Family Has Nothing to do with Blood

Today I said goodbye to my Rwandan mother, Christine. It was the third time I saw her and she made a special stop at the WE-ACTx house bearing gifts on her way to night school. In Rwanda it is customary to offer your guest something to drink immediately. This typically ends in a Fanta request and man, Christine likes her orange Fanta! I ran next door to get her a "soda" (clearly there is not enough Midwestern influence here...) and when I came back, she was seated with a present, wrapped in beautiful flowered paper and a peach bow, sitting next to her.

For you, she says as she hands me the box. I smile, murakoze chani, as I unwrap the carefully wrapped gift. I've seen people on the sidewalk gift wrapping to earn money, in the market, as I walk through the streets. Shiny ribbons, hand looped bows, glittery paper. Gifts, no matter how big or small, always come expertly wrapped in Rwanda.

I open the box and pull out a handmade quilted purse. Something I would not pick out for myself, but truly, the perfect present. It's small made with a brown and tan patterned fabric. I love it, Christine! Murakoze chani! It's great! She pulls her purse onto her lap and struggles with a much larger gift. As she hands it to me, she says, for your mother, Christine too. This gift is wrapped with the same special touch. A pink and white bow in place of the peach one.

This all started a month ago when Dr. JMV was running late. Christine walked into the room and introduced herself. All I had to say was, Christine is my mother's name. We are forever family now. She was on holiday, but happened to stop into the clinic that Thursday to finish some paperwork. Christine is in charge of ordering ARVs for the clinic. That's the magic of Africa that I look forward to every day. Chance. Luck. As I reflect on my nearly two months in Rwanda, I think of all the things I've seen, and done, the people I've met, the moments that flash through my memory. Almost all, completely from pure dumb luck. The man on the bus to Nyungwe. Laughs in the kitchen, shared with Seraphine. Hiking through brambles looking for giraffes with James. Seeing the sunrise over the misty hills of Rwanda. Watching the children walk to school. Seeing the rainforest before the sun rose. Being punked by a monkey. Helping Candida with her English homework. Making biscuits with her. Hearing Alice's story on a bus ride to the mosque.

We spent nearly two hours sitting in a room together, speaking broken English and even more broken Kinyarwanda. She told me of her children, that she was a widow, also a student. When Dr. JMV finally arrived, she returned to her office and continued her work. Every time she entered the room, she held my hand or slapped my cheek. Hugs and kisses. Then I didn't see for a very long time.

I asked about Dr. JMV after she hadn't returned to work. The words flowed so nonchalantly. Her family was killed in the genocide. She knew they died closed to her home. She was digging a new latrine for her house and finally found them, thirteen years later. Her family. The people she loved. Hacked up and thrown in a giant toilet. People with these stories are too common here. She took extra time off work to file paperwork with the government, have the bodies exhumed, and reburied in on of the many memorials spotting the country. Thirteen years later and the memorials are still left open. There are still fresh burials.

She began telling me about the day of St. Christine, July 24th. In Rwanda, a common first question is, what religion are you. She is catholic and as most catholics here, their saint namesake day is celebrated. That's what the extra gift is for.

This name connection has come up multiple times in the short while I've been here. Christine was not the first. I was looking at the shops in the craft market when my friends introduced me and the woman started hurriedly speaking excited French, hugging me and kissing me. Turns out her grandmother is also Melanie. She held my hand and showed me around her shop as she told all her friends about me. We are family she said as she hugged and kissed me for the final time. Um, nice to meet you too.

I now have a Rwandan mother, brother, and another family member...granddaughter? When you are called family, you are. Its that simple. You are welcome in their home. You are loved. What if we loved each other simply for sharing a name? What if at home we welcomed people into our lives simply for a coincidence? What if, we truly loved others, strangers, for no good reason? Love is a powerful thing.

The Best Plan Ever Hatched in the History of Plans...

Dad-
I need you to read this aloud to Mom. She already knows most of the story, but this is the true version of events in its entirety. Needless to say, when I describe certain things, you should lie, but act natural, and tell her something totally harmless so it doesn't seem like this was the dumbest thing I've ever done. (It was totally freakin' awesome and the coolest weekend I've ever had in truth.) If you don't help me with this one I'll end up with a series of never ending Mom lectures. Then I will file court papers to disown you. Think wisely and choose carefully my friend...
Love,
Mel

This all started with reading. I remember teachers, early in my life telling me how great ideas come from reading. Well, really bad ideas come from reading too and certainly, really risky ideas. And I love to read...and my mom says I'm often lacking in "better judgment/common sense". I was looking through the Rwanda guide book at the house and noticed that Rwanda happens to have the largest mountain rain forest in all of Africa. I'm in Rwanda. I've always wanted to see a rainforest. Hmm...

Friday morning I'm up and out the door at 5:30 with a backpack full of over overnight/rain forest essentials and trudge my way to the bus stop. That's right. Getting on the bus (well the first bus was sold out) for a five hour bus ride (remember those minibuses I was talking about...) setting out on my first solo adventure. [Ok Dad, instead of five hours away from Kigali, you say "45 minutes, in fact you can still see the city. Actually, it was right down the street from the American Embassy. And replace solo adventure with "group organized mediocre events". ]

On the road to Nyungwe National Forest, I hit a bit of a snag as I realize I will need to buy my return ticket in Cyangugu, an hour past my destination of Gisakuru Tea Estates. Travel between Cyangugu and Gisakuru is extremely limited, but lucky me, I'm sitting next to this awesome guy that has the bright idea to telephone the bus company in Cyangugu and have them bring me my return ticket as a bus departing from there passes our bus on it's way in. Great! Problem #1 solved. The other bus passed us up and our bus driver honked madly, waving his arms so fast, they might fly off, then got out of the bus and chased the other bus down. More trouble than I thought it would be, but I got my ticket and thanked the driver.

We also got pulled over by the Rwandan police and had our bus searched. [Again, Dad, you read, nothing eventful happened for the remainder of the ride.] This is actually pretty standard police procedure, seeing as most police are stationed as human road blocks, no cars, and pull people over to check their license and registration. Something wasn't right with the tags from the bus company, so our driver got a ticket. The man next to me said a ticket can cost about $100 USD and a driver is lucky to make $200 USD in a year. The Rwandan government is very good at math, and punishments.

Eventually I make it to the tea estates and walk into the parking lot of the lodge/ORTPN office. I was greeted by a few rangers who took me to the guest house to check in. I meet the man in charge of the inn and am informed they are completely booked. Uh, ok. After a few minutes he comes back to tell me there is an opening because a primate safari group didn't show up, but of course it was the most expensive room.

I moved my stuff in and returned to the office to set up my adventure for the next day. What are you planning to do today? Uh...what can I do today?

Twenty minutes later I'm walking down the main road on my way to a nearby tea estate to go looking for Colobus monkeys in a fragment forest. The whole trip took about four hours and of course, we didn't see the monkeys along the outside of the forest, so the guide decided to take me down a tiny trail into the middle of the forest. After walking down one side, up the other, around the back, down again, and halfway back up we finally spotted a group of them. They were unbelievably difficult to see at first because these monkeys are nearly all black and were hiding in an overgrown bush that was much taller than I am, with branches that hung to the ground. The shadows made it nearly impossible to find them. At first you only see one, then one more, then twenty, thirty. There were a few young ones in the bunch and I watched them for over an hour, jump fearlessly from tree to tree. Right over my head. One monkey came within three feet of me, walking out onto a branch and sat checking me out while he ate. He kept sticking his head out towards me and sniffing. I assure you it's because I smelled good.

After a while they moved on and my guide was off. Racing to keep up, I almost plowed right into the back of him as he stopped and looked into the tree tops. My gaze followed his and I watched as the troupe jumped from one branch to the next like the long jump skiers in the olympics. Arms back, head first. I heard a strange sound around me and thought the overcast sky and started to rain down. Nope, monkey pee as my guide stated so nonchalantly. Great. After walking back out of the forest, I checked myself and my bag...no pee so I'm ready to get back to the guest house.

One the way home we passed a school as the kids were getting out. After walking for a bit, I turned around to see who was making all the noise behind me. Twenty kids were following me. My guide told me they were arguing and daring each other to talk to me. So I said hello to them, Muraho. Amakuru? Twenty little voices yell Ni meza! and we all laugh. They followed me all the way back to the ORTPN office and stand at the driveway entrance waiving at me until the park rangers shooed them away.

I ate dinner. The best cream of something soup I've ever had! I climbed into bed exhausted and listened to an episode of Wait! Wait! Don't Tell Me! until I fell asleep...it'll be an early start the next morning.

4th of July means something very different here

The fourth of July is a day celebrated as one of the few national holidays in Rwanda. No fireworks, no BBQs. We all woke up very early and left the house around 7 am to hike the half hour to the bus stop. The buses were so crowded the five of us had to split up and we arrived a short time later at Amohoro Stadium for the day's festivities. We arrived along with the rest of Rwanda. To celebrate Liberation Day. The day the RPF took over Kigali, which led to the end of the genocide.

The sidewalks and streets were so covered with people we had a hard time finding a place to walk. The group I was with entered the stadium area and were faced with a mob scene, that rivaled Navy Pier on New Year's Eve for the turn of the Century. We walked from line to line looking for a place to enter and finally settled into a mob of people. The women were taken into their own line so we were all pushed to the front for our standard Rwandan pat downs. This security check would certainly have ended up with plenty of lawsuits if done in the U.S. Every person that entered, even children were patted down and all bags were searched before anyone was allowed to enter.

After about an hour of walking around to find an entrance, a line, and finally making our way to seats, we were inside and ready to watch the show around 8:30. The stadium hasn't been renovated since, I'm guessing the early '70s, judging by the decor. We sat on concreted slabs in the cheap seats section. The festivities didn't get started until around 10:30 when a tiny marching band entered the stadium.

This band was followed by the largest military showing I've ever seen in one place. This was the theme of the day. Liberation Day was about one thing and one thing only...step out of line again and the army will get you. The presidential marching band entered dressed all in blue. The people in the crowd cheered and rose to their feet as Paul Kagame entered. The RPF leader, the hero himself. Now, thirteen years later, the president of Rwanda enters the stadium to watch was turns out to be a military show.

After my time in Rwanda, I've begun to assume the national slogan is "Never again". Personally, being in the presence of enough firearms to level the state of California is more than a little chilling, but not so for Rwandans, the survivors. Members of the military lined the track in block formations while groups of four to ten soldiers displayed their hand to hand combat skills in staged battles. At one point three blocks of soldiers marched forward and put on a coordinated performance of a karate kada I had actually learned for green belt. The statium shook with their movements and their voices echoed in the silence. It was chilling.

The games continued with targets set up in the middle of the field. Soldiers came forward to demonstrate their weaponry skills beginning with knives and ending with machettes. The same weapon, thirteen years ago, that was used to lop off arms, legs, heads...no one seemed to notice the connection. The crowd cheered each hit and laughed at every miss.

The final event was by far my favorite. It very much depicted the situation of the genocide, with an alternate ending. It began with camouflaged soldiers pretending to be hidden. A man and a woman, nicely dressed, carrying a briefcase and purse respectively, walked into the area where the other men were hidden. They were jumped. Both the man and woman threw their belongings to the ground and dove right in to fighting with the attackers. At one point I sat there with my mouth hanging open watching a woman in high heeled shoes run up the side of a soldier, kick him in the face (not connect though) and hang, suspended vertical in the air at his face level. This was an unbelievable show of amazing skill and the entire stadium erupted as the two, seemingly ordinary Rwandan citizens walked off the field victorious. Never again.

The military acts were followed by traditional Rwandan dancers and singers, but they were performing with their backs to the crowd, facing instead, the president. The speeches and songs were difficult to hear because the stadium had some reverb problems and the acoustics were terrible.

After the formal celebration, there were to be two soccer games: the business men vs. some other old guy team and the match of the day: ATRACO, the city transportation system vs. the military, Paul Kagame's team. Margot and I peaced out before the games began because it was hot and we weren't really in the mood for soccer. Walking out of the stadium in the mob of people I thought a lot about the day. The message.

People here are still very much afraid, suffering from '94. The promises found in the Geneva Conventions were sadly,not found in Rwanda for the 100 days of extreme violence. The people are put somewhat at ease today by knowing that the leader of the RPF, the man responsible for leading the rebels to victory and thus ending the genocide, is in charge of Rwanda and it's armed forces. Many people I've worked with have commented often over the past month that Rwanda is an incredibly safe country, undoubtedly, the safest country in Africa. It is impossible to walk to the clinic and see under ten men with guns standing at various buildings or patrolling the streets. While their presence doesn't end the flashbacks of the WE-ACTx house cook, nor the stigma faced by the HIV+ receptionist at WE-ACTx, who by the way fought in the RPF and acted as a front line nurse, it gives citizens a sense of security that lets them know, with or without the support of the rest of the world, Rwanda will not let the genocide in. Never again.

Rwandan Wedding, the actual wedding--no monkeys

The Wedding was supposed to start at 4:30 so we left the house at 3:30, arrived at 4:00 and waited for the wedding party until after 6:00. Over eager victims of Rwandan time yet again, but well worth the wait.

The reception is completely different from wedding receptions in the U.S. The chairs for the guests are set up like the church. The groom's guests sit on the left and the bride's guests sit on the right. There are no dinner tables because dinner isn't served. The wedding party, including immediate family, sits on a platform in the front. Theree bride, groom, and their best man and maid of honor sit at a table in the front, with the rest of the wedding party behind them in rows.

After everyone is seated, each side picks a member of their family, typically an elderly uncle or father to finalize the bonding of the families. These two men sit and drink banana beer that is made of a mixture of homemade beer from the towns of both the bride and groom. The two men introduce themselves to each other and sit and talk for a bit. Then the bride and groom come to sit with them and also must drink from the huge jug of beer.

After all of this beer drinking business is done, traditional Rwandan dancers come in to dance for the couple. The women wear tank tops with one shoulder shawl type coverings and a long skirt. The men wear crisscrossed suspenders and a skirt made of dried, long grasses. There is a choir that is accompanied by drummers that provide the music for the dancers. The group comes in and out throughout the evening to entertain the couple and their guests.

They also have the bride and groom toast each other...with Citron Fanta. It's fabulous! Then they make their way over to the cake. The cake has a house on a platform instead of the bride and groom. There are two towers one on each side that are given to the mothers of the bride and groom that are intended to signify the grandchildren they will give them. The friends of the bride help cut up the cake and pass out a piece to each guest. They also give out a Fanta or Coke to everyone.

The best part was towards the end when the dancers came back...bearing gifts. I'm not sure who bought these gifts for the couple, but they are symbolic of the traditional gifts given to help the couple start their new life together. The bride goes first and she was given banana leaf, handwoven floor mats, baskets, and other house related gifts. The groom follows, receiving gifts used to protect his family: a spear, a bow and arrow set, and a leopard skin to display to send the message to enemies that he is a good hunter.

After all the gift giving comes the dance off. That's right a dance off. The dancers start and then one man from each family got up to challenge each other. Guests would run up to them and give money to the best dancer. Everyone was up out of their seats cheering and laughing, watching these men do their thing.

Each relative is given the opportunity to get up and present their gift. Some people decided to make announcements to offer cows, goats, or chicken to the couple. Cows are a sign of wealth in Rwanda and each milk cow costs about $1,000 USD. This couple was given two. Innocent, who took us to the wedding, offered his help to his cousin, the bride, in getting a job.

After the wedding reception, the real party begins as guests move on to the couple's new home and carry in all their new furnature and food for everyone. It was getting too late so we weren't able to stay to go to the house, but I heard it's a good time for all. There's an impromptu dance party that starts and everyone finally relaxes without much formality. An interesting twist to the wedding, and as someone who's moved too many times, much appreciated!

Best plan ever...

I'm going out of town this weekend to visit the Nyungwe National Forest. It's a little known, hidden Rwandan treasure of a rainforest that houses troops of Colobus monkeys that are as large as 400 in number and habituated groups of chimpanzees. I'm leaving very early tomorrow morning for the 4 hour bus ride to stay at the Gisukuru Guesthouse for a night at the tea plantation. Hopefully I'll get some hiking in tomorrow afternoon and then it's Chimp trekking at 5 am Saturday morning!

Each hiker is given a guide as part of the park fee, so someone from the ORTPN (Rwandan national parks service) will help me out both days.

I should have some good pictures from my little excursion. I'll finish posting more stuff when I get back!

I went to a wedding and this is what went down part 1

Last Saturday a friend of mine at the clinic, Innocent, invited me to his cousin's wedding and needless to say it was incredibly eventful.

Figuring out what to wear to an American wedding can be quite a tricky task, but Rwandan weddings require a great deal of effort. My roommate Margot decided to wreak havoc on our closet and turned the morning into a rousing round of dress-up. I decided to wear a dress I had made here earlier in the week, but mention Margot's mess solely to bust her chops. You couldn't see our floor or beds because they were covered in discarded cloth, wrap skirts, and traditional garb.

Innocent showed up at the house to pick up Nina, Margot, and myself at 3:30 with the wedding reception starting at 4:30. We arrived at the hall around 4 and found out the wedding party was running very behind. Surprise! Innocent decided to help us pass the time with a tour of the grounds and explanation of the site. Turns out that the location of the reception was inhabited by some pretty interesting and mildly entertaining creatures. This facility is owned by a Catholic group that rents out the hall for weddings and houses priests and nuns who teach at the local schools. We walked around to the side of the hall where we stood in a wooded park area and listened to Innocent tell us about the property and his family.

As we're standing there I look towards the dormitories and see something vaguely familiar, yet totally out of place. There's a monkey hunched over sitting in the middle of the path leading to the back of the property. Yes, I was wearing my glasses. I just stood there staring at it when Innocent started laughing. Is that a monkey? You've never seen a monkey before? Well only in the zoo. They don't look different when they're in zoos. Thanks Innocent...

This was a truly bizarre experience. I've watched enough Jack Hanna and read enough Zoobooks to know that monkeys live in Africa, but still, I was completely caught off guard. My first instinct led my feet to move me directly towards this thing and my second instinct was the voice in my head saying, um you didn't get the rabies vaccine...hmmm...

This little monkey, about the size of a cat, came running towards me so fast, I thought he would be lucky to skid to a stop as he crashed into my legs, but at the last second he veered off to one side and flew into a tree. He stood perched on a low branch staring at all of us. I was watching him watch me when I see a flash of tan flying past me and realize we now have double the fun! Two whole monkeys. Fabulous. The other interns and I watched these two little guys for about 20 minutes as they chased each other around the clearing and up and down the trees. They were a riot.

The trees around us were filled with some very hard leaves that looked like they had started to develop into fruits, but got bored and quit. I found some green ones hanging close enough for me to pick, but too far out for the monkeys to get to and still remain in the tree. I picked the first one and dropped it at monkey A's feet. He snatched it up, scampered away and seemed to enjoy his treat. He came back and sat at my feet staring at me, so I picked another one and he took it from my hand. I turned around and the other interns were laughing. Looking around, I noticed that monkey B is jumping up and down making monkey noises reaching his tiny hand out to me. Ok. I'll see what I can do.

I turned back to the tree and reached up to grab another leaf. This one was tough and took me a longer time to break it off. I finally freed the weird fruitish thing and turned around looking for this monkey. No sooner had the words, "where'd he go," come out of my mouth, than that stupid monkey ran up behind me pinched the back of my ankle and ran away. Both of us screaming like little girls. Despite my instinct to chuck the hard leaf at him and smack him, I walked over to the tree he was in, reached out my hand, and offered him the treat. He took it as I looked up to see that a crowd had gathered to watch the mazungos playing with the monkeys. Needless to say everyone was laughing hysterically, including my intern friends.

When Nina stopped laughing, she looked at me straight-faced and said, "Dude, you were like, where'd he go? And I was laughing to hard, but really wanted to yell, "He's on your leg."

And that was how I got punked by a monkey...This is already the best wedding I've ever been to, and it hadn't even started yet.

some stuff

So I didn't add the picture web addresses as direct links. This has been brought to my attention as a source of some confusion so I thought I'd post a brief instruction.

All you have to do is copy the whole address for each set of pictures, one at a time and paste it into the address bar at the top. It would help to open another tab first so that you can still get back to my blog easily if you want to view all of the albums.

I hope that makes some sense, though my explanation sounds a little generic and confusing to myself so good luck.

I love the ordinary moments most of all...

"You've gotta know when to hold 'em. Know when to fold 'em. Know when to walk away. Know when to run." This was the music playing in the car on the way to pick up Dr. JMV before heading off to Nyacungu to spend a day at the rural clinic. That's right. Kenny Rogers. This was followed by a rousing tune by Dolly Parton and some other guy, clearly a fabulous remake of the Sylvia and Mickey song: Love is Strange. I couldn't make this up if I tried. Nina and I are sitting in the back of the WE-ACTx car on a dirt road while Freddy, our driver, listens to a mix tape of old school country. "Do you like country?", he asks me. Oh man, do I ever! Freddy and I continue singing Kenny's gem of a song when it comes on a second time. Well I was singing, Freddy was screaming out what he thought the song lyrics to be. I couldn't have asked for a better start to my day.

We get to Nyacungu and see a handful of patients. Nothing too serious today, until this old woman walks in. Sorrowful face, sullen expression, hunched over, settles into the chair beside Dr. JMV's desk. I watch as she tells Dr. JMV something and he responds. This continues for a few minutes until the woman's eyes light up. She sits up straight and begins talking, quite animatedly, arms flailing, loud voice. What is going on?!?! Dr. JMV explains when she's done having her moment. She was tested for HIV this past October and the results came back positive. The woman was returning today for a standard 6 month follow up treatment, and today I was there when she found out the test results were wrong. She is in fact HIV negative. With one sentence back in October her life changed, seemingly forever, but today, with one sentence she her life did a complete 180. I can't imagine the heaviness of her diagnosis in October, but I was there to see the weight lifted, which is not a cliche description in this case. Dr. JMV continued to translate her words for us.

She was a genocide survivor, but her husband was not. She never remarried and swears she has never been a prostitute. She has spent the last 8 months trying to figure out how she, a celibate, church-going old woman, could have gotten this disease. She thanked and praised God, Dr. JMV, along with Nina and I. I swear, she danced her way out of the room. Until that moment I have yet to see such a spectacular moment in a person's life. Something so private. And I was there.

So how does it happen? Careless mistake? Could be. Rwandans don't have surnames that are passed from generation to generation like we do in the US. Instead, they are given Kinyarwanda surnames by their parents. Commonly, their first names are Christian names and so it is highly likely that there will be some people with the exact same name, certainly similar names. Most of the patients I've encountered here don't know the exact date of their birth, and are lucky if they can tell me the year they were born. The blood is drawn, labeled (sometimes sloppily), and then taken to the national laboratory for testing. Here samples are frequently mixed up due to the similarities in name. When the results are taken back to the area from which they came, they may not be for the right person.

Poor testing procedures? Maybe. There are some sights that do their own form of rapid testing where they use whatever testing kits are available to them at the time. The rapid test is pretty self-explanatory. It's a fast test for HIV, in the US it takes about 30 minutes. Dr. JMV explained that there have frequently been cases of people using expired testing kits that lead to greater false positive results. Keep in mind that while HIV/AIDS has been around and identified since about 1986, testing in the catchment area of Nyacungu started this past October.

That's right. October, 2006. And still the argument is made that Sub-Saharan Africa is receiving plenty of international help in dealing with the epidemic. How very George W. of us. Just ignore it and it'll go away. What you don't know won't hurt you. That's exactly right. People go away here every day and the international community continues to ignore it. It won't hurt us if we don't know. Hey, it's not like we're going to get AIDS. It's this exact ignorance that's killing Rwandans. Africans. Haitians. South Americans. Indians. The Poor.

My day didn't end there, though my preaching does for now. I came home after seeing a few more patients and found Seraphine, the woman that cooks for us during the week, preparing dinner in the kitchen. I was done for the day with my WE-ACTx duties, so I decided to step a little farther out of my comfort zone, right in my very own kitchen, and try to cook with Seraphine. I say 'out of my comfort zone' because I do not cook, nor speak French, both of which Seraphine does flawlessly.

I come in and ask her if she needs help. She tilts her head and squints at me like I'm completely nuts. I try again, remembering that she knows some English. Can I have a job? Job, she repeats. Yup, job. I pick up the knife she's using to chop vegetables and mime cutting. Oh! Job! she says. At this point another intern comes in and translates Seraphine's questions for me. Do you know how to cook rice? I reply, how hard can it be? It's just rice. Jocelyn translates. I get another strange look from Seraphine and she hands me a knife and a pineapple.

I've never sliced a pineapple before, but I'm now assuming it's easier than cooking rice so I hold the knife up to it to get a confirmation from Seraphine that I'm doing it right. Seeing me, the knife positioned in the middle of this daunting fruit, she takes the knife and the pineapple and makes the first cut horizontally across the top. Apparently, I should have stuck with the rice. I make exaggerated Oh I see faces, which I doubt very much actually convinced her that I have in fact, held a knife before. I cut the pineapple and soon, I'm in need of another job.

I get a look from Seraphine that tells me she was hoping I'd stay occupied with the pineapple for the next few hours while she finished her cooking. It was in that instant that I saw myself as the pain in the ass kid who needs a 'job' helping mommy in the kitchen by staying away from the real work. But I'm tenacious and so I pick up a knife and help her skin tomatoes. These tomatoes are smaller than the ones back home and the insides are very sweet, but the skins are very bitter and not commonly eaten. This is hard. The naked tomatoes are squishy and slippery. I spent more time picking them up from where they fell in the sink than actually skinning them. I look up and notice that Seraphine has been staring at me for a while, as she's shaking with silent laughter. You too slow tomato. She hands me a grater and a hunk of cheese. I'm banished to the dining room and I laugh my way out the door.

Now, I've made enough taco dip in my time to be able to work a cheese grater. Finally, success! I'm able to navigate my way through half a block of cheddar and as I hand the plate back to her, she laughs and says to me, you make me happy today.

I'm happy too, Seraphine.

The story of my life in Rwanda...

Today I went to children's support group. I almost killed Burtan...the group supervisor. I get there and it's the hottest day of the season so far. It's so hot that the kids can't play. Over 100 kids between 5 and 18. Rounding up small children is difficult enough when I speak the same language as them, but forget it here. It took about 45 minutes to get them all seated, but that's only half the battle because now we need to get their attention.

Burtan gets up and starts yelling. They ignore him for a bit longer. Then he begins to quiz them about the lectures he has given them in the past. They talk about HIV, associated infections, nutrition, and healthy attitudes. I'm listening to Nyla, a trauma counselor, as she offers her hand at translation and randomly hear my name, look up, and see Burtan smiling with a million little hands waiving in the air. Uh-oh...

Burtan called me up to the front and informed me that the kids wanted me to give a lecture on Vitamins, nutrition, and healthy eating. Fabulous...let's all enjoy a good laugh about that...the future physician that openly detests fruits and vegetables has to explain good eating habits to a group of kids that are generally malnourished. I slowly walk to the front of the group and wait for Alice to translate for me. Alice is a great person with a huge personality, but nearly inaudible voice. Here's the scene: Me, standing in front of 100 kids, screaming "how many of you eat one piece of fruit each day" followed by Alice's hushed murmur of a translation and a sea of confused faces. Uh...ok. Once the kids got the general idea of my talk and my question, only about half of them raised their hand. I kept asking about their diets, following the same line of questioning and each time less than half the kids raised their hand.

After my quick polling, I started to lecture on the two fruits, most important for their immune system: oranges and bananas. About thirty seconds after I opened my mouth I leaned over and quietly asked Alice if they even have oranges here...it was going to be a long day...Once I had a list of culturally appropriate food, I started telling them about how to eat a little from each food group and what things were best for staying healthy while HIV+ and came to realize that even though Burtan claimed to have taught them about the immune system, they had no idea what I was talking about. So I back tracked a little and explained about the part of our bodies that fights off disease and protects us. At which point I had kids making gun motions and smacking each other. Not going well...I look around for Burtan to maybe help me out a little and he's no where to be found.

Ok, so let's move on. I get a suggestion being shouted at me from the back of the mob. It's another intern trying to convince me to tell them about the benefits of antioxidants in tea. Um, if these kids don't understand the immune system, I'm pretty sure terms like 'antioxidants' are going to be a bit more elusive. Eventually, I got across a couple of main points: bananas and oranges are good. Milk is good. Eat some fruits and vegetables each day and try to eat some meat. This is really quite a big joke because I've seen these kids eat and I know that if meat is available, there's not a chance in hell, they're going to pass it up. If they could maintain healthy eating habits, they would because anything is better than not eating and fruits and vegetables are cheaper than meat. There is virtually no chance of obesity, diabetes, or heart disease for this community.

My brief vitamin/nutrition lecture concluded with a question/answer session. This is the most important part of the discussion and I got in a fight with Burtan because he tried to cut it extremely short. He informed me that in Rwanda students are lectured to and not allowed to ask questions, so he felt that as long as I covered what he asked me to (which was pretty vague to begin with...vitamins, go!), things had been adequately accomplished. Well, the kids had quite a few good questions about sugar. I had to laugh because, despite their limited diet, kids love sugar. So I asked how many kids like Fanta. This time everyone raised their hand. So I tried to explain the little nutritional value held by soda and stressed the importance of milk and water. The day eventually concluded with Burtan volunteering me as the guest lecturer each week on a different health topic. This is only funny to me because it's so typical of my experience here. You're supposed to teach 200 kids english...last minute change to health topics two weeks earlier than your lectures were supposed to begin. I always felt like a pretty flexible person, but I now feel 100 percent justified in considering myself to have quite a bit of adaptability. Most days I'm flying by the seat of my pants...and yet it always works out.

Pictures Pictures Pictures

Since my blog has been misbehaving...really, it's more like me taking far too many pictures and then the poor blog gets overwhelmed and it yells an error message at me and I scream back and then we end up exchanging a few obscenities...I've found a way to show everyone my pictures with captions. Hopefully this works.

Gikongoro and Murambi Genocide Memorial:
http://luc.facebook.com/album.php?aid=2068687&l=da2fa&id=20003653

Traditional Rwandan wedding:
http://luc.facebook.com/album.php?aid=2068686&l=1ee03&id=20003653

Day of the African Child:
http://luc.facebook.com/album.php?aid=2067233&l=7d7dd&id=20003653

Rwanda Misc.:
http://luc.facebook.com/album.php?aid=2066262&l=f77a6&id=20003653

Children's Support Group 1:
http://luc.facebook.com/album.php?aid=2066253&l=47475&id=20003653

Children's Support Group part 2:
http://luc.facebook.com/album.php?aid=2066260&l=ddc03&id=20003653

Kigali and Icyuzuzo:
http://luc.facebook.com/album.php?aid=2065982&l=b08ac&id=20003653

I will try to post the links again each time I add new photos. Please let me know if this works. Enjoy!

Some helpful resources

Since arriving here, I've read a lot. Here are a few of the books I recommend:

We Wish to Inform You that Tomorrow We Will be Killed with Our Families by Philip Gourevitch (spelling? sorry I don't have the book in front of me...my roommate stole it...)

Left to Tell: Discovering God Amidst the Rwandan Holocaust, the personal survival story of Immaculee Ilibagiza as told by herself.

Useful websites:

Of course the WE-ACTx website!: http://www.we-actx.org/

A favorite video of mine by Sarah McLachlan for some thought with a bit of great music:
http://www.youtube.com/watch?v=6SkdyRcK9KM


The UNAIDS website, while the UN has their critics, pros and cons, effectiveness debated, it's a good source for getting some general ideas of what's going on
http://www.unaids.org/en/

Some stats from the World Health Organization:
http://www.who.int/hiv/countries/en/index.html

I'll try to add sources as I remember them!

Concerns from the clinic

I thought I'd post some of my notes from a meeting I went to last week about HIV+ teens a long with a few of my other thoughts. Dr. Donna Futterman is a dear friend of Mardge and she gave an excellent talk.

Some basic stats about HIV and transmission according to Dr. Futterman

• For every 4 HIV+ people, 2 of them contracted the virus as teens/young adults

• The average age of infection of girls is 5 years younger than boys--due to the tendency for girls to have male partners that are older than them and not being able to negotiate condom use in their sexual relationships
  
• The average age at first sexual encounter in Rwanda is 13 years old
• It is also easier to become infected via sexual transmission when younger

The majority of children in WE-ACTx have been positive since birth from mothers infected through genocidal rape. Ok, so they've been dealing with this since their first day of life. Not true for many of our teens. The heartbreaking dilemma of when to tell kids is something Rwandan mothers have been struggling with for years. Turns out, they're not so good at it...
The story, common to many Rwandan teens, is one of a struggle to reach the age of five. Battling malaria, TB, dysentery, malnutrition, poverty. Then a struggle to find money to go to school. Finally, they have hopes of more than basic survival...a family, a job, love and a home. Until their mothers announce to them they are HIV+. That's right, many Rwandan teens find out they are positive as teens, through no fault of their own. How do you cope with that?

HIV patients are heavily stigmatized all over the world and their situation is no different in Rwanda. Worst case scenario: death at the hands of the misinformed, scared community members; at best, social rejection well past being the odd duck or the black sheep of the family. I say family, because many people don't tell anyone outside of immediate family due to fear of abandonment. I say abandonment because that is truly what happens. These people are left to fend completely for themselves and often physically and geographically pushed out of their village or town because no one will hire them for work, no one will sell food to them, no one will help them get milk or clean water. Simply, they are seen as walking disease bags. Trash. To be stepped over.

Finding out their positive status as teens is devastating and often causes them to act out against their parents. There is definitely a blame game going on here. The question being is it temporary or will the teens be angry, pushing their parents away forever? The sad truth is that they can't afford to stay angry for long, not at their parents. These may end up being the only people who will support them if the community were to find out their status. The counselors at the meeting attested to stories of teens turning to drugs and alcohol and engaging in many reckless sexual encounters as a reaction to their new label. An increasing number of children are taking ARVs, which has much better success rates of medication compliance when they grow up on medication because they are used to it. It is part of their daily routine. Like a Flintstone vitamin if you will. However, when teens are striving to be like their peers, to fit in, to be accepted, introducing something as small as a pill each morning and night, can have a great effect. Throughout my stay here I have often heard ARVs are a daily reminder of the genocide and of it's direct or indirect consequences. For the young people of Rwanda who find out later they are positive, they are no longer one of the lucky ones. They are a statistic. Support services need to be in place to help them recover from the shock, work through their anger, and find hope in a future that is entirely possible.

I have attended the children's and adolescent support groups. I have spoken with many teen girls who need someone to share with and I am honored and privileged to have been chosen. This about sums up their worries: what will I do? The support groups here, for all age groups are truly the most striking feature of WE-ACTx and definitely a much needed service. The people, at any age, who attend their respective groups are able to find friends to confide in, extended family that shares their worries, shares in their burden. At every meeting I have been to, participants express the most sincere gratitude for the existence of the support groups. This, along with peer education has been life changing according to these patients. It is amazing to sit in a circle with young men and watch them open up about their fears and to see them comforted in each other.

So I suppose the question on everyone's mind, well at least mine, is what can I do about it? Yes, I'm finally here, in the middle of this new place, but still an outsider make no mistake. What will I do when I come home? What can people who are feeling incredibly ordinary do? It will take more than giving money. Giving money doesn't give hope. Giving money doesn't show love. There is a world of difference between charity and justice. So stepping down off my soap box, I say to you, educate yourself. I have come here to learn first. No one can act without first understanding.

Before I came I realized how truly confused many people are about HIV, transmission, and treatment. I was asked how I would avoid getting AIDS. My immediate reaction to this question was pure sarcasm...so I'll leave that to your imagination...But the more I thought about friends and family reaction to this trip, the fear of international travel was nothing compared to the fear of working with AIDS patients. And that's exactly it...that's the answer...the job waiting for me at home...Education. I have not been afraid, not for an instant, while being here. I am not afraid because I am educated. I have sat in a circle with older women and talked about domestic violence, HIV transmission through breast feeding, and their options for safe sexual encounters. I have sat with prostitutes, orphans, substance abusers, victims, thieves, and the lonely. The best learning experience of my life has been spent listening to the outcasts. Lessons learned: 1) listen...It is so hard for some to speak, but the voices of the people I have been working with need to be heard. It is out of respect at the least and love at the most. Simply listening makes all the difference to the Rwandan people. I heard this, straight from many mouths, while I was listening.
and 2) question...It is hard for us to ask questions partly because we don't want to admit to not knowing the answer, but partly because we are afraid of what the answer might be. My hope for my writings is that someone reads them and hears the stories of the people in Rwanda and the world's poor, wherever they are, and are truly shaken. I hope to challenge the fundamental beliefs of our community in such a way as to stir up our way of life. I don't think that anyone can begin to help without first evaluating their own lifestyle and making a conscience effort to include the poor in it.

Some stuff from this week

I spent most of my time this week working in the WE-ACTx town clinic doing the study. Patients were scheduled for Monday when I was supposed to be at Nyacungu and it was my turn to stay. The study is going well and progressing along at quite a rapid pace so hopefully we won't be away from the shadowing/clinical experience and support groups for much longer.

Tuesday I went to Icyuzuzo with Dr. JMV. We had an interesting day as we found out the local private pharmacy is scamming WE-ACTx and the patients. The Icyuzuzo clinic and WE-ACTx town clinic are partner associations. When Icyuzuzo doesn't have the medications the patients need, they are sent to the WE-ACTx town clinic. If the town clinic doesn't have it, they are sent to a private pharmacy in the area that is under contract with both associations to provide meds up front to patients. WE-ACTx pays by prescription each month and the patients still get their meds without having to pay. The patients were being turned away, told to come back each day for months at a time because the private pharmacy told them they ran out of their meds. They'd hand them a card stamped by their business with the date and medication written on it. Then, they'd turn in the original prescription and get paid by WE-ACTx as if they had given out the meds. The only way WE-ACTx finds this out is when patients come back to the doctor and tell their story. A trip that they can typically only make once a month. The man who told us about this came to the clinic for his July ARV meds and was still waiting from the private pharmacy for his May and June ARVs! To properly stress the significance of this--ARVs are saving his life...without them he will progress to AIDS and die. Period.

Another report this week was from a patient who came back from the private pharmacy with the wrong meds. They charged WE-ACTx for the expensive, top of the line meds (in Rwanda) and provided the patient with a cheaper drug that wasn't even the same type of medication. Unbelievable. Dr. JMV asked me to pass the message along to Mardge and now WE-ACTx has another issue to add to their list of concerns.

On Thursday at the clinic, I met a nurse who has been on leave named Christine, who spoke quite a bit of English. I told her that was my mother's name and she jumped out of her chair, hugged me, kissed me and we've been family ever since. Don't worry Mom, she told me to tell you that since you're so far away she'll be my Rwandan mother and I am now one of her girls. She said she will keep me safe, and make sure I'm eating well...It was as if my mother had teleported into this Rwandan clinic exam room...hahaha. She is bringing me a picture of her family as a gift, 'so you will know your new Rwandan family'. I need to find a picture of my family in return for her, which should be interesting since I don't have one on me, nor do I have any still left on my sim card in my camera, or have access to a printer...hmmm...

Every time this woman left the room she'd slap my cheeks...it's tough love all the way here... and when she left for the day she hugged and kissed me again and gave me a flower she'd brought to brighten up her office that day. The people here continue to amaze me. Something as simple as having the same name makes you family here. True, there are many Rwandans who are extremely interested in mazungos as it is a sign of privilege to have white friends, but today it was clearly beyond that.

Candida's Fabulous Biscuits

Today Margot and I made dessert biscuits with Candida, our friend who works at the WE-ACTx house we're staying in. She's fabulous and so this recipe is all thanks to her and her fabulousness. It makes a lot...

Ingredients:
8 eggs 8 tablespoons flour 2 limes (trust me on this one) 8 tablespoons sugar
1 tablespoon baking powder oil for frying

Grate both limes (rinds only--for zest) with the finest side of the cheese grater. Set aside.
Add all 8 eggs and 8 tablespoons of sugar into bowl and mix well.
Add 2 tablespoons of grated lime rinds to bowl and mix again.
Add 8 tablespoons flour to bowl and mix well.
Add 1 tablespoon baking powder, mix.
Add more flour if necessary to make the consistency of pancake batter (We ended up with 10 tablespoons of flour total in our batter). Mix it up again.
Add the rest of lime and mix it.
Fill a shallow pan halfway with oil and turn on low/medium heat.
Put some oil in a small bowl (not in batter).
Coat hands in oil (we did all the scooping by hand). Dip tablespoon in oil and use to drop batter into pan with oil once oil is heated. The batter is going to be fried so heat the oil appropriately and be careful.
Drop about 1/2 teaspoons of batter into oil and fill pan. Dip tablespoon in oil when batter starts getting stuck and hard to drop into pan. The batter should drop fairly quickly otherwise it (like my first few) ends up stringy, but tastes great anyway so I suppose it doesn't matter.
Use a strainer spoon to turn over each biscuit when the top of the biscuit bubbles (like pancakes). Each side should be lightly browned, then take out and put in strainer.
Make sure to use strainer spoon and put in a strainer to drain any excess oil before eating.
Tada! Eat and enjoy!

I'm really bad at updating

People were telling me that promising to post everyday is quite a lofty goal and I turned up my nose at them saying, 'Pish. I'm on top of my stuff.' I lied. Sue me.

Last Saturday was day of the African Child. MOST FUN EVER!!! I started off my day at the futball field welcoming some kids and then made my way over to the crafty activities. No, I did not participate in the futball fun.

I worked at the mask making station and all of our supplies were jacked by the kids before I even got there. Poor Nina...she never saw the stampede coming...The kids were incredibly creative with a few stickers each and some garland. Note to Rebecca: All of your stickers were snatched up and considered a very hot item! I have a picture of a little boy wearing some. I tied masks on little heads for about two hours. The kids took pictures with my camera and while most of them turned out with people missing body parts, they still look great! Pictures are difficult to post on my blog because the internet takes a very long time to load them here so I will be adding an online photo album soon.

After masks I was mobbed at the face painting station. Being one who isn't known for artistic abilities, my lizards looked like bloated turtles, flowers looked like blobs, and cars were unrecognizable. Good thing there weren't any mirrors.

Lunch followed craft time. Fanta's all around. Fanta is a strange fad here. It's a very coveted treat and unfortunately is cheaper than clean water here. I find this to be absolutely ridiculous. Especially since I've yet to see a dentist anywhere here and tooth decay is clearly an extensive problem for this population...can't blame it on the food, they don't get a lot to eat...For lunch we had some meat, wedge french fries, and a really good roll/cake thing. The little girl in the photos I posted with the yellow hat and red coat sat on my lap while she ate and I felt very much at home, like Thanksgiving dinner, cutting up food and helping to control the milk spillage situation. The girl on my lap and the little boy next to me kept sneaking pieces of my meat, so by the time I started eating I didn't actually get to taste any of it. Everything else was delicious though!

The kids danced and sang...I've got video and audio recordings that sound amazing. After the festivities concluded, the other interns and I broke into a spontaneous dance party and I must say, my dance skills were quite good. I danced with a lot of the kids who just really enjoyed the attention and the fun time in such a safe and welcoming place.

Sunday was definitely a day of rest and relaxation. The perfect end to a fabulous week!

How to Ride a Minibus in Kigali

Coauthored by Margot R. Moinester
1. Is the Minibus Right for You?

When arriving at the bus stop you will see a variety of modes of transportation. There will be mottos which look like adult dirt bikes and private taxis which are all white with an orange stripe down the side. Lacking in seatbelts, these vehicles are also quite expensive. Lastly there are the minibuses. These are large, white conversion vans with more windows and incredibly funky upholstery. There are four rows of seats including the most coveted spots next to the driver. Squish in because everyone’s family in Rwanda! If you are at all claustrophobic, be wary. If you are highly talkative and enjoy close interaction with those around you…this ride’s for you.

In addition, it’s the cheapest mode of transportation in Kigali. Enough said.

2. Choosing the Appropriate Bus

It is key, when traveling, to pick the correct mode of transportation as well as the correct route. A happy trip starts with heading in the right direction, geographically speaking; no one likes to start off being lost. However there are often complications for even the savviest traveler. Be sure to speak directly to the driver, though this position may vary as the driver seems to switch at almost every stop. Be wary of the money man. He just wants your money and will tell you any lie to get you on his bus. More about the money man to follow.

On occasion the final destination of that particular bus is written on the back of it. If you have a poor sense of direction or are in any way less than an expert on the layout of Kigali, the final destination does not assist you in any way on successfully getting to your desired location, but simply exists to further complicate your life. We suggest ignoring it completely unless, conveniently, that’s where you’re going.

Choose a bus that is primarily full because you are now on Rwandan time and the money man will not signal to the driver to leave until the bus is completely full. There is no sense of urgency here; and yelling at the driver about strict time commitments will not make the bus start moving any sooner. Therefore we advise you to choose your bus wisely!

3. How to choose a seat

This only applies to nearly empty buses.

If you’re getting out early in the route, sit closest to the sliding door on the right side of the van. This will allow you to trample and inconvenience the least amount of people on your way out.

However, we are often the first on the bus and therefore have some advice about which seat to choose. You can always wait until the bus fills up more, but you run the risk of losing a seat and being stuck on the outside, having to get up every stop to allow other passengers to exit. This can be quite cumbersome, especially when carrying any bags. Authors’ note: we recommend not carrying anything with you that is not absolutely necessary because it will be residing on your lap the entire trip.

Seats are not clearly demarcated on the minibus. This means the number of people riding in each row, depends solely on the size of each person and the money man. If he says move, you’d better move in because more people are going to join you. Don’t forget that there are two seats on each bus that fold out from the inside rows, closest to the door. Avoid getting stuck between the folding seat and the main row, as this is an incredibly uncomfortable position which will leave you with a pole in your butt.

Authors’ choice: the window seat, on the left side of the bus, is the way to go as it provides a nice breeze and a place to lean as well as allowing you the comfort of not having to get up with each passing passenger.

4. The Money Man

The money man is an integral player in every bus ride. Obviously, he takes your money and assures that every passenger pays, but his job extends far beyond fare collection. He is a recruiter and advertiser, a cheerleader of sorts. He will run to other buses and try to steal passengers to fill his own bus. If it’s a slow day, a persuasive money man can make your trip begin a lot sooner.

Side note: if the bus starts moving and you’re looking around, thinking, “where did the money man go?” No worries. Look out the window, as he’s probably running alongside the bus. Money men are dedicated and will sacrifice their own seat for another 100 francs from an additional passenger. Look forward to cheering on an out of breath money man at the next stop. The whole bus will share a laugh at this entertainment.

5. Bus etiquette

Move over, move over, move over. You must fill every nook and cranny in the bus and the driver won’t leave if you’re taking up enough room to fit in an additional passenger. Don’t be offended if someone actually sits on you. Just hope they move over a bit.

The upholstery is unexplainable and can serve as entertainment. Enjoy.

While you may be pleased to recognize US ‘90s pop music blasting on the radio, don’t sing too loud. You will get looks from the passengers around you.

When you are ready to exit, you must signal the money man who will get the driver’s attention to stop the bus. This is done by knocking loudly on the wall or roof of the bus. The money man, hearing this, will collect your money and make sure the driver knows to stop.

Authors’ note: it is common that you will have no idea where to get off the bus. As Rwandans don’t use street signs, it is best to be aware of major landmarks. If you are sitting in the middle of a row, it might be difficult to see out of the windows so attempt to alert the money man of your final destination before getting on the bus. If you look lost, he may take pity on you and alert you to exit the bus at the appropriate time. Otherwise, Good luck.

Pictures from Day of the African Child

Let's Play Pretend Again

It's officially last Thursday...

I arrived early at the clinic to await a ride to Icyuzuzo and sat down at a table on the balcony where the women wait to be seen. I decided to put my headphones in and listen to some music while I was cutting out more of those eyeholes for the paper plate masks. At first I was alone. Being engrossed in my own musical world, I continued to feel alone and ended up singing loudly. I look up as I feel eyes watching me to find that I was no longer alone...a few women had filed out onto the porch and as I looked up, began laughing hysterically at me. I continued to sing, and playing the fool, started to dance. It was great, and I'd like to think everyone was entertained. These are the little moments that make my day here.

I also played with another cute baby that was crawling around on the floor by her mother. She kept watching me out of the corner of her eye and I was really hoping this wouldn't end up a repeat of the sobbing toddler incident from the day before. After a few minutes she wandered over to me, stuck out her chubby hands, and pulled herself up. Within a few short minutes, she was on my lap giggling and cooing in that special way that only little ones do. All the women seemed to let me in after that and became very smiley and talkative. Fabulous start to my day!

The WE-ACTx clinic in town (our home base if you will) accidentally scheduled patients for our arterial stiffness experiment/project, so I went to the Icyuzuzo clinic and Nina, awesome as she is, graciously volunteered to stay behind and work with these patients. At the clinic I began my ARV (anti-retroviral) non-compliance study with Dr. JMV. We're asking patients what kinds of things effect their ability to take their medication correctly each day.

Another little boy came in today. He looked to be about 3 years old, but appearances are very deceiving here with respect to age. Many people look far younger than they are. Anyways, little peanut walked in stuck out his hand, which I took to shake and, with lightening speed, was settling into my lap. (I swear, I've held more kids in my two weeks here than I have my entire life in the US.) He snuggled with me and had an intense desire to hold my hands. He was sitting on me, laying his head on my chest, and yet that wasn't enough. Every time I moved my hands, his fingers found mine and he just wanted that special attention. I was goofing around with him, looking at him, then away, little kids are excited by the simplest things! Then, out of the corner of my eye, I see a tiny finger sneaking up to the side of my nose and he started talking to me. Dr. JMV told me the little boy noticed my nose piercing and thought it was pretty (ha! mom, some people do like it!).

Dr. JMV continued, by telling me the young boy that had clearly worked his way into my heart with lightening quickness was here to start ARV therapy. His CD4 count was 246. Under 200 is AIDS defining. This child was very sick, though you'd never know it. (CD4 is a receptor found on the surface of white blood cells that alert the immune system of a need to mount an immune response when you're sick. HIV strips the cells of these receptors and so your body is not able to get its shit together to mount a successful immune response. Hence the severity of the disease and the commonness of opportunistic infections, such as TB, herpes, etc. The more severe the stage of HIV, the less CD4 receptors-->the worse the immune system functions.)

This is the epitome of my experience in Rwanda. Powerful, loving interactions that leave me feeling drained and heart broken. Everyone's story has a twist...it's never good. I knew that this would be a hard place to spend the summer. But I never expected to see such hopeful, loving people here. This is what makes it hard. I feel jerked around emotionally, even in this short time, because I build up hope that the patient in front of me will be different. Something will be positive for them. It is uplifting to interact with them, and crushing to hear their story. How can people so loving, have such terrible lives?

I'm really learning a great deal about Paul Farmer's theory of structural violence here. The idea that social structures act in ways to keep the poor, poor. More on these thoughts later, I'm sure.

Friday:
Masks, Masks, Masks. I saw patients at the WE-ACTx clinic for our study then worked on those damn masks all day. They're finally done! We had awesome pizza for dinner and had a mask making party. I don't know how I always seem to volunteer for the most time consuming stuff. I can't wait to see the kids decorate them. That'll make it all worth it!

Tuesday and Wednesday Ongoings

Tuesday:
Nina and I spent all day working to get the machine ready to gather our arterial stiffness data for a project examining ARVs and their effects on blood flow. Stupid piece of crap...enough said.
After all day pulling out our hair at the clinic, I went home to cut 300 paper plates in half to make 600 masks for Day of the African Child and cut 600 nose notches. Thrilling.

Wednesday:
Nina and I worked all day at the clinic running the first round of testing with the women. We didn't have a translator, which made for an interesting revelation/confirmation. We have to place electrodes for an EKG on the women and measure the distance between the two pulse point we're using and the top EKG lead, then place a tonometer that gives us a reading of blood flow (velocity) at each point. Very Frankenstienish feeling. We were stuck in a tiny office with dim lighting that reminded me of horror film portrayals of mental institution...essentially, we were only missing the weird smells and the dripping water you see in every scene. My interactions with the women were completely different from what I had experienced every other day I was here. Medical sterilization at its best. I had to fight to keep the humanity I'm fond of in the room. At one point I was taking blood pressure measurements and Nina whipped out the tape measure and began taking the pulse point distance measurements. Immediately I felt uneasy, pulled my stethoscope out of my ears, took the cuff off and stood there staring into the eyes of the woman we were prodding. Instantly, I realized the uncomfortable feeling in the room...how very Tuskegee Institute. My mind flashed to the racist scientific experiments that measured head circumference, nose size and made bold, degrading, and downright ignorant statements to oppress those of African decent in our own country.

What bothered me the most, was that Nina didn't seem to notice. She continued measuring, continued rushing around both of us without lifting her head to really see the woman, without noticing the feeling of the room. I cannot conduct any work this way. I simply refuse. But in reestablishing that human connection with the woman, the tension was relieved with a smile and a touch--this is the importance of hand holding, of human contact.

It was in this instant that I understood a piece of Rwanda, and it's people, that I made a significant connection. The genocide started with systematic measurements that were used to divide people in to ethnic groups based on physical characteristics, many years before the 94 genocide. The Hutus and Tutsis were divided up long before the world turned its eyes to this tiny country (I still find it sad that my first education on Rwanda was through a mainstream movie, ten years after the devastation). Our behavior in the clinic that day was a parallel to that. Something that, clearly, I never intended, but seen too commonly in medicine and science in general. I strongly believe that this is not the inevitable fate of medicine. Not every interaction needs to be this way, so sterile, so mechanical, and I was happy to find that today I confirmed this idea in a smile. Again, it comes down to De Mello and his life changing idea of truly seeing people.

So, how do I do that in this experiment situation? I don't care if I look like the biggest nut alive, I talk to every patient. I use all the Kinyarwanda words I know. I'm awesome at miming. I show the women on myself where I will place leads. I show them every step on myself. I touch the tonometer to my skin and I watch their faces. I may be slower in getting done with each woman, but I will gladly sacrifice my time for maintaining the humanity and respect that these people have a right to. I am glad that I have figured out a way to connect again, in such a difficult setting. I extra glad I'm not a culturally incompetent moron, which was definitely the road I was heading down with this project.

Last Monday Cont'd

I've finally recovered from the week and ready to blog again...
So continuing with the rural clinic work...
I attended a meeting for two hours with Mardge, Nina, Dr. JMV, the clinic director, and a woman named Aren who does something...she doesn't speak much english and Mardge was a little too busy for some explanations. Anyway, our meeting was to address the HIV+ pregnant population of Nycungu (spelling?) and their breast feeding practice. (Vertical) Transmission can occur at birth when mom and baby's blood can mix, but there are prophylactic pills that can be given to the mother and baby to reduce the risk a great deal. The other method of transmission is through breast feeding, which harbors a 10% risk for the first 6 months. All risk for all modes depends on viral count of the infected person--the more copies of the virus, the more chance of transmitting HIV. Here's the problem: the women don't have clean water for formula and dysentery is, I believe, the top cause of mortality in children under the age of 5 in most African countries. Mothers know that dirty water = death. The other problem is that the babies won't be getting mom's antibodies for certain diseases, which translates to generally weaker immune systems and poorer health. Bottom line is kids will be sick one way or another here. There have also been new studies out of South Africa that show mixing breast feeding and formula for the first 6 months increases not only the incidence of poverty related disease: malaria, TB, dysentery, but also the risk of HIV transmission.

The debate now becomes, how do we keep them safe from diseases and get these women milk/clean water for formula--for 6 months? This was the topic of the day. Two hours, six of us in a crowded office, Kinyarwanda and French with very little English translation. I am amazed by the ability to understand and communicate without speaking the language. This is what I took away from the meeting:

The rural clinic of Nycungu serves 28,000 people, most of whom travel a great distance through the mountains to make it for a visit. (One grandmother walks two hours through the mountains to pick up ARVs for her grandkids once a month.) We are dealing with an estimated 96 HIV+ pregnant women each year. Not only is there a need to increase efforts for bringing these women into clinics and hospitals to deliver (to receive prophylaxis as mentioned above), but fresh milk and water needs to find its way into their homes. The proposed idea is to raise two dairy cows at the clinic and each day boil fresh milk and water to mix for each woman to come and get 1-2 liters to replace their breast feeding. Problems: too far to travel each day...
So, give each village or neighborhood a cow. Problems: not enough milk to share with people who aren't pregnant and you know everyone will want some. Still have to boil milk and water--water's not commonly boiled now. Run the risk of dividing milk up and the women are so poor they might still breast feed to save the cow milk for other children who are typically getting one meal a day.
This debate was obviously not settled.

We left the meeting to tour the rest of the simple, yet elegant facilities. (True beauty in extreme simplicity.) Nina and I were waiting for Mardge when I saw a toddler in the waiting room. The room was extremely crowded and everyone was looking at the Mzungo's standing around. The toddler takes one look at me and starts balling. I generally don't have this reaction from children, so I was slightly surprised. Everyone in the waiting room was pointing and laughing at me...I imagine "Oh silly mzungo! Hahaha" Every time she saw me, crying. Not just quiet sobbing or clinging to mom, but down right horrendous screaming. I looked at the women, threw up my hands, shrugged, and we all laughed.

I am impressed by this aspect of human nature: the uncanny ability to share thoughts and feelings that overcome the language barrier. Every day I have these encounters, especially with the children, where I feel connected to others, who seemingly live in a totally different world, yet there is a strong, stunning something that links us all. I know this sounds like a Lion King song, but it is entirely true. It is humbling and awe-some, in the truest sense of the word, to be welcomed in this way and to feel a universal, innate bond, true love, I suppose. It always makes me wonder, How would these people be received in the US? Why have I never felt this connection with strangers I meet in my daily life back home? After all, we speak the same language. I think it's because language often colors our world and attitude in such a way as to distract us from this feeling. I often find myself losing my patience with those around me and thinking negative things after my interactions with many other people. This all comes back to the Anthony de Mello quote I posted earlier. I suppose, I am not truly seeing those around me at home. It is sad in many ways that it takes something as extreme as a trip to another continent to come to this realization. Better late than never. I am anxiously awaiting the search for this connection when I return.

The Rural Clinic

Today (Monday, honestly you should probably assume I'm writing a day behind) I spent the day with Nina, Mardge, and Dr. JMV at the Nycungu clinic, not sure how to spell that one. The drive was interesting and beautiful. We drove through the east end of Kigali and around a bunch of hills to the south. Personally, I was shocked I didn't have to get out and push the car. At one point the car rocked back and forth as we teetered on the verge of rolling back down the dirt road we came up on. The clinic is halfway up a hill and the roads are far from paved. I loved being able to look out the window on the way there and see the houses and the roadside change as the trip progressed. The homes reflected a much poorer community as did the far more ragged clothes. The houses were made in a lean-to style with large sheets of crimped metal for the roof. The entire way to the clinic we saw people selling things like fresh fruit, lone pairs of pants, and water. Young boys have cardboard boxes filled with candy and travel packages of kleenex. Very strange combinations of goods are being sold here. The roadside is incredibly interesting. When I say 'lone pair of pants' I mean one person holding up a pair of pants and trying to sell it to everyone walking by.


So I'm temporarily suspending the blog until Sunday. Sat. is day of the African Child! and so, I'm super busy after work getting everything ready for tomorrow. What are you doing, you might ask? Well, I'll tell you. I cut 300 paper plates in half to make 600 paper plate masks, then cut 600 nose notches, and 1200 eye holes, then tied a string on each mask...they're finally done, but tonight I have a pre-celebration meeting...so hang in there 'til Sunday!

Grrr...Blogging is hard

So once again please use your imagination and pretend today is Sunday. I'm already getting bad
with updates...

Today was by far the most fun I've had in a very long time. It was children's support group day!! I sat in a group for men 18-25 and we talked about what happens when they isolate themselves from the community. I suggested journal writing and role models who could come speak at the support group and the guys wanted to try writing. We had lunch and a treat, orange Fanta, and then off to the children's group.

The group is held at a mosque in Nyamirambo and we took a very crowded minibus to get there. All of us from the morning support group got out and walked to the playground and soccer fields in the back...you could hear the voices of tons of kids...Then, when we stepped into view about 200 kids shared a collective moment of silence before the stampede.

I didn't even get to put my bag down before I had children swarming me from four years old to ten. Boys and girls. Two little girls one about seven and another about four ran up to me and held my hands. This is a reaction kids give mazungo's a lot here and they're incredibly desperate for some sort of contact. The kids were fighting over who got to hold my hand. There was pushing. There was shoving. We were one step from complete and utter chaos. (Hear that Brandon, some people enjoy holding my hand in public...) anyways these kids were adorable.

When I finally made my way to the picnic shelter area, a group of girls were dancing. I walked over to see them and they taught me to dance. Not too bad, dancing in less than five minutes. Then we played relay games. There were two lines of kids and each sent one runner with a stick starting from opposite ends to run around in a big circle and they tried to touch the other runner with the stick. When you got back to where you started, you passed the stick. The kids were slightly losing interest and the other adult facilitators were trying to keep them playing so I kicked off my shoes, hiked up my skirt and hauled some major ass. I could just hear laughing and the occasional shouts of "mazungo" (I imagine there was some pointing as well...) The kids were cheering me on and I was trying not to trip or get caught by the seven year old behind me. My team lost, but the important thing is that I did not lose my dignity to a first grader. Almost, but not quite.
After playtime we sat under the picnic area. We finally wrangled 200 kids and then I busted out the camera...I have a new found appreciation for the professional photographers that take the class photos in elementary school...Eventually the group shots were done, but I made the mistake of trying to take pictures of smaller groups and more natural shots of the kids which turned into an act of mob violence eliciting an exhibition of major police force. Well, 200 screaming kids crowding me reaching for my camera, pulling on my clothes and yelling at me is just as serious. They were great though. It was truly an enjoyable day and I'll let my pictures tell the rest of the story. All of these kids are HIV+.

A day behind

Yesterday I went with Nina to the genocide memorial in Kigali. I bought a book from the exhibit because I truly have no words.


I did get a chance later to check out the craft market...

At night we all went to Republica to have a celebratory good bye tea for another intern Rebecca who's leaving tomorrow.

That was pretty much it, very depressing.

The big day, with relatively little activity

So I just finished yesterday's post and it still listed it as a Thursday post, so the first couple sentences about pretending it's still Thursday makes me look stupid. Whatever, such is life. (At least I don't look as dumb as mom in that turkey hat...hahaha, Just kidding mom, great hat.)
I say today was a big day because I had my project meeting with Mardge. Or Dr. Mardge as she's commonly called here. We've decided on two projects. One being an ARV non-compliance issue. We're going to ask the women, while we're gathering medical data for a project for something else, questions about what makes it hard to take their medication. Very light, very conversational, very relaxed. We, Nina and I will also be asking these questions at the Icyuzuzo clinic and the more rural clinic we will be traveling to on Mondays. Our other project is a little bit trickier and we're looking to address the issue of disclosure. Who do these women tell about their positive status? Why do they disclose, why not? How do they feel afterwards? What reaction do they get? One teen girl reported that her grandmother found out her positive status, told her whole town, and then no one would play with her. I'm finding that many people don't tell anyone outside of their immediate family. It should be interesting to see what everyone says.
Nina and I also did a little shopping today and I discovered my hidden talent for haggling. Originally, the saleswoman wanted to sell me a pair of sandals for 8,000Francs which is $16US and I told her nope, walked away and ended up with them for 3,000F ($6). I truly have a shoe shopping gift. (Don't worry Grandma, I only bought one pair to replace the painful pair.) I came home and we had the second awesomest pizza ever (I heart Lou's!). Which is saying a lot, since I have high pizza standards being from Chicago and all...
Other than that, I spent the night writing two days worth of blogs, reflecting a lot on yesterday, and reading for fun. Tomorrow it's a sobering trip to the genocide memorial in Kigali and possibly the memorial at a rural church.

The True Thursday Events

Ok, so I started a whopping one sentence of Thursday's actual events and then fell asleep. So just pretend it's still Thursday. Also, I've heard that a few people have tried to post comments and were unable to do so. Good news! I changed the settings and you can feel free to comment, question, or critique as you like. Please let me know what you think and what you're wondering.

So much happened at Icyuzuzo today that I may have to split this all up! I'll keep it brief, I promise...hahaha. I spent the day following Dr. JMV. Nina and I sat in his office and saw patients with him. Phenomenal experience! A car drove us to the clinic and we went immediately into Dr. JMV's office to wait for him. On the way to the WE-ACTx clinic in Santra-Ville, my shoes were bugging me and I ended up with a bunch of blisters on my feet. I asked for band-aids at both clinics and was informed that neither clinic had any. Let me repeat that, no band-aids. Ok, again for those of you struggling to fit your head around that one (much like my initial reaction, so you're not alone!) NO BAND-AIDS. A clinic that performs routine blood draws on HIV+ patients and sees people who end up with skin lesions...doesn't...have...band-aids...Insane? Yes. Shocking? Not so much. These clinics are lucky to be staffed with physicians and have supplies of ARVs so band-aids aren't really a priority. Close your eyes and imagine being that poor.

Nina and I sat all day with Dr. JMV from about 9am to 2:30pm. This experience was absolutely amazing and I'd like to split my thoughts into two areas: the physician-patient relationship and patient issues.

Dr. JMV saw about 15 patients with yesterday being a slow day. The nurses also handled a lot of routine, HIV negative patients while we were with him. My focus question going into this shadowing experience was: How does he maintain the physician-patient relationship while seeing so many patients? It didn't take long to see what made him special. He is sitting when the patient enters and shakes their hand, says hello, and gets down to business, but he is never rushed. His questioning style is one that is both deliberate and detailed, but also slow and intimate. He never wrote a word while the patients were speaking. He never interpreted or explained while the patients were talking to him. If a patient started talking again while he was writing his notes, he immediately put his pen down and sat back to face the patient. Each patient sat in the seat right next to his desk where the barriers were broken down. He never slouched, but leaned in to be closer and hear better. The Rwandan people are very stoic and quiet. They often talk without looking at you. The tone and volume of his voice matched that of each individual patient and he never forced eye contact. His focus was intense and it was clear that he was both physically and mentally present. For that time, as far as he was concerned, Nina and I were not in the room. After he wrote his notes, he explained the patient's complaints as well as the purpose of each medication. For every single patient.

The patient that I see when I close my eyes and think of that day was a young boy probably about nine or ten years old. Old white Nike gym shoes stained brown by the dry red dirt, long yellow shorts with the three familiar green stripes of ADIDAS running along the side, and a dirty gray t-shirt. He came to the clinic alone and I never asked where mom or dad were, there was really no need. This young boy spoke softly and looked down at his hands as he answered Dr. JMV's questions. This physician was patient and kind. He prodded the boy and leaned in to lock his eyes and ask his questions. This boy was going to begin ARV therapy and needed a few other medications for a cough. Dr. JMV wrote the script and then did something I've never seen a physician do for a child: he carefully, one by one, explained each medication by name. Directions and all and asked the boy questions to make sure he understood. I had to go to the doctor a few days before my trip and my mom still asks me if I need her to come along. I'm 23. He was about nine. Hmmm... I know that he is alone because of necessity, but this speaks to the ability of understanding treatment in pediatric patients. As a future physician specifically interested in children's Infectious Disease, I am greatly concerned with the doctor-patient relationship. Too often I see physicians talk over and around children directly to the parent while never truly acknowledging the actual patient. And we, as a medical community, are wanting to see children feel comfortable with trips to see the doctor to grow into adults who trust us and come to see physicians when necessary. Do we expect this relationship based on trust and understanding to happen via magic beans and fairy dust? This boy came in and was able to describe his symptoms in his own words, expressing himself in a very poised and eloquent way. Many people do not hold the expression of a child equal with that of an adult, but this is to do them a great injustice. This is not to say children are capable of the same maturity or level of understanding as an adult, but their voice and the words it speaks are important. Just as important as that of the parent. This is something I will encourage in my own patients. In fact, for the first five minutes, I would love to cover the parent's mouth with duct tape and only hear from the child. So many adults feel uncomfortable in the presence of the physician, enough so to deter them from going. I feel this is an attitude that must be changed, and even better, never developed. It comes from years of talking to the doctor, finding their voice and the right words to explain their problems. How can a mother or a father know if a child's pain is sharp or dull, pulsating or steady? They, themselves are not feeling it, they must be told. If parents are encouraging their children to speak to them about illness, why not encourage them to speak to the person responsible for treating them as well?
The patients feel so comfortable as children and adults seeing Dr. JMV that I was surprised at the ease with which shirts came flying off! A little boy came in with his mother had a very severe and painfully swollen case of shingles (think Brandon... sunburned...100 times worse). Truthfully, I've never seen a human being that shade of red before. And the whole area was covered with tiny, painful blister-like spots. Dr. JMV asked him what he was in for today and before I knew it, we were looking at a bare back and a little kid butt crack. Just like that. He never appeared embarrassed and he was never prompted to drop trow, but there he was, quite matter-of-factly. I see London, I see France...I saw a lot today.
While it's true that the Rwandan people are very serious in appearance, with little show of emotion this is not usually true at Dr. JMV's office nor at the WE-ACTx clinic. In these places pain is not hidden. Physical weakness is not covered. Concern is intensely expressed. Is this due to feeling relaxed in the physician's office? Partly. Dr. JMV is comforting, attentive. They let down their guard with him because he is respectful of their vulnerability. It has nothing to do with physical exposure. It has everything to do with emotional exposure. He moves and speaks slowly. He asks questions that can be difficult or stigmatizing to answer, but he does it in such a way, with such an emotional tenderness, that shows each patient he or she is loved. Unfortunately, this cannot be taught to medical students. Too often, this relationship is taken for granted or never cultivated to the level of trust and true partnership that it should be. When one has the opportunity to witness an encounter of such quality between a physician and a patient, it is truly both inspiring and humbling.
So, what's the other part? Simply stated, desire. Necessity. These people are very sick and very poor which makes for the most deadly combination. I love hearing people use the phrase, "Oh that's the worst. I hate that." Poverty and illness, whether it's malaria, dysentery, HIV, or TB, that's the worst; I hate that. No higher, I call. Patients know that, especially in resource poor settings, they have very limited time to spend with the doctor and that the waiting room is often overflowing with people just as sick as themselves, waiting to be seen. They are always waiting. To see the physician, to feel better, to find their next meal, to find work, to get their test results. Once inside the physician's office, Rwandans no longer wait. The second the doctor asks the first question, many patients speak with a fiery quickness, voices raised, emotional faces. They have come to see the doctor and there is no confusion about why they are there. Many patients don't acknowledge Nina and I. The ones who do, shake our hands, sit, and don't look at us until Dr. JMV begins to write. They are finished, and now, again have time to wait.