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.