Quirk and Customs of Rwanda

I figured without being here its hard to appreciate all the strange and wonderful things that make this country what it is. So here is a quick list of things I have found quirky, funny or interesting:

Holding Hands: I think Sean may have mentioned this one earlier - it is still worth mentioning again though. When we first arrived here I thought the country had just done away with heterosexuality - if ever there are two guys in the street walking together they will be doing so either holding hands or with their hands low around each others waists. The shock came seeing the police officers doing it - while pulling cars over. Now we are a little more accustomed to it - the hospital staff hold our hands in between wards on a regular basis!

Road Rules: Right hand side and left hand side seem to fuse here - unless you are 5 metres away from an oncoming vehicle - then that make a momentary allowance and move back to their side of the road. The main roads are policed quite vigorously, regularly pulling cars over to check lights, mirrors, number of passengers, tyres or to give you a ticket for speeding. And yet there are no speed limit signs or radars for that matter, so I guess the Police Officer's opinion is gospel. This strict policing of the roads was recently introduced because of the high rate of MVAs. It is still high (although reduced so we are told) and it is not uncommon to see an overturned truck on the side of the road...Exhibit A:


The Countryside: This one falls under the interesting category, and it's one I have written about before. There is not one bit of land left uncultivated here - the sign of a poor country with rich soil. It does however make for a fantastically beautiful landscape. It's like a patchwork quilt rolling off into the distance.


Mobile Phones: Absolute status symbol here - many have them and those that do are considered 'wealthy' by Rwandan standards. There is no landline system (except in the capital) so short of shouting, the only long-distance voice communication here is done via mobile phones. Sim Card's are AU $2.00 and phone credit is a similar price.

Taxis: Come in four forms. Type 1 - bicycle, quite popular around small towns, involves an old push-bike with a steel pannier rack on the back and a pillow if you are lucky. Type 2 - Motorbike, in Rwanda they give you a helmet, in Uganda they don't. I have experienced both, sorry mum, both are as scary as each other. Type 3 - Toyota Hiace, I think Sean mentioned this one. A spaceous vehicule with 10 or so seats and at least 20 Rwandans. Type 4 - a guy who owns a car (only found in Kigali) who offers you a lift somewhere as you pass him by in the street. Not a bad option but can be expensive being a muzungo.

Prices: White people will inevitably be offered an initial price thrice what an African would be offered - much haggling is required. The trick I have found is being able to count in Kinyarwanda. The reasons are twofold; firstly if you start telling them the price you will pay in their own language all of a sudden they realise you aren't a tourist and you probably know the going street price. Secondly, you can listen to the previous buyer or discussions between the sellers and discern the real price. This came in handy one day at the markets when an elderly woman gave me the price of igihumbi (1000) for a basket, her son then came forward thinking I was a French tourist and translated the price as mille cinq cent (1500). I told him that I would take his mother's price. The markets:


Age: As has been mentioned, Rwanda is a very young country. Although one thing Sean and I have found very difficult is guessing someone's age - and apparently the Rwandans have the same problem with us. Most kids look much younger than they are (probably a result of malnourishment in many cases) and adults look much older than they are (no idea why). As for us, they can't believe I am twenty and are perplexed when I say I have no children.

Greetings: It is considered very rude not to shake someone's hand if you know them - this occurs ever time you see them, even if it means ten handshakes a day because thats how many times you pass by them at the hospital. It is also rude if you don't shake the hands of everyone this person is currently walking with/talking to even if you don't know them. Also if you feel the person is older or more senior to you then you are supposed to shake with your right hand while simultaneously holding/supporting your right forearm with your left hand. Usually during the handshake this sign of respect is only performed by one person (the less senior). Trouble is that being white (and often confused as being a doctor) everyone assumes that you are somehow owed respect - so when we shake the hand of an elderly patient we never get to show them the respect they deserve because they are already giving you this undue respect. And that is handshake etiquette Rwandan style.

Genocide: This one obviously falls under the interesting category. It is a rare day here when you don't hear mention of this atrocity. Usually in the news (just yestereday a Rwandan singer was sentenced to 15 years imprisonment for some of his genocide songs/propaganda that were published in 1994), or often from someone talking about it and where they were during it all or sometimes on a sign on the side of the road. What you will almost never hear uttered by Rwandans are the names of the two groups involved (Tutsi and Hutu) or any suggestion of national segregation. Mentioning either of those names is not only culturally unacceptable it now also punishable by imprisonment.

Dancing: They have their own dance - it's called inhore (pronounced innoray) and it is amazing to watch for both the style, the music and the outfits. It involves a lot of coordinated feet stomping (its very graceful I assure you), with bells around their ankles.

Uganda

So as I said previously I took a few days off away from our strenuous hospital schedule to visit the neighbouring country of Uganda. Lara and I spent most of Thursday on a bus from Kigali to Kampala (respective capitals). The trip to the border was fairly uneventful, couldn’t say the same for immigration control - quite the ordeal. This involved getting off the bus, ‘checking out’ on the Rwandan side, walking the 200m or so through no-man’s-land passed the heavily armed national guards and ‘checking in’ on the Uganda side. This wouldn’t have been so bad if I hadn’t arrived back at the bus only to have some Ugandan man vigorously delving into my bag. I told him in fairly stern French to get his hands out of my bag. No response. Then realising that I was now in a Commonwealth State translated the message into English, only to have him rummage through his pockets for 30 seconds and pull out his police badge. Why the border federal agents decide to search people’s bags in plain clothes is beyond me. Ordeal over - six hours to Kampala.



Seeing the slow change in scenery during the eight-hour bus trip was a sight in itself. As soon as we passed through the border we rapidly descended to the planes of Uganda. It certainly gave us an appreciation of the geography of Rwanda - a mountainous plateau surrounded by the flats of Burundi, Uganda, Tanzania and to a lesser extent DRC. The other distinct geographical difference is the density - Uganda is sparse by comparison and the land is a lot less cultivated. Their farming is also a quite different - more like Australia with a bigger focus on livestock and the meat industry (almost non-existent in Rwanda)

Kampala itself is a very busy town, really stressful with traffic jams everywhere. Lara and I found a man on the side of the road to change our US dollars into Ugandan shillings. It’s the way to do it in Africa - roadside dealers will inevitably give you a much better exchange rate than any bank - as long as you have post 2005 US currency in either 50 or 100 dollar bills. The only thing you have to worry about is the quality of the currency they give to you - we are told a quick look for the hologram badge and that it hadn't been printed by an inkjet printer and you are all good. As we were, now some 900 000 thousand Ugandan shillings 'richer'.


That night we stayed in dorms before setting out for a three day trip to Murchison Falls National Park - a large game park in the north of Uganda. We saw giraffe, elephants, water beast, water buffalo, waterfalls, hippopotami, crocodiles, eagles, hornbills, kingfishers + many other birds, warthogs, baboons, Americans, rhinoceros and monkeys. Basically everything in The Lion King except lions - still completely worth it - especially the families of elephants - absolutely awesome to see up close in the wild.


Lara and I stayed in a tent for the two nights we were there - fully equipped with velcro+zip anti-mosquito doors and kerosene lanterns. It was unfortunate there was no honeymoon suite because with the amount of people who asked us ‘is your wife coming to dinner’ or ‘what does your husband do as a job’ we might as well have gone along with it for the free upgrade. They must get married much younger here, surely I don’t look older than twenty?

On the first night we were told not to leave any food in our tent. Neither of us remembered this particular detail before setting off on the safari on the second day. Consequently we were greeted by a warthog who had nested himself on our front porch. Not being able to penetrate our sturdy Velcro+zip-shut tent and find the bananas we had left inside, this particular warthog had found the nearest ‘edible’ item, Lara’s running shoe, and had started munching on it. Fortunately warthogs have a short attention span and he gave up on the shoe quickly and trotted away when we arrived.

My last day in Uganda we decided to go a little more adventurous than the tame old safari bus - white-water rafting on the Nile was the go - yes Mum I checked my insurance beforehand and it covers such extreme outings. We left Kampala for Jinja - a small riverside town about 2 hours away. Our guide was a Canadian extreme sports junky - who also asked whether we were married? together? brother and sister? - I think we disappointed him. White-water rafting is crazy fun - we spent an entire day on the water doing level 3, 4 and 5 rapids, we flipped the boat once and got completely soaked on every fall. It was a scorcher of a day - we reapplied sunblock at least four times - even the Ugandan in our boat had started itching. Every chance we got, Lara and I were out of the boat and into the water to swim and cool off. This came as a bit of a surprise to the two Italians, two Belgians, one South African and one Ugandan who took a least a minute to prepare themselves to jump in.



That's where my Ugandan experience ended. Lara spent a few more days in Uganda, then Tanzania and finally back to Australia while I took the bus back to Kigali. Traveling eight hours on a bus by yourself is not fun I discovered - lucky I had a good book to read - thanks Mum.

Our First 'Week' at the Hospital

And now what we came here for - our hospital placement. We signed up for four weeks at Nyanza District hospital - a 148 bed establishment with five ambulances that serve a district of 250 000 Rwandans and fifteen health clinics. It’s main ward is maternity with around 15 births per day. It also has surgery (with a focus on obstetrics), an internal medicine ward and an HIV clinic/dispensary. As far as human resource - there are about 10 doctors and 30 nurses, a pharmacist, radiographer, dentist, physiotherapist and two Australian medical students.


We were taken under the wing of the chief of staff, Dr Marcel Polepole, a fantastic doctor who spends most his time between maternity and surgical wards. He is an amazing teacher and we are truly lucky to have him as a preceptor. For the first few days he had us mainly watching natural births, caesareans and spent a good few hours of his time running through the protocol of maternity and the steps of childbirth as well as its complications. One other good thing about Dr Polepole was that he was Congolese - which means at the hospital he spoke French and only French. Sean and I are slowly picking up some basic kinyarwanda but fortunately all the staff meetings and most conversation when Dr Polepole is around is in French.

Our second mentor was Dr Yuma - the other Congolese doctor and the training surgeon at the hospital. He had us doing circumcisions by ourselves on day three - a nifty procedure for us to know considering there are few young doctors in Australia who know how to do it. We also observed him and Dr Polepole doing a couple of hernia repairs - also quite a common procedure at this hospital.

By Wednesday I was getting pretty excited - we were learning heaps of procedural skills and it was only day three. Alas this is where my week ended, I had decided earlier that I would go to Uganda with Lara since she was down a traveling companion. And so she and I left for Kampala on Thursday, but more about that in the next post. I finished this arduous three day week on Wednesday afternoon with my first ever obstetric surgical procedure - none other than an episiotomy repair. I think for the fifteen minutes it took I was quite the novelty among the maternity ward nurses - muzungo sitting down in front of a mother 4 minutes post-partum, meticulously (OCD comes in handy) suturing away. And that was the end of my first week.

Eighty Metres From DRC

Following our gorilla expedition we decided that Lake Kivu was too close not to visit. It is the largest lake in Rwanda, sandwiched between its western border and the eastern border of DRC. We spent Saturday night in Gisenyi - which sits on the DRC border just next to Goma. We stayed at an amazing waterfront lodge called Paradis (French: Heaven) suggested to us by Mark. This place truly deserves its name - you would never have thought that you would find a spot like this on the edge of a county listed in the top 20 poorest in the world. We almost felt bad paying $2.50 for a 800ml bottle of Belgian/Rwandan top quality beer (Mutzig), served chilled by our own personal Rwandan garcon at our choice of location; at a table or out on the rocks at the lakes edge, they even said they would serve it to us while swimming. We chose the rocks with a view to suit - the sun setting over lake with the mountains of DRC as a backdrop and a dozen or so Rwanda fishing boats setting out for the night shift - see above and below.


Naturally I did my best to add to the excitement of the evening - in true Andrew Hobson style I managed to skilfully leave the car keys in the car...locked. I say skilfully because this car is not just any car - I chose to leave the keys in quite possibly the hardest car to break into - Toyota Hilux 2002 model. I reckon even John Peters' BMW 2008 model would be easier snitch. After our beautiful sunset + boats + beer afternoon, Sean, the concierge, our garcon, a guard and I got cracking on our Fort Knox of cars. A mixture of coathangers, pliers and metal shears were utilised to no avail for nearly two hours. Almost about to give up - we decided to go the extreme option - that's right - I jumped on top of the roof and started levering the top of the front driver-side door open with the metal shears while sticking my finger, then wrist, then forearm down in between the door and car, frantically (I was in some pain at this stage) feeling for the lock nob, hoping the glass wasn't going to break. Now I have never considered myself as buff in any sense of the word, but apparently my muscle mass was a little too much to fit through the gap. Along comes our garcon - traditional Rwandan build - thin, short and paler than the average African. Thanks to him our Hilux was defeated. Now I am never again allowed to be in possession of the keys, unless driving.

During all this commotion we ran into a couple of Mark's Australian friends, Diana and Naomi. We went for a drive with them that evening to see the glow of the volcanoes above us and to visit the Goma border. Too cloudy for the volcanoes so the was a bit of a nonevent. The Goma border control was quite eerie - standing only eighty metres (width of no-man's-land) from a country/town currently in civil unrest is a spooky feeling. Although for what it's worth it didn't sound or look like there were any troubles over there - just a calm lakeside township - unfortunately as we know, this is not at all the case.


Only a week before a rebel Tutsi group had displaced some 300 000 Congolese and threatened to continue all the way to Kinshasa if they weren't granted a discussion with the Congolese President. This posed some threat to Rwanda if its President, Paul Kagame, openly sided with his Rwandan expatriates - this rebel Tutsi group. For a little while it was suggested that this may have been eminent (along with our evacuation) and as such we submitted our emergency contact details to the British and Canadian Embassies in Rwanda (Australia's is in Kenya) in case of an evacuation call-out. Fortunately nothing came of it on the Rwandan side of things and now we are really about as safe here as at home.

Volcanoes and Gorillas

Last week Sean, Lara and I visited the Volcano National park - situated in the Northern Provence of Rwanda, on the border of Democratic Republic of Congo (DRC). Our aim was simple - to see the Rwanda national icon - the mountain gorilla. We borrowed the school car and made our way there via Kigali, dodging Rwandan children, livestock and buses that seem to think they are on Australian roads. These buses will come hurtling at you on the left hand side of the road while we are still on the right. Only at the very last moment will they pull back to there side - followed by an amicable wave and honk of the horn. This is Africa.

We stayed three nights in Kinigi - the closest village to the national park. We reserved our Gorilla experience for the second day. First off was Bisoke (pronounced bissokey) - the second highest Rwandan volcano at 3711m. The walk was muddy and lacking in oxygen, and unfortunately it was too cloudy at the top to get a good appreciation of our achievement. We settled for the view of the crater lake on top of this dormant volcano - split right down the middle by the DRC border. Very rarely do visitors see gorillas on this mountain stroll - so we were considered extremely lucky to have happened upon a silverback feeding on the trail - too bad we had already paid US$500 to see them the next day.


We were escorted up by a NP guide, a porter and three machine-gun armed soldier from the Rwandan Defence Force. It was mentioned that this was for our protection against mountain buffalo, antelope and elephant - although we were quite convinced that it also conveniently allowed the Rwandan government to survey and maintain their Congolese border.


The same applied to visiting the gorillas (guide, porter + guards) - this time with the addition of trackers that we intercepted 40 minutes up the mountain. We spent an hour watching a family of gorilla's called Group Sosa - the largest mountain gorilla group in the world - 43 strong. It has one head silverback (adult male) weighing in at 250kg. Fortunately they are herbivores. It was well worth the money for first timers - but apparently it is going up to US$1000 - pushing it wayout of my budget for a second visit. Money aside, it was totally worth it, seeign the gorillas was amazing - I probably shouldn't be suprised at this but they were really quite human in their mannerisms and social interactions. Dad and mums sat relaxing while the children had it out with each other. Children would go to mum for attention, realising it was a lost cause would move on to dad, who would brush them off with his 80kg backhand. Truly amazing - a definite must see for anyone visiting Africa.


Thats it from me tonight - a little more on our trip to Gisenyi/Goma border, Hospital Rotation (who would have thought that's why we are here)and Uganda when I can. Currently trying to balance blog posting with hospital attendance (at least eight hours per day, plus sometimes night shift) and writing/submitting report for School of Medicine(so far I have done zip towards this).

Gisenyi/Goma: It was incredible. Such a wet, beautiful place on a huge lake (Lake Kivu) looking accross the water at congo and the setting sun. The drive was a mixture of good and crap roads - the good were being built by a German company called Strabag, (and they drive really really crazy), the bad being ripped apart by taxis and trucks driving a million miles an hour through the potholes. I reckon you could scuba dive some of them.... We almost got killed at one point, ironically it was by a Strabag employee driving on the wrong side of the road around a blind corner on a mountain road at a ridiculous speed!

The first couple of nights we stayed at a town called Kinigi, right up in the mountains next to the gorillas. After arriving Thursday night, we woke up early on Friday morning and climbed Mt Bisoki, a 3700m high volcano with a crater lake on top. It is the highest mountain I have ever climbed, and i found the altitude a challenge. It was hard to keep the oxygen replenished at the top but I found the going good if I went slow. It was very muddy, slipping and sliding so much it was like skiing at times!!! We got up in 2hrs, which is apparently a really good time, passing through alpine meadows, forests and large areas of herbs and so on.

The absolute amazing thing about Mt Bisoke was that we saw a silverback gorilla male (at least 20y.old) on the trail. Apparently that is very very rare to see one out and about on his own - maybe he had decided he was never going to be the top so he set off on his own to start a new group. So we were lucky. They are big creatures - the ground was thumping as he ran past, probably about 180kg. Lucky we had 3 armed guards, plus the porter, plus the guide!! But in fact, it is the buffulo that are the most dangerous. Also, luckily we didn't meet any geurillas.... Dian Fossey had her camp very near to where we stopped for a breather, it was amazing to see the area where she lived and worked. "Gorillas in the mist" was filmed nearby - I'm sure at one point they were walking on the same track we were (I saw the film after going there!!)

So we went to bed with aching legs, covered in mud and without a hot shower. The next day we woke to a light drizzle - the day for the gorillas!! We ate brecky and arrived at the ORTPN meeting place at 7am where I drank my first cup of coffee in weeks... ahhhh sweet african nectar! It went down well. We were soo lucky - the ORTPN have about 14 or 15 groups of gorillas, 7 of which are visited, and 7 are studied. We wanted to go to Susa, the biggest group of wild mountain gorillas in the world - but we were told we couldnt. With 41 gorillas, including 3 or 4 silverbacks, a dozon or more females and a stack of immature males and females and babies, it was the ultimate chance. We were pretty down when we heard the news, but we kept asking and then suddenly a guide grabbed us and said "Susa? Lets go!!" They only let 7 ppl visit per group, for 1hr per day. So off we set, with 4 crazy Dutch doctors (2 plastic surgeons, 2 anaesthetists in Rwanda to do 50 or 60 cleft palates). It was about a 45 minute drive to where we started walking. When we got there, the guide told us the walk could be up to 6 hours, depending on where the group was located. We shouldered our packs and hit the trail. Again it was muddy on the flanks of Mr Karisimbe, the highest peak in Rwanda, but there were more stones on the western side than in Bisoke, so the mud wasn't as thick. But, the undergrowth was something else!! we waded through the thick herbage, into bamboo forests, all the time getting wetter and wetter as the famous mist rolled in... and then there they were!! the trackers!! that meant we had found the gorillas. I glanced at my watch, it had only taken about an hour - what luck.. we ditched our bags and our sticks (no food or threatening objets), had a quick discussion about how to behave, and then we scrambled through the undergrowth in single file, clambering through the fleshy plants. Then suddenly, we found ourselves face to face with a subdominant male only a meter or two away, sitting in a pile of branches he had flattened, chewing on a branch. For a 180kg individual, he has to eat 30-40kg of leaves a day -they are vegetarian. awesome. We continued a little further and found ourselves in amongst the dominant silverback and his harem of wives with children playing around at their feet. We stayed nearby for the hour, watching these giant creatures at rest, the guards imitating the gorilla speak - low grunts of contentment to say that all was ok. It was an amazing experience, unlike any I have every had before. I can't really put it into words, they are so huge, so much like a human it is a kind of uncanny experience. just to watch the kids play... so much like us.

So then on saturday after the gorillas we busted out of kinigi and headed up the road to Gisenyi next to Goma. When I say next to, I mean right next to. The border is in town - we went to see it just to say we had been there. But we didn't stay in town, we went to a place called Paradis, and it was paradise. What a spot. wow. Beautiful scenery looking out over the lake to the congo where the sun was setting. we were far enough away that we couldn't hear the gunfire, we might as well have been on another planet. So while we had a Mutzig (rwandan beer), there were 250 000 refugees massing on the border trying to get away from the rebels. Africa is a continent of absolute contrast. It was hard to believe that one of the most peaceful places i have been was so close to so much misery and anarchy. Anyhow, the border was closed so we couldn't get across to Goma. We met some Australians there that Mark knows, so we chatted and had a few drinks. Unfortunately, Andrew locked the keys in the car, and we had to spend 3hrs trying to break in. We eventually abandoned finnesse and went for brute force - we just bent the door open and a very thin rwandan bellboy bunged his hand in the hole and opened the door!! A quick bend back into place, and bob's your uncle (except for the slight leak in heavy rain...). Lets just say the beers were well deserved!!

So then the next day (Sunday) we drove back with the two Aussies. Things were getting hot in Goma, but we didn't know at the time. I'm glad we left when we did, but also glad that we went. Interesting experience.

Then, we stopped on the way back at a couple of little markets and Di (the Aussie nurse) taught us a thing or two about aggressive bargaining. I will never be ripped off again!! hehehehe... She is a nurse at King Faycal, a rwandan private hospital in Kigali.

So monday, we started at the hospital. we were met by the congolese Dr Polepole. An awesome teacher, a great obstetrician and a talented surgeon. he is deputy director of the hospital. we went on rounds with him, and then I saw my first ever live birth. I have learnt how to track a pregnancy and what sort of problems can arise. We then scrubbed in and saw the repair of a patent tunica vaginalis with an accompanying hydrocoele repaired by Dr Polepole and Dr Yuma as assistant. He is very good. they went into the inguinal canal from a suprainguinal approach, found the genitofemoral nerve, ductus deferens and the patent vaginalis behind it, then ablated it by tying it off and cutting it. they then sucked out the fluid from the scrotum - finished!! very neat, excellent work. we also caugh tthe tail end of a caeser after lunch, as they were closing. What a first day!

Second day was a bit harder. Dr Polepole went to Kigali for a meeting, so we were with Dr Ishmael. We arrived and a women was in labour who had been in labour all night, but the nurses hadn't informed the doctor of teh foetal distress. Bad news. At about 930 the doctors decided to caesar her because the baby was in such distress. But, by the time they got her into theatre, Yuma did a final listen with the foetoscope and the baby was dead. So instead of doing a ceasarien they gave her ergometrine and she gave birth to a still-born child. I saw her a few days later, she was distraught at having lost her child. Then, we followed Yuma into a repair of a hydrocoele in an adult prisoner. Prisoners have a HIV rate approaching 80%, so there wer extra precautions in place. The man was so frightened, he was very very jumpy. The doctors said all the prisoners were like this - they have a particularly shit life.

As he was serving a life sentence, the guy was may have been one of teh people involved in the genocide and tried under Gucaca (a local law system used to give payback to the genocidaires). His skin was very thick, presumably from his hard life. So now I have seen the repair of both communicative and inflammatory hydroceole. How they fixed the inflammatory one was quite ingenious - you dissect through the scrotum until get the tunica vaginalis and you slice it open to release the fluid. once released, you extend the breach until you can evert the testicle. You then get the air out and sew the vaginalis shut. Sounds wierd, but that puts the serous surface of the tunica vaginalis on the OUTSIDE - so any fluid is absorbed by the dartos muscle!! ingenious. you then close the layers surrounding the testicle. Fantastic operation. It does nothing to cure the cause of the inflammation/fluid build up, but it does remove the symptoms. Filiariasis is a common cause here - in another 5 years the prisoner may have elephantitis.

We then say a little boy who had been smashed in a car accident. The mother had died, and they didn't know who he was. When the relatives arrived, they had absolutely no money. They could not afford the 6000RF to give him antibiotics and anticonvulsants for his head injury (cerebral oedema, skull fracture, raised ICP, focal signs of decortication). He was very ill. So I gave them the money - about $15AU. I saw him again today - he is not getting much better. I think he will die either tonight or tomorrow - there is nothing more we can do for him here - they don't even have mannitol - and the family definately cannot afford to send him to Butare where there is a teaching hospital. So. Thats why it wasn't a good day. We then had the amazing opportunity to see a c-section of breach birth. The baby already had a leg out when the woman came in to hospital. Straight to the OR. She couldn't be anaesthetised because the baby was alreay in too much stress, so they just gave her a quick local and made the incision. The doctors needed to move fast BUT the intestines where IN FRONT of the uterus. they had to push about 4 loops of bowel that herniated out of the midline incision back into the cavity and wedge them there with padding. I won't say what they use for padding... but it is rudimentary. so that took time. the mother was in some pain, so they gave her diazepam. then the tricky bit. Dr Yuma incised the uterus low, and grabbed the leg still inside, and tried to get the bum oriented around while the other surgeon assisting (Dr Ishmael) pushed the other leg back inside. they managed to get both teh legs out, and then they had to deliver the head. The baby popped out after some manipulation, and they passed it to the nurse and turned their attention to the mother, who was given a big bolus of ketamine straight away to knock her out. During the proceedure the uterus tore and it took them another 35 mins or there abouts to control the bleeding. Luckily, the baby was ok. I have never seen soo much blood, all over the floor, everywhere. With my lack of experience I thought she was going to die for sure, but I kept quiet as the doctors remained calm and continued to work hard. The worst part was that there was a posterolateral tear on the left side of the uterus so that even after suturing the main tear kept on bleeding. I monitored her for shock, but it remained on the curve of compensated shock - pulse 120, breath rate 40, veins still palpable - no venous collapse. Phew. What a scary experience. I must have been showing my concern, at one point Yuma turned to me and said with typical doctor panache "Blood is red, you know??" Yes I did know, but I didn't UNDERSTAND. Massive blood loss is a scary thing, but the healthy person has an amazing ability to compensate. It turns into a mass of goooey goop that schlooops onto the floor sticks things together with the most incredible hue, eventually dulling off to a dirty smudged brown on the gloves and tools of the trade. A valuable experience. After closing, the doctors let out with a bit of nervous banter, joking about the case. It had been a close call, and they knew that having both mother and baby alive at that stage was more than they had secretely hoped for. C-sectioning a well progressed breach birth is a dangerous business, however both may have died without thier intervention. Needless to say, I was amazed to see the mother conscious and weakly smiling today in ICU when we went to visit the little boy (ICU being 6 beds with no equipment that really sick people go to after operations).

The doctors here are great, all under 35, verygood at what they do with almost no equipment. Like i said, no mannitol, to ability to pay $15 for drugs, no basic equipments. they make do with what they can. It has been an educational experience for me - somehow I don't think a rural australian hospital will be radically different from Nyanza - at least here they have X-ray and a lab!!!

So today we observed another birth, and Andrew restitched the episeotomy under the direction of Dr Polepole back from Kigali. I watched them animate the newborn, so to speak by aspirating the amniotic fluid from the mouth and nose and rubbing it, and then I did the APGAR scoring and the initial examination. After a slow start, he was a happy little chappy. We then went back and checked up on the injured little boy from the car crash - he had had his drugs but was having convulsions, still decorticate. I am very scared for him... life has a definite price here, and it isn't very much at all. We went on ward round with Dr Polepole again, what a champ! he is teaching us a lot about maternity. Andrew and I then went and did a circumcision each on 22yo guys. Quite a bizzare experience, but there we were. I did mine first - I had never seen a circumcision before so I didn't know what was going to happen - i just had to do it as Dr Yuma told me - quite a novel experience. Andrew had the benefit of having learn't by observation, and his ended up neater. But both were considered excellent by Dr Yuma, and he said we have now started earning our keep because we made the hospital about $30 today!! hehehehe.... So that was amazing, my first minor ops! and it was a total success. And that is all i have to tell.

Thoughts...

Today I have been in a reflective mood - there is much to think about. I helped Japhet with the clothes washing - all the washing is done by hand here. We are lucky at the school house - we have laundry powder and running water. Most Rwandans live some distance from a water source, and it is the young children (<8) who seek water for all the daily needs, which can be several kilometers. The slightly older children are charged with cutting grass to feed cows and goats, and they walk around with child-sized sickles neatly mowing any patch of healthy looking grass and bundling it into sacs which they carry on their heads.

Laundry is a big business for the women and children (usually), and best undertaken at the spring. Here you will plenty of water, people to chat with and an abundance of natural clothes lines in the shape any spare shrub or tree. After the clothes are clean and dry, it is time to return home to cook whatever dinner the rest of the family has managed to get together.

Children ran away from us at the spring - these children live some distance from the main road and for them, muzungu are a rare sight, especially up in the valley head. We were told a rumour the other day by Emmanuel - apparently Muzungu eat small children, which may explain the shyness! But it was all smiles among the squealing and running. There are so many children here and it influences the whole society - sometimes little kids walk around like old men and sometimes old men walk around like little kids. At times its hard to say who is serious and who is playing...

We went for a walk with Polo the other day - he took us to see his pump that brings water to the school. It a dual system, the latest from Belgium, only a few years old. Like everything in this country, it is all or nothing - these pumps are state of the art, but it can take months to get a spare part from Belgium. The pumps push water up several hundred meters to the header tank, to give pressure to the school. It is a very good system, taking water directly from the spring. It means the students at our highschool are lucky - they have running water to wash and bathe in. Students in most other schools need to get up early enough to walk to a well for water to wash their clothes and have a quick bath/brush their teeth. It is hard to imagine waking up and carting water everyday just to wash your face.

The view from the top of the hill is fantastic - rolling hills in every direction. To the south you can just see the flatlands of Burundi reaching towards the horizon, 40km away. To the west are the mountains of the western rift valley, Lake Kivu and the Congo. Theres gold in tham thar hills, and diamonds and nickel and copper and rare metals used in silicon chips. Along with all the wealth comes the misery of war, of thug culture and terror. Its more thug than any LA gang-banger could ever dream of - the President of Congo has more accrued wealth than the queen. Roaming bandits terrorise the population and drive people from their homes, stealing children to become child soldiers and practicing witchcraft and cannibilising people to make strong sorcery and attain greater power and wealth. And then when they are powerful enough, then they become politicians.

At least here in Rwanda, this does not seem to happen any place I have been yet. The country is open, education is good, and people live free from any overt oppression other than that of dire poverty. Many students have talked to me of the realities of thier situation. They will finish with a better education than most Australians, with little job prospect even for the best. So they return to the fields and their mudbrick homes to scrape together a meagre existance. Many of the questions we get are onesided, and heartbreaking. They ask how much a ticket to Rwanda has cost - at RF1,800,000 it is an incredible sum. A skilled Rwandan, a mechanic or a builder for example, would earn only RF40,000 a month - or $20US a week. To get those sums of money together is out of the question, especially when the daily essentials are not overly cheap in this country. Things we take for granted, like soap to wash your hands, is a luxury for the working poor. The boarding school sleeps 2 to a bed - and for many families coming up with the $46 per annum fees is a major major issue. But for their hard-earned they get 2 square meals of beans and cassava a day, and running water, and an education.

What can I say to this? I tell them of what I see - and that is hope. The country feels more united than many I have visited - certainly with that sense of unity can come hope for the future. It is together that they have a future, not in division. For these kids, there are no jobs. Their education has no endpoint, no job. So why do it? Because, perhaps in 2 generations, their kids will have jobs. In the meantime, the country needs to keep a stable government and a good heading so that the flowdown can occur. Already, some cooperatives are building, and maybe soon they will be able to export goods and build industry through cooperative development of agriculture and industry. But for most it is simply a struggle to get food into hungry mouths - of which there are plenty in this tiny, densely populated country.