Wednesday, September 30, 2009

Not Architecture for a Rainy Day









I've always liked rain, in part for the cozy feeling I get when I'm inside, warm and dry, looking out at it. And when it rained yesterday here in Japan, I had occasion to think about people whose homes aren't quite so warm and dry in wet weather.

I visited the Congo during the dry season, but having lived in and traveled around tropical and semitropical Asia for 20 years, I can easily imagine how wet the rainy season is. The rainy season will see the dusty unpaved roads (and nearly all the roads in the country are unpaved) turn into impassable rivers of mud, which will connect seamlessly to the dirt floors of refugee/IDP (internally displaced people) huts (the roofs of which are made of those not-very-waterproof building materials, leaves and tree bark).

Above are some photographs of the huts refugees and IDPs construct for themselves, and a shot of a mother and child who invited me and my MSF nurse/guide Didier (whose shoulder is visible in the shot) into their tiny hut. Their hut was partitioned into two spaces: one for living/cooking, and one for cooking. The entire hut was the size of the passenger cabin of a compact car.

Sunday, September 27, 2009

One Among Many













As I've written before, I spent a day while in Rutshuru (where Medecins Sans Frontieres shares the administration of an excellent hospital with the Ministry of Health) riding with Didier Kaubi, a Congolese nurse who has been working for MSF for three years.

Our first call-out (pictured above is the ambulance leaving the MSF residential compound – the service starts at 0800 and that's when the call came in) took us to a small health clinic in the tiny village of Kinyandoni, where we found a mother and her badly burned 18-month-old son Elie. Elie had fallen into the cooking fire, which in huts with only a few square meters of floor space, is easy to do.

Didier spoke with Elie's 24-year-old mother Antoinette, who has three other children at home, and put a line into Elie's arm to administer a pain killer and Ringer's lactate solution, which comprises sodium, chloride, potassium and lactate and is used to rehydrate children who have suffered burns or blood loss.

Then we all piled back into the vehicles and drove Elie the 10 kilometers to the hospital, where Didier handed him off to the doctor in charge of the pediatric unit. [I've included a shot of the Lund-Browder chart for estimating the extent of burns in children, allowing for the varying proportion of body surface in those of different ages.]

Elie was a brave little soldier, and I hope he's recovering okay.

Saturday, September 26, 2009

There's No "Internet" in "Team"









As I've written before, I had the opportunity on this trip to see quite a few different Medecins Sans Frontieres (MSF) operations, administered and staffed by MSF offices in France, Belgium and Switzerland (staffers were from all over the world, but I mention this because the different national headquarters have slightly different operational philosophies).

As far as I could tell (in the very short time I had in each place), the national origin of the operation (e.g. MSF France in North Kivu, MSF Suisse in Ituri, etc.) and its specific mission (e.g. emergency response, hospital administration, etc) had far less to do with the team dynamic than the size of the team.

Because of the (poor) security situation in the Democratic Republic of the Congo (DRC), expat (including from other African countries and including Congolese from other parts of the country) MSF staffers live for the most part in guarded compounds, and don't go out after dark. An exception is Kinshasa, and during the time I was there, Bunia, in Ituri province (Bunia has not seen heavy fighting since 2003, and is the site of a large encampment of United Nations peacekeepers).

Elsewhere, however, staffers are "home" well before dark, and because in many places Internet connections are via (expensive) satellite phone, no one spends the evening on Facebook.

The best team dynamic I saw during my trip was in Nyanzale, where a small team of men and women from three continents (a Frenchman, an American and Africans from at least three different countries) operate a reference clinic providing support to Nyanzale town and to 33 smaller, less well-equipped clinics in surrounding towns and villages.

[The photos above show the Nyanzale team in their compound, where for two of the three days I was there, we didn't have electricity, thanks to a broken generator and an AWOL backup generator. Breakfast, lunch and dinner are taken at the outdoor table, which doubles as a coffee shop (sorry, Nescafe only) and "business center". The last photo shows the team, plus two visitors from MSF's Paris headquarters – Danielle, at left, and Isabelle, center in orange.]

In (large?) part, a team dynamic comes down to the team leader and the individual team members, but from what I could see (and I saw this also with the MSF operations in Kabizo and Gety), small team size makes it difficult for people to form cliques. Also, nightly lockdown and a lack of outside entertainment mean that people spend virtually all their time with one another, eating, drinking and talking, learning to respect one another and of necessity, learning to get along.

Obviously there must be instances of toxic personalities poisoning a team atmosphere, but I didn't see any of that. What I did see was more social fragmentation in the larger MSF operations I visited; self-selection into groups of bon vivants and non vivants (joke), Francophones and non-native French speakers, etc. As a visiting outsider, I was instantly and warmly welcomed into the social matrix of the smaller operations; at larger operations I saw the teams break into different groups every evening, and it was easy to imagine that every evening, the groups were the same.

I'm not saying the level of professionalism is different in smaller and larger operations; I just know where I'd prefer to work.

Thursday, September 24, 2009

Mobile Clinics ... Mohammed Goes To The Mountain













During my short time in the Democratic Republic of the Congo (DRC) I visited nearly a dozen Medecins Sans Frontieres-operated and -supported clinics and hospitals in Kinshasa and North Kivu and Ituri provinces. I spent a day with a nurse providing ambulance service to the area surrounding a rural hospital, and I visited a mobile clinic operated by MSF out of its Kabizo clinic.

MSF operates mobile clinics in the DRC (and elsewhere) in large part because there is next to no public transportation in that country.Most people, if they need to get to a hospital or clinic, walk there. That may take hours, or it may take days. The government-run rural health clinics in the DRC are for the most part extremely basic, short on medicine and equipment and trained medical personnel. Basic supplies such as rubber gloves can be hard to find. As a result, where MSF can provide regular support to local clinics, the quality of medical care in those communities is greatly improved. If the mountain won't come to Mohammed, Mohammed must go to the mountain.

The mobile clinic I visited in Upper Tongo is held twice a week between 0800-1500, with two doctors/nurses treating around 100 patients a day for the complete range of Congolese ailments – malaria, cholera, measles, diarrhea, respiratory infections and malnutrition. Patients with urgent medical problems, e.g. gunshot wounds, will find a way (motorcycle taxi, MSF ambulance) to get to the nearest hospital (in this case, Rutshuru, a few hours away from Tongo by car). Around 50 percent of patients at the Upper Tongo clinic are internally displaced people (IDPs), and there are around 3,000 IDPs in the region immediately surrounding the village.

In the last photograph above, the girl with the cast on her left arm is named Solange. She broke her arm while fleeing an attack by armed gunmen on the fields her family was working and had the cast put on at the hospital in Rutshuru. She lives in Tongo with her parents, five sisters and brother, and was at the clinic to have her arm checked by the doctor. She was a cute and very self-possessed little girl, and I hope her arm is healing well.

[In the third photograph are a couple of guys from MSF's Kabizo operation. On the left is Gaspard, the administrator, and on the right is Jean, the assistant logistician.]

Thursday, September 17, 2009

Follow the Money









As I've written before, the Democratic Republic of the Congo is not a safe place. It's not safe for foreigners, but it's REALLY not safe for Congolese.

I snapped the above photographs of an MSF nurse on his day off, riding his son around on a bicycle ... in so many places on earth, an everyday domestic scene. In the D.R.C., however, this nurse (I'm sorry I didn't get his name ... I was walking past with one of his colleagues, and we stopped only for a moment) is a target. He has a job; therefore he has money. The bicycle is visible proof.

I don't know if this man has been robbed in his home at gunpoint, but I met others who had been, and simply because as jobholders, they are obvious targets.

The war, the banditry are the root of all evil in the D.R.C. Until security can be assured, the Congolese people cannot cultivate their fields, educate their children, establish businesses ... and ride their bicycles.

Tuesday, September 15, 2009

Daily Worker

Nathalie, psychologue



On bulletin boards in several MSF compounds I saw the above notice, a simple handwritten sign with the name and number of a psychologist [I've changed the number because hey, this is the Internet.] Obviously, dealing every day not only with extreme poverty and its health-related consequences of disease and malnutrition, but also conflict-related injuries such as gunshot and machete wounds and burns, can take its toll psychologically.

I didn't speak on this subject with anyone I met while I was in the D.R. Congo, but I read about it in Dan Bortolotti's "Hope in Hell", a good book I quoted from yesterday. Bortolotti interviewed a number of people about the psychological effects of their experiences in conflict zones, and one story stayed with me.

He writes about a nurse who served in Africa who on her return to the tiny community in northern Canada where she worked and lived, had trouble adjusting. Substance abuse was a major problem in the community, and the nurse was frustrated not only that many health problems were to a great extent "self-inflicted", but also that people had little understanding of their relatively privileged circumstances.

She said, "I really had a problem with the drinking-related stuff – people calling me inn the middle of the night, getting yelled at, cursed at. I remember having no sympathy for my patients and really having to cover that up, because that could have got me in trouble ... I just wanted to take them by the shirt and shake them and say, 'You're so damn lucky. You have a life, you're relatively healthy, you don't risk being shot every day, you can be vaccinated for meningitis.'"

Bortolotti then goes on to quote from an e-mail the nurse sent to a colleague who had been in Burundi with her: "We had a murder here last Tuesday. First one in five years – not too bad for a community of 850. As I performed CPR on this man's lifeless body, I was surprised to note how detached I felt. He'd attached someone and then got stabbed in the chest – both of them were screaming drunk. Later, when we pronounced him dead, I felt no empathy for the man, nor for the family. No sadness. The two nurses I worked with that night were quite freaked out. When they offered us 'debriefing and counseling' the next day, I almost laughed ... It is snowing and dark now at 3 p.m. Nothing to do but walk the dog and visit friends. It is true, nobody really wants to hear about Burundi. I am talking on the local radio this Tuesday. I will keep it very simple. I would love to tell them how fortunate they are to live in a country with such great access to health care, even if it sucks by Canadian standards."

For the most part, it's true. "... nobody really wants to hear about Burundi ..."

Panga



I snapped this photo of a panga, or machete, lying on the ground at a health clinic in the village of Tongo in North Kivu province. I snapped it because although the panga is a commonly used tool in Central and East Africa (and by other names, in many other places around the world), it has also been used (and is being used today, as I write these words) a great deal as a weapon.

It was one of the main instruments of death (and maiming) during the Rwandan genocide of 1994, and I can't look at one without thinking of that, rather than its utility for cutting brush or dismembering a chicken. I recently read a good book about MSF called "Hope in Hell", by Dan Bortolotti, who recounts the experience of a Belgian doctor in the Rwandan town of Butare during the early days of the genocide.

The doctor recalls that on April 22 and 23, 1994, Hutu soldiers hacked to death in front of the MSF medical staff 150 Tutsi hospital patients, and then grabbed a nurse who was a close friend and seven months pregnant: "They came to take Sabine and I intervened physically and said, 'Leave Sabine alone. Sabine has nothing to do with this ... and besides, she is a Hutu.' The captain who was responsible for the different [killing] teams looked at me very carefully, and then he opened his pocket and took out a piece of paper, and on this paper there was a list of names, typed. And Sabine's name was on it. He looked at the paper and he looked at me and said, 'Yes, you are right. Sabine is a Hutu. But her husband is a Tutsi. And his baby is going to be a Tutsi.' I suddenly realized the cruel reality that in Rwanda the baby follows the paternal line. So Sabine was killed and so was the baby."

So I took a photo of the panga.

Sunday, September 13, 2009

Petit (tres petit) commerce













The Democratic Republic of the Congo is one of the world's richest countries, judged by natural resources, and one of the poorest, judged by the amount of wealth that trickles down to the general population. This can be easily seen through a comparison of the relative economic purchasing power parity (PPP) standings versus the rest of the world of the country and one of its average citizens.

In 2008, the DRC's GDP was $20.64 billion, which ranked the country 121st globally. Not great, but ahead of a significant number of other developing countries. In the same year, the per capita GDP (PPP) was $300, which ranked 228th globally! Only Zimbabweans ranked worse, and Afghanistanis earned more than twice as much (Burmese earned four times as much, Vietnamese and Indians almost ten times as much)!

Ongoing armed conflict, of course, is the main reason people cannot establish regular businesses, and is the main reason there is no national infrastructure to support business, with the result that fiscally, the country is even worse shape than the United States under George W. Bush, with revenues of $700 million and expenditures of $2 billion (2006 estimates).

That said, people try to do what they can, and when/if even a tiny amount of extra cash is generated, many people try to convert it into a business of some sort, whether that's selling extra manioc at the side of the road, or making a long trip into a city to buy Chinese-made flipflops or batteries or toilet paper to resell in a rural market.

The above are photographs I took of the weekly market and some shops in Nyanzale, in North Kivu province, and of the "copy shop" in the street outside the main building of the University of Goma. [In the first photo, the guy in the foreground is shouting at me and showing off his best kung fu moves ... he was almost certainly drunk and venting his socioeconomic frustration at the passing white man. In the second photo, as our jeep came into the market, sellers picked up their things out of the road to let us past ... there are so few vehicles the market simply takes over the road.]

Campaign for Access to Essential Medicines











Anyone's who has ever paid for their own medicines knows how crazy the pricing can be. Before I left for the Congo I had a yellow fever jab, which I think cost $100. And I had to get it in Yokohama because the (one) clinic in Tokyo that offers it had no more stock.

Setting aside the question of punitive pricing by pharmaceutical companies (a subject that has been thoroughly covered in many places ... The Economist is a good place to start, and a few years ago The New Yorker published a superb profile of Bill Gates and his foundation's work), the main issue is the provision of drugs at any price. [Even if a drug company reduces the price of treatment from $18 a day to $1 a day, if you don't have $1 a day, you're still out of luck.]

In addition to pricing is the problem of (lack of) focus by pharmaceutical researchers on diseases that primarily affect the developing world. [Soft penises and hard arteries pay drug company shareholders a lot more than, say, treatments for leishmaniasis or human African trypanosomiasis, not to mention tuberculosis, meningitis and malaria.]

The Campaign for Access to Essential Medicines is an international campaign started by Médecins Sans Frontières to increase the availability of essential medicines in developing countries. It aims to to lower the prices of existing drugs, vaccines and diagnostic tests, to stimulate research and development into new treatments for diseases that primarily affect the poor, and to overcome other barriers that prevent patients getting the treatment they need.

From the MSF campaign website, a summary of the barriers blocking access to medical tools in developing countries:

* Many medicines, in particular those that are still relatively new such as HIV medicines are too expensive for use in poor countries. Patent protection has increased in developing countries and this pushes prices up because patents provide a monopoly for the originator company for up to 20 years, blocking competition.

* When new and better treatments exist it can take a long time until they are registered, treatment policies are changed and they become truly available to patients. This has been the case, for example, with the more effective malaria treatment, artesiminin- based combination therapies that are replacing old, ineffective drugs.

* Research and development is not geared towards the needs of people in poor countries. Drugs and diagnostic tools are being developed on the basis of their future market potential rather than on patients’ needs. Only 1% of the drugs that have come to the market in the last 30 years were developed for tropical diseases or tuberculosis while the existing drugs for these diseases are often toxic and are becoming less and less effective due to resistance.

* Once medical tools are made available other barriers to access to care can become more apparent. One key problem delaying the further roll-out of HIV treatment is the chronic shortage of health staff, particular in Southern Africa, often due to inadequate salaries and poor working conditions.

My photos above show the (tiny) pharmacy stocks in several of the clinics/hospitals I visited, and a nurse distributing drugs to patients.

The Plane, The Plane!

Thursday, September 10, 2009

Cholera Bed





I posted a shot of the above bed previously, but at the time, I didn't know what it was. A bed, obviously, and one with a hole cut in the middle to allow non-ambulatory patients to go to the bathroom. And yes, that's true, but this bed is specifically designed for cholera sufferers, and is called a "cholera bed".

Refugees/IDPs (internally displaced people) are especially susceptible to cholera infection because the disease is transmitted when bacteria in feces comes into contact with the mouth, either via contaminated water, unwashed hands, flies, unhygienic latrines or some combination of the above.

In developed countries cholera is easily prevented and treated, but among refugees/IDPs it can and often does result in death, and not a pleasant one, if there is such a thing. Vomiting and diarrhea can result in fluid loss of up to one liter an hour, and left untreated, cholera can be fatal in up to 60 percent of cases.

Cholera trivia: American President James Polk died from cholera.

Monday, September 7, 2009

A Gourmet's Guide to the Congo

















As I've written before, The Democratic Republic of the Congo is a country essentially without an infrastructure. The Medecins Sans Frontieres teams I visited have for the most part built the infrastructure that supports them, including building kitchens, hiring cooks, and to some extent training (with mixed success, from what I could see) those cooks to prepare dishes that the organization's international workers would like to eat (in addition to the Congolese dishes the cooks already know how to prepare).

In these photographs you can see the kitchen in the MSF residential compound in Nyanzale, a goat that made lunch and dinner (and more, probably, but I had to leave) one day in Gety, and the talented salad maker Gaspard, slicing fresh avocado for his lunch in Kabizo. The logisticians buy what fresh vegetables and meat (chicken, goat, fish) they can locally, and some things are imported, mostly by the workers themselves.

Best things I ate: fresh avocados, roasted potatoes, spicy little meatballs and ratatouille in Bunia, Jose's homegrown lettuce in Nyanzale.

To wash it down there's purified water (when it's been purified; otherwise, it's best to go thirsty), Coke (wherever you go on this earth, no matter how little there is of anything else, there's always Coke), local beer of varying qualities (Primus the worst, but most widely available), and box South African wine (stay away from the white, is my recommendation; the red is passable).