Employees must wash hands before returning to work

Believe it or not, October 15 was "Global Handwashing Day". There really is a day (or week or month) for everything, but despite the silliness of designating a "Global Handwashing Day" (and yes, yes, it provides a focal point for awareness raising activities), handwashing (or not) is an activity that can help save (or not) millions of children's lives every year.

According to the Global Handwashing Day website: "Of the approximately 120 million children born in the developing world each year, half will live in households without access to improved sanitation, at grave risk to their survival and development. Poor hygiene and lack of access to sanitation together contribute to about 88% of deaths from diarrheal diseases, accounting for 1.5 million diarrhea-related under-five deaths each year. Children suffer disproportionately from diarrheal and respiratory diseases and deaths." Children older than five suffer as well: diarrheal and respiratory diseases kill around 3.5 million children a year worldwide.

Handwashing with soap is one of the most cost-effective means of preventing infection in developing countries, but a recent study of behavior in 11 countries found that on average, only 17% of child caretakers wash hands with soap after visiting the toilet. Of the 11 countries (Ghana, India, Madagascar, Kyrgyzstan, Senegal, Peru, China, Tanzania, Uganda, Vietnam and Kenya), Indians washed their hands with soap most frequently (42%) after visiting the toilet, while Ghanaians and Madagascaris washed least frequently (3% and 4% respectively). Chinese washed their hands 12-13% of the time, and Kenyans 29% of the time.

Including people who rinsed their hands with water but did not use soap, the numbers were much higher, leaping to 39% in Ghana and 57% in Kenya. The India study did not report "no soap" handwashing statistics, and bizarrely, the two China studies, done in Sichuan and Shaanxi (and admittedly featuring small data samples), which produced nearly identical "handwashing with soap" results, returned extraordinarily different results on the question of handwashing without soap (Sichuanese rinsed 87% of the time and Shaanxi only 14% of the time).

Hygiene is in great part a function of culture and convenience (if you had to collect all of your washing and cooking water every day, and had no water facilities in your toilet, which you were sharing with hundreds of others, how good a handwasher would you be?), but poor hygiene is not exclusive to developing countries. A study in the U.K. found that only 43% of mothers washed their hands with soap after changing a dirty diaper/nappy. That's five points ahead of Kenya (38%).

Of course, you don't have to be a health and sanitation researcher to know that poor hygiene knows no economic or national boundaries. The next time you visit the toilet in a luxury hotel or posh restaurant, pause for a moment (trying not to get arrested for loitering with intent to solicit) and see what percentage of people wash their hands with soap. No matter how exclusive the venue, a sizable minority (or majority!) of people will head straight out the door without even a glance at the sink.

I included a couple of photos above, The first shows a handwashing cistern at a Medecins Sans Frontieres hospital in Gety, Ituri province. These cisterns frequently have a piece of soap nearby, but although this one doesn't, the water contains antiseptic. The second photograph shows a toilet in a camp in North Kivu for internally displaced refugees (IDPs). The toilets are scattered around the camp and segregated by sex (though I imagine that in the middle of the night most people head for the nearest). They're drop toilets and probably needless to say, they don't feature sinks and running water. If you want to wash your hands, you do so after returning to your hut.

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.

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.

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).

Security Situation Prompts Partial Withdrawal of Gety Team

In Gety, militia units have recently entered the town on two occasions, looting some houses, and forcing the MSF team to suspend visits and support to health centers outside the town. A reduced team is still working at Gety’s hospital. The safety of the medical and support team is of paramount concern, but of course the real victims are the local citizens whose access to medical treatment has been reduced. Above are some photographs of the Gety area and team.

Something is better than nothing

As written in a previous post, MSF medical teams have to import pretty much everything when they set up somewhere in the D.R. Congo, and MSF's surgeons, who come from all over the world, usually on one- to three-month contracts, for the most part are used to far better equipped facilities.

Above are a handful of shots of equipment and facilities, mostly snapped at a hospital run by MSF in Gety, Ituri province. MSF teams will build the beds in which patients convalesce. The centrifuge you see in one shot is hand-cranked. There was only one microscope in every Congolese medical facility I saw, and the "blood banks" I encountered in hospitals contained only a handful of bags of blood. [Other shots that may require brief explanation are of a hospital pharmacy (the second shot) and a bin of handwashing solution (last photo).]

And yet for the most part, the facilities established and operated by MSF are vastly superior to those run by the government, and the available care so much more attractive that the communities in which MSF sets up shop see dramatic population growth. Something is better than nothing.

It can't hurt ...

Next door to the MSF hospital in Gety, Uturi province, are a couple of colonial-era (I assume; they were among the most solid and architecturally interesting buildings I saw in the Congo) buildings. One is a mostly disused school, and wandering around, I heard music emanating from one classroom. I poked my head in the door and found a church singing group practicing for Sunday. When I asked if I could take a few photos, the group leader welcomed me in, and I managed to get off a few shots, record some digital sound, and shoot a short video clip. There's not a lot of music in the rural parts of the Congo - for most people, survival requires their full attention - so it was nice to hear and see people singing and playing instruments (the instruments you see in the photos are lyres, and go by that name in the Congo; they're handmade, of course).

Perhaps surprisingly, and according to Wikipedia, Christianity is the main religion in the Democratic Republic of the Congo, followed by about 80% of the population. Christians are divided between the Roman Catholic faith (about 50% of the total population), Protestantism (about 20%), and Kimbanguist (10%). Kimbanguism was seen as a threat to the colonial regime and was banned by the Belgians. Kimbanguism, officially "the church of Christ on Earth by the prophet Simon Kimbangu," now has about three million members, primarily among the Bakongo of Bas-Congo and Kinshasa. As well as being the largest religious organisation in the country with about 30 million members, the Catholic Church of Congo (Kinshasa) is one of the largest churches in Africa. The Congo has more Catholics than any other African country, and one of the highest proportions of Catholics.

[However], a clear delineation of religious affiliation into these membership categories can give a misleading picture of Congolese reality. The number of persons who can be categorized as belonging exclusively to one group or another is limited. Overlapping affiliations are more common. As with class identity or with ethnic identity, an individual's religious identity may be situational. Different spiritual traditions, agents, and communities may be sought out for assistance, depending on the situation at hand. For example, Christian students may employ sorcery with the objective of improving their individual exam scores or of helping their school's soccer team win in competition against their opponents. Sophisticated urbanites, faced with disease in a family member, may patronize indigenous healers and diviners. And Congolese practicing traditional African religions may also go to both established Christian clergy and breakaway Christian sects in search of spiritual assistance. In the search for spiritual resources, the Congolese have frequently displayed a marked openness and pragmatism.

Given the situation in which most people find themselves, it certainly can't hurt to gamble that (a) god might be watching, and decide to lend a hand.

Water, water, every where; Nor any drop to drink

There's no shortage of water in the Democratic Republic of Congo, but for millions of people, there's none clean enough to drink, or to wash in. Among the most important health care services aid groups provide to rural villagers is water sanitation facilities.

I took the above photos in Soke, between Gety and Bunia in Ituri Province, where MSF personnel had constructed a water sanitation plant and piped clean water 800 meters uphill to the main part of the village.

MSF Water-and-Sanitation Engineer Barry Gutwein, who worked in Katanga Province in 2006, wrote in detail about his experiences delivering water to villagers there: http://doctorswithoutborders.org/news/article.cfm?id=1758&cat=voice-from%20the%20field

For the biologically (gastronomically) challenged, goat is not lamb

Not much time to post right now (the malarial mosquitoes are beginning to swirl around my ankles) and will catch up tomorrow, but wanted to post at least once after five days away from the Internet.

A few meals were missed on this trip (and cold beer was REALLY missed), but George the Goat (perhaps not his actual name) made an appearance the other day on the table in Gety.

I confess I did not slay George, though had the task fallen to me I doubt I would have hesitated. Could not resist posing over his fallen body, though, in the manner of the great white hunters who preceded me to this continent.

Coroner's report: some bits a bit chewier than ideal.