Partners' Hospital

In the midst of Rwink lies the main Partners in Health hospital. I got the chance to have one of the lead doctors show me around on Saturday. It was awesome to see the current baseline version of the electronic medical record system in use, but there are some other, more poignant images that really stick in my memory. Since it was the weekend, it was a bit quieter -- none of the big HIV/AIDS treatment groups meet on the weekends, though there were definitely lots of people around for other purposes...

• Birthing! Want to hear something crazy / amazing? Women in Rwanda are TOTALLY silent while giving birth. I can't imagine. We were walking past the maternity ward, and Michael, the doctor, was like, "hey - want to go in?" He then realized he should check to see if anyone was in labor first (um, YEAH) ... and it turns out there was! And she was not uttering a PEEP. I asked some Rwandans why it is not considered appropriate to scream and shout and curse and whatever during birthing, and they looked at me quizzically. (They were men.)
• Pediatrics: The Peds ward was PACKED. Two or three to a bed. A couple of beds were dedicated to premature babies. There was this one premie who I just wanted to hug forever and ever - she was SO incredibly beautiful, and about the size of my forearm. And she was sleeping in this big bed, all tucked in, but all by herself! It is so, so hard for these mothers -- if they have children in the hospital, they are not caring for the home (which often has lots of other little ones). You'd see tiny babies alone, and mothers rushing in and out -- but sometimes the moms cannot leave the hospitalized kids and are forced to stay in the hospital as well ... and then they either have to find another community member to mind their family, or else BRING all the kids to the hospital with them - UGH.
  
• Hippo mauling: There is a CODE in the diagnosis handbook for hippo mauling.
• Snake bites: The little boy in my pic - he had a snake bite. I think he was super proud of his bravery and valiance - hence wanting it all documented on camera. (I don't think the woman next to him was of any relation -- she just wanted in on the pic!)
• Malnutrition: This is hard for me to see. But the great thing is that a LOT of the people in the malnutrition ward at PIH are recovering really well. Their main treatment is "plumpynut" - this really fatty peanut butter in pouches. Interesting note: they use the "plumpy" instead of regular old rice and beans because you can send it home with the malnourished kids and it is less likely to get eaten by others, because it LOOKS like medicine from the package. Rice and beans, well, they're bound to get divvy-ed up amongst the family. Side note: the malnutrition ward is one of the coolest ones in the hospital -- it has this GORGEOUS jungle mural on one wall, painted by some villagers.

Good Africa Books

Interested in thoughts on good books about Africa! Fiction or non-fiction. Here's what I've got so far... leave me a comment to add to the list!

• Baking Cakes in Kigali
• Say You're One of Them (note: if you like Jhumpa Lahari's short stories, you will LOVE this)
• Shake Hands with the Devil
• Half the Sky
• It's Our Turn to Eat

A City Girl in the Countryside

OK, so I’m not exactly Carrie Bradshaw (though I think my wonderful husband might tell you that I’d like to be…). I like to hike up things (though I dislike the part when you have to come down), I don’t mind getting dirty (though I like the long shower afterwards), and I don’t jump and scream about bugs or rodents or reptiles (though I reeeeeaaalllly hate snakes and lizards the size of the one in Thailand that I named “Godzilla”). I’m level-headed, not too easily excitable, and pretty darn good at putting my mind onto the “practical” setting and getting through tough physical and mental situations. But I’m not one of those die-hard wilderness-loving activists, and I am certainly not going to use my blog to pretend to be something I’m not. Though I was sufficiently enthralled by it, I don’t know that I could live out in Rwinkwavu.

I mentioned in an earlier post that Rwink is pretty freakin’ gorgeous. It’s all covered in red and green (from the clay and banana trees and papaya trees) as far as the eye can see. The ridges call out to you, make you want to scale each and every one to see what’s on the other side. The birds are almost tropical-looking and tend to be as unphased by you as are Manhattan pigeons. The houses and huts are made of stone and red clay brick and tin and match the countryside (except for the Partners in Health hospital compound and training center, with its white buildings and bright blue roofs! I loved this because I could always find my way back!). It’s dusty but the air is clean, and the rain, which comes in extremely strong 5-min bursts, smells magnificent. If you get caught in one, you’ll be dry again in ten minutes. The people who have picked this lifestyle – working out in the hospital center or the associated labs – are amazing. They are laid-back and adaptable (you have to be!), but so committed to making an impact in the community (again, you have to be!). And Partners really gives them the resources to do that. I look at them and wonder if I could do it, what I would give up to gain that sort of an experience. I’m not sure I would cut it, for several reasons… among them are: (1) The food (it’s hard to get – meaning there aren’t many stores – and it consists mainly of beans, rice, and goat). (2) The showers (though I have a habit of taking cold showers after workouts – even in the winter – I definitely don’t like my early morning wake-up call to be cold water. Wait, make that loud roosters followed by cold water). (3) The quiet (it’s funny how different our individual preferences are … but I LIKE the sounds and the rush of the city. In a way, I find them comforting and inviting. There are people out there, things going on, and while they may exhaust you at times, you will very rarely find yourself bored.) (4) Snakes in the dark (um, yeah – word to the wise – don’t tell the city girl about the “two step mamba”. If this snake it bites you, you apparently have about two steps to live. Especially don’t talk about it right before said city girl has to walk ten minutes back to her room alone in the dark.)

So there’s my dose of realism for you. It’s not all beauty and helping wonderful people. It’s snakes and a trying lifestyle too. Some people – even the really committed ones – don’t make it out there. I talked to one at a party out in the game reserve who was miserable… he loved his work but was so sick of being in Rwink. He talked about going to restaurants in Boston as if they were like visiting the Taj Mahal – a dream. To each their own, I guess. Every situation has its ups and downs, and you’ve got to find the spot for you where the downs don’t overpower the ups.

Where Does the Money Come From?

I would like to chat for a minute about where countries like Rwanda get the money to do things like install Electronic Medical Record systems. Are the governments taking this money from food programs, or from building schools in rural villages? No, not really. The answer was interesting to me, and thus, I think it might be interesting to other western world taxpayers. Ready? It largely comes from us. For example, the three biggest donors of the money for the Rwandan EMR system are the CDC, a Washington, DC-based organization called PEPFAR (which stands for the President’s Emergency Program Funding AIDS Relief (or something like that)), and the Global Fund. Why do they do this? Why isn’t the CDC spending that money on, say, H1N1 prevention here in our own country? I asked a new friend from the World Health Organization for his thoughts, and here’s what he said. Firstly, the CDC and these other guys have long since been made aware that global health figures prominently in the state of American health (and the health of other countries; I’m just using the US as an example). Epidemics – such as swine flu – that don’t start in the US will likely make it across our borders and affect us too. Therefore, it makes sense for the best monitoring to be available in places where epidemics are more likely to start – places where health is poorer in general. Secondly, the AIDS epidemic has taken a toll on the whole world. Period. And it has got to stop. Just because you don’t see someone with AIDS in your backyard doesn’t mean the disease hasn’t indirectly impacted you. Think about how much potential productivity and economic contribution has been destroyed in African nations because of AIDS. Think about how much more global GDP will be someday when Africa is the next China – a new consumer and producer market. This will not happen if AIDS continues to devastate the market. So, they give money to direct relief, as well as to supporting structures that they think can help improve the quality of care overall.

I am not saying one way or another if I agree with this assessment, but I figured I’d throw it out there for you to ponder. So go ahead, ponder.

Electronic Medical Records in Africa

I have to talk a little bit about what I came to Rwanda to do, and some of the lessons I learned. My trip started out with a week-long conference at the posh Kigali Serena Hotel, where I worked with the World Health Organization and governments of several central and western African nations including Rwanda, crafting policy and architecture guidelines for eHealth. Us Americans are naturally amazed by this – if we in the United States can’t figure out how to effectively deploy electronic medical record systems, how can Rwanda? Nigeria? Ethiopia? Tanzania? But the really cool thing is how unencumbered they all are – they are open books ready to do this stuff right. They have the opportunity to avoid the ridiculous issues we have here, like bureaucratic IT contractors who convince complicated hospital networks to let them send in 200 people to bumble around with computers and write lengthy processes for two years, only to be left with a system that meets nobody’s real needs. (Sorry, that was kind of a lengthy, bumbling example!) And they have a mission – a mission in addition to the goals of practice efficiency and streamlining of patient care (they want that, too). But this other mission is to really track and properly treat HIV/AIDS and Tuberculosis patients. I didn’t know this until recently, but if you are on Anti-Retrovirals for AIDS or on the TB treatment program (I don’t know what that’s called), you absolutely MUST take your meds according to your treatment plan. They are not nearly as effective otherwise. And can you imagine how hard it would be to track patients and their individual plans, track their test results, track whether they’ve picked up their meds at the pharmacy, track their scheduled weekly treatment appointments, track who’s paying for all of this, without a good computer system? So many people slip through the cracks. These Sub-Saharan African governments seem to really get how devastating these diseases have been to their economies, and they want so badly to control them, reign them in, and ease population suffering as much as possible. How can you re-instill economic activity and growth with a large percentage of your population too sick to work? (By the way, I can just hear some of you skeptics and realists reacting and telling me all about the corrupt government officials who funnel money away from important care and treatment programs. I am sure that also happens – I’m not a total idealist – I’m just telling you that I saw a really refreshing other side to that picture. I saw representatives from Ministries of Health across this region really dedicating themselves to technologies that they believe can help their countries.) Overall, I think it’s exciting. I think soon in Rwanda, you will be able to walk into these little one- or two-room village health clinics with dust on the floor and people lined up outside, and you will see a computer in the corner, with power and internet (um, at least sometimes). And I think it’ll be really beneficial. Doctors or nurses will be able to access recommended treatment plans for patients of a specific diagnosis. Community Health Workers who help administer drugs can enter and track commonly seen side-effects – which is especially important for new drugs being introduced to this market. Patients can go to the district hospital for emergency care, and the clinicians there will be able to quickly access their basic health summary to understand who they’re treating – whether it’s an AIDS patient, for example, or access a list of their allergies or adverse reactions to drugs. Yes, there are a lot of other problems in Africa – violence in the Congo, potential famine in Kenya, etc. – but it is cool to see that there are also steps being taken in many Ministries to build infrastructure that will help their countries move forward.

Mzungu in Heels, Part I

I’ll use my first entry for the tale behind my blog’s name, “Mzungu in Heels”. It starts with a rather amusing conversation that I had with my Partners in Health colleague and new friend, Dave, on our way out to Rwinkwavu, Rwanda. (Rwinkwavu, by the way, is a rural district or province in – I think – eastern Rwanda. The reason I’m not sure is that Google Maps can’t seem to find it, and since I don’t really know other methods besides Google and my Blackberry to find where things are, I’ll have to settle with my best guess.) So, Dave is one of the very few Mzungus (pan-African term for “white people”) living amongst the villagers in “Rwink” (pronounced as if it had a silent “w”, which I feel a certain affinity towards, having lived with a silent “w” in my own name for 28 years). As we drove down the hillside on the curvy red-clay road into the valley where Rwink is situated, our shiny 4WD SUV attracted the attention of some of the villagers. They ran out to the car, waving and pointing. I didn’t know how to feel or react – were they hoping for money? Food? Dave sighed. “Yeah, it gets a little old, you know? Never being able to go anywhere without attracting attention.” I looked at him questioningly. He continued, “it’s like that game you used to play when you were little – the punch buggy game. You know, when you got to smack your brother and sister if you spotted the punch buggy first. Well in this case, we’re the punch buggies.” What a fabulous analogy, huh? Within only a few hours of hanging out in Rwink, I began to understand what he meant. Of course we wanted to chat and joke with the village kids, but sometimes when all they wanted to do was run after you, laughing and pointing, it could get a little frustrating. So when finding myself walking around with a fellow Mzungu and being overwhelmed by the “punch buggy” feeling, a source of a good laugh was of course to punch my colleagues on the shoulder and say quietly “Mzungu ________!” But how to fill in the blank? We couldn’t use colors. I mean, “Mzungu white” is basically redundant, “Mzungu green” only happens when you’ve accidentally drunk the unpasteurized milk, “Mzungu black” is like an oxymoron … So we were left with descriptions of however we were dressed: “Mzungu in plaid!”, “Mzungu in shorts!”, and of course, “Mzungu in heels!”

So, you may now be thinking, who in their right mind would bring high heels to central Sub-Saharan Africa? OK, I admit while staying out at the hospital in rural Rwink I left my heels in the suitcase and subjected my sneakers and rubber-soled ballet flats to becoming balls of red clay dust. But in Kigali, heels were actually rather apropos. Kigali is the capital city of Rwanda, and is shockingly clean, safe, and businesslike. It’s like the entire city is in the midst of an unspoken rebellion against what the western world would naturally think of them after the horrific mid-1990s genocides – like they are so determined to be exactly the opposite of the violent, disorganized image that their relatively recent history suggests. They take pride in their beautiful city – one day a month is a day of service, and all residents join in cleaning up their neighborhoods. As a result, there is seriously no litter on the streets lined with healthy vegetation, and there are sidewalks and paths nicer than a lot of streets in Boston. It really is picturesque. Rwanda, c’est le pays de mille collines – Rwanda is known as the land of a thousand hills. Kigali is set on a few rolling hills and deep-set valleys that glow red and green during the day and twinkle with tiny white lights from the city’s inner neighborhoods at night. Yes, electricity – pretty darn constant – throughout the city. There is even a weekend salsa-dancing scene!