R U N D R C

MSF’s involvement in health care in Lubutu is going to end. Phasing out of a large project such as this is a lengthy process and so plans are being made now to end the organization’s activities here. It is likely to be a bumpy transition.

The intervention in Lubutu grew out of past failures. Years ago, and in other parts of Congo, MSF had a wide network of primary care Centres de Santé. Analysis of public health indicators (death rates, for instance) before and after the presence of these primary care services was disappointing. Without a hospital to refer more complicated and severe cases, the Centres de Santé alone did little to lower mortality or morbidity. Thus a new model emerged…. the Lubutu project. It was a risk and a new paradigm for MSF. Go into an area with a very high death rate and quickly open up a referral hospital. Try to get the existing government-run Centres de Santé to refer appropriate patients to that hospital. Finally, take over a couple of the existing Centres de Santé, in order to make them examples of high quality primary care clinics.

It appeared to work. Death rates fell dramatically, up to 80 percent. The result was likely due to a combination of factors (the end of war, an improving economy) but certainly the hospital’s opening had an impact. Good for everyone.

But all good things must come to an end. MSF’s charter is to respond short term to emergency situations. The organization does not generally engage in long term development. At one time the death rates here were so high that this area did qualify as an emergency environment, but no more. Lubutu was planned as a five year intervention. Three years have passed, two to go.
For those of us working here, thoughts of an MSF exit are difficult to imagine. Yes, possibly another non-governmental organization (NGO) can be found to take it all over. Perhaps they will have the resourced to employ all the doctors, nurses, cleaners, orderlies, drivers, pharmacists, operating room assistants, laboratory technicians, and people who cut the grass. Maybe they will be able to maintain the high quality of health care being provided here. But how many other NGOs exist that can manage this project and its organization ? If no one can be found to take over, then what? What happens to all of the local people who get malaria and can’t afford medicine? How about all the malnourished children? And the people with chronic disease who now receive care and medicines for free? Or the women who need emergency caeserian sections?

How do you exit gracefully from the only business in the area that provides referral health care? There are many points to consider. In the best case scenario, MSF quickly finds a partner who can take charge. Then train as many local (Congolese) people to do the jobs that the expatriates are currently doing and concentrate on the present high quality of care.

If no suitable partner can be found, the situation is more problematic. Is it better to work maximally until the end and abruptly withdraw? Or is it smarter to pull out of programs slowly while trying to maintain the health of the population? Should the hospital in Lubutu suffer a slow decline or drop dead?

Our team discussed a few options MSF might have in the remaining two years. One idea I found interesting was to see if eliminating selected hospital services would impact quality of care. For example, how about if the hospital continued working exactly as it does now, but eliminated radiology? It is an expensive part of the system. Does an x-ray really add much to a good clinical examination? Alternatively, what if we eliminated certain expensive medicines? Does doing so increase death rates or the burden of disease in the population? At first these questions sound harsh and morally dubious. But wouldn’t it be a good thing to know the minimum requirements needed in a hospital that makes a significant positive impact in the health of a community? That minimum would likely be a less expensive hospital than this one. If it were less expensive, perhaps these “pared down” hospitals which could still continue to positively impact public health would be a good idea for places like Lubutu. Retaining the same positive effects but at lower cost. More hospitals could be opened for the same costs.

MSF has spent a lot of time, money, and effort to develop and expand this project . To have the hospital return to its pre-MSF days of insufficient supplies, unavailable medicines, and turning away patients who could not pay, is a difficult concept to accept. Like me, I am sure that everyone who has participated in the success of this project is hoping that a solution can be found and that the people of Lubutu can continue to enjoy high quality health care.

I travelled to Mungele this morning, as usual. Initially nothing seemed out of the ordinary. The staff greeted me with smiles, handshakes, and “bonjour”s, as they do each morning. The niceties, however, were followed by a gruesome and disturbing story. Last night a 4 year old local girl was murdered. The killers used machetes to cut off her arms, legs, and head. They carried away her internal organs and stuffed her disembowelled trunk into a cloth bag. Her remains were discovered 300 meters into the jungle, about 3 kilometers from Mungele. She was an albino.

Albinism is a hereditary disease. Inheritance is autosomal recessive, meaning if a person carries only one abnormal gene they are not affected. A person manifests the disease if they have both genes abnormal, one inherited from each parent. People with albinism lack melanin, the pigment that darkens our skin and protects it from sun damage. Their eyes also lack pigment. In animals with albinism, the blood vessels of the retina show through, making the eyes red. In humans, red eyes are more rarely seen. People with albinism have a higher incidence of problems with visual acuity and other ophthalmologic disorders as well as a higher susceptibility to sun damage. Otherwise they are generally as healthy as those who have normal pigment.
For several years there have been reports of witchcraft-related killings of albinos in Africa. Body parts of albinos are used to make potions, believed to confer wealth on those who ingest them. In late September 2009, three men in Tanzania were convicted and sentenced to hang for the murder of a 14 year old albino boy, his body mutilated by machetes.

As with most horrors, the locals of Mungele are quick to blame “others” for the local girl’s murder. I’ve heard theories of “people from North Kivu” (the next province, 20 kilometers away) and “people from Tanzania.” No one wants to entertain the thought that a local person could be capable of such horror, especially against their own neighbor, yet no strangers have been seen in the area. This is a tiny community and it is difficult to believe an outsider could infiltrate the village and abduct someone without notice. The police from Lubutu are investigating.

A wonderful, varied, and puzzling aspect of life here in Lubutu is the greetings. The Congolese are very polite. When passing me on the street, the vast majority smile and offer both a physical and verbal acknowledgement.

As in most parts of the world, the physical greetings are usually a wave or handshake. The one handed wave is the most common. A special treat is the two handed Congolese wave. Both palms outwards and a broad smile. It’s enthusiastic and welcoming. A few people don’t wave, but it is uncommon. Even this group makes some effort, smiling or nodding their heads instead. The extremely polite are more common; several men have tipped their hats as they pass.

Most physical gestures are coupled with verbal greetings, which are more varied. Most common are “bonjour” (before 1 p.m.), “bon après-midi” (1-2 p.m.) and “bonsoir” (after 2 p.m.). Less often I hear “jambo” (Swahili for “hello”). “Karibu” is nice, meaning “welcome.”

Young children’s verbal greetings are incredibly diverse. By far their most common way to say “hello” is to scream “MONUC!” Puzzling? The Mission de Organisation des Nations Unies en République Démocratique du Congo is the UN Peacekeeping force. It has been in this country for over a decade. In the minds of the local children, all white people logically work for the UN. There must be an assumption that these same white people wish to hear the name of their employer shouted by children, accompanied by jumping, smiling, and waving. It’s cute but strange. Being in an MSF vehicle or wearing MSF t-shirts makes no difference. “MONUC” rules.

Stranger yet are the children screaming “Good MONUC!” This must have originally been “Good morning” and was merged with “MONUC!” The result is an approbation of international peacekeeping interventions shouted by innumerable Congolese kids.

Unlike most places in the world I have travelled, I never hear the word “hello.” This, despite my American accented French betraying my anglophone origins.

Regardlesss of the specific nature of the greeting, it is the culture here to always acknowledge another person as one passes by. As I walk around town, I am continually saying “bonjour”, waving, and nodding. I can’t help but think how shocking it must be for a Congolese person who visits or immigrates to Europe or the US. In these places people rush past one another, sometimes bumping into one another, without any exchange whatsoever. For a Congolese, the silence would be deafening.

My life is very busy these days.  Since Sophie left and Joseph is on vacation, I’m trying to juggle the work of three people.  I’m stressed and very tired.

I arrive at the hospital at 6:30 a.m. having several tasks to attend to before the Centres de Santé can open and function for the day.  I pick up boxes of vaccines stored inside cool boxes, retrieve the newly sterilized materials I deposited the evening before, grab any supplies I have ordered, and jump in the car to start my journey to work..

The first stop is Kalibatete, where I unlock 10 padlocks, drop off supplies or pharmaceuticals, and give instructions to the staff.  The clinic has been very busy the last few weeks and there are usually several patient care or staff issues, all of which I solve at 7:15 a.m.  Then back in the car, off to Mungele.  I arrive between 9 and 9:30 a.m..

The first order of action is to greet the staff with a “bonjour” and handshake.  I have only two to three hours to spend there, so I must organize my time wisely.  I see patients with the Consultants and Sage Femme (midwife), help with immunizations, see babies being born, help take the inventory in the pharmacy, and make long lists of things to do, order, print, or photocopy, once I return to the hospital.  I tell everyone I am returning to Lubutu at noon but it never happens.  Patients needing further evaluation at the hospital are loaded into the car and the engine starts.  Inevitably, a Consultant comes out running with another sick person needing transport to the hospital.  No problem, as that is why we are here.  We drive to their homes to get their personal belongings.  Patients supply their own food and wash their own clothes, so we sometimes have to battle as they attempt to bring more luggage than the vehicle can accommodate.

Finally we’re off!  It’s back to Lubutu, arriving about 2:30 p.m.  I stumble back to Couvent with an aching back, starving for my first full meal of the day.  Breakfast was a cup of bad coffee I drank at eight and a half hours previously.

Lunch, though the biggest meal of the day for the rest of the team, is small for me.  There is often little left to eat after 22 other hungry stomachs have been filled.  It is 3 p.m. and I generally have to attend meetings, to order items essential for both Centres de Santé, or document statistics.  Oh yeah!  Theoretically I am also supposed to pay attention to Kalibatete, the busy urban health center I am responsible for managing.

Unfortunately, due to this shift in my job description, I’ve been neglecting the place, spending between zero and thirty minutes there per day.  After my daily obligatory and rushed evening visit, I return back to the office for more computer work, begging for supplies, and preparing for the next morning, eleven hours away.

With all this work, my mood has been bad the last few weeks.

That was the state of affairs when……enter Eva Goossens.

Eva works for MSF Base in Kinshasa that manages all the Belgian projects in Congo.  We’ve been corresponding by email for several weeks, communicating mostly about training and education needs of the staff.  Fortunately, Eva morphed into my personal management consultant.  During the last two days she has visited both Mungele and Kalibatete, interviewed each staff member privately, and did a group exercise.

Afterwards she and I discussed her findings.  The people at Mungele are happy because I am there every day;  those at Kalibatete feel abandoned.  We talked about this unfortunate situation where there are not enough hours in the day to give the personnel at Kalibatete the attention they need.  Even starting at 6:30 a.m. each day and finishing 12 hours later, I cannot do it all alone.

This new work schedule has been killing me leaving me physically and emotionally exhausted.  Eva then gave me permission—virtually ordered me—to change the situation and especially decrease the travel.  This is a great relief.  With my new schedule, I’ll be able to spend whole days at Kalibatete, more equally splitting my time between the two Centres de Santé.  In addition, Eva helped m recognize that some of the education I have been doing has succeeded, some not.  Yet even the less successful presentations were taking up a huge amount of my “free time” (Saturday nights and Sundays).  No more.  She helped me strategize on how to more effectively focus these educational efforts.

It has been wonderful to have Eva as a distant objective observer.  She has helped me view my job in a new light.  I cannot do it all and must stop trying.  Eva made me realize how I can get so focused on one routine that I fail to realize there are alternatives.  As an outside observer, she helped me “step out of the box”.

I am halfway finished here in Lubutu.  I’ve done some things right, but a few wrong.  Thanks to Eva’s help, I have a second chance.

We all know that women are treated differently than men in this world.  As a man, this usually slips by me unnoticed.  People treat me a certain way so I assume everyone is treated equally.  This morning, however, the difference struck me especially hard.

In order to keep myself from getting too fat, I’ve been exercising.  Once a week I swim at Lac Vert.  The remainder of the time I’ve been running.  Two or three days per week, my alarm rings at 5:45 a.m., just before sunrise.  I pull on a t-shirt, running shorts, and shoes.  By the time I stumble outside, it is light.  The guardians at Couvent sleepily say “Bonjour”, open the gate, and I’m off.

I cross in front of the main church in town and turn left onto a narrow path.  It winds through a neighborhood of square mud houses with leaf roofs and bamboo fences.  I’ve taught the children on the route my name and that I am working with MSF; they scream these words to me, mixed with “bonjour”s and ask how I am feeling.  I run by, wave, smile, and try not to trip on the uneven dirt path.  Finally, I emerge on the road leading to Kindu.  It is dirt and gravel, brick red, and very hilly.

On my way out, there are few people awake and I concentrate on running.  It is hot and humid and feels like New Orleans on a summer’s morning.  Some days the mist is so heavy that I stop to wipe my glasses several times and I return home with wet hair.  Eventually I get to turn around and head home.  By now, the people living on the route are awake and outside.  When I first began running there were a few stares, but that’s now stopped.  People appear to have grown accustomed to the early morning sighting of a sweating, panting American trying to avoid middle aged spread. The trip home is filled with smiling, waving, and saying “bonjour.”

Two weeks ago another American joined the ex-pat team in Lubutu.  Terra is a family practice doctor and works in the hospital.  She’s forty, fun, and fit.  Terra has been joining me on my runs and I love her company.  We talk about our lives while trying to avoid brakeless bicycles hurtling down the steep hills.  Terra is a good looking woman and in great physical condition.  When I began exercising with her, my run changed.  At first I couldn’t pinpoint the origin of this difference, other than I had someone to talk to.  Now, in retrospect, I realize I wasn’t hearing as many “bonjour”s.

I didn’t figure it out why until this morning.  We had a new arrival to the team yesterday.  Jana, a Norwegian anaesthetist, joined the team.  Like Terra she is good looking and physically fit.  This morning Jana joined us on our jog out Axe Kindu.  On the way home I ran a few meters behind the two of them.  Compared to my previous runs, all was quiet.  The three of us hardly got any “bonjour”s, waves or smiles.  Why?  Everyone was silently staring.  One woman running with me had provoked a few stares and closed a few mouths.  But with two women the route was silent.  Men, women, and children stared as we wound our way home.

This got me thinking about the different ways men and women are treated.  In general we are lucky to be expatriates.  As white men and women, we are seen first as Mzungus (white skinned) and second as men or women.  Both white men and women are subject to a combination of respect, puzzlement, curiosity, and derision.  But white women are treated differently than men.  If I had run with two white men this morning I doubt we would have provoked the same silent stares.

Women have it worse.  I walk down the street alone and people smile and say “bonjour.”  A woman walking down the same street, navigating through the same crowd of friendly faces, often encounters stares and unwelcome advances.

When we got home from our run, Terra and I discussed this.  She told me a story that reinforced the point.  Two years ago she was working in a small town in Peru and went to eat at a local restaurant.  She sat down and ordered.  A few minutes later she realized the remaining clientele had stopped eating.  They were staring at her, the lone female alien.  They watched as if at a sporting event until she was served, quickly ate her meal, and left.  Would I have provoked the same reaction?

Sure this is true in Peru, but such a thing would never happen in “civilized” America right?  Right.  Think about when a man is seen eating alone in a nice restaurant.  Most people assume he is on a business trip.  Now think about a woman of the same age, eating alone in the same restaurant. Is the first thing that comes to mind a business trip?  Probably not.  Questions arise.  Why is she alone?  Why couldn’t she get a date? Perhaps she even evokes pity.

Here in Lubutu, despite their strangeness, female foreigners are actually treated with greater respect than women in the general population.  They’re foreign and special. They’re “not really women,” partially exempting from the notion of what is or is not appropriate.  This makes me wonder what kind of inequalities a Congolese woman encounters.  Undoubtedly, many more than silent stares along the road to Kindu.

My work life has changed dramatically in the last week.

My department is SSP (Soins de Santé Primarie, or Primary Care), the first line of patient care. SSP works through the Centres de Santé, improving access to the hospital, and through sensibilization (health promotion and education).

The head of our department is Sophie. She is Swedish and stereotypically so. Ever been to Sweden? Everything in our office is clean, absolutely on time (in a country where very little is ever on time), and efficient (in a place where everything is inefficient). She is strict and demands excellence. Not a bad boss in my book. In real life, Sophie is an Intensive Care nurse. She departs a week from today. I’ll be sad to see her go.

Working side by side with Sophie is Alphonsine. She is being groomed to eventually take over Sophie’s position. Together they are responsible for all of the Centres de Santé in the Lubutu health district, the sixteen run by the government and the two run by MSF.

Except the two run by MSF are my turf.

Sophie and Alphonsine go out to all of the government-run Centres de Santé and offer advice to their Consultants. They encourage the government-run clinics to refer patients to the hospital in Lubutu. They are also in charge of a huge team of sensibilateurs (pronounced sahn-see-beel-ah-tour, they are health educators) who daily disperse across the four main roads leading out of Lubutu. Sophie and Alphonsine help choose the educational topics. Recently we had an outbreak of monkey pox caused by eating undercooked simians. Thus recent messages have included tips on cultural preparation of monkeys. The gamut of topics is wide- basic hygiene, need for immunization, or contraception and family planning. This work is very important here where the level of health knowledge in the general population is low.

Me, I am in charge of the two MSF-run Centres de Santé, Kalibatete and Mungele. Analogous to Sophie’s relationship with Alphonsine, I have Joseph Nyembo, a Congolese person working side by side with me. Only Joseph and I don’t work together; we work in parallel. If I’m at Kalibatete, he is at Mungele, and vice-versa. This arrangement has been disappointing for both of us. I can’t train Joseph to do my job as we never work together. We have to have one of us in both places each day. It’s a challenge. With my time remaining, our geographical separation must change. Neither MSF nor I will be here forever and Joseph needs to learn how to manage a Centre de Santé.

The first two months I was here, I worked exclusively to improve the quality of care being given by everyone at Mungele and Kalibatete — the Consultants, the midwife, the people doing bandages and suturing, the staff taking vital signs and registering people, the guardians and the cleaning ladies. I have talked to and worked with them all. In addition I learned some administrative tasks ranging from management of the pharmacy to gathering and calculating statistics. I learned how to beg other departments to mend roofs, make photocopies, supply us with soap, or a myriad of other tasks necessary to keep the doors open.

October has been a shocker. Joseph is on vacation for the entire month. Sophie departs in seven days. Since the first of the month my work has transformed from 95% clinical to 95% administrative. I’m hardly seeing patients anymore. As a change, I suppose I don’t mind being an administrator. If I wasn’t here who would be crazed enough to run his butt off travelling daily between Mungele and Kalibatete, writing lectures and other teaching lessons, and begging for cleaning supplies? I volunteered knowing I would do some administrative work, just not quite this much.

Joseph will be back on November 1st. Why does October have to have thirty-one days?

Have you ever had a place that is very special to you, where you feel you could spend hours and hours and perhaps forever? I know it is silly, but a tiny little lake just outside Lubutu is becoming my weekly psychotherapy session.

Lac vert

The worst thing about having my elbow torn up is that I haven’t been able to go to Lac Vert. When you think of volunteering to do overseas medical work, the natural questions are about the nature of the work. What exactly will I be doing? What is the population like? What is the security situation? Another very important question is how you will be spending free time. Can you go running or take long walks?

When I arrived in Brussels for my briefings, I was delighted hearing that we could go running and take long hikes. They also mentioned that there was access to a small lake near to Lubutu. Each weekend, the group takes a car to Lac Vert for swimming, communing with nature, and just to get away from it all. When I ripped up my elbow, my inability to go swimming was my worst restriction. I couldn’t eat well (had to hold the fork with my left hand), had to shower with one hand (sounds easy but just try it), and would get severe twinges of pain. But the worst of it all was that until everything was healed I couldn’t join the group to go to the lake.

Today, after thirty-four days of healing, I returned.

The trip out from Lubutu is twenty minutes of highway. The vehicle turns onto a jungle track and the real ride begins. Forty minutes of being thrown around the vehicle, traversing the worst driveable path I have ever seen. All the windows must be closed as the jungle is so thick that any open window shears off plants and their accompanying insects. The truck is an oven by the time we reach the lake, but it is all worth it.

The Green Lake is small and surrounded by dense jungle, just like everything else around here. The banks are lined with ferns. The only animals we see are birds. Two ducks live on the lake. They are small russet shaped birds, six inches in length, and unafraid. During the three hours we spend in the water, they swim with us, coming a meter away. Occasionally a hornbill flies over. When these huge birds fly their beating wings sound like slowly turning helicopter blades. There is the sound of frogs and insects, but nothing else. No traffic, no people.

After the swim

When we arrive, the first thing I do is get some exercise in, swimming back and forth across the lake. Having fulfilled my exercise quota, I dog paddle, side stroke, and elementary backstroke around the perimeter, trying to see if this week one of the ducks will let me touch it. After I get out, someone has always brought along a carefully hoarded snack, something delicious from Belgium or France to share.

Dried off, it’s back to Couvent, the hospital, Lubutu, and real life. It’s OK, though. I got to visit this little bit of heaven and will daydream about it until next Sunday.

What is it about teaching that is so irresistible?

One of the reasons I was recruited to the Lubutu project is that I have experience with teaching medical professionals.  When I lived in New Orleans, I taught pediatric residents from Tulane University.  I found the experience rewarding but exhausting.  The fatigue was primarily my fault, as I taught a one month course over and over.  By the time I got good and burned out, I had taught the same two dozen lessons about sixty times.  Not smart.

I took a few years off from teaching but was eventually ready to dive back in.  In 2007 I taught a one month course in pediatric neurology at Queen Elizabeth Central Hospital in Blantyre, Malawi.  I took my old Tulane lesson plans and changed them to fit the context.  With the topic of Acute Flaccid Paralysis, I added a large section on polio, something not needed when I discussed the topic in New Orleans.  Malawi was my introduction to tropical medicine.

When I sent my resumé to MSF, I emphasized my teaching experiences.  The recruiter told me that this was one reason I was placed in Lubutu.  There is a log of formation going on here. Formation (fohr-mah-syohn, accent on the final syllable) can be loosely translated as “teaching” but involves much more.  It means to mold or form someone into someone else by imparting knowledge.

The goal of many non-governmental organization projects is to teach local (in this case, Congolese) staff.  In Lubutu we are teaching them the work necessary to run both primary care (the Centres de Santé) and referral health facilities (the hospital).  We do this through a series of formations and working side by side.  I have three main targets of my teaching- the Consultants, a mid-wife, and a supervisor-trainee.

The Consultants have attended a four year course in the diagnosis and treatment of disease.    There are six of them- two at Mungele and four at Kalibatete.

When my ex-pat predecessor was here, only Mungele was open, so he concentrated all his efforts there.  In general, the results have been good.  The Mungele Consultants are both intelligent and can follow the MSF primary care protocols.

At Kalibatete, three of the four consultants are ex-hospital employees.  They have worked for MSF for years.  I enjoy spending time with the three of them.  We share interesting cases and discuss treatment options.  They have all the protocols memorized.  The fourth consultant was recruited from outside the MSF system.  She worked for many years in government-run Centres de Santé before getting the job with MSF in Lubutu.

When I arrived, Soki was challenging.  Her book knowledge was excellent.  When I asked her the signs of tuberculosis, she could recite all eight.  But she was terribly disorganized.  In English-speaking medicine, we write SOAP notes.  This stands for Subjective (what the patient tells you, the history), Objective (the physical exam and any laboratory tests), Assessment (the differential diagnosis- what are the possibilities here?) and Plan (therapy, including prescriptions).  One learns to write SOAP notes early in medical school.  Soki never learned this organization.  Her physical exam skills were excellent in some areas (abdomen, pelvic exam) and poor in others.  Her biggest challenge was thinking about the history and physical examination together and coming up with possible diagnoses.  Initially , diagnosis and treatment were reflexive.  Patients who complained of pain in the upper abdomen immediately received a prescription for antacids.  No further questions (“what makes it worse?”) and no physical exam.  Chief complaint led to prescription.

I have spent dozens of hours working with Soki and she has dramatically improved.  Patients now get a complete history and physical examination.  She can follow the protocols we use in the Centres de Santé—everything from a cold to measles to whopping cough.  She knows when she is beyond her limits of knowledge and needs help some someone with more experience.

Aside from the six Consultants, I also teach Kenimbe, the mid-wife at Mungele.  My predecessor in this position made sure that Kenimbe received lots of instruction in the MSF systems of prenatal and postnatal care as well as childbirth.  Kenimbe is thrilled to have an ambulance to summon in case of a difficult delivery.  Most of my formation with Kenimbe has been on family planning and care of pregnant women.

Of all the formations with which I am charged that of my assistant, the supervisor-trainee, has been the least successful.  Part of this is structural.  There are two Centres de Santé for the two of us to supervise.  We are rarely in the same physical space.  Joseph is being groomed to take my position when I leave.  We have a lot of work to do.

Today, a new phase of my formation of the staff began.  Every other week I am doing formal presentations on a selected clinical topic.  This week schistosomiasis, next is family planning, after that typhoid fever.  Preparing the lectures is a huge amount of work.  I have to make a PowerPoint presentation (printed out as there is no electricity at the Centres de Santé), handouts, and a pre-test and post-test.  Three weeks ago I sent all of this off to Kinshasa for approval, received their suggestions two days ago(!), and did the first presentation today.  It went great.  As usual, part was through I ran into a verbal wall.  I did not know the verb “to hatch.” We had a momentary diversion while I described chicks leaving eggs.  I was rewarded with “éclore”, the answer to my word search.

The educational level of my audience was a change for me.  In the past I have usually taught physicians.  The original PowerPoint presentation I created was inappropriately technical.  Fortunately, the people in Kinshasa reformatted my slides.  They added graphics and eliminated some complex wording.  All the participants succeeded, with scores on the post-test perfect or nearly so.  Afterwards we had a long discussion about schistosomiasis and public health, out of the boundaries of the lecture.  They learned and then thought about the implications of this new information for their patients.

So why do I think that teaching is wonderful?  Personally I love the moment when a student has an imaginary light bulb illuminated above their head.  They’ve had information crammed into their brain.  At an AH HA! moment it all comes together. They can think.

Ever have a day that just sucks?

It started before dawn.  Last night was sleepless.  Was it the handful of milk chocolate covered espresso beans I ate at 7 p.m.?  Or that it is 80 humid degrees at night and for the last two weeks I have not stopped sweating?  Or possibly the conversation outside my window at 11 p.m. extolling the virtues of a particular brand of dried Belgian sausage?  I have to be at work at 7 a.m..  Since the world was conspiring against me and sleep was clearly not going to happen naturally, I did what any sane person would have and took a pill.  Benadryl twenty-five milligrams.  Just a mild sleep inducer.  No big deal.

It worked.  I slept well but when Couvent’s workers began noisily cleaning the dining room at quarter till six in the morning, I was not happy.  With a Benadryl hangover—mouth like Arizona and vision unable to focus—I stumbled into the bathroom, washed my face with cold water and dressed.  I poured a cup of coffee and again wondered why. We are not far from Rwanda, where some of the best coffee beans in the world are grown.  Why must I drink bitter lousy coffee to rouse myself from this hangover?  I would happily trade the four kilograms of Belgian chocolate in the refrigerator right now for one Starbucks latte.

That settled, it was off for my 3 minute 24 second commute to the hospital.  The day loomed especially loathsome.  It was evaluation day at Mungele.  I have no problem with evaluating people, but the MSF forms are extremely long and involved.  I was still only fuzzily awake and couldn’t yet focus on the written word.  Though important, the process is painful for everyone.  The person being evaluated fills out a section about their job, usually copied verbatim from their Profil de Poste.  This very detailed document describes work duties and responsibilities, for each position in the organization.  Employees are expected to comply with each word of their Profil.  After I read aloud what the employee has written about their job duties, we get into the nitty-gritty.  This is a discussion of several aspects of the job, like Autonomy and Accepting Responsibility.  As an evaluator, I chat with the employee, come up with a quasi-mutually agreeable grade, and write everything down. It is a thorough evaluation and each one takes at least an hour.  Since I had six evaluations, I had six straight hours of going over the same forms glowing in the distance.  And my vision was so blurry I couldn’t read anything.

But I’m way ahead of myself.

Almost exactly three and a half minutes after leaving Couvent, I arrived at the hospital to find I had no transportation to Mungele.  The logistics/ transportation people know the SSP (Soins de Santé Primaire—Primary Care) team needs a car for Mungele each day.  Once every two weeks, for some reason it does not happen.  A 7 a.m. departure time sometimes happens much later, once a vehicle is found.  I have learned that the best way to resolve this problem is to walk into the Radio/Transportation Room and demand that they do their job so that I can do my job.  It wasn’t actually as bad as usual, and we were off by 7 25 for the standard trip to Mungele.  I still wave at kids and look at the incredibly green jungle, but mostly I use this time to read.  As the Benadryl was lingering and my vision was still nuts, I held The Devil Wears Prada six inches from my nose, laughing like a maniac as the driver took me safely to EvaluationLand.

Mungele!  Finally it could begin.  But first I needed to get out of the truck and rip open my right elbow.  You remember my right elbow?  The one with the 5 inch gash from last month?  The one that had twelve stitches, a surgical drain, and eighteen dressing changes?  The one that finally healed two days ago?

I suppose the newly grown skin was thin and fragile.  I bumped it or scraped it and off it came.  Blood dripping down my arm I walked into the clinic for a wound dressing.  I sat down and felt like crying.   Only last night I was talking to someone about how much I was looking forward to returning to swimming at Lac Vert this weekend.  For the last four Sundays I have patiently waved to the group as they depart to this little piece of heaven.  Finally my elbow had healed and I could join the group on Sunday!  Only now I couldn’t because there was no skin left and it was bleeding like crazy.

Bandaged up, I plowed through the evaluations and survived.  The exploits of Miranda Priestly entertained me on the drive back to Lubutu.  I felt like I could be that mean today, no problem.

One unmemorable lunch later, I walked to the hospital to start the task of typing the evaluations into the computer.  At 32 minutes each, it only took a little over three hours.  Finally at 6 p.m. I turned the computer off and headed for home.  On my way out, I was told that next week I get to do evaluations at Kalibatete, where there are twice as many employees.  Yippee.

Dinner, beer, chocolate- my Holy Trinity tonight.  I lay in bed writing and am listening to the humongous anvil-headed fruit bats make incredibly loud mating cries.  You know the lovely relaxing sound of frogs?  I’m hearing that, too.  Just add a second layer or deeper, louder, and longer fruit bats into the mix.  In Lubutu, nature is really loud.

I suppose one has to have days like this to appreciate the good things in life.  Honestly, I can deal with the lousy coffee, begging for transportation, evaluating people, and the Benadryl-hangover lack of vision.  But my elbow?  I have to go through a day like this and then get to feel my elbow seep bodily fluids into the sheets all night?  It’s looking that way, Tonto.