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Challenges abound

We've been in Burundi for about three weeks now. William has been diligently working on making new hyperbilirubinemia lights for newborns. Essentially, premature babies can get a buildup of bilirubin in their tiny bodies, and their livers aren't mature enough to handle it. If the levels get too high, they can have seizures, brain damage, or even death. Phototherapy can help turn the bilirubin into a substance that can be excreted from the body, lowering the levels into a safe range. The hospital previously used lights that became too hot for the babies, and several strands had burnt out, meaning that they weren't getting enough phototherapy. William has been working on building new 'bili boxes' with updated LED lights and a fan to ensure the temperature remains appropriate. He finished the first one last week and the trial run went perfectly- the temperature remained stable, even after running all day! He plans to finish the rest of the boxes this week so that the hospital will be able to treat up to six babies with phototherapy at a time.

William has also been helping Ben, one of the general surgeons here, with his personal project. Ben loves to rock climb and decided to build a rock-climbing wall on the compound, both for himself and for the kids here. He had been working on it for a few months, but doing everything by himself on his few days off has been challenging. William helped him with some of the construction, and I helped them with the finishing touches, including putting the holds on. It's awesome.


I've been really busy in the OR. They usually have 3 rooms running. On Tuesdays and Thursdays, OB/Gyn gets their own room to do cases & C-sections. Otherwise, they fill the board with any & all cases possible. About 40% of their cases are orthopaedic, and they are very rarely straightforward. Usually I'll be in OR 4, which will be stacked with ortho cases. This last week I have been working with the residents, which has been a lot of fun. I've also been doing ortho lectures every Wednesday and Friday morning for about an hour. Last week I did a Sawbones lab, where the residents practiced reducing and fixing fractures on model bones. I think they enjoyed it.

In one of my lectures, I was teaching about cancers that most commonly metastasize to bone- breast, lung, thyroid, kidney, and prostate. I was taught the mnemonic 'BLT with a Kosher Pickle' to remember this list, which I shared with the residents. I didn't even think about the expression until Ben, the general surgeon, explained what a BLT was, then what kosher was, which then continued into a conversation about delicatessens. It was a novelty the the residents and it was great.

The surgeons here continue to amaze me. They do so much with very little. They treat patients who would otherwise go untreated. This past weekend, the team celebrated 10 years at Kibuye. Four families (all of whom knew each other in residency/medical school from Michigan) decided to move out to Burundi and start this huge undertaking in 2013. Originally, there was an ophthalmologist, a general surgeon, a family medicine physician married to an OB/Gyn, a pediatrician and an engineer (the general surgeon's brother). Since then, the team has continued to grow. They work with several Burundian doctors. They have an internship for medical students to further their training before starting practice. They have a general surgery residency and plans to start a family medicine residency. They have nursing students. They partner with Hope Africa University in Bujumbura and have medical students rotate on their services here. They employ over 100 construction workers year-round for various projects at the hospital and the residential compound. They have their own solar field for electricity, feeding program for malnourished children, and provide free care for children under 5 and pregnant women. And yet, there are many challenges. The XR machine is very temperamental and has quit working three separate times since I've been here. There are a handful of CT's and MRI's in the country but are prohibitively expensive for most patients. Medication options, lab testing, and pathology are very limited. In order to get a biopsy, tissue samples are sent back to the States in someone's luggage whenever someone goes back, and then are sent to a pathologist in Texas for fixing & review. From the time a biopsy is taken to getting a diagnosis is typically three months. In malignant cases, most patients are already dead by then. Even if there was a timely answer, there are only a handful of first generation chemotherapy options in the whole country, again, mostly prohibitively expensive. I saw a patient this week that haunted me. He was an 11-year-old boy with a huge facial mass. His parents said it had grown over the last two months until he had trouble eating and speaking because of the size. They had seen other providers but they were unable to offer anything. We did a biopsy, but we suspect he has lymphoma, a very treatable cancer in developed countries. But he will likely die, either from his cancer or from malnutrition, before we get an answer. And surgery isn't an option either- half of his face is involved, and it's useless without chemotherapy. He was in so much pain he could only moan and cry. His father held him as they sat on the floor, waiting to go to the OR for the biopsy. His father's face said it all- hopelessness that he could not ease his child's suffering. Even with all the good done here, it feels like a drop in the bucket compared to the great need. And this is just one small corner of Africa. There are so many places that do not have access to a hospital like Kibuye. It's hard.

As I walk back from the hospital to the residential compound (about five minutes away), I pass a primary school on my left side. Often, the kids are out on the nearby open field, kicking around a ball made from elastic bands. They stare as I go by, sometimes saying a shy "Good morning", no matter what time it is. I reply, "Good morning." They giggle and say "How are you?" and I say "Good, how are you?". They usually respond with "Good morning", because that is the extent of their English. More often than not, they'll yell "Mizungu!", which in Kirundi means "white person". The kids usually say it like "Mizuuuuuuunguuuuuuuu!", which makes me laugh.

The area around Kibuye is beautiful- lush green rolling hills. We're now into the rainy season, which means it usually rains once a day at some point. Thankfully, the rain usually moves on in about an hour or two. The rain on the metal roof here makes a soothing sound. I've spent a lot of time reading, which I forgot how much I loved. On the recommendation of one of the surgeons, I picked up "Shake Hands with the Devil", written by the Romeo Dallaire, the United Nations General in command of the peacekeeping operation during the Rwandan genocide in 1994. It is a well written account of what lead to the genocide and how little response it gathered from the United Nations and the rest of the developed world. It is horrifying, astonishing, and deeply human.

Many people have heard of the Rwandan genocide, in which 800,000-1 million people were slaughtered in 100 days, from April- July 1994. Most were killed by machete. But the ethnic and political tension has been present for many years, increasing during independence from Belgium in the 1960's. Several incidences of ethnic killings, both in Rwanda and Burundi occurred in the 1970's-1980's. A Hutu government generally discriminated against the Tutsis. Many Tutsis fled to neighboring countries. In the 1990's, the exiled Tutsis joined together, known as the Rwanda Patriotic Front (RPF), and invaded Rwanda to return to their homeland. This started a brutal civil war that lasted for three years. In the fall of 1993, the RPF and the Hutu President Habyarimana signed a peace deal, known as the Arusha accords, to end the hostilities. Many Hutu extremists were opposed to the deal and incited anti-Tutsi sentiments. On April 6, 1994, a plane carrying President Habyarimana as well as Burundi’s newly elected President Cyprien Ntaryamira, was shot down. Both groups blamed the other, and to this day no one knows the truth. However, this acted as the match to incite the massacre in Rwanda. The Hutu government and an anti-Tutsi militia, known as the Interhamwe, had been preparing for the mass murder, and systematically identified and murdered Tutsi civilians throughout the country. Moderate Hutus who refused to participate were called traitors and killed as well.

The RPF took control of Rwanda in July 1994, but by that time, nearly 1 million Tutsis had been killed. The Hutu's in power fled west to the Congo (known at that time as Zaire), which shares a border with Rwanda. They told the remaining Hutu civilians that the RPF would kill them in revenge (and some of them did) if they stayed in Rwanda, and over a million Rwandans crossed the border into the Kivu region of Eastern Zaire. More civilians died in the refugee camps from malnutrition and disease. The perpetrators of the genocide used the border to regroup and launch a renewed civil war on the RPF over the next several years.

Eventually, Rwanda united with several other nations to invade Zaire, overthrowing the long time dictator Mobuto, and starting a decade long war in the newly created Democratic Republic of Congo, where over 5 million people died from direct violence or as a result of malnutrition or disease (I highly recommend 'Dancing in the Glory of Monsters- the collapse of the Congo and the Great War of Africa' by Jason Stearns on this topic).

The story of Burundi is similar, but has had much less press than Rwanda. After years of military dictatorships from independence in 1960's, they had their first free election in July 1993, in which a Hutu won. In October 1993, a Tutsi-led army group launched a coup and assassinated the Hutu president as well as most of his cabinet. Chaos ensued in the country, as Hutus and Tutsis clashed, leading to the death of about 100,000 people in a year. In early 1994, a Hutu rebel group gained more control, and various factions of Tutsis and Hutus vied for ultimate control. Things worsened when the newest president of Burundi was assassinated with the president of Rwanda in April 1994, as previously mentioned. Although there was no widespread massacre in Burundi like in Rwanda, their civil war dragged on for over ten years, until 2005, when a peace deal was signed. An estimated 300,000 people died during the civil war and 1.2 million people were displaced. Burundi was at peace until an attempted coup in 2015, which failed, but caused significant unrest in capital for the next several years. An estimated 430,000 fled the country by 2018.

Burundi has now been stable for several years, but the effects of the civil war and political unrest have been lasting. William and I were talking to the former dean of the medical school in Bujumbura (Hope Africa University), who said that there were no students for two years because of the violence in 2015. In a country with a significant shortage of doctors, that makes a huge difference. People have told us that the ethnic tension still exists under the surface, but it's hard to see from an outside perspective. Most of the Burundian Tutsis live near the capital, Bujumbura. In the rural areas, Hutus make up 99% of the population.

I have loved my time here in Burundi so far. I have never felt even the slightest bit unsafe. But sometimes I think about people my age- they would have been 3 or 4 at the worst time of the civil war. How many of their parents, grandparents, aunts, or uncles were killed? Would I still feel lingering resentment to a different ethnic group because of the legacy of violence? How would I envision a safe and bright future for my own family? I don't know.

I do know that the work being done at Kibuye, although a small contribution to a great need, is like a light in the dark. There is hope here. There is growth here. There is even joy here. What a privilege to see it and be a part of it.







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