Back in Business

December 26th, 2010 by douglasp

For the last several weeks there has been low intensity military trouble around Mungele.  Two groups have been intermittently shooting at each other, creating anxiety in the general population.  Unfortunately, the people here are accustomed to shootings, battles, and war.  They have grown used to armed men entering their homes, stealing animals and other belongings.  When military activity gets too “hot”, the population flees into the jungle, sleeping in the dense forest until things calm down.

Seven days ago, I took the early morning car to Mungele for my usual Saturday trip.  Nearby there had been some military activity a few days previously so there were not many patients.  At 10:30 a.m. I departed to return home.

One hour later a battle began in the village and continued for hours.  Soldiers from both sides were injured.  When a truck transporting cargo and passengers passed by, it was stopped and the wounded from the Congolese army were loaded on for transport to the hospital in Lubutu.  Shortly thereafter, bullets sprayed the truck.  Miraculously, no one was killed, but seven of the civilians were struck.  The truck rolled on to Lubutu.  Since there is no mobile phone coverage outside Lubutu town, the injured arrived in the Emergency Room without warning.  At 10 p.m., the hospital personnel heard the roar of the truck’s engine, lots of shouting and moans, and then eleven bleeding, gravely ill people arrived.  Almost all of the injuries were severe and it is still unclear whether all the patients will leave the hospital.

The staff of the Centre de Santé and the population of Mungele and nearby communities had fled their homes and were encamped in the jungle.  Virtually every home was pillaged, burnt, or both.  In the Centre de Santé, all the doors was broken down and many items were stolen.  Fortunately, though all of them were living in the insect-filled jungle, the staff of Mungele’s Centre de Santé were thought to be all alive and unhurt. All total, they spent five days in the intermittent torrential rains before most of them reached Lubutu.  I was worried for their safety and was relieved to hear no one had been physically injured.

Today, seven days later, I went back to reopen the Centre de Santé.  All was well until the car reached Amisi, the village 5 kilometers before Mungele.  In the two towns, the only humans I saw were looters, leisurely stealing everyone’s possessions.  With me came the two consultants, the pharmacist, and our receptionist.  We cleaned for one hour and then opened for business.  Magically patients appeared.  They were examined and given treatment before hiding again.  It is in no way safe for them to return home.

Clearly the local population was happy we were back.  So was I.

Christmas

December 25th, 2009 by douglasp

This was my first Christmas completely removed from the United States.  It has been very different and wonderful.

The most obvious differences have been the weather and wonderful lack of commercialism.  As anticipated, Lubutu’s Christmas weather is tropical.  Christmas Eve was very hot, with the blazing Equatorial sun in a cloudless sky.  Though I cannot say I enjoy sweating on Christmas, it has been nice to escape the West’s commercialism.  No one has disposable income here and there is nothing to purchase anyway.  Last week I spoke to Kurt and we talked about his anxieties of his yet unbought gifts for his parents and siblings.  It was difficult to relate.  In a different conversation, my mother asked if it was all right for us to exchange Christmas presents in February, after my return home.  The question was so alien to my current situation that it took me a few moments to think and answer.

Though the contexts of weather and commercialism are different, I had an unforgettable holiday.  On Christmas Eve I went to church at the cathedral directly opposite Couvent.  Four of us entered into a crowd of about 600 people, all beautifully singing, swaying, and dancing.  Ten altar boys danced in synchrony, surrounding a motionless singing priest.  The interior walls of the church’s vaulted ceiling amplified the passionate voices.  We initially joined the large group standing in the rear, dancing and clapping.  When the hymn was over, several people offered us their seats.  We initially refused but it was clear this was a losing battle.  We eventually sat down on a backless wooden bench and listened to the service being conducted in Swahili.

In a forward corner of the church stood a crèche.  The figures all had black skin and the manger lay under trees and a roof constructed of banana leaves.  The only other decorations hung across the width of the sanctuary.  Strings of thousands of packing peanuts criss-crossed over the congregation’s heads.  Many more hymns followed with drums providing the only accompaniment.  We clapped in time to the music as everyone sang passionately of the holiday.

It had a fantastic Christmas experience here in non-commercialized tropical Lubutu.

Bisoke

December 5th, 2009 by douglasp

I planned to spend two days in Rwanda’s Parc National de Volcans.  Yesterday I satisfied my curiosity about the mountain gorillas.  What next?

There are three choices of non-gorilla activities.  The most popular is a short hike in the forest to spend time with golden monkeys.  Like the gorillas, these small primates have been habituated to human contact.  I asked several people about the experience and received reviews varying from “fantastic” to “they were up in the tree tops so don’t waste your money.”  So no golden monkeys for me.  Another possibility for a day trip is a hike to Diane Fossey’s grave.  She lived in these mountains, studying and educating the public about mountain gorillas.  She was murdered in 1987 and is buried just outside the park boundaries.  Not having read or seen “Gorillas in the Mist” I decided to forego this activity.  The third possible choice is Bisoke.  Parc National de Volcans encompasses five extinct volcanoes.  They form the border between Rwanda, Uganda, and the Democratic Republic of Congo.  From the Rwandan side it is possible to climb two of these mountains.  Karisimbi is a two day trip but Bisoke can be hiked in a day.  To me, on a visit to Volcanoes National Park, isn’t it logical to try to climb one of the volcanoes?

Photo: D Postels | Volcano at the Parc national de volcans

Photo: D Postels | Volcano at the Parc national de volcans

The National Park charges seventy-five dollars per person (including a guide) to climb the mountain.  As I predicted, there were no other tourists wanting to go today.  I had the guide to myself!  I am sometimes a fast hiker and groups of varying abilities can be exasperating.

We began the trip by walking through beautiful fields of flowers resembling daisies, grown and harvested to produce a natural insecticide.  After a gradual ascent through the flowers, we crossed a stone fence that encloses the national park, built to keep people out and wild animals in.  The going got rough almost immediately.  The path was steep and very muddy.  Following each step forward I slid back a half step.  The guide and I proceeded through several different vegetation zones and saw a lot of fresh droppings (including gorilla) and footprints, but no living animals.  The path got steeper and I repeatedly thought “how are we going to go down this?”  I considered calling it all off several times (40% of tourists do so) but 4 ½ hours after starting, we arrived.  At the summit of 3711 meters (about 11,500 feet) lies a perfect crater lake.  On the other side of the water lay Congo—home!

After a short break for lunch we started down.  For me, this was much worse than ascending, though faster due to my innumerable falls and slides.  My hiking boots were dirtier than I have ever seen them, likely due to hundreds of dunkings in 6 inch deep mud.

The path down took slightly under four hours.  When we crossed the stone fence to exit the park I was exhausted, happy, and relieved to have stopped sliding and losing my footing.

Photo: D Postels | Parc national de volcans

Photo: D Postels | Parc national de volcans

Was it worth it?  Definitely.  Would I recommend it?  Only for people who are very fit and have excellent hiking boots, rain gear, and lots of determination.  And only in the dry season, though the guide told me there is mud even then, as the summit is usually in clouds.  If descending steep muddy trails makes your ears burn with anticipation, it is perfect.  I loved the experience and am pleased I persisted to the summit but tonight am hungry, tired, and sore!

Gorillas

December 4th, 2009 by douglasp

It is only money but 500 dollars is a lot. I debated about buying a permit to see the mountain gorillas in Rwanda for a long time. To me, 500 dollars is many days of sweat and toil. Permit holds spend only one hour with the gorillas. Is anything worth 500 dollars an hour?

Here is Rwanda’s Volcanoes National Park there are eight groups of habituated mountain gorillas. Each day, seven people are allowed to visit each group. A typical gorilla group contains seven to twelve members headed by one or more male silverbacks. The other members are females, babies, and younger males called “blackbacks.” Each gorilla group has a name. After arriving at park headquarters at 7 a.m. I was assigned to see the Susa Group. Susa has the most members but is also the most remote. Tourists wanting to see them must be willing and able to hike a long distance.

It was a hard trek of three hours straight up the side of a mountain, beginning at an altitude of 9000 feet. The path was toppled trees and trampled plants. My feet rarely made contact with solid ground. Without a walking stick to plunge down to the earth and use as a third leg, it would have been nearly impossible.

Photo: D Postels | Silverback mountain gorilla of Rwanda.

Photo: D Postels | Silverback mountain gorilla of Rwanda.

So at noon today I had my contact with the mountain gorilla. Susa has two silverbacks, the extremely large (200 kilogram) dominant males. There were approximately a dozen females and as many blackbacks and babies. Bigger gorillas lazed on the ground while the babies swung in the trees. National Park rules state that humans are to stay seven meters away but one especially friendly female came much closer to inspect us.

Photo: D Postels | Mountain gorillas of Rwanda

Photo: D Postels | Mountain gorillas of Rwanda

When we were halfway down the mountain, the wind picked up, clouds rolled in, the temperature dropped, and I was drenched from my first Rwandan rainstorm. By the time we drove back to town the sun was out. Our group celebrated our successful gorilla encounter with cold beer in the warm sun. There are approximately 710 mountain gorillas in the world, all threatened due to territorial encroachment. I spent part of today with a few of them and felt lucky to do so.

Kigali

December 2nd, 2009 by douglasp

Kigali is a one day city.  I have been here exactly twenty-four hours and feel I have done and seen it all.  There isn’t a lot here for the tourist, but what I did see was powerful and nearly had me crying in public.

Mention Rwanda to most people and they remember the genocide of 1994.  For one hundred days the majority Hutus slaughtered the minority Tutsis.  After it was over, one million people had been murdered.  When recounting this story, Rwandans pause here and then invariably add “Rwanda was dead.”

Perhaps not dead but badly hurt.  To begin healing the national wound, dozens of genocide memorials have been opened around the country.  Today I visited one of them, the Kigali Memorial Center.

The Center has two floors.  On the first, rooms are arranged in two circles, one inside the other.  The exhibits in the outer circle begin with photographs and commentary of the colonization of Rwanda, steadily leading up to the events of 1994.  Video screens tell the tales of eyewitnesses and survivors.  It was chilling as I remember those 3 1/2 months very well.  I remember thinking “uh oh, this is not going to be good” when the president of Rwanda’s plane was shot down on approach to Kigali airport.  I remember the killing extensively covered in the press while no government intervened to stop the massacre.  And I remember being relieved when it was over.

After finishing the outer circle of commentary, the inner circle of exhibits were even more chilling.  One room was filled with carefully stacked skulls, many crushed by blows.  Another held thousands of photographs of victims, submitted by their families for display.

That over, I ascended the stairs.  To the left were huge photos of children.  A plaque below listed their favorite toys and foods and the way in which they were murdered.  The remainder of the second floor detailed other genocides throughout history – Armenian Turks, European Jews, and Cambodians, among others.

I exited the building and walked around the gardens encircling the Memorial Center.  The flowers and fountains sit atop the mass grave of 250,000 Rwandans.

After an emotionally wrenching three hours, I spent the remainder of my day shopping and walking the streets of Kigali.  I have ended my afternoon and now sit with a drink next to the swimming pool at the Hotel de Mille Collines, made famous in the film “Hotel Rwanda.”  Only fifteen years ago, hundreds of people sought refuge here, drinking the water from the pool to stay alive.

As with all genocides, the most puzzling question is “How could people do this to each other?”  Not to strangers but to neighbors and friends.  My one full day in Kigali was interesting and emotionally exhausting.

Worlds Apart

December 1st, 2009 by douglasp

This morning I woke up at my usual early hour, went for a run on Axe Kindu, and returned home for breakfast.  There were new arrivals last night so for a nice change I had camembert with my usual horrible coffee.

At 11 a.m., a car brought me to Tingi Tingi, a widened section of pavement called an “airstrip”, located 20 minutes outside Lubutu.  Seconds after we arrived, a small plane landed.  Out popped three expatriates and their baggage.  In response, Kirstin (a Belgian expatriate leaving Lubutu) and I jumped in.  The twelve seat plane took off over the thick jungle.  Slightly over an hour later we landed in Goma, far eastern Congo.

Photo: D Postels.

Photo: D Postels.

After a few minutes at the MSF base, I was driven to the border and crossed into Rwanda.  What a change!  The roads are well paved and have shoulders or sidewalks where people can walk.  When I jump on a taxi motorcycle the driver hands me a helmet.  There are stoplights and there is currency other than the US dollar.

Thankfully one of the drivers from the MSF base helped me cross the border, travel by taxi motorcycle to the nearest Rwandan bus station, change money, buy a bus ticket, and get seated on the next bus to Kigali.  From the border this entire procedure took twenty minutes, unheard of in Congo.

Three and a half hours later the bus arrived.  I took another “taxi moto” to the recommended but not very nice Hotel Okapi.

So many things are strange here.  There is a lot of traffic.  In contrast with the quiet of Lubutu, Kigali is deafening.  No one stares at me or says “bonjour” even though I saw few other white people in town.  There are sidewalks, lots of traffic signals and glass buildings taller than one story.  There is almost everything except ice cream parlors and movie theatres.  Of course these were the two things I most eagerly anticipated!  Too bad.

The countryside is drastically different here.  There are mostly big rolling hills, almost completely deforested of their native trees, every inch divided into square cultivated plots.  No matter how steep, nearly all of Rwanda is being used to grow food.

Photo: D Postels | Cultivation of land.

Photo: D Postels | Cultivation of land.

It is overwhelming to be in this city after four months in Lubutu.

Thanksgiving

November 26th, 2009 by douglasp

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

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

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

So I think the gravy is out, too.

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

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

Thanks for reading and Happy Thanksgiving!

Maiko Too

November 24th, 2009 by douglasp

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

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

Photo: D Postels | Motorcycle crossing

Photo: D Postels | Motorcycle crossing

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

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

Photo: D Postels | Motorcycles

Photo: D Postels | Motorcycles

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

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

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

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

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

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

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

Food Too

November 15th, 2009 by douglasp

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

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

Photo: D Postels | Buffet lunch

Photo: D Postels | Buffet lunch

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

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

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

Photo : D Postels

Photo : D Postels

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

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

King for a Day

November 14th, 2009 by douglasp

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

Photo: D Postels | King for a Day

Photo: D Postels | King for a Day

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

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

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

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

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

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

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