Closing thoughts

I'm sitting at the restaurant of the Iris GuestHouse waiting for my ride to the airport to arrive in about 20 minutes. I have been here for nearly 2 months and have had an extraordinary time. I will likely write a few more things and post more photos in the coming weeks when I'm home and have a more reliable internet connection, but I wanted to leave one last post that was "truly from Rwanda."

My thoughts on international development and public health:

• Poor or developing countries that have good leadership can provide excellent primary health care for its citizens. And even ensure 100% affordable access.
• Any Non-Governmental Organization (NGO) that is working in a country to provide clinical services, such as family planning, has a duty to train the local providers in these services to a level of competency that they can pass this knowledge onto their colleagues and the next generation. If such a capacity building component is absent from the mission of an NGO, it only serves to perpetuate a developing country's dependence on international assistance. The goal should be for local health care providers to be self-sufficient.
• Significant successes can be accomplished in solving difficult problems if they are approached in the proper manner, but they cannot be attained without support from the right people.

My thoughts on Rwanda:

• Rwanda is a wonderful place to hide from the Chicago winter! I can't think of a better place to live and work in January and February.
• Rwanda is has some of the most beautiful scenery in the world.
• Rwanda has some of the most beautiful people in the world.
• It is time Rwanda is known for its successes and its future.
• Rwanda has some of the best coffee in the world!
  

My thoughts on places to stay, eat, travel and things to do in Rwanda:

• Best hotel for the money in Kigali: Iris Guest House
• Best place for coffee in Kigali: Torero Cafe
• Best place for Pizza in Kigali: New Cactus Restaurant
• Best lunch buffett: Karibu restaurant
• Best tour agency in Rwanda: Rwanda Eco-Tours
• Best place to hang out for the day and/or people watch: the pool at Novotel hotel (Note: the Serena and Mille Collines were under construction when I was there)
• Best restaurant in Gitarama/Kabgayi area: GM Chez Lando

Other random thoughts:
Most important words to learn in Kinyarwanda:

• Murakoze (mura-koz-eh) = Thank you
• Muraho (mura-ho) = Hello
• Muramotse (mura-mot-seh) = Good morning
• Amakuru (Ama-kuroo) = How are you?
• Ni Meza (nee me-zah) = I'm fine

My ride is here. Back to the States!!!
See ya!

Family Planning in Rwanda

Rwanda is an amazing place! Less than 15 years after one of the worst possible breakdowns of law/order, government, culture, society and even concern for human life, Rwanda is quickly becoming the star example of how a developing country can succeed!

Though I came here "to teach family planning," I expected to learn more from my experience than anyone would learn from me. As I come to the end of my trip, I think I was right. My first experience in medical education in Rwanda came from fortunate timing--I was able to join a program teaching basic obstetrical ultrasound. At the end of this 3 day course, the midwives and doctors who participated had received an introductory experience with ultrasound. In the 6 weeks since, I have been able to arrange only one other teaching session to reinforce this newly acquired knowledge. My concern that such a brief introduction would not be adequate was justified by the difficulty I had in the follow-up session. This lack of follow through and training to competency in a new skill is a frequent flaw in educational programs. It was further highlighted by the effective model implemented by IntraHealth and sponsored by USAID.

In fact, the family planning teaching programs I participated in with IntraHealth/Twubakane are so well run that I learned a lot from them. I participated in a teaching session dedicated to long acting reversible contraceptives for 6 nurses who will work at rural health centers.
By the end of their week-long training session, each one was capable of effectively counseling a patient on her contraceptive options and competently performing the minor procedures required to place an intrauterine device or subdermal implant.
This photo says a lot about how important it is to have health care providers trained in family planning. The woman is in her mid-20's, holding her 10-month-old infant son while she follows through on the most basic promise of humanity: to provide the best possible future for herself and her family. When a woman uses contraception in Rwanda she is avoiding the very real chance (about 1/20 lifetime-risk ) she will die in childbirth during her next pregnancy while increasing the likelihood that she will be able to afford to pay for her child to attend secondary school. (For those who are interested, most recent maternal mortality statistics in Rwanda are from 2005, with 750 deaths per 100,000 live births. That is approximately 100 times greater than the US!) These are just 2 of of the most basic benefits she and her family will gain by using contraception. When you consider family planning from a community, country or society perspective the benefits are even greater.

To highlight the issues further, I'm finishing a 2-week educational program for general practice physicians who are stationed at district hospitals in the areas where IntraHealth/Twubakane has been working for the past 4 years. The doctors who attended the lectures last week, and are traveling to the rural health centers to provide family planning services this week, had nearly no training or experience in family planning. They have cared for patients who ask about contraception and have not been able to provide them the complete care they need. All of the physicians expressed gratitude on behalf of themselves and their patients that they have the opportunity to learn these vital skills.

Rwanda is doing a lot of things right in its rise from the ashes of war and genocide. I've been told it is the safest, most secure country in Africa and I believe it. Walking around Kigali at night can be dangerous because of traffic, but I don't have to worry about street crime. Rwanda's health care system is already doing something the US can't figure out: provide affordable health insurance for 100% of its citizens. This includes coverage for family planning services. Many international NGO's and the Rwandan government are responsible for these and other successes. My personal knowledge of the IntraHealth programs in Rwanda makes me feel strongly that they have contributed significantly to the increase in use of contraception from a low of 4% of married couples in the year 2000 to 27% in 2007.

Having spent a lot of time riding to/from rural health centers in Rwanda in a truck that has the USAID logo on the side has made me even more proud to be an American. Rwandans who I have met and cared for are extremely grateful for the assistance they receive from abroad, but they realize their future successes rely on more than international support. I have no doubt that Rwanda will continue to be the star of Africa.

As a former athlete, I've learned it is always more fun to play for the winning team. I hope I get the opportunity to return to Rwanda and participate in future victories.

Game Safari--Akagera National Park

Akagera National Park is one of three national parks in Rwanda. There is one in the north called Volcanoes National Park where the gorillas live and Nyungwe National Park in the South-West which is home to five different primate species and lots more. Akagera is located along the eastern border of Rwanda with Tanzania. It is a more typical African savanna than the rest of the hilly lush areas of Rwanda. We continued with the Rwanda Eco-Tours company in our trusty Toyota LandCruiser 4x4. It is a 2 hour drive from Kigali to Akagera so we left our hotel at 6am...ugh!

The drive out of Kigali was not as spectacular as the other drives through the countryside because of a dense fog that blanketed the area. Just prior to our arrival, the sun started to break through. In the end, we had a beautiful sunny day driving through the park to see giraffes, buffalo, 5 different species of antelope, hippopotamuses (hippopatomi?), baboons, and countless birds. Our guide from the park was named James. His English was flawless and he had an encyclopedic knowledge of all the wildlife we saw. Did you know that a giraffe's tongue is approximately 45cm long (17+ inches)?! That makes it easier to pull the leaves off the thorny Acacia trees without getting stuck.

The LandCruiser was specially made for safaris--the roof over the 2nd and 3rd row of seats opens so you can stand or sit on top of the vehicle as you slowly drive through the park. James pointed out that there are also leopards and elephants in the park, but they are rarely seen during the hot sunny days. Erin and I got a lesson in how strong the sun can be when you are near the equator--though we used sunblock, we still got burnt. After 4 hours of driving through the different areas and seeing all the wildlife, we parked at a little fishing camp on the edge of Lake Ihema. A large troop of baboons live side-by-side with the fishermen. At first, Erin and I marveled at them and took lots of pictures. We watched as they groomed each other and scavenged for food. The fishermen were loading their catch from the night before and fixing their nets. The baboons here have a reputation of stealing from the fishermen who have been instructed by the park rangers not to attack the baboons because they are protected. We sat in one of the gazebos of the fishing camp and talked about what an amazing day we had. James said we could go ahead and have lunch while we were there. I thought it might be a bad idea to tempt the baboons with the ham & cheese sandwiches Erin and I had brought, but figured James knew if it was OK. After we each had 1/2, we decided to put the rest back in the LandCruiser. James tucked the bag with out leftovers under the front seat and closed & locked the doors.

Jamada, our driver, and I walked a few hundred yards away to see the fishermen loading their catch of tilapia and captain fish. James and Erin stayed near the truck to make sure neither the baboons or fishermen had a chance to steal our backpacks from the truck. Some of the fishermen were filling the back of a covered Toyota pickup with their catch among the blocks of ice that were driven there from Kigali that morning. The catch would be driven back to Kigali to be sold that afternoon. Jamada and I had walked past a dozen more baboons and an enormous termite mound to see the catch being loaded. On our way back we noticed that one of the baboons was sitting on the hood of the truck. James and Erin were less than 50 ft away keeping an eye on the baboon as Jamada and I approached. The doors were closed and the windows appeared to be rolled up. James told Erin that the baboon was nicknamed "Star" by the rangers at the park because he is the most mischievous of the bunch. He has been seen opening the the doors of trucks by the handle if it is left unlocked.

Just then, "Star" jumped over to the driver's door and was hanging from the window. He discovered that the window was open just enough to slide his fingers in at the top. He rocked back and forth with his feet on the door a couple times before the window exploded and he jumped in! James hopped up and threw a water bottle at "Star," but it was too late. In less than 2 seconds he had broken the window, jumped inside the truck, found the paper bag with a ham & cheese sandwich under the seat and jumped back out to run away and enjoy his spoils! James ran after him, but it didn't matter. Jamada and I ran to the truck. We couldn't believe what just happened. Our cool, calm, collected driver was shocked! After a few minutes, Jamada shook it off and he called a car shop in Kigali to make arrangements for the window to be fixed. It was early afternoon and we knew that there would likely be rain in the late afternoon on our drive back. We decided we should hurry back and try to beat the rain, which we did. While we were driving back to the park entrance, James nonchalantly mentioned that wasn't the first time "Star" had pulled that kind of move. Wow! What a memorable day!

A small world: lunch with the US Ambassador

I happened to arrive in Rwanda a couple weeks before a reception at the home of the US Ambassador here that was being held to introduce him to the American Ex-patriot community. He was appointed here by George W. Bush after being Ambassador to Djibouti and Niger in the past. Ambassador W. Stuart Symington comes from a well-known St. Louis family. When I went to the reception a few weeks ago, I mentioned to him and his wife, Susan, that Erin and I are moving to St. Louis in August and that her parents live there. Susan and the Ambassador were interested in the work I'm doing here, but also excited to hear that I will be moving to the Wash. U. School of Medicine in St. Louis where their daughter is a first-year medical student. In fact, they invited us to lunch this past Wednesday to take advantage of Erin being here. We had a fantastic meal and very interesting conversation. They invited two other St. Louisans (or is it St. Louisians?) to join us: Laura Hoemeceke--the IntraHealth director, and Christina Bryant--who is here working with Partners in Health. We played the name game a bit and realized that when we move to St. Louis in August we will know more people than we thought. The Ambassador and his wife have lived all over the world. How small a world must it feel to them?

From what I understand, one of the thousands of appointments President Obama had to make in his first week was reappointing Ambassador Symington to Rwanda. He and his wife make a great team. He is extremely passionate about the work he is doing and the work other Americans in Rwanda are doing. It was a wonderful opportunity. Erin's family is already familiary the St. Louis Symingtons and we look forward to getting to know them as well.

Gorilla Trek

Getting to see mountain gorillas in the wild was one of the coolest things we have ever done. After a briefing about our expected hike and how to behave around the gorillas we set out for Karisimbi, the biggest of the 5 dormant volcanoes in Volcanoes National Park. We were going to see the Susa group. This is the largest of the habituated (used to being stared at by humans) groups of mountain gorillas in the park with 46 members, including 5 adult-male silverbacks. It is one of 5 groups that you can see with a permit from the Rwandan national tourist office (ORTPN). Though I knew it could be the most difficult and muddy hike through the bamboo and tropical rain forest that protects the upper part of the volcanoes where the gorillas live, I felt it would be worth it based on what I have heard from other peoples experiences. Given that the gorillas change location every day as they look for food, it could be anywhere from a 30 minute stroll to a 3.5 hour grueling uphill hike to find them. Felix, our official ORTPN guide, was in radio contact with the other ORTPN park rangers and trackers who were already out looking for the group.

After driving to a parking area on the outskirts of a rural village, we hiked up to the edge of a dense bamboo forest that was marked by a rock wall called "the buffalo fence." We were told this keeps the mountain buffalo and other wild animals from coming down to eat the crops of the villagers. Erin and I were 2 of 7 tourists traveling in convoy with 2 guides and 2 soldiers from the Rwandan army as well as a few porters to help carry our backpacks and ensure we made it up & down the steep, slippery trail. The soldiers bookend the single-file convoy with machine guns slung on their shoulder in order to protect us from the buffaloes that can occasionally block the trail. The hike was pretty difficult in places and the fact that it was >2,500m above sea level translated into a pretty wicked headache after awhile, but I had no other ill-effects of the altitude. Of course, I had the luxury of living in Kigali for the past month where it is >1,500m above sea level. Erin, who had just arrived a little than 2 days earlier from the flat lowlands of Chicago, didn't seem to show the effects of jetlag or altitude. We hiked up through a dense bamboo forest then through even more dense tropical forest. There were many places where the our feet were not on ground, but a dense bed of shrubs and plants called "stinging nettles" which are very well named. It took a little less than 2 hours, but we finally met up with the other ORTPN rangers who had tracked the gorillas from their nesting site the night before to their current location. We were very lucky to find the Susa group mostly in a clearing where they were eating their typical lunch of bamboo shoots and wild celery. Felix said we saw 26 members in total. It was amazing! We tried to stay the prescribed 7 meters away, but frequently found ourselves within a few feet of these enormous, gentle, nearly-human creatures who were peacefully eating and napping in front of us. Occasionally they would look at us with the same curious facial expression that many of us had. The silverbacks are enormous, weighing upto 200kg! There were quite a few juvenile ones as well. We even got to see a baby who Felix said was about 3 months-old. The ORTPN guides, who see the gorillas everyday, seemed to have the same wonder and enjoyment that the tourists had. They kept a close eye on all of us, making sure we didn't endanger ourselves or the gorillas during the 60 minutes we spent there. We snapped hundreds of photos and lots of video of the gorillas going about their daily routine. The guides also took pictures of us in front of the gorillas. It was really an amazing experience!

We hiked a short distance down the hill to meet our porters and take time for lunch. Afterwards, we hiked down the volcano back toward our waiting vehicles. The hike down was not as strenuous as the one up, but in many ways it was harder. The mud made footing difficult at best, but it was the fallen bamboo that was the biggest obstacle. The usual trail had been cut off by a dense thicket of bamboo that could not be penetrated. The porters hacked a passage with machettes, but there were a couple times that I thought we weren't ever going to find the trail again. In places the bamboo was so dense, no sunlight penetrated to the forest floor and the only way to pass was to turn sideways and squeeze through while bending the bamboo away from your body. After a little over 1.5 hours we made it back to the trail and then to the upper crop fields from the village we passed through. We walked along the fields back to Jamada waiting with his LandCruiser near the village school to take us back. We received certificates from Felix and his colleagues noting that we saw the Susa group in front of hundreds of children. We purchased a couple of hand carved & painted gorilla figures as souvenirs from a guy on the roadside sitting in the center of the throng of children staring at us. We then embarked on the long drive back to Kigali for the night.

I split our tours between the gorillas and our game safari in Akagera National Park so that Erin and I could have lunch with the US Ambassador, W. Stuart Symington, back in Kigali on Wednesday. I also volunteered Erin to come with me back to Muhima district hospital to continue teaching obstetrical ultrasound that morning.

Here is a link to photos from Erin's week here in Rwanda with me.

Erin in Rwanda

I will write more about our lunch with the Ambassador and our game safari at Akagera soon.

Kigali City tour and Drive to Ruhengeri

On Monday morning, Erin and I met Jamada--our guide and driver from Rwanda Eco-tours. He was excellent and spoke English well. In a 10 year-old specially fitted Toyota LandCruiser, he drove us around Kigali to see some of the tourist sites. Besides seating for 6 passengers and two rooftop hatches to get a better view during game safaris, the truck has an extra fuel tank and 2 spare tires. In the end, this well-outfitted 4x4 was no match for a baboon looking for lunch (more on that later...)

Our tour began at the Kigali Genocide Memorial. I was looking forward to my second trip there since I hadn't seen the elaborate gardens during my first trip because of the rain. Each province in Rwanda has its own memorial, but the one in Kigali is the largest. The Memorial is well done inside and out. It officially opened in 2004. It serves as the final resting place for >250,000 victims of the genocide, who are buried in mass graves, as well as a museum. We began with the beautiful gardens dedicated to the victims of the genocide. Each one laid out with a specific message in mind. There are also mass graves for the remains of victims in the Kigali area. The graves are marked by huge concrete slabs the size of two bowling lanes side-by-side. We didn't count how many were there, but we did notice that there is space for more. In the area still under construction, one of the slabs had a metal cover in the center with bouquets of flowers laid there that allows newly discovered remains to be added. The museum is divided into sections that first displays the history of events that led up to the genocide, the horrible period of April-July 1994 when nearly 1 million people were systematically slaughtered and the lack of international intervention. The aftermath of the genocide included some quotes from international leaders taking responsibility for not having done their part to help stop the horror. There is an area similar to Yad Vashem (the Holocaust memorial in Israel) where some of the material and human remains of victims are displayed. An extremely well-produced section is dedicated to the various Holocausts, genocides, ethnic-cleansings, and other systematic mass murders that have occurred throughout history. The final section is dedicated to the children who did not survive this genocide and the hope that their memories, displayed in photographs, will light the future in a way that does not allow humanity to repeat its mistakes.
A continuously recurring thought I had during both my visits to the memorial was:

Humans must be the dumbest species on Earth, unable to learn the lessons of past generations.

After completing our visit to the memorial, Jamada took us on a short driving tour of some of the new neighborhoods in Kigali. There were beautiful modern mansions built behind ornate walls and a gated townhouse complex that could have been anywhere in an American suburb. We ended at at the home of Richard Kandt, a German explorer/naturalist who spent a significant amount of time in Rwanda cataloging the geography, ecology and people. Though the museum was small and many of the displays were only in German, French, or Kinyarwanda it was interesting and offered an amazing view of the city. We had lunch at Karibu restaurant before setting out from Kigali north toward Ruhengeri. Karibu has a wonderful buffet (similar to many restaurants in Kigali) offering many typical dishes. Erin and I were unable to stack as much food on our plate as Jamada and many of the other Kigali residents who were there. We filled up on saute`d beef over rice, stewed bananas (not the sweet kind), cassava leaf, roasted potatoes, beans, chips (french fries), roasted cassava, browned sweet bananas, and many salads with amazingly flavorful onions, cucumbers, tomatoes and carrot. One of my favorite dishes there, though, is simply avocado halves with a light sauce.

Our drive to Ruhengeri was as breathtaking as any drive through the mountains of Colorado. There are amazing vistas with lush green hillsides covered in banana trees, tea plantations and many other crops. I continuously marvel at plots of crops that create a quilt of patterns over every hillside, no matter how steep or high. As we climbed the mountains northward out of Kigali, the sky had the appearance Erin and I have come to know in the midwest--a severe thunderstorm approaching that would raise tornado alarms. Jamada insisted that there are no tornadoes in Rwanda, but it sure looked like we were driving into one. The rain and wind were ferocious which made the scenery hard to appreciate. Making the scene a little more difficult was the fact that the wipers on our Land Cruiser's windshield kept sliding past the normal stop point and off the driver's side where they would become stuck until Jamada could reach his hand out to get them moving again. After a while he got tired of straining his hand to reach the stuck wipers while driving and decided to pull off to fix the problem. Not only is Jamada an excellent driver and tour guide, he is a bit of a field mechanic keeping his Land Cruiser moving. He bent the wipers just enough that they would not fly off the side of the windshield yet still contact the windshield enough to clear his view.

Jamada's persistence in moving forward though the wipers weren't working and his fix are just 2 examples of what I've come to feel is the motto in Rwanda: It is what it is. We'll deal with it and make the best of it, but we won't stop moving forward.

It took a couple hours of driving over winding, hilly, potholed 2-lane highway, but we arrived in Ruhengeri around 3pm. Unfortunately, the continued rain meant that we would not visit the Rwandan cultural village as scheduled. We missed out on a traditional dancing and drumming display.

We had African tea after we arrived at the Le Palme Hotel. African tea is an excellent way to warm up from the chilly rain. It is mostly milk with tea, ginger, and cardomon brewed in it. Each restaurant here makes it a little different, but it is always really tasty. The room at Le Palme was very nice and spacious. There was a queen-sized bed with an extremely firm foam mattress beside a twin-sized bed with a sagging, soft spring mattress, an amazing view of the volcanoes with the tops shrouded in clouds. Each bed had a mosquito net hanging above it from the ceiling which might have been 16 feet tall. After a short nap the rain stopped and we decided to walk into town before it got dark. Ruhengeri is not a large city, but it was busy. At the corner of a 2 main streets that seems to serve as the bus stop, we were approached by a group of teenagers who were interested to find out who the Mizunga were. We had a short conversation with a guy named Vernon who may have been the only one who spoke enough English to talk with us or maybe was just the least shy of the bunch. In typical fashion, we quickly found ourselves in a circle of many staring pairs of eyes. Vernon was curious if Chicago was similar to Ruhengeri. I told him it was very different, but that I thought he would like it. Knowing how dark Kigali is to walk around at night--where there are some streetlights--we decided to walk back to our hotel before it got too dark. But, we found ourselves walking back in pitch black night. When there was no passing traffic, it was dark enough that avoiding obstacles at your feet is very difficult. When cars, trucks and motorcylces zoomed by we were temporarily even more blind. But, it didn't seem to matter to the many residents walking with us in both directions. Erin and I wondered if our night vision never developed as well as it could living in a country where streetlights are always on. We made it back to the hotel without a problem and met Jamada for dinner. The food was excellent accompanied by cold Mutzig (a really good local beer that is similar to Heineken). We went to bed early, knowing we had to be ready to go by 6:30am so we could be at the Volcanoes National Park when it opened for out gorilla trek.

National Heroes Day-February 1st

At approximately 6:30am we heard the blair of a loudspeaker driving along the streets near our hotel. There was a loud, stern announcement in Kinyarwanda followed by some upbeat music. This continued for about 20 minutes before it trailed off into the distance. The birds outside the window made it futile to keep sleeping, so I got up to see what the announcement was all about. Raymond, who was sitting at reception, explained that February 1st is National Heroes Day in Rwanda. The announcement was telling everyone to wake up and come to Amahoro National Stadium for the ceremonies that mark the holiday. Here is an article about the celebration from the daily, English-language newspaper in Kigali, the New Times. As this is an important holiday in Rwanda nothing was open. So Erin and I decided to enjoy the beautiful, equatorial sun by the pool at the Novotel hotel.

Erin and I are off to see Volcanoes National Park and the Mountain Gorillas tomorrow and Tuesday. We are going with a really great tour agency called Rwanda EcoTours.

A week in "the field"

Last week I spent working with the IntraHealth/Twubakane program in Family Planning in the regions west and south of Kigali called Muhanga, Kamonyi, and Ruhango. I tagged along with Dr. Jeanne (a general practice physician from Rwanda), Sophie (a nurse), Chantelle (a trainer), and Christian (our driver). Thankfully, they all speak English so I knew I would be able to communicate with out trainees. We left on Monday morning and were not supposed to return until Friday afternoon. However, I returned to Kigali on Tuesday evening to attend the Presidential Inauguration celebrations at the US Embassy and Heaven restaurant. (More on the inauguration later) We stayed in the town of Kabgayi, a little over 1 hr from Kigali via the main road/highway, at the Center de St. Andrew. The trip provided amazing views of the countryside. It is clear why Rwanda is "the land of 1000 hills." We traveled in a crew cab Toyota Hilux pickup truck with the "USAID from the American people" and Twubakane logos on the side. The road was winding and steep, but well paved and maintained. Alongside were many mud/clay/brick homes and some concrete structures. The landscape is very green and covered in crops of all kinds (banana, tea, coffee, cassava, avocado trees) regardless of how steep the hillside. Nearly all the roads leading away from the main one are dirt and in varying condition. Just before coming to Kabgayi, there is a sprawling town called Gitarama where we ate dinner most evenings. The only way I could tell what villages we were passing was by looking for the signs designating the local health center. Each sign has the Rwanda Ministry of Health, USAID, and Twubakane logos.

The Center de St. Andrew is a huge compound that has a Catholic Church (the oldest in Rwanda, built in 1925), a hotel, primary school, teaching center and more. The Kabgayi Hospital is also located on the grounds. The church is undergoing renovations after the roof collapsed a few months ago. The rooms were utilitarian and there was no hot water 2/3 nights I stayed there. The other night, there was only scalding hot water. It turns out that a cold shower is way better than a scalding hot one--at least you can take a shower without injury. Who knew?

On Monday, we provided lectures to the 6 family planning nurses who were our trainees.

From Rwanda-1st 2 weeks

We also used models for simulations of IUD insertion and subdermal contraceptive implant insertion. This teaching session was held in a classroom on the grounds of the Center. The irony of teaching about contraception within a Catholic center was not lost. In fact, many of the health centers and hospitals are affiliated with the Catholic Church. Because the Church feels that contraception is wrong, the patients who seek care at these places may or may not receive information about contraception, but are all referred to the secondary clinics that have been set up away from the Church grounds to provide family planning services. This is true throughout the country (as well as many other places throughout the world). Regardless of what the Vatican may feel is best, the people of Rwanda realize that fertility control is crucial to their individual and collective futures.

Each of the next 4 days we spent at health centers in some remote areas of these regions doing hands-on teaching with our trainees. Each center was unique in whether it had electricity, running water, sufficient space and more. I don't know the exact numbers, but at each center there were between 15-70 women present for the informational/counseling sessions on contraception at 6 different health centers. Many of the women had infants tied to their backs or were breastfeeding. They asked excellent questions and expressed concerns about some of the same myths & misconceptions American women have regarding contraception. The trainees did well. However, I struggled given that they primarily spoke French and Kinyarwanda. Most of the time I had someone nearby to translate, though. These trainees will now become family planning trainers in their local health centers. This creates a sustainable model of service delivery that was clearly lacking from the ultrasound course I taught the week prior.

Here is a table of the services we provided at the 6 health centers we visited:

Sophie & Dr. Jeanne & Chantelle are amazing, dynamic, committed providers who will revisit these health centers and trainees for reinforcement in the future as well. I learned a lot from them and am grateful. I am impressed by the level of care provided under the circumstances, but am most impressed by the distances and terrain traveled by our patients to obtain the care. Though these women happen to be born in a place where roads are not paved, electricity and clean water are luxuries, and they must work extremely hard for everything, they have access to contraceptive services that many American women don't.

Football (Soccer)

This week and next, Kigali hosts the African Youth Football tournament. They have 8 teams playing in 2 pools this week to seed the elimination bracket for next week. This past Sunday I went to Amahoro (Peace) Stadium where upwards of 30,000 fans cheered Rwanda to a 2-1 victory over Mali followed by a 1-1 tie between Ghana and Cameroon.

A note: Amahoro Stadium was the site where UNAMIR (the UN "peacekeeping" force that witnessed the genocide in Rwanda) was housed in 1994. It has been updated recently and is a great place to see an event. The area under the overhang has proper seats and a cordoned off spot for VIPs. The other 3/4 of the stadium are rows of concrete benches with marked seat numbers that apparently don't mean anything.

As I wasn't sure how to go about getting a ticket and felt it might be a little ambitious to go it alone, I made a deal with Raymond-one of the guys at the Iris hotel who I has been teaching me Kinyarwanda in exchange for my teaching English. I asked him about the details and he suggested it would be best if I didn't go by myself. I promised to buy his ticket if he would come with me. I'm glad I made that deal! As we arrived about 30 minutes before the match there were probably 500 people trying to buy tickets at the gates to the stadium, but there were only 4 people selling tickets. It was a small mob scene with a lot of pushing and shoving accompanied by some who were jumping the fence and making a dash for the stadium. Some made it, but the ones who were caught received a whip of a baton from the National Police before being thrown back outside the fence. I stood back a ways and watched the scene unfold as Raymond disappeared into the crowd. Just after the game started, Raymond came up to me from a different direction having secured tickets. I don't know how... He then had to sweet talk the security staff/ushers within the stadium to let us in to the clearly overcrowded seating area. It took 4 tries, but he was able to get us in. We found ourselves sitting opposite the VIP area. There were no concessions, but there were some entrepreneurial kids selling bottles of water in the stands. I couldn't see any other Mizunga (White people) sitting in our area, but I felt more out of place because it was a football/soccer match and I don't know much about it. Afterwards, I took Raymond out for beer and pizza at a restaurant near our hotel called the New Cactus. It was a great day. I could even become a football fan.

Rwanda played Cameroon to a draw on Wednesday and then lost 2-0 to Ghana today. I'm not sure what that means in terms of Rwanda's chance at making it to the championship, but I figure it can't be good to be 1-1-1 in a pool of 4 teams. Anyway, I am beginning to understand why most of the world are crazy for football/soccer. However, I still think American Football is a better spectator sport!

More Photos

Here is a link to a Picasa Web Album with some of the pictures I took during the first 2 weeks.

Rwanda-1st 2 weeks

A homecooked meal & personalized city tour

A week ago, one of the midwives who was participating in the ultrasound course I helped with invited us over for dinner to her home. Annika is a Belgian woman who has lived many different places in Africa and has been in Kigali for the past 5 years with her husband and 4 children. She was extremely generous to invite 9 guests over for dinner on Friday. Besides her family, the original faculty of the ultrasound course (Eric, Raj, Nerea, and Nicola) and the BBC film crew (Juliette & Glenn), their neonatology colleagues (Tom & Frances) and me, we were joined by Professor Joseph (the Ob/Gyn who I hope to work with here in Kigali) and a Congolese gentleman who was passing through Kigali before catching a flight to Amsterdam. Over a fantastic fish stew, crepes and homemade ice cream we had a really great evening. I believe there were conversations in about 5 different languages. Much of the conversation revolved around improving health care in developing countries, but there was a also a lot of discussion about whether the inauguration of Obama will translate into real progress in the developing world.

The following morning, I joined the same crowd for a driving tour of Kigali led by Annika. Since there were too many to fit inside the cab of her truck, most of us piled into the bed of her pickup. This was perfect because Eric, Glenn & Juliette wanted some driving footage of the city.

BTW--If you want to know more about Eric's organization that creates teaching films and documentaries about health care in the developing world, check out www.medicalaidfilms.org

Annika was an excellent guide. We ended at the entrance to the Kigali Genocide Memorial. That evening, the Londoners returned to the UK.

The fortune of meeting them and being able to help with their course was fantastic! As I told some of them before we said goodbye, if the rest of my time in Rwanda is 50% as productive as my 1st week, I will consider the trip a success.

A quick update

In the past week I have not had time to write, nor a reliable internet connection, but hope to catch up when I return to Kigali on Friday. I am trying to use a French keyboard right now, which is very frustrating.

Here are some of the things I hope to write about:
One of the midwives from the ultrasound course, Annika, had all of us over for an amazing dinner last Friday. On Saturday, she took us on a driving tour of Kigali before dropping us at the Kigali Genocide Memorial. In separate posts I plan to write about the memorial, the African Youth Football (soccer) tournament where Kigali beat Mali on Sunday, my week in and around Kabgayi teaching family planning, and watching/celebating the Obama inauguration at the US Embassy and at Heaven restaurant in Kigali. it has been quite a week; stay tuned...

First Impressions--Kigali

Here are some thoughts about my first few days here:

The City--it is clear why Rwanda is known as "the land of a thousand hills." Kigali is a collection of city centers on hilltops. My hotel is nearly on the main city center hilltop called Kiyovu. (The hills are "San Francisco steep" by the way!) There are beautiful views of the different neighborhoods from the top of each hill. I haven't had much opportunity to explore beyond the city center near my hotel and CHK. I hope to see more this weekend.

Transport--Though it is hilly, many people walk. There are lots of cars, SUVs, trucks, Land Rovers etc. In fact, it seems like 1/4 of them have the logo of some international NGO on them. There are lots of minibuses that I have read are a form of public transportation (your fare is based on how far you go), but I haven't figured them out yet. There are taxis--with a light on top and a meter--and then there are taxis without--negotiate your price and hope you are not overpaying. And there are LOTS of motorcycle taxis. The moto-taxis are regulated--they all wear green & yellow vests and must carry an extra helmet for the passenger, but they too have no meter and prices are negotiable. The main roads are paved and generally have a sidewalk on one side. The side roads may not be paved and do not have sidewalks. As a pedestrian, it is CRUCIAL to be aware of the varied types of vehicles and the somewhat erratic way they drive.

Cityscape--green rolling hills and lush valleys--including one with a golf course. The sky has been generally blue in the morning, but hazy with humidity during the afternoon sun. The night sky has been brightly lit by the moon the last few nights, but the stars are visible before moonrise and they are impressive.

Architecture--in the city center between my hotel and the IntraHealth office there are no less than 5 very large, modern appearing buildings occupied by various banking institutions. The Hotel Mille Collines and the Kigali Serena Hotel (formerly the Intercontinental) are also modern-looking exteriors, but both are undergoing renovations. There are a few mid-rise buildings under construction as well. Along the hillsides and in the valleys there is quite a range of structures from mud/clay walls to cement/stucco. Most are one story, but some are 2-3 with balconies.

People--Everyone I have met have been warm and welcoming. Sometimes I have noticed people will stare at me, but I realized everyone stares at everyone else too. People have been helpful and generous with their time. When I ask for directions, many times the person will walk me to where I am going. Most are dressed business casual or more formal, some women wear more traditional Rwandan dress--the mushanana--which resembles a sari.

Language--There are 3 official languages, Kinyarwanda, English and French. Most of the time I have gotten by with just English, but I have heard that it will be more difficult outside of Kigali. I am trying to learn Kinyarwanda and have been thankful that morganinafrica.blogspot.com had published an informal Kinyarwanda-English dictionary. Just saying Hello (Muraho) and Thank-you (Murakoze) in Kinyarwanda makes all the difference in the world.

Money--I was told before I came that Rwanda is a cash society. Most places do not accept credit cards and if they do, they charge a 3-5% service fee. Only the nicest hotels & restaurants, the national tourist office (ORTPN) and some tour agencies will accept them. I've only seen VISA signs. The local money is the Rwandan Franc. It is approx 560 Rwandan Franc (rF) = US $1. The exchange rate for the dollar is different based on where you change money (bank vs forex bureaux) and what denomination you have. Also, because of concerns for counterfeiting, only US bills more recent than 2001 are accepted. I don't know what the exchange rate is for the Pound or Euro, but that is pretty easy to find. I have been surprised by how pricey some things in Kigali can be. My hotel is not too expensive, approx US $55/night w/ breakfast included. The Bourbon Coffee shop at the town center gets about $2 for brewed coffee and $3+ for cappuccino. The Nakumatt supermarket has reasonable prices (1.5L bottle of water for 500 rF), but some things are not cheap. Most places charge 250-500 rF for a coca-cola (no diet/coke light by the way), 900-1500 rF for a beer, 2500-5000 rf for a main entree. The Moto-Taxis are supposed to be cheap, but I haven't tried them.

Food--I have eaten well while I've been here in Kigali. The restaurant at Iris Guesthouse serves a modest continental breakfast each morning. Their lunch/dinner menu is more varied than a New York City diner. The food is OK here. Next door to my hotel is the Shiang Hai Chinese restaurant. I have had dinner here twice--both times I was impressed. In fact, I think I may have discovered the first Chinese-African fusion cuisine: Sweet & Sour Goat! It was fantastic. I also ate at Heaven--which is an amazing restaurant 2 blocks from my hotel. It was opened last summer by 2 Americans and is an awesome story of empowerment for Rwandans and good food. I have been told that outside Kigali there are not many restaurants and they are not very good. We'll see. For those who know me, I'm sure I will have more to say about food soon.

TIA

I'm not sure if it was a real phrase before the Leonardo DiCaprio movie Blood Diamond, but I have heard this a few times since my arrival. When asked why things don't seem to work out as planned, that is the answer: "This Is Africa"

I was told from many sources that international work can be challenging for many reasons, but number one is the logistics. Specifically, the Fellowship in Family Planning runs a workshop every year to prepare the fellows for their international experiences where there was ample explanation of the need to be flexible and patient. Thanks to the efforts of my mentors over the past few years, I was given excellent contacts at the teaching hospitals in Kigali and the medical school where I could possibly teach family planning/reproductive health (FP/RH) topics to students, house officers (residents) and even possibly some other clinicians. The details of what I would be doing, the timing of my trip and what my objectives for the trip were never entirely clear because they kept changing due to communication, logistic, and global financial issues (i.e. my funding).

Thankfully, I was able to coordinate with IntraHealth to help them in their FP/RH teachings outside Kigali through the Twubakane program. A family planning fellow from the University of Pittsburgh was here about the same time last year and had an excellent experience working with them. The staff at Twubakane are fantastic and generous with their time. They have arranged for me to participate in a set of trainings on long acting reversible contraceptives (LARC) that are set up for next week in a few provinces outside Kigali: Muhanga, Ruhango, Kicukiro, Kamonyi.

After my arrival in Kigali, I met a couple of the Ob/Gyn faculty here on Monday. Dr. Jean-Baptiste Kakoma and Dr. Joseph Vyankandondera are extremely busy physicians who have full patient schedules, teaching, and significant amounts of administrative responsibilities; even though they made time to meet with me and discuss how I could be useful during my time here. It turns out that they felt I should help with the ultrasound course being taught by a group of British physicians this week. Crazy how things work out, but those Brits are staying at my hotel!

While in line to board our flight from Brussels on Saturday, I met a British Neonatologist and a neonatal nurse who were traveling to Rwanda to continue their work to improveing neonatal care and the education of health care personnel around newborn and pediatric care. It turned out that we are staying at the same hotel! They introduced me to their colleague who is a Belgian fetal medicine specialist now practicing in London who is here to teach a 2-day course in basic ultrasound. After lots of discussions about what we are all doing here and that I wasn't sure what I would be doing this week, it turns out that I will help with the ultrasound course. I'm glad to see how things fall into place and am looking forward to helping.

As I'm trying to learn French, I guess it is appropriate to say:
C'est la vie

Some Photos

The 1st photo of my trip:


(There is only one, because I haven't been able to get any others to upload before a server timeout occurs.) This one from my arrival on Brussels Airlines at Kigali airport has a strange effect from dirt on my camera lens that made it seem like it was snowing. I promise you it was NOT snowing. It was a humid upper 70's F when I arrived on Saturday night. On Sunday, 11-Jan, I walked around the Kigali city center that is near my hotel--Iris Guest House. The hotel is very basic, but nice. I have WiFi access there and get a continental breakfast for $55/night. I purchased a cheap mobile phone and get some lunch. There is a very modern shopping center nearby that has a 24hr supermarket that is the Rwanda version of Walmart (they have everything!). I found the hospital and offices of IntraHealth where I'll be working. It was hot and humid, with a short afternoon shower. It is true that very few places accept anything other than cash (Rwandan Francs). I have seen ATMs, but they only work with local Rwanda banks.

Though there is an emphasis on becoming a more English-speaking nation, most people I spoke with expected me to speak French. Of course, I don't speak French and many don't speak English. However, there was generally someone nearby who was able to help me. At the ORTPN (The National Park & Tourist Office) they spoke English and answered all my questions about seeing the Gorillas at Volcanoes National Park in the North and taking a game safari at Akagera National Park in the East. I got a couple of maps and decided to make my travel plans later.

Landed safely

Hi everyone!
Though it was a long day of travel, I have arrived in Kigali with all my bags and very excited about the opportunity. I'm sitting at the airport waiting for Andrew, the IntraHealth driver, to pick up a bag that was lost earlier this week by someone else. Unlike O'hare, Kigali's airport WiFi is working and FREE!

I met one of the IntraHealth administrators, Sara, in the Brussels airport and she was joined by 2 other colleagues. They sat toward the front of the coach section and I was in the 2nd to last row. I read a lot and slept some. I sat on the rear right of the plane in a window seat so I had a great view the Alps, the Mediterranean, and the Saharan desert from 50,000ft before watching a beautiful sunset. Once it was dark, all I could see were faint orange lights below in the darkness for the last 3 hours. I sat next to a woman named Kris who is Belgian and is working with the parliament in Sudan. She was going to travel there tomorrow. She has spent lots of time in Rwanda as well and gave me lots of advice about what to see, where to go, and more. We had a very soft landing. Overall, it was a an easy flight. I could feel the humidity before I walked off the plane, but was surprised that it is pleasantly cool tonight. All can see from the front of the airport are lights in the distance. It is overcast, so I can't see any stars or the moon.

It turns out that the Twubakane group is having a party tomorrow afternoon at the IntraHealth offices which I plan to go to. I also plan to walk around Kigali, get a feel for the place, find a mobile phone store and book our Gorilla trekking permits. As soon as I get settled in my hotel and get a chance to take some photos, I'll post them.

Day of departure

After packing yesterday, I had the morning perfectly planned: sleep in, spend some time with Erin, have a leisurely breakfast and post something witty about the amount of stuff I'm bringing. Or better yet, I could post about how I'm leaving 3 inches of fresh snow in Chicago for 80 F temps and sun in Rwanda. I even took photos of the fresh snow and all my luggage. But you know how best laid plans go...

Instead Nate, the AT&T DSL repair guy, showed up at 7:30am and spent the next 3hrs getting us back online since our internet service cut out yesterday. That was just enough time for Erin and I to enjoy our "leisurely breakfast" with our new friend Nate. I left early for Ohare given the fresh snow and well, it's Ohare... Of course the ISP at Ohare is not working properly today either where I planned to post something while waiting at the airport. However, I figured out how to post something from my blackberry. Ahh, technology.

Anyway, if I find time to do it when I arrive you can all see the photos.

So I'm off to continue my attempts to change the world. I'm glad I can "take everyone with me" by writing this blog. Let me know if there is anything you all are dying to know.
I will think of you all often and miss you. Thankfully I won't be on my own the whole time, Erin comes to visit the 1st week of Feb. When we will do some travelling, sightseeing, and Gorilla trekking!

Take care,
D

Pre-Travel Preparation

With less than a week before I depart, it is hard to concentrate on anything other than my upcoming trip. I was lucky enough to see most of my family last weekend to celebrate the New Year and catch up on how big & grown-up my nieces and nephews are getting. My wife and I enjoyed our short stay with them. I am thankful I could see everyone before I leave.

In talking with my family (who are generally very informed about politics, history, geography, and current events) I realized most Americans do not know much about Rwanda beyond what occurred there 15 years ago. I have already learned a lot about Rwanda that may help put my trip into context. Here is a short summary of answers to many of the same questions I get:

• Though Rwanda is primarily Roman Catholic (up to 2/3 of the population), there is a concerted effort by the government and health care institutions to increase the use of modern family planning techniques. The government recognizes Family Planning as an important tool to curb both maternal and infant mortality, reduce poverty and promote economic and social stability. According to the World Health Organization (WHO), the total fertility rate (TFR) in Rwanda is estimated at 5.6 children per woman. The use of contraception is becoming more common, but is still significantly underutilized at 13.2% prevalence rate (meaning over 87% of women do not use contraception).
• Rwandan women have one of the highest maternal mortality rates (MMR) in the world at 1400/100,000 live-births. This is considerably higher than the average MMR of 910 in Africa.
  
• Rwanda is 10,169 sq miles (26,338 sq km) with a population of a little over 10 million. (That is an area similar in size to Connecticut, with the population of Michigan squeezed into a hilly, but verdant landscape.) This translates to the most densely populated country in Africa and 29th in the world. Nearly half the population is under the age of 15 which means Rwanda may be looking at a population boom in the very near future.
• As a former Belgian and French Colony, there are now 3 official languages: Kinyarwanda, French, English
• Rwanda is a small land-locked country in East Central Africa, bordered by Uganda (north), Tanzania (east), Burundi (south), and Democratic Republic of Congo (West).
  
• Though Rwanda is still reconciling the events of the 1994 Genocide, it has become a safe, stable and successful country with a very bright future.

Here is a Google Map with Rwanda marked:


View Larger Map


If you want to read more about Rwanda, here are some great books I have read:
1) A Thousand Hills: Rwanda's Rebirth and the Man Who Dreamed It by Steven Kinzer. This is an excellent read that covers most of the history of Rwanda and an in-depth view into the current President, Paul Kagame.
2) Shake Hands with The Devil by Romeo Dallaire. This is a much more in-depth look at the events that lead to and occurred during the Genocide in 1994. It is also a very revealing look at how the international community failed to intervene even though the UN was capable of doing so if their member nations had the will.
3) Rwanda Bradt Travel guide (2006) by Philip Briggs & Janice Booth. This was the only tourist/travel guide on Rwanda that I could find.