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 ;)


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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.


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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...


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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.


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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.