Pré Avis in the Congo

Whenever you leave the base for any kind of road trip, there is bound to be some excitement. The destination was the Town of Kilwa and the goal was to meet Dr. Wilma…the “Médecin Chef du Zone” for the health region where Dubie is located. As the guy responsible for medical activities in most of the health structures where we work, he is my most important counterpart and this visit was already a bit overdue.

Although Kilwa is only 130 km away, the roads really are nothing more then glorified footpaths. It is literally impossible to picture what it would have been like in the Belgian era where cars could travel these EXACT SAME ROADS at 80 km/hr. This trip took us a grueling 11 hours and did not disappoint in terms of excitement along the way!

Photo: G. Assenheimer | A typical road in Katanga.

Breakdown

It started at 6:00 am on a Tuesday morning. Travelling with me was a nurse heading back from a training session, the driver and a ‘convoyeur’. While it may seem a bit excessive, a convoyeur is a guy who comes along specifically to help in case there are problems along the way.

We had to jump-start the car (i.e. 4 guys pushing from behind to get the car rolling and then the driver pops the clutch) so that never bodes well…but the driver assured me we’d be fine once we had driven for a bit and the battery had had a chance to charge. A bit fishy, but its 6:00 am and we need to go so I let it slide.

Not even an hour from the base, we encountered our first obstacle. A pretty big tree had fallen across the road and we had to find another way around. Our driver paused for a bit and, as if out of a commercial advertising landcruisers, he slowly backed up, took a sharp right and climbed up on to the bank beside the road in an attempt to get around the log.

It was rough, he was all over the place and there simply wasn’t enough clearance. Sure enough, halfway through the maneuver he stalled and, as feared, the car wouldn’t even turn over. So…stuck one hour from base with a car that wouldn’t start!

Photo: G. Assenheimer | Road blocked... now what?!

We used our radio to call for a rescue car and one was dispatched from the base right away. We were really quite stuck and the handful of people who came from a nearby village to check us out couldn’t help. So we wait. In the meantime, the convoyeur lit a fire under the log to weaken it in the middle and to allow us to at least clear the path for our return trip.

An hour later, our rescue car arrives. The fire had burnt through a big part of the log and we were able to pull it apart and roll it out of the way. Once we had freed the car and got it started again, we swapped vehicles and, as we continued along in car number two, the first car limped back to the base and the waiting mechanic.

Photo: G. Assenheimer | Getting a boost from the rescue car.

Stuck

Not even another hour along the way, it started to rain and we came across a deep puddle. Our driver carefully switched to 4×4, placed it in first gear and started slowly through the muck. Unfortunately, he missed the “normal” path, sunk into a bit of a hole and suddenly the wheels were spinning.

Everyone gets out and both the driver and convoyeur jumped into action. Up to their knees in water, they were busy jacking up the back end and placing logs under the tires to fill the hole and to make a bit of a ramp. This was obviously not the first time that they’ve done this and we were back on the road in less then 30 minutes.

Photo: G. Assenheimer | Stuck again!

Village after Village

The normal, more direct route to Kilwa is currently not passable due to the rainy season. Forced to use an alternative route, the detour doubles the travel time. Following the shores of Lake Mwero and passing through countless small fishing villages along the way, it really is a beautiful drive. At times, the horizon opens up displaying a spectacular vista – lush green hills flanking each side of a red earth path snaking away in some version of a road. The lake is huge and, in places, you can’t even see across!

Photo: G. Assenheimer | The fishing village of Lewanza.

However, for the most part, this beautiful scenery is obscured by the 10 foot tall grasses growing along the side of the road. We bounce along at a painful 20-30 km/hr and slowly, slowly approach the destination. Lewanza, Lukenzolwa, Kongolo, Lusalala… and many others that even our drivers have a hard time remembering. My job on trips like is radio the base with our position every hour and to wave back at the people who greet us as we drive though. Each village is similar and, as we approach, the tall grasses give way to towering mango trees and adobe huts lining each side of the road.

As you near the center of town, there is usually some sort of market. While the selection depends on the size of the village, there is always something for sale. This could be as simple as a table selling bananas or a small stall with batteries, cigarettes, pots and flip-flops. In the larger centers, it could even be a real ‘store’ with a bit more variety and even a door that could be locked.

Photo: G. Assenheimer | The main market in Lekenzolwa.

Photo: G. Assenheimer | Roadside stall – we stopped to buy mushrooms and tomatoes for dinner.

Opps!

There are always people around. Women (young girls usually!?) pounding manioc, men making fishing nets and children screaming “Mzungu, Mzungu!!!” and rushing out to greet the car as we continue on. There also seems to be lots of animals around. Goats, chickens, guinea fowl, pigs. A definite sign of improved stability and a return to normalcy in Katanga, this is also the reason for the next unplanned stop.

We were slowly passing through one of the villages when a goat decided that instead of running away from the car, he would try to run under it! Not a great idea and we got him with our rear tire. Yup…ran over a goat…
Our driver stopped, checked his review mirror, sighed and got out of the car. The villagers were already starting to gather and clearly this wasn’t going to well for him. The driver, not MSF, is totally responsible in cases like this. According to the local law, the driver is only at fault if you run something over with the front tire. In this case, it was the rear tire so he should not have had to pay anything.

A discussion continued, money exchanged hands, we continued on and the villagers feasted on goat that night. In the end, he did run over a goat and felt responsible for compensating the owner, regardless of who was at fault! This is NOT the sort of thing you get in your MSF training courses!

Belgian Bridges

Another hour longer, we get to a spectacular bridge that had clearly been built by the Belgians before independence of the DRC. While the metal structure was in seemingly good shape, the years had not been as kind to the wooden slats that are needed to ensure safe passage. Some had been stolen and others had just rotted away and had been replaced by small logs. One word – Sketchy.

Most of the time, the driver just pushes forward, trying to avoid the largest holes and get to the other side without falling through. Although I’m not usually too concerned about this sort of thing, even my gut clenched a bit. The bridge in the picture below was especially bad. In this case, the driver actually had to rearrange the sticks and use his sand plates to cover a pretty big hole towards the far end.

Photo: G. Assenheimer | Where is the maintenance crew?

The way back

…and THAT was all on the way there!

The meeting with the Doctor was quite productive and definitely made the trip worthwhile. I had almost 20 issues to discuss and we were able to come to agreements on most of them, with both of us leaving with action items. .

The way back was no less interesting. We had to drop off letters at a few of the health centers and ended up transferring a small boy with severe malaria / anemia to one of the small regional hospitals. That was a stressful ride and whenever he stopped crying I held my breath until he started again…as at least this way I knew he was still alive.

Since my meeting went a bit long, we left a bit late and had to spend the second night with the Sisters in a small town halfway back to Dubie. Although nothing is free, they fed us, provided rooms for myself the driver and our convoyeur and even found us some breakfast the next morning.

As per the heading for this entry…NEVER a dull moment!

Photo: G. Assenheimer | Nice view!

Hello Everyone! My last entry has been a few weeks ago and I feel like I haven’t been so consistent to all my readers back home. Sorry about that…but it is definitely not from a lack of things to write about. Quite the opposite as my last few weeks have been absolutely action packed and I have either been on the road, too busy or simply too exhausted to go back to my computer after dinner and to organize my thoughts into a blog entry!

Highlights include a 3 day road trip to Kilwa to meet the “Medecin Chef du Zone”. As the Ministry of Health doctor responsible for all of the medical activities in the health zone where we work, he is my direct counterpart and one of the most important contacts/relationships I need to maintain. The meeting was good…but the road trip in itself was incredible.

I was also busy hosting community meetings in 5 of the villages where we currently support the local Ministry of Health clinic. In principle, this is a ‘town hall’ meeting where MSF explains our reasons for leaving, describes what the actual handover process will look like and gives the village leaders a chance to ask questions. In practice, this has me sitting in a sweaty classroom for 3 hours telling 50 people that they are losing their free health care and that now is the time to step up and to start working with the Ministry of Health to take responsibly for the health care in their community. Interesting. Important. Draining.

Finally, as we have less then 2 months before the actual handover date, I have also been busy giving notice letters to many of my staff. I have done about half…which means that I have had individual meetings with over 50 staff members where I give them their pink slip, explain their final payment details and discuss their plans for ‘after MSF’. I’ve had some interesting responses that I thought I could share.

After 20 straight days on the go, I was finally able to take my Sunday off! Over this next week, my schedule is a bit less hectic so I plan on writing about each of the topics above. However, for today, I want to leave you with a description of my visit last week to see a traditional healer in action…

They Are Only Roots

Witch doctor? Fetisheur? Shaman? Traditional healer? I suppose all of these would be an acceptable way to describe the man to which I was currently being introduced. Although barefoot, he was wearing a green and black striped golf shirt with grey slacks and was quite presentable. His eyes were shinning and he seemed genuinely impressed to receive a Mazungo as he invited me to join him in the shade of one of the huts that were scattered around his yard.

Here I am, sitting in my white MSF T-shirt and representing all forms of western medicine. Not only does this contradict his beliefs and those that he tries to install in his clients, it also represents a direct competition to his business of healing.

So, as you can imagine, this conversation was going to be a bit awkward and an invitation to sit with him in the shade was a good start. We (I was here with the expat nurse in charge of the outreach team and one of her Congolese staff) were not just dropping in either…we had heard that there were a few patients in pretty bad shape that really needed to be transferred to the Ministry of Health clinic and we were hoping to take a look.

The Pharmacy?

After introductions, I started by asking about his patients and how things were going. He confirmed that he had a couple of difficult cases with fevers but that his treatment seemed to be helping. Curious, I asked what, exactly, was his treatment for a fever. A bit surprised, he asked if I wanted to see his pharmacy. Of course…so off we go.

Rounding the corner of one of the small huts, we arrive. There is an axe, a few small piles of roots and various chunks of wood obviously from different trees. Oh…this is the pharmacy!? It really looked more like an empty wood chopping pile. He then proceeded to pass me different pieces of wood explaining that this one is for fever, this is in case a woman cannot get pregnant, this one is for worms. You just boil them for a bit and sometimes you drink it or sometimes it has to be injected. It depends.

And your patients with fever? Sure…come take a look.

We walk over to another small hut and the outreach nurse ducks her head and enters to examine a one year old boy that is clearly in the late stages of severe malaria. His eyes were rolled back, he was clearly anemic and he was in desperate need of a blood transfusion…not more of the root concoction.

Now the negotiations start. If we aren’t able to convince the traditional healer that this boy needs to go to the health center, there isn’t much we can do. If he tells the parents to go, they go. If he tells them to stay, they stay. If he tells them that their son has offended the evil spirits and will die, they accept. That is the kind of power he holds.

Follow up

In this case, we were successful. The parents quickly collect their things – a pot, blanket and a few pieces of manioc – and carry their son to the waiting landcruiser. It is hard to know why the traditional healer accepted. Maybe he was trying to put on a good show for the foreigners. Maybe he knew that the boy was going to die anyway. Maybe he honestly cares about the health of his patients…

We arrive a few minutes later at the health center, quickly confirm that it is malaria and give some medication to try to stabilize him. You need a fully function lab to do blood transfusions so the outreach team prepares to transfer him to the hospital. The parents pick up their child, climb back in the car and are joined by a Congolese nurse who will do what she can during the painful 3 hour trip back to the hospital.

He died halfway there.

Always too late

Although we are pretty good at saving lives, it is certainly not always the case. One of the main reasons patients die in our health centers is that they simply show up too late. There was really nothing that we could have done for the boy. If he had arrived a few hours earlier, he would probably still be alive.

Sometimes, they don’t even realize that their child is sick until it is too late. Sometimes they have to walk for hours – or even days – to reach the health center. Sometimes they simply think that there is nothing we can anyway and don’t bother.

However, more often then not, they simply trust their traditional healer and his pile of roots. We do what we can to educate and sensitize, but we are going up against hundreds of years of tradition and that is not easy. MSF does not pretend to address sorcery or think that all of these traditional remedies are useless; while there really is a time and a place for these beliefs, it is just NOT when a child is suffering from severe malaria.

Sometimes the realities in the field are pretty hard to take.

As the Project Coordinator, human resource management fall under my responsibility and with almost 100 Congolese staff working in our project this is a big part of my job.

So what exactly does this mean? It means working with the supervisors to reduce the amount of overtime their staff works. Making sure that employees get 3 days off for the birth of their child or 6 for a death. Ensuring everyone has a valid contract (last month alone we had 7 people whose contracts finished or were renewed). It is promotions and recommendations, but also warnings and suspensions. Health care for family members, transportation allowances and per diems. It is conflict resolution. It is all of this and so much more. Throw in some French, a bit of corruption and a culture that is completely foreign and you get can start to understand how my days here in Dubie are just flying by.

We’re only managers

This is the behind-the-scenes part of MSF that no one really considers when donating money to help save lives and alleviate suffering. However, when you do think about it, it makes sense. We are running a hospital with over 100 beds and, just as it does back in Canada, this requires staff. You still need to have doctors on call, nurses working night shifts and labtechs who can be called in case an urgent blood transfusion is needed. You need cleaners and cooks and receptionists and guards. And you need people to supervise everyone.

When expats leave for the field for the first time, a common misconception is that they will be totally hands-on in their work. That the nurse will be changing dressings and the logistician will be fixing generators. While this is more valid for certain positions (i.e. surgeons) and in certain projects (i.e. the emergency response in Haiti), for the most part expats find themselves in the role of supervisor and spend a lot more time managing staff than they do managing patients or their fleet of landcruisers. In Dubie, for example, the expat nurse manages over 30 Congolese nurses.

It is true that, at the local level, it is hard to find qualified doctors and nurses. Dubie is a village without electricity and where access is practically a footpath, so you can imagine that it is difficult to get a University education in town. However, this is not the case for bigger cities where there are various public and private institutions that produce graduates of a decent caliber. While this means we end up bringing most of our medical staff in from the big cities, it is definitely possible to find qualified staff in the Congo.

Responsible employer

MSF is in fact a significant employer in Katanga and we do our best to act as a responsible one. Although it may be hard to imagine that in a country with such a HUGE unemployment rate (when I look online, all I can find is “n/a”!!) and a fairly minimal economy, the DRC actually has incredibly complex labor laws. A legacy left by the Belgians when they granted independence to their former colony, this is one thing that has actually survived the dictatorship of Mobutu, the war that followed the end of his reign and the fragile peace after that.

MSF takes pride in treating their staff well and, as project coordinator, it is my job to make sure that this is implemented fairly at the field level and across all positions. In reality, it means that I spend a lot of time discussing promotions, approving overtime and checking paystubs, but I think that so far we are doing OK!