"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

Welcome!




An exciting journey






Walking Safari





Culinary Specialties

Démesures climatiques et temporelles

Rien ne vient en demi-mesure ici. Hier, pendant la journée, la chaleur est revenue de plein fouet après quelques jours de répit. Il faisait si torride que respirer faisait suer. La torpeur nous volait la moitié de la journée. Dans la soirée, l’abcès a crevé: il a plu tout doucement, pour quelques instants. La clarté du ciel et la fraîcheur de l’air sont revenues, à notre soulagement. Les étoiles de l’hémisphère Sud ont fait leur réapparition. Car depuis deux semaines, leur place au firmament avait été volée soit par les nuages, soit par la pleine lune trop claire.

Donc, on croyait que ce serait tout pour la journée, puisqu’on n’attend pas la saison des pluies avant octobre. Mais il y a eu un orage terrible au beau milieu de la nuit. Les éclairs et le tonnerre faisaient à qui mieux-mieux, les volets et les portes claquaient, le vent soufflait en rafales. Les premières gouttes sont tombées, doucement d’abord, puis tambourinant bruyamment ensuite. Une mousson congolaise, tout en vacarme et en lueurs, qui est tombée pendant une heure. Les toits de tôle résonnaient pendant que les éclairs créaient des kaléïdoscopes sur les murs, et l’orage semblait tonner du jardin même. Je me suis réfugiée sous mon moustiquaire avec Passion de Peter Gabriel, musique parfaite pour accompagner une Mère Nature déchaînée. Je pensais aux villageois sous leur huttes de foin, faiblement couvertes par des bâches de l’Unicef. Je pensais aux petits patients sans doute terrifiés dans la tente principale qu’est notre hôpital. Et tout de même, un petit réconfort égoïste me remplissait. On ne perd jamais ce sentiment d’enfant, derrière sa fenêtre, bien au chaud et au sec, à regarder le déluge dehors.

Ce matin, c’était comme si tout n’avait été qu’un rêve. Sauf que les bacs laissés dehors étaient plein d’eau de pluie, et quelques bâches avaient été déchirées. Notre femme de ménage n’a pas eu à aller loin pour trouver l’eau pour faire la lessive, et les dames qui amènent notre eau ne sont pas venues. Dans une des tentes secondaires de l’hôpital, quelques flaques d’eau avaient persisté. Les patients s’étaient réfugiés du côté sec de la salle. Un infirmier a dit: ‘Ah, les patients, ils ont souffert un peu cette nuit’, mais pas tant que ça, on aurait dit. En allant au marché, je n’ai pas vu de huttes détruites – quelle naïveté de ma part finalement: les villageois doivent être habitués à ce climat après tout...

Les journaliers à la porte le lundi:



* * *


Today, the elusive ‘pipeline’ disengorged itself at the base, in the format of a gigantic truck arriving from Lubumbashi. The pipeline is where all the material that was ordered from overseas disappears to before it actually arrives here in Shamwana. Having placed this week all our orders for the next six months, we came to the realization that a good proportion of the past orders were still ‘in the pipeline’; for example, we have been expecting our operating room table and generator for the last few months. The pipeline is where our medications pass their expiry dates before arriving here, and where our cold chain breaks, most recently, our anti-venom serums – just a few thousand euros’ worth. Coincidentally, the replacement for our nurse has not arrived on the predicted date either. Hence, she must be also in the pipeline. We have images of her sitting on the operating room table in a container somewhere between Amsterdam and here. Where are Amazon and E-Bay when you need them? We sure could use ‘Spock, beam me up’ or some Floo powder (pick your favourite fantastic world).

It’s the distances and the inexistent roads that create this elusive pipeline. Being a child of immediacy and instant gratification, I forget that they did not accompany me to here to the Congo. The truck took ten days to arrive here from Lubumbashi - what usually less than two hours by plane. Kilometers do not describe the ordeal. Distances are best described in measures of time. For example, one of our national nurses is going on vacation back home to Manono, his hometown. It will take him two days by bicycle on sandy roads to get there. Hence the point in having a month’s worth of vacation - and very little luggage indeed. And this is the good season, still. In rainy season, distances can more often than not be described as ‘never’. Concern, the only other NGO sharing Shamwana with us, still has trucks full of material stuck on the road from last year. In rainy season, patients are best brought from our villages by foot or bicycle than Land Cruiser. Maybe we should go back to pre-colonial times. Stanley, the British explorer who discovered this land, was best served by walking or being transported by native porters. He sure never had to deal with the expected modern Congolese experience of revving uselessly in mud for hours.

The infamous pipeline. Gasoline for the generator and for the fridge, Coca-cola for the addicted watsan (Water and Sanitation Officer), the operating room table...but no replacement Canadian nurse :).



The bucket shower


Need I say anything? The latrine, and the infamous squatting plates (we got acquainted to them as ‘shitting plates’ during the PPD).


What makes our delight: the bread oven. Our cook uses it a few times a week, and we have managed to make pizza with it.

Of human resilience, again

This week flew by much faster than last week. The routine is settling in. I now look forward to the week-end movies that we play for the national staff. We’ve also instituted poker: I just hope that the saying ‘unlucky at poker, lucky in love’ excuses my very poor game so far!

The ‘real’ MSF experience is trickling in slowly. Most days consist on rounding on a shrinking ward: 16 patients now, down from the 29 inherited. My bipolar karma is behaving - ah, but just wait till all hell breaks loose. We had an exciting case earlier this week. The expat midwife and the outreach team went to Kisele, one of our villages, to do some health assessments. They found a woman actively seizing while in labour, kept in a hut for the last eight hours or so. So we organized a ‘kiss’, that is, one Land Cruiser leaving from Shamwana with medical supplies whilst the other car was driving back from Kisele. We met halfway through. The patient was unconscious. Her firstborn baby was lifeless and stuck in the birth canal. This is the Congo: no oxygen tank, let alone an ambu-bag so all we had was... an oral airway. We transferred her into our car and injected her with some intravenous magnesium sulphate. I was picturing the same scenario back home, on an airplane med-evac up North, and was ridiculously praying for an endotracheal tube, a laryngoscope, an IV pump, a monitor and an oxygen tank to magically appear. A long hour on the bumpy road punctuated by two stops while she was seizing: diazepam pushed in. Finally, we got back to the hospital. In the delivery room, our excellent Congolese doctor extracted the fetus with a ventouse. I treated her eclamptic hypertension, seizures and fever. The midwife thought that she wouldn’t make it. I replied: “You’d be surprised, she is young, humans are resilient.” I thought, if she survives the first day, she’ll be out of the woods. We continued aggressive fluid resuscitation, antibiotics and magnesium sulphate. The diligent nurses watched her closely, checking her vitals every hour. Two more convulsions overnight. No labs so no need to treat her likely numerous metabolic abnormalities - I am fairly sure that she has a touch of rhabdomyolysis. Four days later, this morning, she is talking and requesting food. She did make it. I can only imagine, had we had a case like that back home, what a commotion... The whole hospital would know about it, all the services would be consulted, the residents would talk about it at lunch, rounds and case presentations would be held about her.

The lady with the Bible uterus will be discharged this week-end. She is now making jokes with us at rounds and is walking around the hospital helping out the other patients. Apolline left for Lubumbashi; we hope that she comes back looking like a supermodel.

On the ward, there are three babies (a pair of twins and a singleton who lost his other twin) about a month of age and under 1.5 kg of weight. They play tricks on us, gaining weight one day and losing the next, playful one day and listless the next. It’s the yoyo of life. I’ve elected to treat them for their mild lethargy without any labs. I just couldn’t get myself to perform lumbar punctures on little patients the size of kittens – it would have been an academic consideration since the only result the cerebrospinal fluid would yield would be macroscopic, that is, using my eyes in plain daylight. They are back on the upgoing trend today. I hope that the antibiotics work their magic. And I can’t wait to have a functioning laboratory. And internet, and ice-cream, and sushi – might as well dream in Technicolor while I can :).

The main tent, pardon, ward.


Kitten-size singleton and his mommy


The future operation theater and bricks being laid for the next medical ward.

The future of aid workers

This was a mass e-mail forwarded by our new finco... quite amusing isn't it?

You're an aid worker with 10+ years experience under your belt. You earn a pittance but it works for you because you are non-resident at home so you don't pay tax, you are catered for on assignment so you don't pay rent,and your mortgage is covered by the people renting your place because you are never there. You can't hold down a relationship for more than 3 months and you secretly know that despite what you tell him/her it's really not because you're only ever there for 3 months... it's because you can't live without the independence.

Things are ok now but you're approaching 40. What should you do? What does the future hold? Are you one of the new world order of aid worker gypsies?

Welcome to your future - These are your Life options:

Option 1. You go back to a headquarters job. Instead of doing what you want to do, you now advise people who are doing what you used to do. You earn the same more or less as you did before, but your costs of living shoot skywards because you're now paying tax, rent/mortgage and utilities... You consider sharing accommodation and, bingo, you're a student again and like a student can't afford to do
1% of the things you think you would like to do.

Option 2. You go work for the UN. Keep the job you love and the lifestyle that goes with it. Your salary jumps to levels that used to get you all riled up after a few drinks back when you used to work for "honest" down-to-earth INGOs. Now you're cynical about them all and aggressively defend your need to raise a nest egg to plough the way for the family/dog/cottage/brats you're planning. You've done your bit after all. You do this for a while before you realize you sacrificed every dream you ever had in this work and can no longer look yourself
in the mirror.

Option 3. You find something suitable in the commercial sector and live happily ever after. This only happens to 1/10,000 aid workers and if you're a logistician, forget it.

Option 4. You retrain and change course. You take a massive pay cut. Your skills and experience in aid work go unused and unappreciated. You marry someone who will never fully understand where you are coming from and why you are quiet for long periods of time. If you haven't left it too late to have kids, just remember - dysfunctional.

Option 5. You write your memoirs and someone makes a movie out of it starring Leonardo De Caprio or Angelina Jolie. You become an even more arrogant git, lose all your friends, and make a lot of cash. This only happens to 1/100,000 aid workers and will definitely not happen to you!

Option 6. You become that lonely, jaded expat sat at the bar in some third world piss pot letching over young locals and making snide remarks.

Option 7. You decide to set up home but not in your own country. Forget moving back to London, Paris, New York, Munich but head for the Balkan Adriatic or one of the emerging Eastern European States before the property developers get there, and develop a serious liver problem.

Option 8. You hit the road along with thousands of your cohorts with visions of huge bands of ex-aid worker families roaming the European countryside in caravans, plastered with "No guns on board" stickers and of course pulled by white Toyota Land Cruiser hardtops and pickups, scratching out a life by erecting latrines and living under plastic sheeting. You take stock count of everything you come across..... and from time-to-time you seek charity.