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...




* * *


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.


* * *


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





* * *


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.


* * *


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!


* * *

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 ;)

* * *

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