R U N D R C

Thursday is Thanksgiving and it is looking like it will be quite a celebration here in Lubutu. Although every European living at Couvent is anxious to eat a traditional American Thanksgiving dinner, it looks unlikely to happen. Rather than think about what I might prepare (or, rather, have the cooks prepare) I have been making a list of the foods unavailable here, but necessary to prepare the traditional meal.

First is turkey. A fellow expatriate swore that last week they saw one “somewhere down by the river.” After the sighting, I took several walks down to the river, approaching it from all known directions. I have talked to everyone I saw, drew a picture of a turkey (as no one knew what I was talking about), and been met only with amused puzzlement.

Even if we could delude ourselves into thinking that one of the scrawny chickens here was a turkey, nothing else is available either. Stuffing? Yes, there is white bread but no sage, pecans, or celery. Cranberries do not exist and neither do oranges. No sweet potatoes or yams, brown sugar, or marshmallows. No one has ever seen a pumpkin and none of the spices are available anyway. Yesterday I described the fabrication of gravy to the kitchen staff. In return they traded glances that subliminally said, “does he really want us to mix fat and flour together, whisking constantly over a low to medium heat, then slowly add preheated turkey stock (what is a turkey anyway?), continuing to whisk so as not to form lumps? Does anyone actually bother to do this and would anyone eat the results?”

So I think the gravy is out, too.

That leaves mashed potatoes. We have those here in Lubutu. We have them twice per day, every day, in fact. There is no milk or cream or butter to make them palatable, but we have plain mashed potatoes. From what I can tell, my Thanksgiving dinner is likely to be a huge pile of mashed potatoes covered with the ubiquitous Couvent tomato sauce.

Even though lacking in the culinary side of the holiday, I am still thankful for much in my life. I’m thankful to be healthy and able to improve the health of others. I’m thankful for my privileged background and the opportunities this life has afforded me. I’m thankful that I have known love, forgiveness, and friendship. And I am thankful to be here in Lubutu.

Thanks for reading and Happy Thanksgiving!

Today for something completely different I stepped out of my shell and went up Axe Maiko on the back of a motorcycle.  I’m glad I did it but I will never do it again.

Lying in the four cardinal directions are four major roads leading away from Lubutu.  These are named “Axe” followed by what lies at the other end.  I have extensively explored Axes Kindu (dirt, my running route and the way to the cascades), Kisangani (paved, the road to the second largest city in Congo), and Walikale (paved, the road to Mungele’s clinic).  Axe Maiko is the road leading straight north and ends at a huge national park.  It is really nothing more than a path, not a road.  Its rolling hills lead through thick jungle with each shallow valley containing a small creek.  Four or five tree trunks haphazardly thrown across these waterways serve as makeshift bridges.  The route is extremely rough, impassable by even 4 wheel drive truck.  Four times per month, two people from SSP (Soins de Santé Primaire, my department) ascend Axe Maiko on the back of motorcycles.  MSF has professional motorcycle drivers who take medical staff and health educators to areas unreachable by the normal MSF Toyota Landcruiser.  Today it was my turn to brave the journey.

Photo: D Postels | Motorcycle crossing

But there was one other small complication.  Friday is Eid el Kebir, a major Muslim holiday.  On this day, Muslims ritually slaughter a goat in honor of Abraham’s obedient willingness to sacrifice his son Isaac, though a goat was substituted at the last minute. After slaughtering the animal, they cook it, eat a tiny bit, then distribute the remainder to those less fortunate.  Thus, in places with sizable Muslim populations, goats are in short supply this time of year.  Lubutu’s Muslim population is not huge, but big enough to make live goats unavailable in town.  Three of the expatriates living in Couvent are Muslim and wanted to share in the festivities.  So they asked me if I would bring back a live goat from Axe Maiko on the back of my motorcycle.  Sure, no problem.

At 7 a.m. this morning, the two motorcycle driver, my SSP co-worker, and I left for the two closest Centres de Santé.  We were doing nutritional screening and follow-up, measuring and weighing children while giving their parents advice about feeding them.  The 32 kilometer (20 mile) trip (one way)  lasted 3 hours.  I was outfitted in big white rubber boots and knee, shin, elbow, and forearm guards.  The boots were crucial as several times I was forced to get off the motorcycle and walk through deep mud, through streams, or across logs.  The professional driver proceeded through the difficult sections alone, the wheels of the motorbike often sinking in the mud above their axles.

Photo: D Postels | Motorcycles

Finally, after one hundred eighty minutes of bone jarring, butt shattering, yet scenically beautiful ride, we arrived at Centre de Santé Mundo.  After weighing and measuring the children, we sang songs about nutrition, distributed handouts to the parents about constructing balanced diets using local foods, and gave hints about food hygiene.

Meanwhile the two drivers found and negotiated the purchase of a goat.  They piled the radio, first aid kit, my backpack, and a mysterious nylon sack on the back of one motorcycle.  On the other they constructed a bamboo frame that held one furtively bleating male goat.

A goat’s cry sounds like a woman screaming.  Our goat in particular was not excited about being strapped onto a wooden frame on the back of a motorcycle and his cries were especially loud.

To complicate matters further, a half hour into the return trip, the wind picked up, the sky darkened, and we heard thunder.  Shortly thereafter, the skies opened with rain.  We sought refuge in someone’s home (people don’t hesitate to invite strangers into their homes here), opened the mysterious nylon bag, and pulled out four yellow rain suits.  Perfect, I thought!  Perfect except for a very agitated goat.  Goats apparently hate to get wet, especially when tied down on the back of motorcycles.  He began protesting wildly, crying continuously and kicking.  And we were only two and a half hours from home.

At the halfway point, we stopped at Centre de Santé Twabinga and did more nutritional follow-up.  By this time I was lame with stiff painful legs, sore muscles, and an aching back and butt.

At 5 p.m. we arrived at the hospital covered in mud and sweat.  I led the goat to the Couvent on an improvised leash.  Both of us were trembling, me from muscle fatigue and him from Post Motorcycle Stress Disorder.

All in all, it was an experience that, in hindsight, I’m glad I did despite the challenges.  I wouldn’t mind doing it again, but next time……..  I’ll go goatless.

I woke up late this Sunday morning, brushed aside the mosquito net and swung my bare feet on the warm cement floor. Stumbling into the dining room, my eyes opened wide at a much welcome sight. René, a Belgian surgeon, sat at one end of the long dining table, an open can of French foie gras before him. Fortunately he was willing to share his little piece of culinary heaven with me. We both ate so much that we left the table contented and ill. During our breakfast conversation I had heard loud noises coming from the kitchen. Jana and Remo, German expatriates, were making coffee cake. Brushing aside any thoughts of satiety, I dug in. It was delicious. Finally free, I waddled out to the terrace where Maria poured me a tiny cup of ultra-strong Lebanese coffee.

As expatriates in Lubutu we eat very well, but the food is not varied. Breakfast is bread, butter, and jam, along with coffee or tea. The bread is tasteless and has the shape of a slightly elongated hot dog bun.

Photo: D Postels | Buffet lunch

Lunch is at 1 p.m. and is the largest meal of the day. It is served as a buffet on a side board in the dining room. Several identical, covered serving dishes hold the food which varies little from day to day. The buffet starts with rice, potatoes (mashed and boiled) and badly overcooked pasta. Next are vegetables, usually one raw (sliced peeled cucumbers or whole cherry tomatoes) and two cooked. Spinach is a constant and the second is always poured directly from a can, usually corn or green beans. We always have two meats. The most likely is pork cut into little chunks prepared grilled or in a bland oily sauce. Chicken sometimes appears, but into pieces and floating in a mysterious brick red sauce. Once every 2 weeks there is terribly smelly fish that forces me to eat on the terrace. The cooks deep fry plantain slices to eat as slightly sweet chips. Dessert is usually pineapple chunks. Someone drags out a few bars of Belgian or French chocolate out of the refrigerator, breaks it into chunks, and we argue the merits of one brand over another.

Dinner is mostly lunch leftovers but often the cooks prepare two plain roasted chickens (plucked next door in the kitchen- watch out for feathers!) and either bread, pizza, or quiche. The last two are a bit different from what I am accustomed. The staff uses the same dough as to prepare bread, but they allow it to rise in the pizza or quiche pan before baking. The result is a delicious thin topping sitting atop a one inch thick crust, occasionally raw in the center. Pizza toppings are corn, tuna, chicken (with bones) or canned slimy mushrooms. The quiche is always leek.

It sounds delicious, right? It is but it is also repetitive. The staff who cook our food appear to have no knowledge of spices or variety. The spinach is prepared exactly teh same way each day. There are dozens of bulbs of garlic in the pantry, all unpeeled and rotten.

Photo : D Postels

Condiments have saved me. I slather virtually everything in either ketchup or Bertolli pesto. I do have one special treat I look forward to each day. Remember those deep fried plantain chips? I put several on a plate and microwave until they are viciously hot. I dip a fork into a jar of Nutella and apply the black paste onto the steaming chips. After a minute, this perfect combination is cool enough to eat. People here make fun of me because I eat this every day and am clearly in ecstasy with every bite.

On Sunday the kitchen staff departs at 1 p.m., leaving the afternoon for the expatriates to get creative in the kitchen. A few weeks ago I made Chicago-style stuffed spinach pizza which was a great hit. Other have created Javanese curries, Belgian rice pudding, French eclairs, and Algerian grilled chicken — all delicious. Today started with foie gras and German coffee cake. I wonder what’s for dinner?

This morning I was running around the hospital doing my usual morning preparations. Passing by the Pediatric Ward I saw a striking little boy. He waved and said “bonjour” like the other children. But he was wearing a necklace and wore a homemade crown. I stopped and took his picture and told him that today he was the King of Pediatrics.

Photo: D Postels | King for a Day

The MSF hospital in Lubutu is likely one of the best in the Democratic Republic of Congo. It is a Hôpital Générale de Référence, a place where sicker patients can be referred from their primary care Centres de Santé. In the West, a general community hospital would be the closest equivalent. Most of the wards are the same—Internal Medicine, Pediatrics, Maternity, and Surgery. In addition, this hospital also has a cholera ward and isolation rooms for viral hemorrhagic fevers, like Ebola.

The patient experience is different than in the West. When hospitalized, patients are assigned to a metal bed with a plastic mattress, a single sheet, and an overhanging mosquito net. Almost everyone (including adults) has an accompaniant—a family member or relative who stays with them, does their laundry, cooks their food, and helps with care. All medical care is free of charge. That is a good thing because patients are in the hospital for a very long time.

Those who have encountered hospital care in the West know about Length of Stay. In the US, the government has determined the number of hospital days necessary to care for someone with nearly every medical diagnosis. Private insurance companies follow these anticipated Length of Stay rules. These rules have shortened in my medical career. For example, when I was in training, a woman giving birth stayed in the hospital for two or three nights. Now it is one night.

If a patient remains in the hospital longer than the anticipated Length of Stay, the physician must justify the patient’s continued hospitalization to the government (Medicare and Medicaid) or the insurance company. Several times I have had to speak to someone at an insurance company daily in order to keep a sick child in the hospital.

There aren’t any Length of Stay rules here in Lubutu. Patients are hospitalized for much longer than in the US or Europe. Why? There are several possibilities.

Perhaps here in Lubutu, by the time patients get to the hospital they are sicker than people in the West. Maybe the diseases are at a more advanced state before patients go to their neighbourhood Centre de Santé. Likely more important is the lack of follow-up for patients discharged from the hospital. At home, if a patient has severe pneumonia, they might be treated with intravenous antibiotics and oxygen for a few days, then switched to oral medicines. One day later they go home with a follow-up appointment with their primary care physician. The entire structure of having one’s own health care provider is missing here. If someone is discharged from the Lubutu hospital remaining even slightly ill and told to see their neighbourhood Centre de Santé in follow-up the next day, it is very unlikely to go well. The patient likely has either no (or incomplete) medical records with them. They Consultant they see may not know them. There is no mechanism where the Consultant can contact someone at the hospital to see what occurred. Consequently, patients must remain in the hospital until they are 100 percent cured and back to normal. This makes for long hospitalizations.

Yesterday one of the expatriates decided to do some play therapy in the Pediatric Ward. She came bearing string, white packing peanuts from discarded boxes, and circles cut from colored paper. She and the children made necklaces, bracelets, and crowns. The King of Pediatrics was born.

Sunday morning. It had been 3½ months since I left the US and I badly needed a haircut. Where does one get this done in Lubutu? Sure there are barber shops and salons de beauté here, but I doubt anyone has much experience cutting thin, straight, blondish hair. Fortunately, Dominique Beels, a Belgian expatriate, assured me she is an expert in this area. She practiced cutting hair on her three brothers over the last several years and she is willing to help me, too.

So at 11 a.m., in the Equatorial sun, I sat outside in the back yard of Couvent wearing only a bathing suit. Dominique came bearing scissors and a comb, apologizing before she even began. At the first snip a big hunk of hair fell to the ground. No turning back! Thank goodness Dominique was able and willing to do this, as I would be doing the cutting myself if she were not. Still, I miss my regular barber and the chat we have every 6 weeks.

I like to think of myself as an adaptable person. I’ve travelled extensively, one time for a year continuously. I’ve never before felt the need to be homesick, but this time it is a little different. There are several things I miss about my life at home.

First, of course, is Kurt. I miss him terribly. He is my best friend and spouse. I miss talking and laughing with him. I even miss our “discussions.” He’s a classical musician and I love attending performance where he is playing. I miss our talking about classical music and learning an evening’s program before he plays it.

Living in a group is difficult. I miss my lovely home and the privacy of its walls. In Albuquerque, I can shut the doors and curtains and all is quiet. No one bothers me. I can sit outside on the back porch and no one wants to talk or hear about my day. I can eat in peace. Living in Couvent, it is difficult to ever be alone. Even with my bedroom door and the window shut, noises intrude.

Concretely, there are several things I crave—ice cream, seeing a film in a movie theatre, yogurt, good coffee, walking and playing with our dogs, Indian food, frozen margaritas, garlic, good fresh fruit. None of these things are here.

After an hour in the blazing Congo sun, my haircut was almost complete. As Dominique cut away, I talked to her about all the things I missed while living here in Lubutu. She told me her own story. After a few months here, she scheduled a vacation in Belgium. Before leaving Congo, she swore she would eat ice cream every day once she got to Europe. She was home for 10 days and guess what? She ate it once. We all crave what we can’t have, right?

I’m all grown up and I’ll be fine but a chocolate sundae with a frozen margarita on the side would be perfect right now.