R U N D R C

Even in this country of poverty, people have pets. I don’t see them so much in town, but each time we drive to Mungele, we pass three or four dogs. They look about the same-sandy brown mutts, long pointy ears, and skinny. No matter what they look like, you know their family loves them and gets lots in return. It’s nice to see this bit of “love luxury”.

We have a pet at Kalibatete. It’s a duckling. When I first arrived it was very tiny but is now adolescent duck sized. All day it walks around the clinic, circling the waiting area, the pharmacy, and the four exam rooms. If you leave a door open he’ll walk in, take a look around, peck the hard dirt floor a couple of times, and waddle out. After it rains he’s in heaven. There are puddles everywhere to explores and splash around. Though bold he stays slightly more than one arm length away. I’ve tried to coax him into eating from my hand, but still no luck.

Greetings are interesting here. Since most people speak Swahili as a primary language, they say “jambo” to each other at any time of the day. As a white person, I am always greeted in French. As expected, in the morning that involves “Bonjour.” People generally work from 8 a.m. until 1 p.m. and then take a break, called “le repos.” (pronounced rah-poe, accent on the second syllable). Here le repos is only one hour but it’s a very special hour. Until 2 p.m., people greet each other with “bon après-midi”. Although to my knowledge this salutation exists in neither France nor Belgium, it is ingrained in French speaking Africa. When le repos is over at 2 p.m., everyone switches to “bonsoir” (good evening). This is a bit hard to believe as the sun his still very hot and high in the sky. Yet at 2:01 p.m., I walk down the street, sweat profusely, get sunburnt, and tell everyone “bonsoir.”

Truthfully, it’s not quite as strict as that. I have heard a few radicals saying “Bonjour” even later than 2 p.m.

You know how you go to a nice restaurant and on the menu they usually have some permutation of a free range chicken breast wrapped around something fattening and delicious? You order it and the meat is thick and juicy and flavourful?

Real live Congolese free range chickens are none of these things. The breast meat on a chicken here is ¼ inch thick, challenging to get off the bone, and sometimes difficult to chew. The remainder of the chicken is even leaner. Chicken legs served at Couvent are the size of quail legs served in the US. The wings are laughable.

So what is free range chicken in the US? I’m thinking that probably even organic free range chickens in the US are restricted in activity and have been bred for generations to have really thick breast meat. I know they aren’t allowed to be pumped full of hormones, but they are not chicken in its natural state.

When you’re in primary care you don’t really think about death. Sure, it’s there. I see people with malaria every day and they look awful. You know that if you treat enough people, even with seemingly minor problems, some of them aren’t going to make it. For the most part, that happens outside of your direct vision. The only people you see in the clinic are alive. If they look bad you send them to the hospital and they disappear.

Remember the little girl I wrote about last week? The one from Mungele who had encephalitis and a seizure? The one who was lucky to have a pediatric neurologist around? She died. No one can tell me much. She was admitted to Intensive Care and died two days later. She looked sick but not that sick.

Yesterday I had a typical Mungele day. It was a beautiful drive out and I saw patients with the consultants all day. I even taught my first formal class in French, so was feeling pretty good. About 10 minutes before we were to head back to Lubutu, an 8 month old boy arrived. He was breathing 60 times per minute and had a little “tugging” below his ribs. But he was breastfeeding moderately well and comfortable, despite his high breathing rate. His malaria test was negative and his lung examination sounded awful. Easy enough. It’s pneumonia, of course. He got a shot of antibiotics and a ride to the hospital to stay a few days. It crossed my mind to call an ambulance, but that would have taken longer.

So we packed the baby and his mother up in the car for the one hour trip. We slowed to almost a halt for each group of goats or pigs or chickens, which are plentiful on the roads here.

Fifteen minutes after departure, the baby intermittently started sighing with expiration. That’s a bad sign and means that breathing is getting labored. Great. I was still calm as I thought perhaps the injection of antibiotics hadn’t yet been absorbed. The sighs were now coming with every expiration and I was starting to sweat. Shortly thereafter, the child’s mother opened the window, leaned out, and barfed at 35 miles per hour. She’s never ridden in a car before. Great. The kid now began grunting with every single exhalation. With pneumonia, grunting is what patients do right before things go rapidly downhill. As if they weren’t going downhill fast enough!

As the grunts get louder, I kept waiting for each one, to let me know the child was still breathing. At this point, I was scared that the grunts and the breathing were both going to soon stop. I was in the middle of nowhere with little more than a first aid kit in the back seat.

I told the driver to speed up. Two minutes later, the mother started yelling. The driver put on the brakes and I was about to break I was so tense. Rather than show me her dead child, the mother handed me the still breathing baby and barfed and barfed and barfed. The sight of a vomiting woman was never so welcome. The remainder of the trip was divided into periods of incredible speed and slamming on the brakes for the mother to get out and do her thing .

After this mid-day adventure, I was exhausted. I went back to Couvent and chatted with Gerome, the new big boss over everyone. I explained how vulnerable and exposed I felt in the truck with this very sick child. The only other alternative would have been to radio and ambulance, which would have taken even longer. So had I done the right thing by just bringing the kid with me?

Gerome thought I had. This led to a conversation about the Congolese view of death. He said that here each person is mourned and their death is regretted. But to many Congolese, the performance CPR and rescue breathing are not appropriate. There is an acceptance that for each of us there is a time for death. This should not be fought.

That got me thinking about all the brain injured children I see when working in the US. Every year I take care of children who drown. Well, they don’t actually drown, which means they die from submersion. They nearly drown which means they don’t die. An ambulance is summoned, the kid’s heart isn’t beating, and someone does CPR for 45 minutes. The ambulance shocks the kid a few times and gives him powerful drugs to restart his yet unbeating heart. But then someone feels a pulse. The child gets admitted to the pediatric intensive care unit. If he doesn’t die (which he usually does) he ends up profoundly brain injured: unable to communicate, blind, and without any evidence of perceiving his surroundings. With children submerged in warm water who have no pulse when pulled out, the outcome is universally bad.

What if the parents of these unfortunate near drowned children took the Congolese view and accepted that the time for their child’s death had come? Or do the Congolese hold this fatalistic view only because they have no experience with a Western medical system that can occasionally work miracles?
It’s something to think about after a wild ride home.

Couvent has a steady stream of visitors, people staying between 3 days and 2 weeks.  They come from Kinshasa or Brussels, look around a bit, write a lot of reports, and enjoy the quiet of Lubutu.  Morgan (pronounced mohr-gahn, with the accent on the first syllable) just left today after a 2 week visit.  She’s an electricity expert.

There’s no electricity here except what is supplied by generators.  The hospital has power 24 hours per day, of course.  Couvent gets electricity from 6 a.m. until 10 p.m. daily.  Our electrical problems have two main origins:  the generators themselves and the orages (pronounced “oh-raj”) that come through.

Generators don’t supply consistent current, at least these generators don’t.  The lights dim pretty frequently.  Less often, the whole thing turns off if there are too many lights on or we have the microwave and toaster oven and everyone’s computer running at the same time.  There are kick-your-butt electrical storms (the orages) that come through two or three times per week.  The lightening, thunder, and rain are intense, which can’t do great things for the electrical system.

The brown outs and power surges play havoc on things.  Two weeks before I got here, the television at Couvent was destroyed during a storm.  The week I arrived one of our two refrigerators died after a lightening strike.  In Lubutu, you can’t go out and buy a new TV or refrigerator.  You fill out a requisition and get it signed by several people.  Then you send it to Kisangani.  If the stuff isn’t at Kisangani, your request goes onto Kinshasa.  No luck there and it’s forwarded onto Brussels.  If they don’t have it in the warehouse, someone goes shopping. You can imagine that we haven’t received the new refrigerator.

This is a source for of anxiety as the remaining fridge doesn’t work well, either, just one more lightening strike away from oblivion.  But since we lack all electricity from 10 p.m. until 6 a.m., nothing is particularly cold in the dying refrigerator anyway.

So what do you do when your major appliances keep exploding?  You call in an electricity expert.  That’s Morgan.  She has no formal training in engineering and isn’t an electrician.  She started working for MSF a few years ago, expressed an interest in this electricity stuff, and is now Ms. Electricity Fixit for MSF-Belgium.

Her Lubutu discoveries were amazing.  It seems that when the hospital and Couvent were wired, no one took the orages into account.  No one thought about a master fuse or lightening rods.  This master fuse was described to me as a surge protector for complex electrical systems.  When lightening strikes any part of the system, the surge protector trips.  These things cost about 100 euro each.  Morgan thought that MSF would need two, one for Couvent and one for the hospital.  Lots cheaper than shipping a refrigerator from Brussels every few months.

Morgan has a special place in my heart because she proved that my French is improving.  When she arrived two weeks ago, I couldn’t understand a word she said.  She is from France, doesn’t enunciate well, speaks crazy-fast, and doesn’t pause between sentences.  At first it was not clear to me she was even speaking French!  But something happened during her two week visit.  Either she slowed down or my brain speeded up.  I still only understand 50-75%, depending on ambient noise, her caffeine intake, and my fatigue.  But that’s a shocking improvement from two weeks ago.

Thanks, Morgan, for figuring out why our refrigerators keep exploding.  And thanks for the boost in my confidence in speaking your language.

As you have probably guessed, there are a great deal of differences between medical care here in Congo and the US. At first glance, it’s the technology differences that strike you, but then you start to think, which is becoming increasingly difficult to do.

In Lubutu, we don’t have much in the way of laboratory testing. We can get a blood count, blood smear for parasites, and dipstick for urinalysis. There is no microbiology here, which is striking. In this place full of weird bacteria and invasive parasites, there is no way to culture blood or urine or spinal fluid to definitively diagnose an infecting organism. As we can’t culture anything, we can’t test the sensitivity of bacteria against different antibiotics. Instead, we use protocols.

If someone has pneumonia, they get an antibiotic that kills the most common organisms causing pneumonia in Congo. If they get better, great. If not, the protocol says to give 10 days of a different antibiotic. If that doesn’t work we are to search for tuberculosis using chest x ray and a sputum smear. But if we get to this point and they don’t have TB, there is nowhere to go, diagnostically or therapeutically. There is no way to culture the sputum to try to figure out if your patient has something treatable (and you’ve just been giving the wrong antibiotic) or untreatable. Without technology, the protocol stops. There are no further suggested diagnostic tests or treatment. The patient just keeps coughing.

This came to mind last week at Mungele. A 30 year old man came in two weeks ago with a bad middle ear infection. Per the protocol, we gave him amoxicillin. When he didn’t get any better, we began daily injections of different antibiotic to try to clear the pus behind his eardrum. It didn’t work. So what next? Unfortunately, nothing. In the US, I would have stuck a needle into the pus, sucked it out, and sent it off to the microbiology lab. The lab would culture it and send me a report identifying the organism. That report would also tell me which antibiotic to use to cure my patient. But here I had to tell this man that unfortunately I had done all I could for him. That’s difficult when you know that if this person were in the US, you could easily help him.

Another big difference between medical systems is the lack of focus on chronic disease in the developing world. In the US, as a pediatric neurologist, I deal with chronic disease daily. Half of my patients have epilepsy, a condition that persists for years. Here chronic disease is often not treated.

Last week I saw an adolescent with muscular dystrophy. He was in the hospital for pneumonia, which was being treated. The hospital medical staff asked me to talk to the patient and his family about prognosis and the genetics of the condition. So we had a long chat in Swahili and French. But then I thought….why isn’t this poor boy getting physical therapy and chest percussion, to keep him mobile and free of illness as long as possible?

Most cases like this don’t affect me (except emotionally) on a daily basis. Working in the Centres de Santé I am in the front line of primary care. People usually come to see us when they are acutely ill. Still there are issues that come up, like the chronic aches and pains we aren’t treating.

People here do a lot of hard physical labor. If they have a heavy load, it is carried on the back. A strap is tied around the load and this is looped around the forehead. So guess what at least half the population lists as one of their medical complaints? Yep- headache and back pain. In the West, similar complaints get oral pain relievers, local therapies (heat or cold), massage, or even physical therapy. Here we tell people they need to rest. I’m fine with that, but when they come back after a couple of weeks rest and their knees are still stiff and achy, then what? Well then…..nothing. We don’t hand out a month’s supply of ibuprofen or give them physical therapy. We shrug our shoulders and say we’re sorry and that there’s nothing we can do.

Or perhaps in this place where most people die of malaria, pneumonia, or diarrhea, treatment of chronic conditions is a luxury that few people can access or afford. I hear health care spoken of as a basic human right, but is it only health care for acute conditions that it is basic human right, or all conditions?

As you have probably guessed, there are a great deal of differences between medical care here in Congo and the USA. At first glance, it’s the technology differences that strike you, but then you start to think, which is becoming increasingly difficult to do.

In Lubutu, we don’t have much in the way of laboratory testing. We can get a blood count, blood smear for parasites, and dipstick for urinalysis. There is no microbiology here, which is striking. In this place full of weird bacteria and invasive parasites, there is no way to culture blood or urine or spinal fluid to definitively diagnose an infecting organism. As we can’t culture anything, we can’t test the sensitivity of bacteria against different antibiotics. Instead, we use protocols.

If someone has pneumonia, they get an antibiotic that kills the most common organisms causing pneumonia in Congo. If they get better, great. If not, the protocol says to give 10 days of a different antibiotic. If that doesn’t work we are to search for tuberculosis using chest x ray and a sputum smear. But if we get to this point and they don’t have TB, there is nowhere to go, diagnostically or therapeutically. There is no way to culture the sputum to try to figure out if your patient has something treatable (and you’ve just been giving the wrong antibiotic) or untreatable. Without technology, the protocol stops. There are no further suggested diagnostic tests or treatment. The patient just keeps coughing.

This came to mind last week at Mungele. A 30 year old man came in two weeks ago with a bad middle ear infection. Per the protocol, we gave him amoxicillin. When he didn’t get any better, we began daily injections of different antibiotic to try to clear the pus behind his eardrum. It didn’t work. So what next? Unfortunately, nothing. In the US, I would have stuck a needle into the pus, sucked it out, and sent it off to the microbiology lab. The lab would culture it and send me a report identifying the organism. That report would also tell me which antibiotic to use to cure my patient. But here I had to tell this man that unfortunately I had done all I could for him. That’s difficult when you know that if this person were in the US, you could easily help him.

Another big difference between medical systems is the lack of focus on chronic disease in the developing world. In the US, as a pediatric neurologist, I deal with chronic disease daily. Half of my patients have epilepsy, a condition that persists for years. Here chronic disease is often not treated.

Last week I saw an adolescent with muscular dystrophy. He was in the hospital for pneumonia, which was being treated. The hospital medical staff asked me to talk to the patient and his family about prognosis and the genetics of the condition. So we had a long chat in Swahili and French. But then I thought….why isn’t this poor boy getting physical therapy and chest percussion, to keep him mobile and free of illness as long as possible?

Most cases like this don’t affect me (except emotionally) on a daily basis. Working in the Centres de Santé I am in the front line of primary care. People usually come to see us when they are acutely ill. Still there are issues that come up, like the chronic aches and pains we aren’t treating.

People here do a lot of hard physical labor. If they have a heavy load, it is carried on the back. A strap is tied around the load and this is looped around the forehead. So guess what at least half the population lists as one of their medical complaints? Yep- headache and back pain. In the West, similar complaints get oral pain relievers, local therapies (heat or cold), massage, or even physical therapy. Here we tell people they need to rest. I’m fine with that, but when they come back after a couple of weeks rest and their knees are still stiff and achy, then what? Well then…..nothing. We don’t hand out a month’s supply of ibuprofen or give them physical therapy. We shrug our shoulders and say we’re sorry and that there’s nothing we can do.

Or perhaps in this place where most people die of malaria, pneumonia, or diarrhea, treatment of chronic conditions is a luxury that few people can access or afford. I hear health care spoken of as a basic human right, but is it only health care for acute conditions that it is basic human right, or all conditions?

Culturally, Lubutu is superficially easy to figure out. Look a little deeper, though; and the challenge begins.

As I’ve written before, the Congolaise people are extremely polite. When passing on the street, strangers frequently greet each other with “Jambo” or “Bonjour.” With me, the white guy, it is even more noticeable. Anywhere I go I am treated like a celebrity. The vast majority of people greet me verbally, smile, wave, or do all three. Kids run out of their houses to stare and their parents hold them up to wave. When I go running, all this happens at high speed. I get groups of kids running with me for short intervals, then falling behind with a laugh. Men stand on the roadside , wave, smile, and yell “courage!” But then the word “mzungu” appears. It’s the Swahili way to express “white skinned” and I don’t like it.

For the most part, the word is confined to small children. But when the little ones run and point and scream “mzungu!”, their parents laugh and encourage them. No, I don’t think that children here in Congo are innately racist, but I do think their parent’s attitude makes them see race before any other character in a person.

For me this is difficult to understand. My country has a long history or racism. When children cry “mzungu!”, my mind flashes to the treatment of African-Americans in the US in the 1960s, with racial epiteths being used as succinct descriptors. For example, in those times a physician who was married with children and a prominent community member, but who was also African-American would likely be succinctly referred to as “that black doctor” or something even less politically correct. Today, most Americans would describe this same person perhaps by profession, marital status, where they live, etc. If race is mentioned at all (and in my world, it usually isn’t), it’s at the end of the story, as an afterthought. Like most Americans of my age or older, I’ve worked to overcome the tendency to classify people primarily by race.

So why do people here find it funny and cute when their kids point at me and scream “whitey!”?

I asked the national (Congolese) MSF staff. They couldn’t answer because I don’t think they understood the question. To them, calling someone “mzungu” is not impolite. It is just a descriptor of a person; of course children will say it.

I asked the ex-pat MSF staff their opinions. Like me, most of them were very unsettled by the word after they arrived. After awhile, though, “you’ll get used to it.” One person told me a story of a lighter skinned West African who came to Congo to work and was called “mzungu” like the rest of the caucasians.

I know these children mean no insult, but I cannot help but make the mental leap to racist America of the 1960s. I’m trying to overcome this cultural gap, but am having some difficulty with this one. Hopefully time will heal.

Something wonderful happened today.

Today was the first day I did Mungele alone. It is the more rural of the two Centres de Santé where I am working. Though an hour away by car, the commute is beautiful.

This part of Maniema province is hilly. The entire way, the road is lined with thick jungle. Every ten minutes or so a small village appears. People wave a shout (nicely!) along the way and we often have to slow down for goats or pigs or chickens in the road.

This morning we arrived to the waves and “Bonjour!”s of the staff. As usual, there was a patient waiting for me to see in the small observation room. The night before, this man had been up in the treetops hunting monkeys. He had fallen 25 feet and was unhurt except for the ¼ inch diameter stick that entered the bottom of his foot and exited the top. He had tried to pull the stick out, but unfortunately it had broken. Not good for him but easy for me; he got antibiotics and a ride back to the hospital with me.

I saw patients with the Consultants for the remainder of the morning, and a bit later a 1 year old came in with fever, cough, and breathing fast. He looked very ill so he got antibiotics and a ride back to the hospital with me, too. At this point I felt good that I was managing this place and its staff alone.

Then the cool thing happened.

The Chief of the largest clan in Mungele came for a call. We shook hands and sat down for a chat. Using an interpreter, he thanks MSF and me for coming to his village. He said that the community felt our presence every day. They no longer had to worry about access to good medical care. But he wondered why MSF hadn’t started construction on the permanent Centre de Santé. We’d been open for 3 months and were still in temporary mud buildings. Smart Chief. He knew that until the permanent building went up, MSF could leave as fast as they had appeared.

And then he gave me the eggs. As a gift to welcome me, he handed me four chicken eggs, wrapped in a piece of cellophane, and tied with a string.

I felt very special today. On the ride back to Lubutu I waved to every person we passed. I arrived at Couvent and I told everyone my story. They agreed this whole Lubutu experience was very “chouette”, very cool. Yes the people here are lucky to have MSF, but we’re lucky, too.

Plumpy Nut. I never thought fortified peanut butter could bother me so much.

Last week I wrote about the malnutrition clinic (called CNTA) at Mungele. There are basically two levels of malnutrition care here: inpatient (called CNT for “Centre Nutritionelle Therapeutique”) and outpatient (CNTA- the same but with “Ambulatoire” at the end). In order to get cared for as an inpatient (the CNT in the central hospital in Lubutu) a child must have Moderate or Severe malnutrition and have some other symptom or medical complication: anorexia, severe anemia, severe infection, of just look apathetic and exhausted.

The criteria for the CNTA, however, are different. Kids have to be Severely malnourished but free of those other medical issues. They are basically starving to death but not really “sick”.

To get some perspective on this, even if a child is only Moderately malnourished, they look very skinny. Their arms are tiny and their ribs are easily visible. They do not look healthy.

Unfortunately, if you are “well” but only Moderately Malnourished, you don’t qualify for CNTA. The Consultants and I take your history, examine you, and probably end up giving you some vitamins and some albendazole for intestinal parasites. We sit down with your parent and tell them that they should try to feed you more.

Why aren’t we treating everyone with malnutrition (mild, moderate, severe) to the full extent possible? Apparently, for the general population here, obtaining food is not such a big challenge. Things grow easily. The jungle is apparently full of stuff to eat (both animal and vegetable), and there is no drought or war or anything else in the way of people getting food. Studies have been done in this geographical area that demonstrate only one planting/harvesting season per calendar year. This is amazing to me as plants here appear to visibly grow by the minute.

In other MSF projects where people are hindered from finding food by famine or war, access to food is obviously harder. In these other places, even Moderately malnourished “well” children qualify for the CNTA with free food supplements, a mosquito net, and a cocktail of medicines to help them get fatter.

The other confounding factor in the equation is that apparently mortality rates are not much higher for Moderately malnourished children than for normal kids. Since MSF resources are limited and the average person here isn’t really prevented from obtaining food, it is harder to get help for your moderately Malnourished kid in Lubutu than it might be elsewhere in Africa, even within MSF. If it is true that Moderately malnourished children are not more likely to die than normally fed children, perhaps resources should be concentrated only on curing Severely Malnourished children (who do have a higher mortality) and encourage programs (non-MSF) that help people find food. Like how about two or three plantings/harvestings per year instead of just one?

Today we saw the CNTA patients back after their first week enrolled in the program. One kid stayed the same, but the rest of them gained weight. A lot of weight. Plumpy Nut is 500 calories per package. Since the children get 2 or 3 packages per day, they quickly pack on the pounds. After only one week they looked chunkier and healthier. But we still have to turn those Moderately malnourished kids away hoping they would gain some weight in the next month. Perhaps some kids will have miraculously improved. But without good education about agricultural practices in place, I worry that we might not be doing the right thing by asking these Moderately malnourished kids to wait.

I was initially outraged that we aren’t handing out free food to every child here, no matter what their level or malnutrition. Researching this topic, I learned about limited resources and wellness education for communities. I know I’m being idealistic and unrealistic and simplistic. I understand all of this, but I’m here and it is breaking my heart to not give every malnourished kid a big handful of Plumpy Nut.

Some of the other ex-pats here have said they envy my freedom. They rarely have the opportunity to venture farther than the short distance between Couvent and the hospital. I get to walk to Kalibatete or be driven to Mungele every day.

I love the commute to Kalibatete. It’s 15 minutes on foot and I say “Bonjour” at least 100 times each time I make the trip. At first, the Congolese staff were puzzled as to why I would want to walk. They see Lubutu every day and to them it’s not interesting. I think it’s full or new, fun things to discover.

On my way home tonight, I walked out the dirt lane connecting the Centre de Santé with the main road. There were two games taking place, one on either side of my path. To the right; kids were playing the Congolese version of kickball. On the left, smaller children chased a duckling, screaming as the animal stayed just out of reach.

As usual, the moment I appeared, everything stopped. Everyone stared, some kids smiled; and most of them waved. Smaller children sometimes scream “Mzungu” (literally “white skinned”) while older kids love to say “Bonjour” and hear me repeat it back. As quickly as I had stopped all the fun; it restarted once I had passed.

I turned right on the main paved road and walked downhill towards the bridge, currently under construction. There’s a few businesses on this side of town, but the main attraction are the mosque, a couple of churches, and the MSF clinic.

The best part of the walk is watching the people. The Congolese are well dressed and unfailingly polite. Women wear beautiful dresses made of yards of cotton printed fabric, all strikingly patterned. Men hold things in their hands, but women usually carry objects on their heads. No matter how many times I see it, I am amazed at their balance carrying heavy loads on uneven pathways. They glide rather than walk.

A new bridge is being built over the waterway that the roadway is crossing. Despite the physical presence of a backhoe, I think it’s all being done by hand–digging, mixing cement, and the rest. There are always lots of men working no matter what time I walk past. Today I saw an ex-pat working with them. He was busy and didn’t seem particularly interested in chatting, so I just kept going.

Walking uphill from the river, I got to the main commercial part of town. The stores here include lots of poorly-stocked pharmacies, shacks selling mobile phone credits, and a couple of stores to pick up the odd bar of abrasive, wildly colored soap. Finally I arrived at the main square of town. There is a pole in the center, with a faded and slightly tattered Congolese flag flying. Every day at 7 a.m. and 6 p.m. the flag goes up or down. An official walks out to the pole, blows a whistle, and the world stops. Everyone on foot, people on bikes and motorcycles, and every single car (in the cities) — they all stop. On my way home today I hit it exactly right. I got to watch the man whistle, salute the flag, lower it, and whistle again. Only then could I continue.

After Main Square, I hit the market. Lubutu’s market is divided like most into food and non-food sections. The foods available are surprisingly limited. Today I saw dried fish, spinach, avocados, red caterpillars the size of a finger (served deep fried), raw rock salt, beautiful multicoloured beans, onions, garlic, cherry tomatoes, and an occasional papaya. As there are no grocery stores here, how do people get variety in their diet? Does everyone just grow food at home? Perhaps it’s just seasonal.

The non-food section of the market is equally limited. Somehow a pipeline has been created between poorly made goods from throughout the world and the Lubutu market. There are garishly colored flip-flops for sale in almost every stand; I’ve heard they usually break within a week. “BIC” pens work for one or two days before drying up. But the market is also where women come to buy the fabric for their dresses. These stands are eye-popping with crazy juxtapositions of color and pattern.

Once past the market, there is a branch of red earth road to the hospital and Couvent. I like to continue straight ahead, even though it’s a bit farther to home. Tonight I took the long way again and passed the only multi-story building in town, the cathedral. Since I’m living in the ex-convent for the nuns, I feel a special affinity.

As an extra special treat today, a 9 year old boy walked with me from the cathedral to my front door. He sang as we walked, the same tune over and over.

Tonight there was another lovely sunset. As I pushed open the front gate; I marvelled at my luck in being here.

Stupid me.

I thought I would be speaking and hearing French all day. After all, isn’t French the official language of central and western Africa? Nope.

When I wake up in the morning in Couvent, I speak French with the other ex-pats and the Congolese staff. I walk 200 years to the hospital, pass about 40 people, and say “Bonjour” to every one. I walk into the hospital and am greeted over and over with “Bonjour, Dooglas!” (not a misprint) or “Bonjour, Doctor!” When I get to the office, my ex-pat co-worker and I speak French to each other, even though Sophie is from Sweden. Then we drive or walk to the Centres de Santé and Language Hell breaks out.

The patients only speak Swahili! So the Consultants take a history in Swahili, and we talk about it in French. We do the physical exam in Swahili and discuss it in French. After we arrive at a diagnosis in French, the Consultant explains to the patient in Swahili. The medical records and prescriptions are written in French and explained in Swahili.

If all this wasn’t enough, some of the Consultants speak with such a strong accent that I strain to understand them. This is actually the hardest part of my language day.

After the daytime language nuttiness, I return home to Couvent and speak French to French people. Except they aren’t really French. They’re Belgian. Amazingly, I can now easily detect the difference in accents.

Couvent is actually home to an international staff. Other than the Belgian Horde, there are two Germans, a Swede, a Finn, a Lebanese, a Mauritanean, a Gabonese, a Sierra Leonean, and me, Mr. America. Crazier are our visitors. Last week had someone from Italy staying with us. Heavily Italian-accented French is both hilarious and nearly impossible for me to understand.

All in all, the language issue is not as bad as I had feared. The scary part is I believe my French is getting worse with time. The Congolese staff are too polite to ever correct me; they nod wisely as I utter nonsense. The ex-pats appear to understand when I’m saying and never correct me. If I had to guess, I would say I am getting less conversant in French the more I speak it. Perhaps if I stay mute for 6 months I’ll be fluent when I return home.