Masks

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

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

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

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

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



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


My absolutely fantastic medical team




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

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

Masques

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

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

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






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



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