Of human resilience part 1

Short of pictures for now, I will recount some medical extraordinaroddities as well as some unfortunate stories. This post is meant for the clinically curious so I apologize in advance for the medical jargon.

There is a baby in our maternity ward called Kalobwa. She was born at term at a minuscule 900 grams, her mother passing away. The nurses wrapped her in aluminum foil and syringed formula in her tiny mouth; they all prayed that she be comfortable no matter the outcome. She had to be passed from caretaker to caretaker; after an initial weight gain, she started withdrawing, losing weight and waning away. Then, her father's second wife gave birth to a full size term baby and decided to breastfeed both babies, Kalobwa first in line. She was encouraged to hold Kalobwa skin to skin. With newly found motherly love, Kalobwa started thriving. She is now a whopping four months old and is doing well. We do expect that she will be stunted for life. But for a maternity ward consisting of gym mats with no electricity, let alone incubators, umbilical lines or neonatal respirators - not a bad outcome. Surely, it tells of motherly love.

Baby Kalobwa happily feeding



Because of malnutrition and precocious first pregnancies, obstetrical catastrophes are common. Women here tend to want to deliver at home. They have the habit of initiating labour voluntarily by suddenly fasting or by ingesting indigenous plants called kapilou, kakelou , or samakagna, with disastrous results: it is dangerous to start labour on a closed cervix. Last week-end, a woman presented to the hospital after 36 hours of labour. An aunt had improvised herself midwife and had kept her home for the first night of labour. Upon exam, the baby was dead, the cervix was torn away from the inside, and the uterus was ruptured. My colleague the Congolese doctor performed an emergency hysterectomy; he referred to her uterus as "being open like a Bible". We do not have a blood bank and cannot even crossmatch relatives. Well, a week later now, she is still alive. Her palpebral conjunctivae are white - correlating with an abysmal hemoglobin that would be deemed "incompatible with life" back home. She is somewhat healing in spite of eating mostly fufu. There is probably an infectious process happening, so she isn't quite out of trouble yet.

Apolline is a fifteen year-old child who fell into a fire. Three quarters of her head were burnt to the third degree, along with her right arm from the shoulder to mid-forearm. A total of close to 15% of body surface area burnt to third degree and deeper, for the clinically precise. She was brought to the hospital a week after the event, only after indigenous treatments failed. Since then, with simple Dakin's solution dressings, flesh has slowly started to grow. It has been three months now and the wounds are looking clean, although the greater part of her right triceps is gone. We are trying to send her down to Lubumbashi for grafts and contracture correction, but it may not happen at all - she may just remain scarred for life.

The law of series dictates that rare diagnoses do not present singularly. Within the same week, we received two young adult patients with polyuria, polydipsia, acute weight loss and unending hunger. Lab tests are not available in Shamwana; but the urine dipsticks were off the chart for glucose and ketones. Unfortunately, type 1 diabetics are left to their own devices here in the Congo, because insulin is unavailable - it requires a cold chain (a fridge and power for it) and is simply unaffordable. I have no idea how long a newly diagnosed type 1 diabetic can live without insulin. It seems longer than a week as they are both still alive, although one went bradycardic and asthénique last night - he is fading away. I can only offer them the services of the... psychosocial team and the local priest. Back home, type 1 diabetes is a manageable disease, not a death sentence.

Shamwana, c'est ici

Phew. The road from Dubie was the worse road that I'd seen. Congolese roads make Cambodian roads look like modern highways. Dustdustdust and bumpbumpbumps. Changing landscapes of bush with enormous termite mounds to semi-arid savannah with baobab trees. The fastest the Land Cruiser could go was about 30 km/hr. Welcome to the Congo. But I am happy to have arrived here and to finally settle in my new home.

Shamwana is tiny. Don't even try to Google Earth it, the wrong Shamwana comes out, closer to Kinshasa. A main road of sand, the airplane strip built by MSF a few months ago, and a few huts. But the outlook, previously grim last year after the IDPs came back from Dubie, is more positive. The Mai-Mai were dismantled, and there was a paid program by the government whereby ex-militia could receive some money upon disarmament, and could return to their families. It leads to the paradoxical situation described in the video last post, where the ex-Mai-Mai comes back to live amongst the very people that he may have tortured or raped. One can imagine the implications for mental health problems, which are rampant. I carry daily conversations with our expat psychologist and am learning loads. The stories may be posted later, when they take form.

There are brick huts, the market is expanding every day, there are eggs, chickens, goats and guinea fowls. They sell the strangest women's nylon underwear from China in camouflage pattern, choice of green, yellow or red. Our compound is basic but nice, I have light to read or write at night, and there is electricity on a schedule. Sylvester the cat (aka Lazy Bastard) is too well fed to go hunt mice and rats. He has been known to fight with the snakes though, so he retains a purpose. I don't even think about the latrines anymore, and we have hot showers as our logistician has the nice habit of putting hot water into the bucket in the afternoons - the showers are simply a bucket in height with a tap, and it does the trick. The food is tomato-onion-flavored with either guinea fowls (more likely) or chicken (I doubt it) with the occasional goat or beans. Plenty of rice, which finds me happy. And Nutella and powdered milk; all four nutritional groups are there! To settle in, I sprinkle my new surroundings with touches of familiarity.

The hospital, which consists of three tents, isn't too busy this time of year. We have a few malnutrition cases, a few tuberculosis cases and a few obstetrical messes. Here in the Congo, not only do I have to re-familiarize myself with malaria and strange multicellular parasites such as worms, but I will see obstetrical disasters rarely encountered in the Western world, such as uterine ruptures and vesiculovaginal fistulas. For my colleagues back home and the clinically curious, I will post later about some medical extraordinaroddities found out here in the Congolese bush. Let's just say that it gives a whole new meaning to the expression "incompatible with life".

The hospital staff referred to my predecessor as Le Grand Vijay. which means the Protective Spirit. It started as a joke because his French was so bad, I'm told. Well my French is fluent so I shall not be honoured with such a great nickname: huge shoes to fill, now! It is true that Le Grand Vijay is a wise old soul in spite of his youth, with a great sense of irony and entertaining inappropriate topics of conversation. Much time of our handover was rather spent discussing whether life is a tragedy or a comedy, or both. If you have the definitive answer, let me know, we haven't figured it out, in spite of his presumed godly abilities.

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La pauvreté ici frappe. Les gens vivent avec rien, et je soupçonne que les temps de guérison à l'hôpital sont doublés à cause de la malnutrition. En Afrique, tout le monde mange du fufu, qui est une pâte pilée d'origine diverse selon la géographie. Au Cameroun le fufu était fait d'igname (sorte de lourde patate racine) et tombait tout au fond de l'estomac. Ici le fufu est fait de manioc qui est plus léger et auquel j'ai pris goût. Le dénominateur commun de tous les fufus est qu'ils remplissent l'estomac mais ne sont que d'un pauvre apport calorique ou protéinique. Cela explique la malnutrition des tout-petits ici, sous forme de marasme (amaigrissement et arrêt de croissance) et le kwashiorkor (malnutrition protéinique avec décoloration des cheveux et édème des pieds) vus ici. Lorsqu'ils en trouvent, les gens supplémentent le fufu avec des légumes-feuilles appellés 'linga-linga' (Vini si tu lis ceci, tu peux imaginer les jokes que j'ai fait avec ça), et une viande douteuse qui semble être une sorte de rat de brousse.

De par cette malnutrition peut-être, les gens ici sont plutîot petits, ce qui m'a surprise. Le poids moyen des patients tourne autour de 35-40 kg, et ils sont à peine plus grands que mes cinq pieds deux. La grosseur de certains bébés à la naissance n'atteint pas 2 kg, ce qui est vraiment tout petit. Quel changement des Cris de la Baie James! La polygamie existe encore, la première grossesse survient durant l'adolescence, et bien sûr les enfants plus vieux aident à s'occuper des plus jeunes - il n'est pas rare de voir une petite fille de moins de cinq ans trimballer son frère à peine moins petit qu'elle.

Ma relation avec les latrines s'est formalisée, je n'y prends plus garde. Sur mes grands temps libres, je pense essayer d'apprendre un peu de Swahili et de Kiluba, qui est le dialecte local. Ma bulle de familiarité s'est créée derrière mon Ibook et un peu de musique - Dumas qui erre dans la neige montréalaise a pris un tout nouvel attrait - et j'apprends à connaître mon équipe. Ce sont tous des gens extraordinairement dédiés à leur travail et on rit énormément, ce qui me rassure sur leur santé mentale malgré l' isolement profond de ce village. La bière coule encore à flots, et le whisky local pourrait servir à déboucher des tuyaux. Le chocolat est
populaire aussi puisque la majorité de l'équipe est féminine, ce qui est souvent le cas avec MSF.


Mon heure préférée est le matin. Il fait encore frais, le ciel est clair, et la clameur du village s'élève vers les cinq heures trente: coqs, chants traditionnels, débuts de conversation, voix d'enfants, odeurs de feux de cuisine. Et tous les soirs, c'est bien l'Afrique, on entend les chants rythmés de tam-tams, parfois toute la nuit durant. Par contre, je n'ai pas vu de très jeunes enfants chanter et danser spontanément comme j'aimais tant au Cameroun. La psychologue me dit que les traumatismes vécus par cette population ont laissé leurs marques et ça, c'en est une silencieuse. On ne voit que peu de traces de la guerre mais sous le sourire éclatant de blancheur des gens d'ici, la tragédie et les pertes demeurent.

Entrée de la base MSF à Shamwana


Ma chambre


Coucher de soleil sur la base

Blog de brousse

I made it. To Dubie, that is, not quite Shamwana yet. The flight over was amusing - the pilot was from Halifax and very, very serious. A Cessna Caravan plane - a 12 seater I think - chartered by all MSF sections in Katanga, just a little smaller than the Twin Otters that I'd gotten used to in the Great White Québécois North. It can land on a dime and soar for a while, I said to reassure a nervous Lucas. Thoughts came of a colleague of mine who would have loved to fly this thing. We were joking around to hide the nervousness of the take-off, then fell asleep during the flight. I took punctual pictures of the landscape - red earth, green jungle, a few
mountains, clouds, fog, a few tukuls. And we landed before we knew it.

Dubie is a nice little village. One main road of red dust, and the MSF compound - hospital buildings abutting the base which consists of a mix of thatch tukuls (huts) and brick buildings. The Dubie doctor gave us a tour of the place: renutrition ward, dark unventilated shady... tuberculosis area (trouvez l'erreur!), nice neat operating theater, tiled laboratory and airy maternity. We were greeted there by a brand new little girl screaming into the world - nice work by the accoucheuse! Everything was clean and well kept, and all the kids were jumping at us, the new Muzungus, laughing out 'Jambo, Jambo' - 'hello' in Swahili - and fighting to hold our hands. A goat was ironically wandering around and eating the grass around the (thankfully empty) cholera tents. The one toddler in the intensive care unit had huge black eyes deep with the unchildlike sadness that tells of the sickness so much better than any vital signs.

We are here for three days for a medical meeting of all the field teams, nationalstaff midwives nurses medco and us. Perfect time for a handover. Numbers are flown around - 1.8% maternal mortality (less than 0.1% in Europe), 10% syphilis positive in target groups, mortality rates etc etc... I won't bore you with them but they paint a country that is still struggling to survive.

My lovely predecessor is a Nigerian colleague my age. He asked if I had any questions - and I found none. Not quite yet. I have to see Shamwana to figure out what I want to know. So we proceeded in exchanging Congolese and Ivoirian music off our mp3 players and dancing to it using my portable speakers for the night party. Not a bad start. Too bad he's leaving, he's incredibly nice and calm. I am writing you from my room in Dubie while those guys out there are still talking and dancing to Bob Marley and drinking Simba and Tembo beer. Who said that meetings weren't fun?

The Dubie main road

Très MSF - nos véhicules de transport, les Land Cruiser


Enfants de Dubié qui regardent les Muzungus (étrangers, Blancs) jouer au volleyball


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Ce qui me terrifie:

1) les latrines

2) les serpents

3) les latrines

4) les scorpions

5) tout être non humain dans mon lit, la latrine, ou la douche

6) pas de nuoc mam sur mon riz pendant six mois (sauce viêt au poisson)

7) la bouffe répétitive

8) pas d'internet

9) les douches froides

10) du mauvais café, ou pas de café du tout

11) de ne pas remplir l'espace laissé par mon prédécesseur le baba cool

12) les latrines


Bon, déjà, deux jours de latrines et de douches froides avec seau d'eau chaude et je n'y vois plus de différence. Mes souliers Crocs sont tellement utiles!!! Je m'habitue aux moustiquaires, à ma lampe frontale et aux douches dans le noir. Par contre, le logement à Shamwana promet d'être encore plus basique qu'ici à Dubié, on va rigoler. Moi la VIP (Viet Important Princess) qui joue les filles de brousse, ça va être drôle! C'est comme tout dans la vie, vaut mieux en rire qu'en pleurer - une approche générale qui sort bien souvent du pétrin. Du moment qu'il y a du riz, je trouverais un peu de bonheur. J'ai déjà stocké en sauce soja à Lubumbashi, pour un bon début!

Introduction to Shamwana

Here's a little background info about my future project.

 

In 2005, there were still clashes between the Mai-Mai rebels and the military in Katanga.  The population of the Shamwana region was traumatized and an estimated 10-15 000 people became Internally Displaced Persons (IDP's) and moved to the Dubie region where MSF-Holland (MSFH) had a project. In May 2006, once the political situation stabilized, MSFH decided to open a health centre in Shamwana because of its remoteness.  It's about 300 km from Lubumbashi but because of the poor state of the roads, it's impossible to join up.  Since then, a small hospital has been built out of nothing, and most of the IDP's have come back.  There are huge mental health issues as one can imagine, but the outlook is positive - the school is back, the fields are being worked on, there are chicken if not goats.  The health centre, where the wards are currently tents, will be turned into a real hospital with an operating room and a functioning laboratory - that's what should happening while I work there. 

 

That's pretty much all I know.  This little movie, available on the MSF website (but very well hidden so I put it on my YouTube), was done in late 2006 and gives an idea of the place.  It's much better now, the link with Lubumbashi is much better and I think that we have electricity at least for emergency surgeries now.

About Shamwana

Landing in Lubumbashi

The briefings in Amsterdam at the MSF Holland headquarters were..well, brief.  We will learn mostly on site. They did load us with extra carry-ons, mostly mail and electronic equipment.  It is not often that five expats were going to the same place, hence, HQ using us as cargo carriers.  Added to our little trio was the log for Shamwana, L from France who is now on his second mission.  There was also a Dutch mechanic.

 

Dragging our bags of Thurayas, we also loaded ourselves with Dutch cheese and chocolates for the expats at Schiphol airport.  Let's say that our little group landing in Lubumbashi looked like a camel caravan, with a whole bunch of extra yellow duty-free bags!  On the flight from Nairobi to Lubumbashi, there wasn't enough room in the overhead bins so we had to keep our carry-ons on our laps.  I hope that this is the first and last time that I am using my computer as a table and a pillow...

 

Landing in Lubumbashi was uneventful.  The MSF welcome team was there immediately so there was none of the zoo that I'd come to expect from developing world airports - the porters haggling about and the crowds.  Finally yesterday after a good meal and some taste of the local blond beer Simba, we collapsed in our first beds since the last 48 hours.

 

Our multiple bags and us will be loaded out to Dubie tomorrow morning by plane, where I will stay for four days.  Then next week L and I will finally stop being in transit and arrive to Shamwana, my future home for the next six months. 

 

 

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Les sensations de l'Afrique m'ont assaillie dès l'atterrissage - cette vague odeur de fumée mêlée de sable, les couleurs plus fortes que nature, la poussière et bien sûr la chaleur.   Neuf ans déjà depuis le Cameroun et pourtant les souvenirs ont été réveillés.  Lubumbashi ressemble à Maroua, climat similaire (en tout cas en saison sèche), poussière poussière poussière, et mêmes quadrillage colonial et vastes maisons enclavées.  Les routes par contre sont en pire état, et on m'a prévenue qu'en région ce sera encore pire. 

 

Tout le monde a été tellement gentil à la base MSF.   Les expressions africaines me reviennent - j'en ferais un lexique plus tard - et les onomatopées aussi: le petit 'tskg' d'approbation guttural, et le 'mffffssssk' buccal de désapprobation, répandus partout en Afrique et même dans les Caraïbes.  Je sens maintenant un peu plus que je suis ici et que la grande aventure MSF commence.

 

Roaming in Amsterdam

Sleep is eluding me. One would presume that after the hectic month pre-departure, I would be capsizing into bed every night. Unfortunately the PPD included sleep deprivation as part of the course - the orienteering game ran well into the night, and the few evenings of Heineken did not improve the situation either (although the mingling definitely improved, to those concerned). Yet the anticipation keeps me hyperactive. A and I walk about wondering why in the world we are so tired - it must be age, I smile. She also reassures me - in spite of having been on the field in Côte d'Ivoire for five years, she is still nervous about starting work in Dubie. Imagine me, then: I can intubate and run a modern emergency room, but I have no idea what to prescribe to a malnourished child burning with malaria...

We are all impressed with the quantity of material that MSF has jammed into our brains in the short intense week of 12-hour days. My mindmap of MSF now includes the words mandate, ethics, accountability, transparency, human resources management, security-security-security, professionalism, advocacy, witnessing, protocols, and logistics-logistics-logistics. From the course material, it seems that MSF is an organization that is down to business, has credibility, is financially efficient and has the merit of setting standards in humanitarian work. I'll have to test my neo-colonialism theory on the field, then.

The PPD wrapped up well. Most people are going home to their loved ones, with a project probably-maybe-sometime-soon. New friendships were forged; we wonder if we'll ever see each other again, maybe on mission one day. The statistics for a first missioner to become a repeat offender approach 50% - again, impressive.

Today, A, M and I took the train into Amsterdam. We said goodbye to L, who will not be going to PNG after all. The compactness of this city surprises me still, even though it is my third time here. I get lost, as usual - canals and cobbled streets and pretty centenarian Dutch houses. It doesn't help that the last time that I was here, I was cycling around following a local and not paying attention. Need to work on that sense of orientation and observation... I had the obligatory smoked herring for a third time and am already longingly thinking of the last sushi meal for the next six months or so. It is coming up. Maybe I should go twice for sushi in the next few days, as a precaution. Hmm... there's a thought.

Pictures of Amsterdam here.

Holland in August

Finally, I've left home for the year! After the prolongation of the departure, I couldn't take it anymore! Stressed for packing, slept about 3 hours that night for many reasons, packed fully completely 24 hours before going to the airplane (that's very unusual for me!), and tired of goodbyes because of the constant emotional tug. Thanks to all of you who had to endure my weirdo moods and my anxiety and moaning and displaced obsessing...

The PPD (Preparation for Primary Departure course) is a well-structured week with lectures and group simulations intended for MSF workers who will leave on first mission. Half the group is from Germany, we are three Canadians and one American, and there are scattered other Europeans. I hit it off very quickly with L, an emerg nurse from Vancouver, and an ex-Montrealer. We are similar in our bluntness and sharpness, peacekeeping abilities, Canadian niceness and constant irreverent jokes; and we also do well in the no-bullshit bottom-line common-sense department, both coming from the emerg. She is New Wave Punk (not Gothic! Sorry!), has nice big tattoos, is totally off the beaten track, wears only black, and we get along great. She was maybe offered a mission in Papua New Guinea having to do with a village that boasts 80% domestic/sexual/child abuse, oh joy! and is wondering if she could work with constant simmering anger all the time. I hope to convince her to come work with me in DRC Katanga instead: Liz, come work with me in Shamwana in two months, when the other nurse leaves!!! The other Canadian is also a very nice guy. He used to be a Harley-Davidson sales manager and has sold everything to eventually go on permanent retirement on the beaches of Viet Nam on the basis that one day in the next decade, all hell will break loose in the developed world. Definitely an interesting life experience. The other medics on PPD are a few older surgeons with prior NGO experience and a few medical interns from the UK and Germany. The group is quite varied. I am also incredibly lucky to have met other people who will be flying down to DRC Katanga with me. There is A, my homolog for Dubie the next village project over, an extremely nice Ivoirian girl my age whose husband is the doctor in Kilwa, the third project of the mission. And there is M, an American midwife who will be working in Dubie as well. I am just incredibly happy to have found two people who will be briefed with me in Amsterdam next week and will travel down to Lubumbashi with me. It's so nice not to feel so terribly alone jumping into this!

The knowledge that we acquire here is various. Security protocols, MSF spirit and mandate, group work and country simulations, cross culture work (within the team) and the orienteering game, an exercise in frustration designed to test our team spirit. There was a strange surgeon from Ukraine with a clear personality disorder who was kicked out of the course today. As we had had him on our team on the orienteering night and managed his rogueness quite well, I suppose now that my teamworking abilities are doing just fine. We learn all the MSF jargon: PC logco finco sitrep security fieldlog MoH nationalstaff HOM capital etc etc... It's another language altogether, and I haven't learned the radio language yet.

Socially, unlike what I'd heard from Rags and SF (ex-MSFer friends from home), it ain't much of a romance scene out here. After all, the chances are slim that we all see each other again afterwards. The female bonding happened so naturally that one of the facilitators came to us and said half-jokingly that the XY part of the PPD were sorry that we weren't mingling more with them :). It doesn't help that the German sense of humor seems to be beyond me (...). There is quite a bit of Heineken flowing about, we take bike rides to the beach (being in Holland after all!), we share our building performance anxiety, and we are happy about the people who hear about their mission being confirmed during the course. The minority of us were matched to a mission already before coming, a few are hearing confirmation while here, and the majority are going home and waiting for the e-mail or phone call dispatching them overseas. I am glad that all is going on plan for me, that I am leaving directly from here to the jungle of DRC Katanga, and that the busy-ness before the departure kept me not thinking too much. I am realizing that I do not deal very well with the unknown after all :)

Pictures of people at the PPD here.