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!

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.

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.