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.


* * *


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...


* * *

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.


* * *


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.

"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.

Of human resilience part 1

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

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

Baby Kalobwa happily feeding



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

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

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

Shamwana, c'est ici

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

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

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

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

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

* * *

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

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

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


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

Entrée de la base MSF à Shamwana


Ma chambre


Coucher de soleil sur la base

Blog de brousse

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

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

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

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

The Dubie main road

Très MSF - nos véhicules de transport, les Land Cruiser


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


* * *

Ce qui me terrifie:

1) les latrines

2) les serpents

3) les latrines

4) les scorpions

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

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

7) la bouffe répétitive

8) pas d'internet

9) les douches froides

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

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

12) les latrines


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

Introduction to Shamwana

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

 

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

 

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

About Shamwana

Landing in Lubumbashi

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

 

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

 

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

 

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

 

 

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

 

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

 

Roaming in Amsterdam

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

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

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

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

Pictures of Amsterdam here.

Holland in August

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

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

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

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

Pictures of people at the PPD here.