sent the Congolese army to control the Mai-Mai. Because of the conflict, people fled to the bush or the Dubie region. Overall, the population mistrusts the army as much as the Mai-Mai. They were extorted by the army for sustenance. Murders, rapes, torture, mutilation, and burning of whole villages were perpetrated by both sides. Finally, the Congolese army dismantled the Mai-Mai. To expedite the peace process, the government offered 300 USD to any Mai-Mai who would surrender and give his weapons away. They are still in the process of disarming fleeing Mai-Mai at this point.

The mental health counsellors go around the villages and do active case finding by doing home visits. They debriefed with me on a weekly basis for problematic cases or for stories simply too heavy to bear alone. Our counsellors were picked amongst local people and have themselves gone through the war. It is amazing how, with good guidance from our psychologist, their empathic and listening skills have blossomed after just a few months’ training. By now, they are working autonomously and come up with their own creative and culturally appropriate solutions to the problems. And it is lovely to see the sparkle in their eyes when they describe how clients come back for follow-up and are thankful for their listening and support. Let me share here some of the stories here. I would like to warn the readers that what follows may be a little hard to take. At the same time, I did not wish to censor anything as it is part of the daily realities that people face out here, and it is MSF’s mandate to offer témoignage, witnessing and advocacy. To shun the stories out or to edit them would not render this place justice.

In the village of Lubinda, a woman witnessed the Mai-Mai kill her husband and two of her children. She then fled to Dubie with her remaining children, where she lived as an Internally Displaced Person for a few months. She then moved back to her original area but to Monga, another village, where her sister lives. The relationship with her sister is strained and she is sad because she sees her remaining children go hungry. She tries to pick up daily work to feed them but life is difficult. And although her family still owns land in Lubinda, she absolutely refuses to go back there because she cannot face looking at the places where the massacres happened. We are encouraging her to smoothen things out with her sister and be proactive about finding work in Monga. But it is, of course, not easy.

Kabala is the village where Gédéon, the Mai-Mai leader, was based at the time of the war. The worse war stories come from this region. A woman there has only recently started sleeping without nightmares and flashbacks, after confiding to our counsellor. Two years ago, her husband was attending the funeral of a man. Suddenly, the sons of the deceased, who were Mai-Mai rebels, pointed him out and accused him of killing their father. Right there and then at the funeral, in front of sixty people, they chopped him to pieces in front of his family while he was denying the accusation and begging for his life. They then put him in a cooking basin and showed him off to his own children. And then, they... ate him. The woman has had flashbacks of the scene and symptoms of post-traumatic syndrome for at least a year afterwards. As can be a custom here, her husband’s family gave her one of his brothers as a new husband, to take care of her and her children. In the words of our counsellors, it was good for her to have at least a new male presence, to feel protected and less lonely. To me, that was... creative to say the least; to our counsellors it seems that it has been helpful and an appropriate solution...

A man has been feeling guilty since last year. The Mai-Mai accused his mother of sorcery and killed her. His father was cut to pieces in front of his eyes. His remaining relatives were burned alive in the house while he narrowly escaped through the window. Of his large family, only he and his brother’s daughter survived the carnage. He has been living with survivor’s guilt since this happened: he cannot work or find any pleasure in life. Our gentle counsellor tried to emphasize that even if his past cannot be changed, he should live for the future of his young niece and help her build a better life. This man will need follow-up on their next visit.

A man’s wife was repeatedly raped by soldiers in front of him. The couple survived the war and is still living together. However, he cannot look at her and feels sad and ashamed. The concept of shame is quite strong in this culture. Rape victims feel guilty and refuse to be seen in public afterwards. Our counsellors were trained to try to make victims realize that they were powerless when it happened, and that the villagers are not judging them. They then encourage them to come out of the house and participate in village life and work the fields. It has worked slowly but effectively so far.

These are pictures collected by the expat psychologist after she asked some children to draw their dreams or memories of the war that ended in 2006.


Children's drawing - a 10 year old describing his mother fleeing a burning house, pots on her head, with a child burnt alive


Children's drawing - a 13 year old's drawing his experience of the war: men with guns, dead child, mother's clothes on the ground while she is taken to the bush by soldiers.

Let me stop here. Enough stomach churning, I guess. But before I finish, I would like to emphasize that in spite of the misery of the war, people are building back their lives, there is happiness, and people are smiling. The change has been palpable over the course of the year and the outlook seems positive. The locals are nice, help each other, and look forward to a more peaceful future. But simply put, human nature is complex, and although we do not like to see it, the human heart has unfathomable darkness that cannot be denied, just as Joseph Conrad aptly described in his novella about this land.

Promenades

Déjà presque deux semaines depuis les derniers écrits... Les sujets ne manquent pas, loin de là, mais c’est que le travail a bel et bien commencé et j’ai pris goût aux nouvelles responsabilités. Vous savez sans doute que l’oisiveté ne me va pas bien. J’ai commencé à visiter nos dispensaires de village pour voir à quoi ressemblent les environs. Que de route cahoteuse et sablonneuse en tout-terrain! Le vrai Congo. Profitons-en avant que la saison des pluies ne nous paralyse complètement. Sur la route, je dois communiquer avec la base notre localisation aux demi-heures, à chaque village que nous traversons. J’aime bien écouter ce qui se passe sur la radio, pour avoir une idée des mouvements de tous les projets de la mission. A un certain moment, notre fréquence VHF était partagée en swahili avec des Tanzaniens qu’on ne comprenait pas; on ne pouvait plus communiquer avec notre propre personnel... La radio est capricieuse sur la route. C’est compliqué... mais “c’est comme ça, chez nous, ici, au Congo”, me diraient les Congolais avec un grand sourire et en haussant les épaules.

Kampangwe, vers le chemin de Dubie, était jusqu’à récemment un site de cliniques mobiles MSF. C’est maintenant un centre de santé. L’infirmier titulaire, comme on dit ici, c’est-à-dire l’infirmier clinicien, vient de s’installer en permanence depuis deux semaines. Il a laissé femme et enfants en ville et est venu travailler, seul et sans vacances prévues, pour la modique prime de 100 USD/mois que MSF lui accorde. Il est employé par le Ministère de la Santé du Congo, qui depuis longtemps n’est plus en mesure de payer les salaires. Kampangwe était un site de réserve des Mai-Mai lors de la guerre. Les murs de la clinique sont marqués de trous de balle et on voit le ciel par le toit de tôle. Une autre ONG a dû déminer les champs avoisinants. Nous venons de creuser une pompe à eau; prochaine étape, latrines et douches. Il faut aussi réhabiliter un tant soit peu la bâtisse afin qu’elle soit utilisable lors de la saison des pluies, par exemple, pour qu’il ne pleuve pas sur les patients et que les salles aient des portes... Le budget de réfection de la clinique est d’environ 600 euros et, me dit-on, c’est amplement suffisant.



Notre sympathique logisticien-forage anglais, un ancien pompier, était tout joyeux d’avoir trouvé de l’eau juste devant la clinique, à seulement 36 m de profondeur. Son équipe a appris à reconnaître un arbre qui souvent se trouve près de sources souterraines. Pour la cinquième fois sur cinq, l’indice a fonctionné. On en apprend tous les jours! La science pourrait-elle bénéficier des arbres congolais indicateurs d’eau à moins de 80 m de profondeur?

Le banc de bambou juste devant la clinique fait office de salle d’attente:





J’ai aussi visité le joli village de Kisele, un autre de nos centres de santé, un peu mieux établi que Kampangwe. Voici un des chefs de Kisele venu nous rencontrer, plutôt solemnel.

Ancient things

De l’ancien français


Les prénoms congolais sont sensiblement différents des prénoms francophones auxquels je suis habituée. Je ne parle pas des noms d’origine swahili ou kiluba – les Muzinga, les Sopo, les Moké, les Dhiam – ceux-là, on s’y attend. Non, les noms qui m’intéressent et que je trouve gentiment insolites sont ceux qui dénotent une trace d’ancien français.

En voici quelques-uns, certains apparemment d’une étymologie biblique éloignée.
- Apolline, discutée auparavant
- Nestor
- Prospérine et Prosper, ou devrait-ce être Prospère?
- Adressé
- Placide
- Généreuse
- Marcellin
- Bienvenu (il y en a deux à la base)
- Héritier
- Pharaon
- Célestine
- Nessila
- Athanase (c’est un homme)
- Costasie (c’est une femme)
- Fulgence (c’est un homme)
- Prudence (c’est une femme)
- et mon préféré: Potiphar, prénom d'origine biblique selon certains et égyptienne selon d'autres.

Ne sont-ils pas pittoresques? Je me demande si je pourrais en ramener au Québec. Ça pourrait partir une nouvelle mode pour la prochaine génération: les Célestine et les Adressé feraient suite aux Emma et Charlie en vogue chez nous présentement...

Aussi, quelques expressions congolaises que je trouve jolies trahissent leurs origines dans un français d’une autre époque ou une langue africaine imagée:
- ne fût-ce que
- bon service! (mots prononcés pour clore une réunion)
- j’aimerais soulever quelques préoccupations (quelques questions)
- il n’y a pas de souci (sans problème)
- une fièvre vespérale (le soir seulement)
- une constipation opiniâtre

C’est donc avec raison que le Larousse accepte maintenant toutes les variantes du français depuis quelques années, que ce soit du québécois ou du congolais. Ça fait plaisir que de voir que notre belle langue demeure bien vivante.

* * *

An ancient disease


Most pathologies seen by MSF workers revolve around malnutrition, tuberculosis, malaria and AIDS. They are the same everywhere because we work in tropical countries where poverty and malnutrition are rampant. On my arrival, the most common diagnoses in the ward were fever in children and obstetric complications. We had cases of diabetes and hypertensive strokes, odd in this context. Then I started going through some reading handed down to me by another MSF faithful, Rags, and thought, hmmm, strange, I haven’t seen much tuberculosis or malnutrition. They should really be the bane of a population like ours. Where did they go? More importantly, am I missing the diagnoses?

Well, ask and you shall receive. With a bang! After a nadir of nine patients in the ward last week, tuberculosis walked in with bells and whistles. We now have five children with recalcitrant cervical adenopathy, a woman with impressive ascites, a teenager who is all skin and bones, and a few adults with weight loss and chronic cough. Now half the ward is likely tuberculosis. And a few pediatric pneumonias that haven’t responded well to regular antibiotics are probably also tuberculosis. If they are complicated by HIV, well, there is no way to find out because there is no laboratory here yet. Which also makes my life more difficult because sputums have to be sent out to Dubie for examination – Ziehl-Neelsen staining. In the meantime, I must follow protocol by treating with regular antibiotics for two weeks to prove that they don’t work before starting antituberculosis medications. We have regrouped all the coughing patients in one tent, faraway from the newborns – no such things as duck masks or negative pressure ventilation out here! (And yes indeed, I’ll need a chest X-Ray when I get back home; the isoniazid regimen is planned; thankfully, I don’t drink much to start with).

Tuberculosis, or TB in medical jargon, is an ancient disease well adapted to humankind. It was found in the bones of Egyptian mummies and in Chinese tombs, so it’s been living with us for millenia. The bacterium causing it, Mycobacterium tuberculosis, also referred to as Bacille de Koch, has developed such resistance that it now requires three simultaneous antibiotics for six months to be eradicated. M. tuberculosis fares well in dark, overcrowded environments and weak, malnourished patients. It is killed with heat, sunlight, chlorine or javel, and the long course of antituberculosis drugs. The disease was the ‘consumption’ of centuries ago for which sanatoriums were invented. It chiefly consists of a protracted chronic process of wasting away. Young healthy people are usually asymptomatic carriers. Back home, the internal medicine people get all excited about it because the disease has become so rare. They love to discuss all its pathologies and different organ involvements. Medical students must learn that TB is at the bottom of nearly every differential diagnosis. I’m now seeing it in all its forms: lymphadenopathy, ascites, pulmonary, arthritis and cold abscesses. An internist’s delight, straight out of Harrison’s textbook. I find myself walking around mumbling ‘scrofula’, ‘scrofula’, which is the name for tuberculosis neck ganglions. (Call me weird). Of course, regrouping all the coughing patients in one warm tent with no air circulation is far from ideal. But it’s as good as it gets out here. Our sickest patient is the teenager who probably has had TB for quite a while. He was unconscious so his brother strapped on a bicycle and brought him in from a village 20 km away. His prognosis remains reserved at this point in time.

The "ambulance" that brought him:


On another note, the lady with the Bible uterus walked out today, and so did the seizing lady who had lost her firstborn. A man who presented with coma and seizures for a few days woke up today and spat out his oral airway, requesting manioc and the presence of his sons. So far, we’ve had amazing outcomes given the in extremis presentations and very few means of treatment: no oxygen, no monitors, no IV pumps, not even IV poles – the bags are hung on strings from the tent ceiling, next to the bednets. It’s a far cry from my university teaching centre practice back home, and yet, patients do get better. Human resilience does not cease to surprise me.

Shamwana Bushcamp Lodge

Put together by Ines and Esther

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An exciting journey






Walking Safari





Culinary Specialties