Sunday, October 25, 2009

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


Saturday, October 24, 2009

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



Sunday, October 18, 2009

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


Saturday, October 10, 2009

Clinical Notes and Accompagnateurs. . .

It’s Saturday afternoon and things are relatively 'settled' at least for the moment…

The skies are beginning to clear after a couple of hours of torrential ‘fire hose’ rains. The birds are singing and the construction crew, who work tirelessly from dawn to dusk on the soon-to-be Community Center, have upbeat tones in their banter with one another. Soon the Saturday afternoon drumming practice led by Mandela (Kitchen Assistant) and Peter (Information Technologist) will begin and the community of Kigutu will gather to witness this amazing spectacle. The lake is beginning to come into view and tonight the plethora of fishermen’s sparkling lights to attract fish should be visible.

The week has flown by. The days are full with many patients seeking consultations with a few requiring hospitalization. Some of those who have been admitted include: a 13 year old boy with newly diagnosed insulin dependent diabetes; an 8 year old girl with a faulty cardiac valve (perhaps from rheumatic fever) who came all the way from Tanzania with her parents; a 25 year old man having seizures (carried by his friends for several hours); a 19 year old boy who had a bicycle accident a week ago who may have a perforated bowel as a result of a blunt trauma injury (also carried); several babies suffering from malnutrition with dehydration and/or malaria; a baby with severe asthma; and a man with a nasty perirectal abscess…the list goes on . . .

I feel very fortunate to be learning so much from Dziwe and the staff about the management of these patients. It’s been gratifying to really feel as though I am able to assist them and be part of their team. I continue to be totally impressed by the high standard of care and commitment of the staff despite not having all the ‘tools’ and diagnostics available. There are many challenges… for example, how do we send the diabetic boy home when there is no insulin (or refrigeration) and no glucometer for him. Last Thursday I had the privilege to meet with the group of accompagnateurs (about 38) who came to VHW for their monthly gathering. The dedication in the Partners in Health teaching manual is a great tribute to them:

“This manual is dedicated to the thousands of accompagnateurs whose tireless efforts make our mission a reality, and who are the backbone of our programs to save lives and improve livelihoods in poor communities. Every day, they deliver medicines and social support to patients in their homes, refer people who are ill to clinics, provide health education, and teach all of us that solidarity is the most potent remedy for pandemic diseases, poverty and despair.”

Per the request of the seven chief accompagnateurs, Achel (one of the nurses) and I, with the help of Tolstoy’s translating, did a teaching session…

Vital Signs: Ibimenyetso bikurubikuru k’umuntu
Blood pressure: Ivuduka ry’umurindi w’amaraso
Temperature: Ubushuhe
Pulse: Kumviriza ukuntu umutima utera

Respirations: Uguhema


When Tolstoy told the group that I had walked up into the hills last weekend they were most impressed and expressed much gratitude for my efforts and interest. At the end of the session, I took individual photos for their new ID cards. Achel then distributed the anti retroviral drugs to them which they will in turn distribute to their patients. Afterwards, we all had lunch before they headed off…some would have a four hour walk home. How I would love to see them all equipped with raincoats, good walking shoes, tote bags, torches, water bottles (anyone out there have any connections at L.L. Bean or REI?), as well as basic medical equipment-a blood pressure cuff, stethoscope, thermometer, watch. Cell phones for all will hopefully be a reality soon. Please consider donating your old cell phones. (Please see www.hopephones.org and the Village Health Works section on the home page for information about donating). Thanks so much!

The surnames of the accompagnateurs are quintessentially Burundian… Nkengurukiyimana ( “I thank God”) and Ndayifukamiye ( “I kneel down for Him”), Havyarimana (“Only God gives birth”) are some examples. I look forward to working with them more. Now that I have all their photos and names on file I have my work cut out for me to learn them all!

Before konking out each night I snuggle in with my new Kindle…I have read Julia Child’s autobiography, the new Jon Krakauer book about Pat Tillman, “Travelling with Pomegranates” by Sue Monk Kidd and her daughter Ann and last night I began ‘The Story of Edgar Sawtelle”.

Helen

Helen with Accompagnatuers


Consult with accompagnatuer

Lunchtime with accompagnatuers

Fungus foot

Mother and baby


Community Centre under construction



Monday, October 5, 2009

Mountains beyond mountains. . .

On Saturday, after a leisurely breakfast, Tolstoy and I departed for our trek around 8 AM.
The sun was shining, the air was fresh from yesterday afternoon’s deluge and the backdrop of Lake Tanganyika was magnificent. The plan was to head up and over the mountain behind Kigutu to visit the commune (community) of Vyanda. This is where Tolstoy went to primary school (Grade 1-6) five days a week. As we left the driveway of Village Health Works, we passed many locals heading down the mountain to Mugara for the Saturday markets. Mostly women and children, carrying a variety of goods on their heads including bananas, enormous bags, a chicken, a goat and a foam mattress. Many stopped to socialize with Tolstoy and have their curiosity quelled as to who this muzungu (white person) was accompanying him. We stopped in at his mother’s house and he found a suitable walking stick for me from a pile of cut branches used for fence fabrication. Tolstoy is very conscientious about my well being.

Initially, we were on a very wide track (calling it a road would be stretching it) and later proceeded to climb up a narrow track passing mud brick houses surrounded by banana trees and burnt fields. I began to feel the heat and the elevation, (about 2000 metres) but the sights, sounds and frequent greeting of other walkers kept my mind occupied. I was also immersed in thinking of the experiences of the locals as they hid and fled the rebels during the war. We continued up a steep set of switch backs and reached a bit of a plateau, which gave my lungs and legs a bit of a rest until we proceeded to climb another steep incline up a narrow track. We were headed into the water catchment area for Kigutu. When we reached the top we had been walking steadily for three hours.

It was now wonderful to walk along the ridge on an undulating road. The views were terrific and gave me a great sense of the gigantic area and population which VHW serves. It certainly gives me a MUCH greater appreciation for the efforts required for people to come to the clinic to receive health care and how vital it is having VHW’s presence here. Without VHW they would have no health care available at all. It also impressed on me the important role that the community health workers play in the delivery of health care to this community. These are locals who have been trained to go to the people’s homes directly and administer their medications for HIV and TB (among other tasks). These committed individuals walk many hours each day to ensure that their job is done properly. I would love to see that they are able to be provided with decent raingear, good shoes, torches (many leave before dawn) to make their jobs a bit easier.

Tolstoy was eager to introduce me to some of his relatives along the way. They were all lovely people and greeted me heartily. Each of theml seemed to be amazed that a muzungu had come to them on foot!

We continued to the community which was another hour away over more hills. Everyone we passed on the track seemed to ask Tolstoy who I was and what I was doing. He explained that I was a volunteer from VHW and wanted to see for myself the communities which are served by VHW. My presence was definitely unusual.

When we reached the village it was wonderful to see Tolstoy have a bit of a reunion with some of his schoolmates. He showed me his school and was very happy and peaceful to be there again. It’s was amazing for me to realize that as a young boy he had done this walk every day, departing home at 0400 and arriving home well after dark at 7 PM.
As we turned back for home, ominous thunderheads were building overhead, which was quite dramatic. They definitely gave me an extra oomph in my walking pace. Tolstoy and I were able to share ideas and visions for the malnutrition project which is currently in the formative stages at VHW and needs to be “officially” launched as soon as possible. Our ‘mountains beyond mountains’ hike was really a great way for me to experience “community outreach” (a common phrase in the public health lexicon) in the truest sense. It’s wonderful having Tolstoy as my walking companion and guide too.

Soon after we entered the driveway of VHW the rains came down. The shower felt good after such a satisfying and memorable day.


Tolstoy & Helen on the track

Locals on their way to market

Helen

Helen with a local family


Thursday, October 1, 2009

Hill walkers, drummers and dancers. . .

It is astounding to realize how far people walk to seek care at the Village Health Works clinic here in Kigutu. Patients include all ages; pregnant women; mothers with babies; children and some very sick who require being carried on a makeshift stretcher. Many walk for four hours each way (some more) and it is not easy walking in these steep hills. “Addresses” are identified as “hill, zone and commune” which could be compared to small neighborhood, village and larger community.

HIV, TB, malaria, sexually transmitted infections, gastric pain and malnutrition seem to be the predominant presenting clinical problems. About 80 people are signed in daily and while they wait they get health promotion talks from the staff. One of whom is Frederick who was at death’s door due to HIV, but was treated diligently by Dr. Melino and the staff. When Frederick returned to his village healthy, people could not believe he was alive and thought he was a ghost. Now he is a vital link between the community and VHW as he tells his story to patients and encourages them to get tested for HIV.

Some older women who come have back and neck pain and when asked how much water they carry, the reply is usually, “Twenty liters only…twice per day.” They aren’t complaining, only stating the facts of their daily life. It is very humbling. They are just grateful to be here and know that they will receive services and attention.

On Saturday I have a plan to walk with Tolstoy up into the hills. This will be a multi-purpose excursion. It will be a good chance to get to know Tolstoy more; a Kirundi language lesson; an opportunity to experience the trek that the patients take to get here and back; survey some local communities and get exercise! My Kirundi skills are pathetic to date, with hopes to improve. Today I brought out a Richard Scarry’s book, ‘Best Word Book Ever’ and the staff are putting Kirundi words under the English words. This might be a good strategy for me and it will also help them learn English.

Three times a week two of our staff, Peter ‘IT’ and Mandela lead a troupe of dancers and drummers next door at the primary school. It is a very festive and remarkable to watch their performance. Many of the young boys in the community are regular participants. They leap and pound for about two hours… an amazing display of endurance and fitness, especially as they carry the drums on their heads and pound on the drums simultaneously in an opening and closing procession. When three year olds get up from the audience and dance too, it’s utterly adorable. They can’t drum as they aren’t tall enough, but they definitely have the moves down!

Since we are almost at the Equator here, dawn and dusk are rather fleeting. The nights are mild and the days are the perfect temperature. The rains have yet to arrive. The moon is waxing at the moment and it’s good to imagine everyone ‘at home(s)’ also watching its progress. Despite being so far away, it is something we can all share no matter where we are.

Helen



Mandela and Peter IT drumming

Children drumming

Frederick