Bill Moyers' Journal on humanitarian work in the Democratic Republic of Congo aired on PBS April 4, 2008. It is now here on the PBS website.
They filmed us in Shamwana back in November, during the cholera outbreak in Kishale, amongst all other things. Very complete reportage. I'm featured at the beginning of part 2 (at about 25 minutes into the episode).
Showing posts with label Cholera. Show all posts
Showing posts with label Cholera. Show all posts
Monday, April 7, 2008
Thursday, November 1, 2007
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
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
Thursday, October 18, 2007
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 ;)
* * *
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...”
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 ;)
* * *
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...”
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