The UN Comes A'Callin!

Wednesday, November 21st


The UN and all the major donors to them and therefore to us came on a visit that they termed euphemistically the JAM, Joint Assessement Mission. We presented, all the various programs, what was happening in them and then took them about to highlight the myriad problems that we have, what we were trying to do to strengthen the program and why we need additional funds. They did listen but whether this will translate into any supplemental grants is totally unknown. Do not hold your breath. We did also learn that BPRM, an American agency with the full name of Bureau of Population Resettlement and Migration, cut their grant for next year in half by $500,000. And where we are to find replacements for that alone is totally unknown. After that I went to the OPD again until we discovered that there was no one checking on the pediatric ward. So I spent the rest of the day there. I have a CO who is the most faithful and we have spent the most time together. He has changed his habits and I do think that he will continue to do so even when I leave. About the others, I have no such illusions. For example, I gave another training session as I do every Wednesday and he was the only CO there. The rest were all Community Health Workers and nurses. I am grateful that they were there.
That's all there is to report today from here where
The UN and donors came and went
A jam they called it
But who knows if it was heaven sent.

7:57 AM 11/22/2007

A small bit of minutia:
One bit of interest from about a week ago. The ants had disappeared for some time. At least they were not in view and not serepticiously biting. One morning last weekend on the way to breakfast, there was a long column of them, about 10 meters, marching through the drainage ditch of my house. Now they were tramping along two by two in a very long line. Generally they were quite orderly and well mannered. Every so often one here and there would break off and scout about. They were, I am sure, a food finding expedition. As they reached the end of my house, there were still more tramping out from their nest in the walkway. They had evidently dug a tunnel at the side of the walkway and no longer were coming out on top where we galoofed by. Nevertheless I was apprehensive as to their motives and, as I could not speak Antese, I decided that this was an act of blatant aggression. I raced into my house for my "weapon of mass destruction", the can of SUPER DOOM and attacked. A rout and shortly thereafter came a heavy rain and washed the bodies away. So I do believe back at ant headquarters they could only report, "lost, whereabouts unknown".

Sunday, November 18th.
Today I do have to prepare some additional teaching guides for the clinicians so that they might think of ear infection without waiting to see pus draining out from an ear. We have been over this several times before but it just does not seem to percolate through to them.The favorite sequence here, as I have written about, for diagnoses is first and always, Malaria and throw in an antibiotic for a respiratory infection though they have done nothing to prove either. If that does not work, gears are switched and the next diagnosis up is Enteric Fever. Now that is difficult to diagnose but it does have a pattern that tends to be more characteristic. A serological test called the "Widal", named after the good doctor who first described it more than a century ago, is ordered. This test has been abandoned in developed countries as useless as it has little sensitivity nor specificity. You might as well flip a coin. We back in developed countries rely on blood, stool and bone marrow cultures. But the news has yet to reach Africa and no amount of discussion can shake this belief, just like dialogue with fundamentalists. Then chloramphenicol is added and that drug, while cheap and useful out here, has a lot of bad side effects. So part of my next session will be on just that disease. I really do not expect any paradigm shift but I have to try.
And that's the news from out here in Tanzania where
the clinicians can diagnose without examining patients
malaria abounds even with negative tests
and the UN keeps trucking them in.

Stephen

The Weeks Keep On Rolling!

Today is the 14th of the lovely month of November and one bright spot, as I was walking over to the car to go back to base late in the afternoon, there appeared on a tree peeping at me a gecko with a bright blue face. But, like some of the children here, when he saw me he just scurried up his tree. Not that the children scurry up a tree but they find me so strange with my pale white skin that they hide themselves in their mother's body and periodically peer out and cry in terror. Tonight the black rain clouds are rolling from the north with some thunder and lightening. The clouds spread across the sky like tentacles and leave patches of dusky blue in between with a few stars twinkling through as if to reassure me. So far no rain though.

November 16th.
It rained a lot last night for about 2 hours but this morning was delightfully bright and cool. As usual down at Nduta it was hot but it never gets as bad as in Sudan or in Kakuma. I am working with a new C.O. and he is good. I am still on the adult wards. Now comes a longer tale with an interesting twist at the end. I have for the past two weeks been giving presentations on malaria and yesterday the health coordinator came out to present a survey that he did on our use of anti-malarial drugs. He found, and this was not unexpected from my observations, that 2/3s of the people treated for malaria did not need it according to the tests that were done. I have been trying to tell the clinicians, ad absurdum, that, if the tests are negative, you have to look for other causes of the fever, which they just do not do. They simply diagnose "suspected malaria", put the patient on anti-malarials and throw in an antibiotic just to cover everything possible but are really too lazy to try to make a proper diagnosis. This afternoon, as I was leaving, the Tanzanian doctor said that the COs wanted me to show them how to do a better examination. Instead of saying something sarcastic such as, "What the hell do you think that I have been trying to do for the past 2+ months.", I replied that I would be delighted to. So Monday I will head back to the pediatric outpatient department and try again. I can deal with this as I have but 3 more weeks to go out here and, who knows, something just might stick. I will not get too excited. I had found myself over the past few days getting too exasperated and that just interferes with my ability to make good decisions. It has been building for some time. I keep getting too personally involved. It really did almost come to an explosion yesterday during the training when several of the people there came out with their personal anecdotes of tests being wrong. None of the examples that were cited had anything to do with malaria. Finally I decided to just laugh and said, " OK, lets just get rid of the tests, treat everyone with fever for malaria and buy beer with the money we save." I do think that the message I was trying to give got heard. Sadly, by today's admissions to the adult wards, not everyone was paying attention.
The camp consolidation process goes on and, fortunately, the weather has not been too bad with rain so that people are constructing their shelters. And so far, despite the very harsh conditions, no outbreaks of diarrhea or other problems. And that's the latest from Nduta where
Two camps merge into one
The UN thinks that this is fun
And, mercifully, no one has the runs.

Stephen

Camp Consolidation

Today the camp consolidation, as it is euphemistically by the UN, started. They are closing Kenembwa as I have written about and the folks are being all moved to Nduta, those that do not want, as yet, to repatriate. I had wanted to go there earlier in the day when the first convoy arrived but there was no vehicle available until late in the day so I went there before heading for Kibondo. You know that I have been questioning my sanity and the purpose of my being here. I guess God, Buddha, The Great Spirit, whatever you would like to call the force that somehow guides this universe of ours got tired of my quengelig mutterings and gave me a very clear answer. I was so overwhelmed by what was taking place that it brought me to tears. I will try to give you an idea of the pictures that I saw. I did have my camera but did not have the ability to use it. I spoke with both the field and health coordinators this evening upon my return and we will go back in the morning to see if there has been any improvement. I arrived there at the "reception center" at about 1630 and it was utter chaos. The center is rather small, perhaps 400 meters square and that is a guesstimate. There were lorries including a container vehicle unloading these poor folks' possessions, mainly wooden objects as doors, window frames and furniture into a large pile in the center. It looked like a pyre that would soon be set on fire to propitiate the Gods. People were scrambling about trying to find what was theirs and cart it off to the shelters. Others were carrying large bags full of clothes, rags and other possessions into the shelters that were only wood frame rectangles covered with plastic sheets with a brick floor. The majority of the bricks were loose and jumbled about.There were no assigned places just the words"men", "women" scrawled on the plastic and people were trying to find spots to sleep. Wandering about were small flocks of chickens and ducks. Outside the wire fence, men were herding about 20 cows and more goats to keep them from wandering off or being stolen. The Nduta inhabitants were all crowded up against the fence trying to see relatives and contact them or just watching the entertainment.There was an NGO, Tanzanian Christian Relief Services (TCRS) that had about 10 people there that were not of any help. A few were at the gate with sticks pushing people back. The rest were just sitting and watching the turmoil, chatting amongst themselves, not trying to assist or control the confusion. Off to one side there was a shelter of about 5 x 10 meters where people were cooking. As they had not taken down the plastic siding, the wood smoke was swirling about in there and it looked like a sauna but the fumes were deadly. No firewood was supplied and they were forbidden to bring any with them so they had to scrounge about and there was precious little. Right in front of these was a large deep pit with a skimpy rail fence around it. the was a garbage pit. The children were playing near and, surely, one will fall in. The water points were adequate but the kids, having little else to do, were playing with them and rivulets were forming and the mud was accumulating. There were only seven toilets for what was reported to be at least 500 and possible up to 800 people. At least that was all that I could find. There were some outside the fence but I was told that the people could not go out there. Now, as I was wandering about asking questions, more trucks kept coming in as the second convoy of the day was arriving. And indeed on the way home here to Kibondo, more trucks went by us. So more goods on top of those already piled up. It would become dark soon about 1900 and there is no electricity to assist unloading. Over the next few days, they will build mud/wattling houses on the plots in the camp that have been assigned to them. The will be given some sisal rope, plastic sheeting, framing posts and a handshake. It rained this weekend. Today was overcast most of the day and there was only a bit of sun late to dry the ground. If it does not clear for the mud to dry then it will just melt right off in the first heavy rain that comes. The next group is slated for Friday and the whole move is supposed to be done by mid-December. So back again tomorrow and, if there has been no significant improvement, we will try to stop the process and get it better organized.I will let you know in Wednesday's letter.

This part was written on Friday, the fifth day of the consolidation process. Refugees keep coming in daily from Kenembwa which is certainly not the way the UNHCR described the move. I went this evening over to the "reception center" which is crammed with people and very unsafe from a health perspective. I won't comment on the social aspects. Construction materials were to be given out on Monday and then there would be three days that were allowed for the men to build their homes and then the next group would be moved in. However convoys arrive daily. For the first time today framing posts were supplied and in very limited quantity but so far no rope and no plastic sheeting. And today is the 5th day that the Monday arrivals have been living in even worse squalor than usual. I went over there again this evening to see so that I could report to our FC (field coordinator) & HC (health coordinator). I can not tell for sure how many are now crowded in there and the UN will not supply us with a list but they claimed earlier in the week that they could safely get up to 1200 refugees in. It certainly looks like that number but it sure ain't safe. Debris still is strewn about. The barnyard animals wander in and out. The shelters are over packed and stuffed with their possessions, enough so that quite a number have to sleep outside. There are not enough blankets, thievery abounds as you might expect in such an unstable condition. And to add those further twists of the screw, there are now two more gathering places with a fourth being constructed. The second is at part of a school and that one is not bad as there are many fewer people, there is more space and the buildings are solid. The newest one opened evidently last evening and consists of four huge WFP (World Food Program) storage tents that are generally used to store food supplies.Now they are supposed to house 100 people each. I have been in each and they will be crowded with 50 as most of the space is taken up by bundles of the refugees' possessions, leaving precious little living space. Some women were cooking inside with charcoal and rather noxious fumes were drifting about. There was only one water point. A second one had not yet been connected and a group of women were digging latrines while the men watched with a casual interest. I was told that even last night, the first night, some had to sleep outside and still daily new refugees keep arriving from Kenembwa. Once again as I was leaving the buses and trucks were rolling in with frustrating regularity. Our FC did write an excellent letter protesting and has been in touch with our country director. The next bit of good news from the UN was that they would give us no additional money to upgrade our hospital/clinic/ outpost complex and we have but a fraction of what we really need to make those critical changes that I have already outlined. That has also draw a strong protest. Whether anything comes of this is totally unknown but I will, of course, let you know.

Stephen

Mirabili Dictu!

At last I have convinced at least one clinical officer that the use of an inhaler with a spacer is the best way to quickly treat and stabilize an acute asthmatic attack instead of their previous dangerous relatively ineffective use of intravenous aminophyllin. Also please note that he is counting respirations on the child. Yippie!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

My Week at Nduta

Here are some of my good friends at Nduta that usually wait for me as I make daily rounds on the pediatric.ward and a view of the compound on weekly wash day.
Monday, the start of my week.I should have known what kind of a day it was going to be when it was inaugurated by that ant attack that I wrote about earlier today. At the pediatric ward the chief CO decided to attend and he was a bit better than some but not by much and he was very full of his importance. Rounds started well but then I began picking up the mistakes from the weekend, the undetected pneumonia because some still do not count respirations nor listen to the lungs. so what was on Friday a mild pneumonia by today was very severe and possibly life threatening. I went to the pharmacy to look for some medications and, how unusual, they were out. I asked if they had ordered them.
"Oh yes", came the reply.
"Well were are they?"
"Oh they will come in with the monthly order in 3 days."
"But you are out now!"
Then comes that rather silly smile that I do so hate and that I see all too often. What to do. I must keep remembering that this is a long term task. It really ain't going to change during my tenure. What I can do has been put into place. Pointing out the deficiencies, suggesting ways of correction and starting a reasonable reliable training program. I have also found a fine physician to replace me.
The heat has returned here over the past 2 - 3 days. The sky starts clear in the cool morning but then the puffy fluffy clouds come slowly drifting in as the day heats up. We see the same type of cloud in Maine but they are just so much more energetic. By then I am down in the valley at Nduta where I do recognize that I am very very close to the Equator. But back up here on the hill it does cool off at night and that makes it easier to sleep. We are in what would be the Fall as many leaves are drifting down but they have none of that vivacity of the colors that we are blessed with. They turn a paler shade of green and give up the ghost with a sigh as the rains are too late to save them. They cover the ground to the delight of the goats that wander through the compound, depositing their small pebbles as a thank you. They have begun to make a habit of lying about in the shade outside the pediatric ward where I daily work so that I see them from the window gazing at me when I go over to the hand washing bucket. Today two young males were butting heads to see who could attract the ladies who were not very interested.
TuesdayI did get another CO so that, certainly at this point, the system does seem to be running. Today's was good and he quickly got the idea that counting respirations is a good idea as is the washing of hands. And to my delight the aides and nurses on the ward are beginning to do the same.
We did lose our first baby today that I am aware of since I came. A newborn who after about 30 minutes started having trouble breathing. It was a good sized baby of 3.3 kilo. Looked normal but had a big liver. It was not cyanotic, had no heart murmur and both lungs were receiving air. We suctioned him and gave antibiotics which really was all that we could do. I ask the doctor involved about transferring him to the KIbondo hospital but he felt that they would do nothing which is generally the way they do things there.
Well now another bit of the ongoing ANT WAR. Last night 2 of the lady ex-pats were attacked as I had been earlier in the day. No serious injuries only lost dignity as clothes had to be removed and brushed out and the vicious little creatures removed, rather pulled off. Fortunately there is more than one room in the staff lounge/dining area. So they were able to discreetly run in the other room to do this. And I do mean run. Those guys really hurt. I had found out where they had built their nest, actually there were two colonies. There were two nests side by side, one with big guys and the second with the smaller fire ants, so called as their bites burn. I had decided that if they behaved, I would not bother them. But they broke the truce this morning. As I walked very carefully by I got bitten again. So after breakfast, I took my can of Super Doom and attacked. Right and left I sprayed. Up and down the canister of deadly poison flared. Meanwhile two of the guards appeared to see what was going on as thousands of ants milled about trying to form ranks and counter-attack. I handed over the canister to them, pointing out the entrance to the nests and left them to mop up the battlefield. Tonight I am pleased to report, no ants and the dead have been buried with proper respect.
On the ward today, well I have noticed it over the past week or so. There must have been a sale on jerseys from the Valencia Fussball Klub as there are at least 6 women wearing the same one that says Rinaldinho on the back. It does confuse me as I tend to recognize some of the mothers from their garments. Around noon today, as the kids were getting medication and, at least, a dozen were crying, I was reminded of the word BEDLAM and its origin from the English insane asylum of the same name.
Wednesday was very sad. We did have another death night before last. A one month old that had been discharged 4 days earlier after an episode of what I was convinced was neonatal sepsis. He was treated appropriately and got better, only to suddenly at home have difficulty breathing and high fever. The CO did put him on antibiotics, not the best ones that we have and the child, a few hours later, grew dramatically worse and died. As we have so little to evaluate anyone and as the records are so scanty, it is difficult to put this together. We also have another child that came in forming large blisters on his skin and actually sloughed about 15% on his upper chest and face. I started him on antibiotics believing it was a staphylococcal infection but he did not improve. I then added cortisone on the possibility that it might be pemphigus, usually a disease of older people thought I have seen it in 30 year olds. Anyway it has also been described in children and the child did start getting better. Now sadly I think that he has a bowel infection caused by the antibiotics called Clostridia difficle colitis. Basically the antibiotics kill off the normal flora and this allows the germ to grow as there is now space. This germ secretes toxins that severely damage the colon's wall. There is a good test for the disease but, obviously, it ain't here. So, like I have to do so often, you go with your instincts. What makes it even more difficult is that I have been trying for almost a week to get a good antibacterial cream for him as I consider him as an extensive second degree burn and I finally today got what I wanted. So we shall see but I do not think that he will survive.
Thursday started cloudy but then gradually cleared and about 1300 we got a strong wind and the fine red dust that I so dearly love coated me and everything. I left the camp early as I had to go to a camp consolidation meeting at the UN. I wrote earlier that they were closing Kenembwa and moving the people to Nduta. Well it will start next week when they move the first group. They will go to temporary housing at something called "the reception center", which has always housed new arrivals. Each family will be given building supplies consisting of poles, plastic sheeting and two rolls of sisal rope. They will have but three days to build a shelter and then they will be moved out to make room for the next group. They want to get this done over a month's time. By their estimate that will be about 9000 people. They were given a choice of the move or repatriation back to Burundi and only about 1000 chose to go back. Meanwhile we have only gotten preliminary plans and cost estimates for the renovations that are so necessary. well I do like living with a bit of chaos as you so well know. I have been talking with folks again about my replacement and they appear to now be convinced. I am just waiting for final approval from the country director. Now no ants have been sighted today and no threatening notes have been slide under my door and no bites have been reported by anyone.
Nothing very dramatic today, Friday, as that child that I described yesterday is a bit better. I think I was right about the diarrhea as it is improving today and there are no more new skin lesions. Mother now tells us that another child in the same family had the same illness last year. As there are no reliable records and the story keeps changing, I really do not know what to believe.
Another child we saw with a mild congenital heart problem that is being followed in the regional hospital. The child also has seizures that are not being treated but mother is so focused on the heart that all she can talk about is to go to a Western country to get it fixed. Well I was able to start the child on anti-seizure medication but I so far have not been able to convince mother that the heart has nothing to do with the seizures as she was told that at the regional hospital. She says that she knows some one with the exact same problem who went to Norway and now everything is fixed. Well you know how difficult it to shake something like that. So I will see her again next week.
Well we might be back in the rains. I am not quite sure but today, Friday, at Nduta about 1530 we had a really torrential rain that lasted a good 30 minutes. The kind that causes the drainage ditches to fill like small torrential rivers. The children love it as they then have a new place to play as they go wading through the reddish waters swirling by while mothers look on a bit anxiously lest one of their charges gets washed down stream. The shelters that they live in get rather wet and uncomfortable but they are still so much more stable than the ones back in Darfur. What I find fascinating is the rather narrow swath that these storms seem to take at least at this point. Back at Kibondo there was only a light shower and nothing else. The road is still quite dry and travelable. There are drainage ditches on each side and, every 50 meters or so, there are deep ditches leading from the road to the adjacent fields. So we have not been mired in the mud as yet.
And that has been my week here in Kibondo.

Stephen

Kibondo Visions