Saturday, May 31, 2008
Update May, 31, 2008
This week a building collapsed during deconstruction, killing one person and seriously injuring six others. I was not at that camp but was told the rescue and treatment went as well as could be expected. This reminds us of the suffering of the people in China and other areas of disaster. Also a twelve year old died of internal injuries after he was attacked by other young people.
More positive occurrences include the completion of a new building for labor and delivery. It is brick with a cement floor and a tin roof. It will replace one made of plastic sheeting on pole frames and mostly plastic floors. Running water will be piped in as soon as funds are available. The community health educators are receiving more training and soon will be visiting all newborn babies and their families weekly for the first few weeks of life.
Nyabiheke, the smaller of the two camps where I spend most of my time may expand in the next several months to accommodate 5-7,000 refugees currently in temporary centers called transit centers. The construction people are preparing to construct houses, roads, latrines and kitchens. The physician there has resigned in order to further his education, so ARC is looking for a replacement. I will be working only four more weeks, so will have some extra duties.
More positive occurrences include the completion of a new building for labor and delivery. It is brick with a cement floor and a tin roof. It will replace one made of plastic sheeting on pole frames and mostly plastic floors. Running water will be piped in as soon as funds are available. The community health educators are receiving more training and soon will be visiting all newborn babies and their families weekly for the first few weeks of life.
Nyabiheke, the smaller of the two camps where I spend most of my time may expand in the next several months to accommodate 5-7,000 refugees currently in temporary centers called transit centers. The construction people are preparing to construct houses, roads, latrines and kitchens. The physician there has resigned in order to further his education, so ARC is looking for a replacement. I will be working only four more weeks, so will have some extra duties.
Friday, May 23, 2008
Oh my aching mugango!
Mugango in Kinyarwanda means low back. It is one of a few words I have picked up because it is either the chief complaint or one of the “by the ways” of over one half of people thirty or moor e years old. Neck pain and headache is also very common. Of course these problems are very common in the US also. There multiple types of conditions and causes of these problems, however one notes many conditions that may cause the problems here. Transport of heavy objects on the head is very common, especially by women. Many people work stooped to wash, cook and work in the fields. People cut grass and weeds using machetes with a 45 degree bend at the cutting end. This saves gasoline and pollution but requires some back flexion.
In the clinic we are limited in imaging (x ray, CT, MRI) as I wrote earlier. We are able to see x-rays a few days later in cases that are more serious or resistant to treatment. The patient must travel by ambulance four to sixty miles to have the procedure. Due to budget limitations, we must select only the most serious cases to referee for x ray. We must think about saving resources for all other patient problems, especially those that are serious and amenable to treatment. Most cases of back, neck and headache pain receive ibuprofen or acetaminophen and posture recommendations.
This week we have been treating a fifteen year old boy with congenital heart disease using digitalis, spironalactone and low salt diet while waiting for approval of referral to a specialty hospital in Kigali for heart surgery. He probably has a ventricular septal defect and aortic insufficiency and possibly other problems. We are not able to monitor basic parameters such as the potassium level and became more uncomfortable as his shortness of breath increased and his pulse rose during the week. The UNHCR declined to fund the referral so we referred the patient to a teaching hospital in Kigali where surgery will not be possible, however better medical management will be possible, at least in the short term.
In the clinic we are limited in imaging (x ray, CT, MRI) as I wrote earlier. We are able to see x-rays a few days later in cases that are more serious or resistant to treatment. The patient must travel by ambulance four to sixty miles to have the procedure. Due to budget limitations, we must select only the most serious cases to referee for x ray. We must think about saving resources for all other patient problems, especially those that are serious and amenable to treatment. Most cases of back, neck and headache pain receive ibuprofen or acetaminophen and posture recommendations.
This week we have been treating a fifteen year old boy with congenital heart disease using digitalis, spironalactone and low salt diet while waiting for approval of referral to a specialty hospital in Kigali for heart surgery. He probably has a ventricular septal defect and aortic insufficiency and possibly other problems. We are not able to monitor basic parameters such as the potassium level and became more uncomfortable as his shortness of breath increased and his pulse rose during the week. The UNHCR declined to fund the referral so we referred the patient to a teaching hospital in Kigali where surgery will not be possible, however better medical management will be possible, at least in the short term.
Saturday, May 17, 2008
Friday, May 16, 2008
Malnutrition
Twenty children out of a population of 8,000 people have been identified as malnourished at the Nyabiheke camp. Moderate malnutrition is based on a weight less than the 80th percentile expected for the child’s height and severe malnutrition is weight less than the 70th percentile. These children receive nutritious food at a feeding center daily in addition to food to take home. The children usually gain weight and leave the program in three to six months. The child pictured did not make progress, but developed pneumonia and dehydration requiring hospitalization, rehydration, antibiotics and warming. On admission he weighed 3 kilograms (6.6 lbs) at nine months of age (less than 60th percentile). He ate well and gained 1 Kg. in two days, so we are optimistic he will improve in the near future. His long term future probably is guarded as his neurologic development may not be normal due to these early problems. After a visit to the nutrition center, a second child with pneumonia was admitted the next day who weighed 6 Kg. at 18 mos. She also has a good appetite and is doing well. We are working on new ways to identify malnourished children and I have led training sessions for the nurses for treating the problem. My knowledge is based not on experience, but from information obtained over the internet from the World Health Organization and from medical journals.
Food rations of corn meal, sorghum, soy meal, beans and sometimes rice are distributed monthly. The refugees frequently sell some of this food in order to buy other foods such as potatoes, rice cabbage and meat if they are lucky. Some raise chickens, goats or cattle which may occasionally add to their diet. Here there is very little space for gardens. I am told that small children receive priority in receiving food. Another person said the father is the first to eat. Family size averages seven or eight children and the more children the larger the rations. Birth control is rare, probably less than five percent of families.
Today we taught community workers how to weigh, measure and plot the information on a growth chart. We discussed causes and results of malnutrition. So there is enthusiasm among refugees and workers to improve the health of the children in the refugee camps of Rwanda.
Food rations of corn meal, sorghum, soy meal, beans and sometimes rice are distributed monthly. The refugees frequently sell some of this food in order to buy other foods such as potatoes, rice cabbage and meat if they are lucky. Some raise chickens, goats or cattle which may occasionally add to their diet. Here there is very little space for gardens. I am told that small children receive priority in receiving food. Another person said the father is the first to eat. Family size averages seven or eight children and the more children the larger the rations. Birth control is rare, probably less than five percent of families.
Today we taught community workers how to weigh, measure and plot the information on a growth chart. We discussed causes and results of malnutrition. So there is enthusiasm among refugees and workers to improve the health of the children in the refugee camps of Rwanda.
Sunday, May 4, 2008
photos May 4, 2008
cooking food at the Nutrution center
food storage, nutrition center
Byumba Hospital, 7 km from Gihembe camp
food storage, nutrition center
Byumba Hospital, 7 km from Gihembe camp
Camp management and funding
Four agencies are responsible for managing the two camps where I work. A branch of the Rwandan government is responsible for registration and food distribution. Save the Children is a nongovernmental organization (NGO) responsible finding lost family members. The United Nations High Committee for Refugees is responsible for overall monitoring, referrals for specialty medical care, materials for construction and basic food supplies. ARC is responsible for primary health care, maternity, immunizations, family planning, HIV counseling and testing, income generation projects (loans for small businesses and group savings programs), water and sanitation (latrines, one per 20-25 people), gender based violence programs, roads and construction of buildings. There are a few other NGOs that play minor roles such as providing scholarships to students for secondary schools.
Funding for these programs comes from many sources. The United Nation’s funds have been reduced due to nonpayment of some members including the US. ARC’s worldwide budget is slightly over 30 million dollars and the budget for Rwanda is 2.5 million dollars. Approximately 99 % of the funding for Rwanda comes from the United Nations and from various US agencies. Small amounts are funded from private foundations and OPEC. Reductions in funds paired with increasing numbers of refugees from the Congo during the past few years has, reduced the quality of some services. A peace agreement was signed in the Congo early this year, however the security there is poor and refugees are still entering Rwanda. This is leading to discussions about expanding some camps.
Limited resources of the NGOs delivering services and of the residents of the camps leads to multiple delays, inefficiencies and hardships. A woman with a fractured ankle was transferred to the local hospital for a cast because casting materials are not available in the camp, though knowledge of cast application is known by personnel. She needs crutches but none are available or affordable. If she leaves the ward and walks on the cast, the cast will soon be ruined in the wet weather and the healing of the fracture may be suboptimal. Another woman needed a pelvic exam but it was delayed for two days, first due to other women in labor and using the room and secondly by lack of sterilized speculums. This week we were out of referral forms and couldn’t print more as the computer was not available, so those patients who needed a referral had to return the next day. The forms were not available so return on the third day was necessary. Several people have had poor distant vision, and have been prescribed glasses, but these are not paid by any of the organizations so are usually are not obtained. The clinic does have a selection of reading glasses free for refugees.
Despite these difficulties, the staff and refugees continue to work and study for a better future. During the drive to work each day in a crowded Land Cruiser (record of 18 people) over bumpy roads, the staff are usually kidding each other (in Kinyarwanda) and laughing. I can’t understand the jokes, but admire their ability to find humor.
Funding for these programs comes from many sources. The United Nation’s funds have been reduced due to nonpayment of some members including the US. ARC’s worldwide budget is slightly over 30 million dollars and the budget for Rwanda is 2.5 million dollars. Approximately 99 % of the funding for Rwanda comes from the United Nations and from various US agencies. Small amounts are funded from private foundations and OPEC. Reductions in funds paired with increasing numbers of refugees from the Congo during the past few years has, reduced the quality of some services. A peace agreement was signed in the Congo early this year, however the security there is poor and refugees are still entering Rwanda. This is leading to discussions about expanding some camps.
Limited resources of the NGOs delivering services and of the residents of the camps leads to multiple delays, inefficiencies and hardships. A woman with a fractured ankle was transferred to the local hospital for a cast because casting materials are not available in the camp, though knowledge of cast application is known by personnel. She needs crutches but none are available or affordable. If she leaves the ward and walks on the cast, the cast will soon be ruined in the wet weather and the healing of the fracture may be suboptimal. Another woman needed a pelvic exam but it was delayed for two days, first due to other women in labor and using the room and secondly by lack of sterilized speculums. This week we were out of referral forms and couldn’t print more as the computer was not available, so those patients who needed a referral had to return the next day. The forms were not available so return on the third day was necessary. Several people have had poor distant vision, and have been prescribed glasses, but these are not paid by any of the organizations so are usually are not obtained. The clinic does have a selection of reading glasses free for refugees.
Despite these difficulties, the staff and refugees continue to work and study for a better future. During the drive to work each day in a crowded Land Cruiser (record of 18 people) over bumpy roads, the staff are usually kidding each other (in Kinyarwanda) and laughing. I can’t understand the jokes, but admire their ability to find humor.
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