Kigutu Reflections. . .

Yungaburra, Far North Queensland, Australia

The rain is pounding on the tin roof of our verandah here on the Atherton Tablelands, so welcome after a long, record breaking dry season. I listen to the inebriated chatter of the rainbow lorikeets as they feast on the nectar from the flowering black bean trees and watch the mists waft through in the valley below. A kookaburra hangs out in the bright red flame tree, so spectacular this time of year. He’s been waiting for a handout, coming to sit on the railing when Robert brings out a bit of fish for him. My jet lag haze laps at my psyche as I recover from the globe trotting marathon…I figure that I had 40 hours of time-in-the-planes since I left Bujumbura. My carbon footprint this week extends like deep mud around my knees, but nevertheless it is wonderful to be back in Australia after an 11 month hiatus.

My last week in Kigutu was full to the brim. According to Melino, the week was a record breaker in terms of number of patients seen... 321, compounded by the arrival of 363 local children under five coming in for polio vaccinations. The staffing was down too. Maneno was in Buj for a week of computer training, Orestine was off with a sick child and Sincerite on paternity leave. It felt good to be an integral part of the team; helping with triage, tending to patients in the ward (including a 2 year old with an infected uluva after he’d been taken to a traditional healer for a uluvaectomy, a commonly practiced procedure by traditional healers), helping with procedures, working in the pharmacy with Hilarie and caring for two newly admitted malnourished children (one quintessentially a marasmus case and the other quintessentially kwashiorkor). Marasmus is a form of malnutrition characterized by muscle wasting and loss of subcutaneous fat. Kwashiorkor is characterised by edema as a result of protein deficiency.

Felicia Price RN, the in-country director in Burundi for the Clinton Foundation, visited Kigutu for the week and it was great to glean more knowledge about malnutrition management from her. A few emergency cases arrived via stretcher too just to keep everyone on their toes, including a woman in labor who delivered precipitously in the hallway about 30 seconds after arrival! Never a dull moment. . .

A highlight of the week was a full in-costume performance of the local Kigutu drummers (including staff members Peter and Mandela) down on the small plateau by the farm with Lake Tanganyika as a backdrop. They are hoping to launch themselves on to wider horizons and use their drumming, song and dance as a means of health promotion. How terrific it would be to have this dream become a reality. Alex Goodell, computer whiz extraordinaire from Oregon, who has come to VHW to for a 6 month volunteer stint has edited some footage of their fantastic performance and has posted it on YouTube. Check it out at: http://www.youtube.com/watch?v=1m-2QP1x1hY

On Saturday, the day before my departure, I had the opportunity to walk down the road with community members (accompanied by army personnel as back up) to observe the community forces in action clearing the roadside where the ambush on the VHW vehicle occurred which resulted in Claude’s murder on July, 13, 2009. It is hard to fathom the horror and terror experienced by the staff that morning. You can read Tracy Kidder’s Opinion piece in the New York Times which reflects upon the events of that day at: http://www.nytimes.com/2009/07/22/opinion/22kidder.html

I was urged by the men to borrow a machete and spent a few minutes hacking at the brush which was obviously an attempt to symbolize solidarity, rather than to utilize muzungu muscle power. Nevertheless, I felt privileged to be part of their group and feel their spirit.

It’s amazing that it has been a week since I said my goodbyes in Kigutu and headed down the mountain to the airport in Bujumbura. My anticipated departure that evening was thwarted by a bird having been sucked into the plane’s engine in Belgium which dominoed to a 24 hour delay for me in Buj. I was able to use the extra day to catch my breath and reflect on my time in Kigutu. Also to write my epic report while sipping cappuccino and checking the internet on the wireless connections in the Buj “hotspots”; meet Alex; have a chance to debrief with Dziwe, and finally have a quick swirl through the local market with Peter and Prime before flying out to Nairobi, then Brussels and on to New York.

During my 24 hour stopover in New York, I loved having the opportunity to speak at an informal lunchtime gathering of employees from the TB Alliance www.tballiance.org , a not-for-profit development partnership accelerating the discovery and development of new tuberculosis drugs. I gave a short presentation about Village Health Works and how TB is dealt with out of “the Wall Street bubble” (as described by an employee). It was quite the contrast to be amongst the throngs walking down Wall Street after being in Kigutu watching the amazing sunset over Lake Tanganyika just 48 hours earlier. I felt as though I was the only one in New York NOT wearing a black coat!!

With this first stint in Kigutu, I think I have achieved my overall goal to become familiar with many aspects the VHW programme and establish a solid working rapport with the staff. More specifically, to assist the nursing staff, the community health workers, get the malnutrition ward more established and acquire a general appreciation of Burundi’s culture and its people. Though there is ALWAYS SO MUCH MORE to learn and knowledge to gain, I feel I have laid a good foundation in terms of achieving these general and specific goals. My learning curve continues from this experience in providing primary care, learning more about the realm of public health in a developing country and working with the local people.

Besides recharging my battery, during my ten weeks in Australia, I hope to procure some much needed items to bring back, practice my French and attempt to learn a bit more Kirundi. I am eager to return to Kigutu in mid January and see all the new developments and reunite with the tremendous staff, hoping that this trip to Kigutu will be the first of many to come.

Helen

Helen back on the verandah in Australia

Feeding marasmus baby

Felicia with baby born in hallway


Kwashiorkor baby


Kigutu kids collecting firewood


Kigutu kids playing in mud


Clearing roadside with community crew


HWW with army personnel


Dramatic weather and verdant hills


Mandela and Melino


Kigutu drummers


Alex and Dziwe cranking out in cyberspace


Helen at Buj Airport


Amazing sunset from Kigutu

Fingers Crossed. . .

Robert here, this came in last night:
"Heading to the airport shortly. Fingers crossed no glitches. . ."

After a 24 hour flight delay (due to a bird apparently being sucked into one of the plane's engines in Brussels. . .) Helen's departure from Burundi appears to be back on track. At last report she was scheduled to depart Bujumbura at 9:00 PM Monday.

She hopes to be in NYC Tuesday afternoon by way of Nairobi and Brussels. After a night in New York, where she'll be giving talk to the TB Alliance on Wednesday, Helen then heads straight to the airport to fly to LAX (where she'll meet up with our friend Becky who is coming to Australia for the first time) and then on to Sydney and finally touch down in Cairns Friday afternoon, where I'll scoop her up and bring her up the Gillies and finally have her home here on the Tablelands for a little while.

I figure she'll either jump straight into the lake or drop into bed. . . We'll keep you posted.

Cheers, Robert

Updated 3:30PM, Tues. Nov. 3, EST:
Just got a call from Helen who was in New York City, looking forward to a hot shower. . . She'll be writing a posting and sending some photos for the blog soon.

Home visit. . .

I have been reading Nicholas Kristof and Sheryl Wudunn’s recently published “Half the Sky” about the tragic plight of women throughout many countries in the world and some of their stories of overcoming oppression. It makes me think of so many of the amazing women I have met on my travels in Kashmir, East Timor, Tuvalu, Sierra Leone and now Burundi. (I also think of the men with whom I have worked who work hard for women’s rights too). I am only 21% of the way through the book (the Kindle notes the percentage read at the bottom of the “page”) and I am devouring it. Despite the tragic tales, it is very inspiring.

I was thrilled that they cited my friend Dara Cohen’s research. She and I met in Dili, East Timor in February 2008 and met again in the Dili airport as we were both departing on the day of the double assassination attempts on the President and Prime Minister. Dara is the person who told me about the West Africa Fistula Foundation too…the dots start connecting.

Today I accompanied Melino on a home visit to his mother (with multiple medical issues) at his childhood home farm. We were also delivering two elderly patients home. We drove down the rough road from Kigutu to the paved road, drove south on the paved road for about 15 minutes and then took another road back up into the mountains to Vyanda (the town I walked to three weeks ago with Tolstoy). As soon as we pulled into Vyanda’s town center, which had throngs of people out for the local markets and church services, the vehicle was mobbed with well wishers. Melino is obviously a well loved and respected member of this community.

The air was cool and the hills/mountains had a verdant hue. The eucalyptus trees were plentiful. I had to blink to realize I was in Burundi and not on the Tablelands of Far North Queensland.

Melino’s Mum, Candide, is a very hard working farm woman in her mid 70’s. She has had nine children and was widowed in 1994. Despite not reading or writing well herself, she has ensured that all her children have been educated. All are successful in their fields… a doctor, a professor, a civil engineer, business owners, all of them major contributors to Burundi’s positive future.

It is frustrating not to be able to speak Kirundi with her, as I know that her life must have incredible depth and that she has many stories. For example, Melino told me a little about her hiding from the rebels in the war. Meeting her was inspiring and humbling; her “simple” life as a mother in the mountains of Burundi has made a huge difference to this struggling country and its people. It was an honor to meet such an amazing woman.

Tomorrow we will begin a three day vaccination programme for under five year olds. I imagine that we will have a tsunami of patients.

Helen

Barack Obama Shop

Cow paddock fence with bananas at Melino's home


Helen with cow


Melino and Mum


Melino with calf


On the road blood pressure check


Woman with bar of soap on her head

Seven more sleeps in Kigutu. . .

It’s hard to believe that I only have a week before I depart Kigutu.

Today Tolstoy and I set off for another exhausting (yet paradoxically revitalizing) trek. We did a 5 hour circumnavigation of the valleys and hills to the south of Village Health Works. Up and down, up and down. (Feels like I walked the “Goat Track” on Castle Hill in Townsville about 6 times!). My respect and awe for the local residents continues to grow. The distances they travel regularly on foot with heavy loads are very impressive.

We were comparatively off the beaten path this time (the last walk was on a very well travelled route). It’s very humbling to see young children sprinting up steep tracks with heavy bundles on their heads, as well as firewood and buckets of water. Seeing two very young children heading off hand in hand to fetch hot coals from a neighbour in a metal pot was especially poignant. Tolstoy explains that they carry the pot back wrapped in banana leaves to prevent burns; the family is too poor to buy matches.

We passed by a local church in which about 15 teenagers (predominantly girls) were gathered for Bible study. The pastor invited us in to talk and I urged them to come to Kigutu for care and did a bit of health promotion too. Once again I am spurred on to try and get solar cooking happening here, as well as rain catchment.

These people would benefit very much from harnessing the sun and the water. (www.she-inc.org and www.savetherain.org are two organisations that I want to follow up with, post departure). As Tolstoy proclaims, there is enough work here for a lifetime! These ‘mountains beyond mountains' community outreach treks have been so informative and memorable. Once again, everyone we passed on the track was amazed to see a muzungu on foot.

It has been wonderful to have a chance to work/learn with/from Melino since his return from the ultrasonography training in Rwanda. He has been able to diagnose renal failure; a renal cyst; and, sadly, severe tricuspid valve regurgitation with heart enlargement and probable pulmonary stenosis in the 8 year old girl from Tanzania. Our fears about her grave cardiac condition were confirmed.

Late Tuesday afternoon, eight hours after Melino’s examination, the little girl suddenly went into cardiopulmonary failure. As Hilarie and Sincerite were getting the oxygen set up and tending to her, I checked her vital signs…respirations (40) and heart rate (140), then the blood pressure…nothing … I checked her heart again and heard nothing, then watched her take one last breath. This all happened in about 2 minutes. Her poor little heart just gave up. Somehow it was a bit easier for me to deal with this tragedy knowing that her heart was in such bad shape and that there was really nothing much to be done for her, except major cardiac surgery. Nevertheless, it was very sad and very intense to watch her take that last, long breath.

When informed, the poor parents were devastated, but unlike my experience with grief stricken Sierra Leonians who collapse in a heap and pound the ground and wail, the people here appear to contain their grief (relatively) and weep silently.

The scenario of the post-death was complicated as the family is Muslim and they were also a long way from home. Muslims require burial within 24 hours of death and also must be in the midst of other Muslims. There are no Muslims in Kigutu, but there are Muslim communities in nearby Mugara and Rumonge (within an hour). The parents were able to make a connection there and carry her body down the mountain for burial with their help.

We continue to see some remarkable pathology here (see the close up of the eye) and the goiter is one of the most impressive I have seen.

The Community Center is progressing well. The women from the community who come regularly on Fridays have done much digging and brick carrying near the site. It will be amazing to see it all completed and in use when I return in January.
The pink sunset was remarkable tonight, especially with the drumming practice as background audio. Now the crickets are thrumming and the crescent moon shines bright.

Tomorrow I will go to Vyanda (by vehicle) with Melino for some home visits and I expect I will have another extraordinary day.

Helen

Helen on the trail

Misty mountains

Children hauling loads uphill

Boy who gave us shortcut directions

Children off to collect hot coals

Young girl hauling firewood

Mountainside farming

Patient arriving at clinic by stretcher

Melino doing ultrasound

Local woman with goiter

Distended eye

Churchgoing women

Kigutu women working on Community Centre

Community women working in the gardens

Back in Buj. . .

I came down the mountain yesterday with Dziwe and Elvis (one of our amazing translators, who speaks Kirundi, French, Swahili and English) here to Bujumbura in the ambulance with two patients who had been stabilized and needed surgery. One is a woman who had a large ovarian tumour which has caused her to miscarry and hemorrhage and the other was the young man who had the bicycle accident. Accompanying us were two armed army security personnel. Since the July ambush and shooting at the VHW vehicle resulting in the murder of the driver Claude, the army presence and security situation is high.

For the past three weeks I have been on the Kigutu plateau/hilltop, working at the Village Health Works hospital and have not been “off site” except for my big walk with Tolstoy two weeks ago and to watch the drumming. Due to the clean air (the rains have arrived clearing the smoke from the burning fields), open space, incredible views, amazing sunsets, great company and all the work to be done I have not been in the least bit stir crazy.

Every morning at the clinic in Kigutu, the local site crews arrive at 6 AM to work in the fields, dig gardens, paint, work on construction…most walking “not far”…nothing more than an hour. The rest of the staff lives on site in the residence where volunteers stay (except for one nurse, Orestine, who has a family and lives in Mugara…she arrives for work always looking fresh and fashionable, despite the hour walk UP hill!). We all gather for meals and it really feels like a family meal with joking and conversation. A few evenings a week many have a work out session on the verandah which is fun to join in on.

I have been trying to fit in learning some Kirundi at mealtimes. Kirundi is a Bantu language and is agglutinative, which means it combines words to make one sentence. Everyone’s been very patient with me and at least my attempts at pronunciation give them a good laugh. It is also a tonal language, so pronunciation is vital. Given that I am far from a language whiz, it’s pretty challenging. For example….the word for “key” is “urufunguruzo” meaning “the thing that we use to open”… I have a hard time recalling all the syllables, not to mention the pronunciation. Even “good morning” is a mouthful for me…”Mwaramutse”…moo-a-ra-moo-tsay. I have managed to remember “inka” (cow) and “umvubu” (hippo)…not exactly words needed in the hospital setting! I will strive to work on Kirundi so that I have more than “buke buke” (not too much/a little). Another tricky thing…”Oya” (oh-yah) means “no”, so I have to be careful saying, “Oh, yeah”!!!

With the approach of the new moon, I have noticed that the lights from the fishing boats on Lake Tanganyika increase exponentially each night. As I mentioned in a previous posting, I was perplexed to see so much “electricity” across the lake in the Congo and then I was told about the fishermen. The past few nights the lake is ablaze and it looks like a huge metropolis from afar, an amazing sight.

The acuity of the patients admitted to the hospital remains high. Some would certainly be in an ICU in a developed country. The hospital has been full to overflowing and we have to get spare mattresses out and put them in the consultation offices on the floor or some stay on the examination tables for the night. Most come with family members and they sleep with their loved ones on a floor mat at the bedside or in the bed with the patient. I continue to be mind boggled by how far these people walk seeking health care. There are plans to have mobile clinics set up in the distant places.

There is also a three bed pediatric malnutrition ward which is soon to be doubled in capacity. One of my focuses has been to help get this unit more established and setup. The children are very fragile and require consistent feeding at 2-3 hour intervals with special nutritional formulas. They are also very prone to hypothermia. The balance between life and death is a fine line. It reminds me of caring for baby joeys in Australia. We currently have examples of clinical extremes….marasmus (muscle wasting and loss of subcutaneous fat). The baby boy is an orphan (mother died in childbirth) and is being taken care of by his aunt and grandmother. The other is an example of kwashiorkor (edema in the legs and face with loss of appetite, hair discoloration and skin lesions). It’s heart breaking.

Dr. Melino, the Burundian physician/medical director, has just returned from three weeks is Rwanda for ultrasound training. I look forward to working with him. He’s extremely dedicated and proficient with his work.
We will be returning to Kigutu in the morning and I am enjoying taking advantage of the wireless internet access here in Bujumbura, but alas the power gets shut down frequently even in Buj, so connectivity continues to be a crap shoot.

Helen

Helen & Dziwe with clinic staff

Helen with Anna and Floride


Cattle, village huts and mountains


Boy leading cattle through village


Breakfast time at the residence

Family from Tanzania


Baby with marasmus

Baby with kwashiorkor


Helen with baby


Scarring from traditional healers


Melino


Basket stretcher used to carry patients
in from far afield


Women on trail

Happy patient discharge

Dziwe in car with armed guard


Local landscape in late afternoon light


Helen at the end of day