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.

War is hell. On Schoolchildren.

War is hell on schoolchildren. The decade-plus of war that has killed nearly six million citizens of the Democratic Republic of the Congo and destroyed the country's industry and infrastructure has also destroyed the hopes of a generation of children that they might get an education and with it, an opportunity to help their country break its cycle of poverty and self-destruction.

In 2005 it was estimated that 4.6 million Congolese children were not being educated, either because their parents could not afford school fees and supplies, or because armed conflict had caused the suspension of educational services in their towns and villages. Data compiled in 2007 estimated that 3% of D.R.C. citizens receive a university education, 30% a secondary school education, 46% only a primary school education, and 21% no education at all.

Travel around the D.R.C. and you see children everywhere. In the IDP (internally displaced person) camps, you are followed everywhere by a crowd of kids. In part this is curiosity; how strange the mzungu are! In part it is hope; can the mzungu help us? In part it's boredom; doing anything is better than doing nothing.

Of course, children also work to support their families. They collect water and they help their parents in the fields in times peaceful enough to permit people to cultivate their fields. The above photographs taken in and around IDP camps near Rutshuru in North Kivu show children collecting water and observing the mzungu photographer.

I brought my "A" game and was, I'm sure, at least as entertaining as usual, but I can't claim my visit was an adequate substitute for a good education.

Essential Drugs

Doctors who work for MSF are pretty much guaranteed they will face pathologies they would not have had to deal with in their home countries, even if their home countries are developing nations with significant health care problems. MSF's mandate is (for the most part) emergency response, and doctors respond to outbreaks of cholera, malaria and meningitis, treat victims of armed conflict, and set up treatment programs for HIV/AIDS sufferers.

Even doctors who served their residencies in Detroit, and have therefore seen more than their share of gunshot victims, have probably not treated too many patients who had stepped on land mines. The same is true of African trypanosomiasis, also known as sleeping sickness. Not too many cases of that at Karolinska University Hospital in Stockholm, for example.

MSF frequently operates in countries and regions where the health care infrastructure has completely fallen apart – the Democratic Republic of the Congo is an excellent example – and in order to maximize the speed and efficiency with which newly arrived medical teams can start delivering care to patients, the organization has developed a number of specialized kits, each containing a wide range of supplies needed to treat a certain number of patients in a particular pathology. MSF has also published a number of guidelines and protocols that share information from doctors who may have been in similar circumstances.

The book pictured above is a manual intended for use in the field by physicians, pharmacists, nurses and other health care workers involved in the prescription, dispensation and management of medicines. This particular volume looked as though it had been well used.

Other volumes published by MSF boast intriguing titles such as "Obstetrics in Remote Situations", "Management of Epidemic Meningoccocal Meningitis", "Blood Transfusions in Remote Areas", "Refugee Health in Emergency Situations" and "Rapid Health Assessment of Refugee or Displaced Populations".

Those titles are far more straightforward, I think, than "Essential Drugs", which has possibly been purchased by mistake by more than a few substance-impaired undergraduate university students.

Augustin, Sign Maker

Sorting through some photographs the other day, I looked closely at these shots I took of department/ward signs in an MSF-run hospital in Bunia. On each of them you can see (click on the image to see in a larger size) the sign maker's signature, Augustin. [I've added another sign, by Pierrot the sign maker, which may or may not have been taken in the same hospital (I can't be bothered to figure it out from the shot timings).]

I love the purity of Augustin's marketing strategy, though I imagine that if he hired an agency they would recommend writing "Augustin" in the size he's written "Maternite".

Wanted: _____ologists

Dr. Richard is a 38-year-old anaesthesiologist working at Rutshuru Hospital in North Kivu province, and he's the only anaesthesiologist on staff. The hospital's surgeons perform 10-20 operations a day, around the clock, and Dr. Richard is stretched.

He has three nurses working under him who have anaesthesiological training, but Dr. Richard, who is Congolese and was trained at the University of Kinshasa Medical School, bears responsibility for their work, and more often than not, he attends in person.

A shortage of doctors in the Democratic Republic of the Congo, combined with an overall very basic level of medical care, means the vast majority of the country's medical school graduates (not a huge number anyway) go straight into general practice rather than undertaking a specialist residency.

The money is better in general practice (though by the standards of almost every other country on earth it's not good), so why spend an extra few years learning to be a gynecologist or endocrinologist or otolaryngologist? Or anaesthesiologist?

Perhaps in order to work overseas, for a lot more money, in a country where you're unlikely to be shot and killed because you have a job and perhaps own a bicycle and are therefore "rich"? No one would blame you.

The D.R.C.'s "medical brain drain" is, like so many of the country's other problems, rooted in the decade of war that has thus far cost 5.5 million lives, and prevents Congolese from establishing a society in which they can live without fear and work toward realizing their dreams.

No one can blame those who have the opportunity for choosing to seek a better future overseas, but equally, few can be unimpressed by those like Dr. Richard who choose to stay, to work for little pay and often at great personal risk to reclaim their countries from the depths of anarchy and despair.

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.

The Early Bird Gets ... The Shower

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.

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.

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.]

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.

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.

Project Galilee

Logisticiens Sans Frontieres

Home, Sweet Home

Before I came to the Democratic Republic of Congo, a refugee camp, in my mind's eye, comprised orderly rows of blue United Nations-supplied tents, perhaps even including an Internet cafe tent, and Silvio Berlusconi wandering around in expensive loafers, an expensive sweater draped over his shoulders and a fake look of concern pasted onto his face.

The Congolese reality is somewhat different. "Camp" simply means "place where people have started to live together, for (often illusory) security and because aid (food/medical) distribution more easily finds large groups of refugees".

Refugees/IDPs build their own huts, from sticks and grass and mud, and hope that aid organizations will eventually build toilets and water sanitation facilities (and distribute food). The plastic sheeting that covers some huts is (as far as I heard and could see) no longer distributed by the U.N. (perhaps this distribution is done only during "emergencies" ... not sure) – those who have plastic sheeting were given it years ago, or bought it from others.

The huts are tiny, only a few square meters (in which it is impossible to stand upright), sometimes divided into two sections, one for "living" (cooking/eating) and one for sleeping. Families of up to half a dozen (and sometimes more) adults and children live in these huts, and when you look inside, you can understand why the MSF medical teams encounter so many burn victims; cooking is done inside the huts as well, either over a small open stove (rocks on which a pot can be rested over charcoal) or a small oven (sculpted from mud).

Not a pair of Ferragamo loafers in sight ...