Kibogora Week Two

Saturday, the 24th, was a day of exploration for many as most of our team went to the National Forest to see a colony of Colobus monkeys and then lunched on a Rwandan island in a river that forms the boundary between Rwanda and the Congo.  The Congo is visible across Lake Kivu from our compound at Kibogora.

Micki and I decided to stay behind to rest up and I had a chance to write some, which is my way of recharging and decompressing the emotions of these days.  We made morning rounds in the "nicu" for Dr. Ngoy, who had a mandatory meeting off site.  We discovered a baby girl who was eating poorly at breast--a real problem in a culture where formula is unaffordable and carries a much greater risk of infection due to unsafe water and the removal of Mom's immune system as the final milk purifier.  More below on this little infant girl.

Sunday began with church at the Kibogora Church located a few yards outside of our compound, a large brick structure which could seat over a thousand.  The second service began at 9 a.m. (the first was a youth service--no late sleepers among Rwandan Christian teens, who came in their school uniforms) and was complete with electric keyboard and guitars that accompanied five different choirs, all of whom had clearly put effort into preparation both of the music and the choreography. Each choir, from children's to adult and all those in between, sang with a rhythmic to and fro side step. They were all quite good. After congregational singing--familiar melodies with Kinyarwandran lyrics--we were formally welcomed, and Duane went before the congregation to express our thanks.  Since the sermon was also in Kinyarwandran we left as it began and had our own worship time at the "black house" (our houses are designated by colors).

The new week began with a busy schedule, including the addition of "health center" visits by two students each day. The nearest center is a 20 minute walk*. There are 11 others throughout the countryside, and they provide much of the outpatient care as well as performing many uncomplicated deliveries. Kibogora Hospital serves as the referral center for all of them for problems that exceed the clinic's level of care.

*(It is notable that distances as measured by miles or kilometers are seldom expressed. In a country where most walk everywhere and even a 90 mile trip by car can take 5 to 7 hours, time becomes the currency of distance.)

Paradoxes abound here.  In a place where McDonald's has not yet sold a happy meal, where Starbuck's is outstripped by the coffee grown down the road and CVS and Walmart are unknowns, where paved roads and air conditioning, mowers and electric dishwashers and elevators are absent, 25 yards from the hospital gate sits a computer store. Cell minutes are sold in 90 cent increments (roughly 550 R. Francs); minutes for your wireless Internet access can also be purchased, or, if you have no computer, you can purchase time on theirs, all in a 10x10 building. Cell coverage here is better than at USA Children's Hospital, and texting to the U.S. is as instantaneous as being in the next room. Our bus driver on the way here, when not actively risking the lives of pedestrians in an uneven game of chicken, entertained himself by texting and talking on his cell, all the while negotiating curves and construction zones. Some behaviors appear to be universal. :)


By Tuesday, the baby mentioned above was no better, and with a persistent heart murmur since Saturday, we had ordered a chest X-ray, which along with auscultation and an EKG constitute the extent of available cardiac evaluation. The murmur had been louder on the right, and as it turned out, so was the heart. About the time we viewed the X-ray the infant's color deteriorated rapidly and we spent some time trying to achieve viable oxygenation, hampered by poorly functioning equipment, an oxygen concentrator as the only source of oxygen, and poor lighting and thermal support. Mom had no resources for transport or evaluation in Kigali, 7 hours away, but the hospital administration okayed the transport anyway and the next morning the babe was off to Kigali with her Mom. No report on her status as of yet, but the ultimate fate of infant's with complex congenital heart disease here is not good.


The entire week we have been treating Destin, a four year old with a major pneumonia and empyema (basically a left chest full of pus).  We needled his chest on Monday, and after the minimal test we can do on the fluid suggested a staph infection and not tuberculosis, Shannon Burgess, on Wednesday, inserted a chest tube, draining about 200 cc's of milk chocolate colored fluid with an odor that made one wretch. We have drained an additional 200 hundred cc's over the last two days, and Friday his fever was beginning to diminish.  Please pray for him--he has a long way to go if he is to recover.


Both of these patients' care have driven home how blessed we are to have simple things like wall suction, portable X-rays (when an X-ray is ordered the mother carts her child, paper in hand to X-ray), blood gases, oxygen with analyzers and saturation monitors, echocardiagrams, and, oh yeah, basic electrolytes.  For those in medicine you will perhaps be amused to know that neonatal bilirubins are reported as positive or negative, making them of use only to those dependent on Braille.  Physical exam is enormously more important when all of the tools (spelled c-r-u-t-c-h-e-s) we lean upon are absent. I think we will all be better doctors, certainly more appreciative doctors, upon returning to our technologically dependent medical worlds.


Thursday was a sad day as two of our team members and another U.S. physician headed to Kigali and on to their homes.  Richard Ellingstad is a family doc from Wisconsin who was here for two months without his wife, who had contracted severe malaria on a previous trip to Tanzania.  He was very gracious and helpful in getting us oriented to Kibogora. We will miss his presence at our group meals. Jeanne Claude Bataneni, a Congolese surgeon who traveled with us from Kigali to Kibogora, returned to his mission hospital in the eastern Congo's jungle. JC, as we know him, has returned to his birth village as the only surgeon, passing up much more lucrative and prestigious positions because he and his wife, also from the village and also a physician, have felt God calling them to serve His Kingdom there in Nebogongo Hospital. He is a kind and gentle man with a great testimony of persistence in the face of major obstacles to the practice of medicine.  Please pray for him and his family.


Our spiritual leader, Duane, also headed home to Kim and the kids.  He did a magnificent job of organizing this trip and in leading the group both in terms of logistical support, spiritual stimulation, and sensitivity to the emotions of a group far from home in a strange culture.  His calm in the face of his own fatigue and a sharp witted bunch of tired travelers has been a lighthouse emotionally. He will be missed.


Comment on week two After two weeks in this land, where Christianity is more of a palpably present influence than in Alabama, we are struck by the fatalistic approach to illness, death, and dying that an animistic cultural inflence produces. Tradional medicine practitioners (think "medicine men") discourage allopathic medicine and value their own power base and influence mor than human life. Compare that to our home culture, where a secular utilitarian view of life also erodes the Christian's high value on the sanctity of life, and deluded influence peddlers (think "politician") sell their souls on the alter of public opinion at the expense of the unborn and unprotected. Both are evils that medical providers who follow Christ will battle throughout their careers.

Here in Rwanda the battle is one on one, a relational effort to change people's hearts through the establishment of trust in our skills, our love and our faith in Christ. In the U.S. the battle is no less intense on the personal, relational front, but is compounded by the increasingly aggressive attack by the government on our rights as providers and patients to determine our own attitudes and actions in protecting all human life. Unless we are firmly founded in what AND why we believe what we do in regards to human dignity and sanctity of life, we risk having our resolve eroded.  On this issue the daily renewing of our minds in Christ through the leading of the Holy Spirit is an indispensable habit of life.  Please pray that these weeks "on a hill far away"** will be a time of formation and strengthening of values that will last a lifetime, however long those lives may be.

**see: On a Hill Far Away by Dr. Al Snyder, who gave his life to serve Christ at Kibogora

Kibogora Week One

Kibogora, Rwanda  24 March 12

Greetings from Kibogora, the site of Kibogora Hospital in SW Rwanda.  To view pictures and commentary from out group please go to:  teamrwanda2012.blogspot.com.

The trip:  We departed Mobile twice.  A short round trip to Satsuma was necessitated by a passport left behind--the owner shall remain nameless.   We arrived in Atlanta with time to spare and spent a considerable time getting our personal luggage and supplies checked.  The flight from Atlanta to Amsterdam, a little over 8 hours, departed at 18:00 EDT and arrived in Amsterdam at around 08:30 Sunday with only about 90 minutes of layover.  Security checks in Amsterdam are at the gate, necessitating a second pass through the gauntlet.  One traveler's otoscope drew attention because of its appearance similar to a gun.  That resolved, we boarded a KLM flight to Kigali, Rwanda, for nearly 8 more hours.

The Kigali airport, while able to accommodate an airbus, has a terminal only slightly bigger than our plane.  We passed through customs without incident.  None of our luggage was inspected, and none was lost in transit (minor miracle considering the volume and short layover.)  We were met at the airport by the Albertsons, who had arrived ahead of us, and the Finleys (included Will the 2+ year old who was kick). The Finleys are missionaries in Kigali, a city of approximately 1 million people and the capital of Rwanda.

 We spent the night at the Eden Motel in Kigali:  as Duane said, picture Eden AFTER the fall.  Beds were slightly softer than plywood, the water was undrinkable (everywhere in Rwanda without treatment/filtering), and the windows had no screens which meant a decision:  be uncomfortably hot or battle mosquitoes that might carry malaria.  We decided to be cool.

The next morning (Monday, the 19th) we had breakfast at the Eden--it was consistent with the bed quality, enough said.  Shortly  thereafter we boarded a 24 passenger bus for the trip.  The buses here are designed for passengers, not luggage, so we stored 30+ large bags in the back of the bus and crammed the sixteen of us into the front portion.  Kudo's to Jeanne Claude, the Congloese surgeon who joined us in Kigali, Lee Ann, our new friend from Montana (friend of the Albertson's), and others for sitting for 8 hours in a jump seat with no padding--the last two hours were on roads with no pavement and under construction, making for a very bumpy ride.

We stopped for lunch in Butare, a sit down affair with a cooked meal in a motel that catered to expatriates.  After that there was a roughly 5 hour test of bladder and bowel for the 17 occupants (driver also) until we arrived at Kibogora.    The test was exacerbated by the uneven pavement and the daredevil driver who must have a utilitarian view of human life.   On the trip we passed thousands of people walking the prepared paths along the main highway.  As the bus would approach, he would blow the horn if anyone dared to wander into his path, but rarely used his brakes.

At one point he rounded a curve in a one lane construction zone and came face to face with a Mercedes transport truck.  The two trucks, with brakes fully applied, stopped a few feet apart and all of our occupants exhaled, groaned, and then laughed with relief.  An argument ensued as to who should back up and we lost, so we backed up a bit, let him pass and we were own our way.  The buses here have very good brakes and very good suspensions.  Going at considerable speed they handle curves with minimal lean, even with a weight load that our baggage had added to its usual burden.  The cost of transporting 16 people and their luggage for 8 hours was 18000 Rwandan francs, or just 300 dollars.

We were greeted at the compound by several people whose first job was to escort all to "the facilities".  Afterwards we were assigned houses, unpacked, and collapsed into bed for the first decent chance at sleep since Friday night.  On that note, I should mention the great spirit that everyone exhibited throughout the trip in spite of considerable fatigue.

Tuesday:  We were escorted around the hospital and oriented by Edi, a nurse from Germany who has just returned here to work, having spent 2004-2007 here, and Kari a medical student from Albert Einstein in N.Y. City, who took a 4th year sabbatical to work on an OB project for one of her faculty in N.Y.  Kibogora Hospital is built on the side of a hill and has three main levels, the highest being the main entrance and then down to the other two sets of buildings.  At full capacity it is said to hold 260 patients.  Pediatrics is housed at the bottom, which is somewhat symbolic, I think, of how the child is viewed in the culture.

Wednesday:  We broke up into teams and began seeing patients.  In our group were Britni Bradshaw, Liz Donahue, Caroline Bryars, Micki, my wife, and me.  Our M.D. host is Dr. Ngoy, a Congolese generalist, who is currently assigned to pediatrics for his day responsibilities.  We began in the "neonatology unit",  a room approximately 10 by 14 in which 5 incubators, 5 cribs are housed along with the mothers of any babies housed there.   While the temperature here is quite pleasant, the neonatology unit is akin to a sauna, with the only moving air coming through old style windows that open horizontally with cranking (jolis?).  Infants are bundled in heavy sweaters and blankets with no monitors, so visual inspection is impossible without entering the incubator.  There are no monitors--if an infant has an apneic event, he/she is on their own.  There are no pumps--intravenous fluids are dripped in with the attendant variations in delivery that arm position produce.  For that reason, every effort is made to get I.V.'s out quickly.

We rounded in neonatology and then in pediatrics with Dr. Ngoy.  He has a broad base of knowledge for a generalist so young (around 32 y.o.).  On the first day alone we were introduced to cerebral malaria, a severe gastric outlet obstruction, pneumonia, sickle cell disease, and a myriad of other disorders.  When not being seen the children generally play outside, watched by their moms, their family wash hung on the clotheslines beside the building.  Our group got to interact both medically and socially as the children love to have their picture taken and to be hugged.  If you smile at them, they almost always smile in return, but the moms and children are wary until they see your expression.

The tendency in medicine is to treat diseases, not people.  I mention the diseases above but not the people--they are gentle, cautiously friendly, and cooperative.  The children are quiet while we round and are amazingly cooperative with exams, in general. A great ice breaker was taking pictures with the various smart phones and showing them to the children and moms.  This always illicits a smile and helps to break the ice.  In both the neo unit and the wards we asked to pray on several occasions and were never refused--in fact on two occasions we were called to another bedside as a result of the first prayer being asked to pray again.

Thursday and Friday were similar to Wednesday except that our U.S. team began to see most of the neonatology patients and were more involved in the pediatric wards.  Our little team had one crisis on Friday when a 5 month old child was noted to have extreme respiratory distress, having presented with the mother's complaint of abdominal pain for 2 months.  The infant's saturations were dangerously low, so Dr. Ngoy put her on oxygen (the only oxygen available is an 02 generator).  We became increasingly convinced that she had a congenital heart problem, probably a Tetrology of Fallot, and doubted she would survive.  Caroline, a high school senior who plans to follow in her mother's footsteps as a nurse, lead a prayer for her.  We were all pretty shaken to leave her, knowing she might not be alive when we came back in the afternoon.  The hope I had was that she was having a "Tet spell" and that if she resolved it, she would improve.  We returned about two hours later and she was breathing quietly and breastfeeding without distress--an answer to Caroline's prayer.  Sadly, unless she can get to a location that does CV surgery, she will probably not survive the next few weeks or months.  That kind of transport cost and surgery expense has to be borne by the family, and few have those resources.

Saturday:  Most of the team decided to go to a National Forest to see the monkeys there.  Micki and I decided not to go, and I made rounds in place of Dr. Ngoy in the neo unit because he was away at a mandatory meeting.  We also checked on the little girl with Tetralogy and she was doing well.

A comment on the first week:  Life here is a struggle, unlike anything we experience in America, though far less dramatic than in places such as Darfur.  Our compound night "guard" walks two hours to work 12 hours and then returns home, being paid 3 dollars per night, and that is about 3 times what he would make working in the fields picking crops of tea or other crops.  The people here live in a constant survival mode, heavily dependent on rain for crops.  Most carry water (50 gallon jugs) from a well at the bottom of the hill up to their abode as their only source of water.  Their fishing boats, which we see coming in each morning, their occupants singing, are made from logs, much as the early American Indian made their canoes.  The grounds of the compound are "mowed" by men using a small machete, cutting a 6 inch span of grass with each swing--we are talking over an acre of grass.  Lawn mowers are non-existent here.

 Life is day to day, sleep, work, eat, sleep.  The vast majority will rarely or never leave this general area, and if they do it will usually be on foot.  So, is their life less valuable than someone who lives in the U.S. or Europe or another developed country?--only if one judges the value of a life by its surroundings.   Instead, if we judge value of life by the relationships that each of us has with our family and friends, and especially with our God, we are all equally a part of God's human creation.

One of the cultural barriers that we have already seen here is the acceptance of death as a matter of course--that is both a healthy attitude (that many in the U.S. ignore/deny until the bitter end) and one that results in a diminished effort to sustain life if too much effort is required.  We would be naive' to think in a few short weeks we can change a culture of centuries, but we can relate, love, and temporarily relieve pain and suffering--and in the final analysis, those are truly the only real meaningful things we can do for each other, whether in medical care or in daily life.  We are not so different from these folks, and the things of real value transcend cultures and do not involve the luxuries and distractions of life--those things actually can either add to our lives or be hindrances but they will never be the core of our existence-that core is our relationship with our Lord and our fellow sufferers.

Please pray for our group and its mission:  for physical health (as we try to remember not to drink the shower water or wash out our toothbrush under the faucet); for emotional health, as we all miss home a bit; and for spiritual health and insight--that Jesus would lead us to our true mission here--to glorify the Father.