Caregiving,Teaching, and Cooking – Susan Boiko, MD, Blogs from Rwanda

Note:  Susan Boiko, MD, is a Kaiser Permanente dermatologist in San Diego. She has been in Rwanda since mid-September performing relief work in support of the Pygmy Survival Alliance, a collection of nonprofit organization that connects pygmy villages in Rwanda with information, leadership, survival and health resources to enable them to transform their health and welfare.  For  background, read her first dispatch from her trip.

Sunday October 9
A beautiful sunny morning, I slept til 8, then had breakfast with a nice surprise- boxed orange juice along with milk tea and a slice of white bread. The morning was spent working on the AIDS lecture.  Just before lunch, visitors arrived in their Sunday best. Members of Betty’s family arrived for a chat. Betty’s nephew had atopic dermatitis, and as is my custom in such situations, I explained that I am not licensed to practice in Rwanda but can give website addresses with more information and make suggestions of medications. As in the United States, there is disappointment that the disease cannot be cured, even if American medicines could be procured.

After lunch and a nap Joseph, Betty, the housemaid Fanny, and the children and I ride in the car to Mama Africa, a restaurant that has the only playground I have seen in Rwanda. Admission is $3.30 for children, and free for parents. A giant bouncy house, several small merry-go-rounds, pedal cars, swings and climbing structures are adjoined by a refreshment tent and tables for parents to look on as their children have a great time. Waiters circle the crowd, asking for drink orders. Joseph and I let everyone else out and then we proceed to the home of one of his patients. It is about a 20-minute drive past the airport to the Kanombe Military Hospital.  Despite the “military” it was a regional hospital and still sees nonmilitary patients, especially those with AIDS. Dr. Joseph manages an AIDS  clinic there 3 times a week. Antiretroviral treatment is free but any complications such as pneumocystis pneumonia or other opportunistic infections require a Mutuelle card to be treated.

Last week, Dr. Joseph saw a young woman of very short stature with AIDS who was malnourished. Compassionately, he took  money out of his own pocket for her to buy food. This afternoon we drove down a bumpy dirt road to a cluster of ramshackle buildings where, as soon as I stepped out of the car, I was surrounded by a mob of shabbily dressed children, all of whom wanted to hold my hand or touch my hair (I think they thought it was a wig, one gave it a little tug). Shyly, but with a big smile on her face, Dr. Joseph’s patient greeted us. She was wearing her nicest clothes. I guessed her age to be 20s. Her face and arms were uncovered by clothing, but covered with the purple polka dots of Kaposi’s sarcoma. Her face glistened, possibly because she had a fever, and she was very thin. Somewhere a bench was procured and she brought it into a small home with a metal door and a small window. A curious crowd gathered outside and small children occasionally wandered in, to be shooed out. The floor was dirt and sloped downwards. In one corner were 4-foot-high decorative clay urns, some glazed, some still drying.  In another corner a man of uncertain age sat, watching us, but not saying anything.  Dr. Joseph and I sat on the bench as she explained about the community members. There were 102 people called “vulnerable” or “marginalized,” mostly women, living in the area. They had housing provided by the local government but little land to grow food on. Dr. Joseph asked her to show him the food she had bought with his donation. Out came a small grocery bag with some half-used small sacks of flour and sorghum.
As we drove away I asked Dr. Joseph what the next step might be. The Community of Potters Health and Development Project and the Peoples Survival Alliance should get involved. The local government should provide assistance and Dr. Joseph was to contact them. Out of respect for her dignity I did not take any pictures of Dr. Joseph’s patient, but her image remained strong in my mind as we went back to the playground to pick up the rest of the family.
As dusk fell the playground came alive with colorful lights and the happy cries of children at play, doted on by their prosperous parents. The contrast from the previous scene even now brings tears to my eyes. This was the most emotionally upsetting experience I have had. The antidote to my gloom was to take lots of pictures of little Josh and Joanna, happily swinging, sliding and riding on purple plastic dinosaurs.

Saturday, October 8
This was the best day so far in Rwanda.  I left Betty and Joseph’s on foot at 7:20 a.m. I was to meet the bus, filled with doctors, at the Kobil station in Kicukiro, 45 minutes on foot. I arrived there at 7:55, my best time so far (but I wasn’t carrying my heavy computer or my backpack). Finally at 8:30 a chartered bus seating 30 (with foldup seats filling the center aisle) arrives. The cookies were devoured gratefully by an assortment of medical students and doctors, including a professor of Pediatrics who arose before sunrise in Butare, the site of the National University of Rwanda medical school, and had already been on buses since 6 AM, a gynecologist, an ENT resident (word of the name change to Head and Neck Surgery hasn’t reached here yet) a pharmacist and an Emergency Medicine specialist.

I chatted with a medical student finishing his second year. Medical school here is for the top scorers on a standardized test given to all secondary students (secondary school goes to age 20-22). Medical education is 6 years; the first 2 years are preclinical sciences and there is no real patient exposure until the last 2 years. So unless the medical students had some clinical experience they would be functioning as assistants.

We stopped at Nyamata Hospital to pick up additional doctors and load the medicines donated by a Christian medical charity, Barry Wood Ministries.  The medical clinic or health station we were going to had sparse supplies.
It was supposed to be a 9-mile journey from the Nyamata Hospital to the clinic. It took over an hour, as once we hit the dirt roads there were no signposts and few landmarks. Twice our bus had to turn around.

When we finally arrived about 10:45 AM, a crowd of more than 400 people had gathered, from newborns to elderly people using tree branches for walking sticks and even someone on an improvised stretcher, all awaited the doctors. Many had never seen a doctor (the clinic is staffed by nurses ). We walked a few hundred yards down the road to a small clinic building where we introduced ourselves, discussed our strategy and had a brief prayer and hymn.
Back down the road we came to an eager crowd. The bullhorn was not working so the ENT resident gave a rousing sermon that the doctors were here to help but Jesus heals. This was delivered in Kinyarwnda but a medical student interpreted for me. Before the sermon was over, I was shown to an exam room which you can see in the pictures. No sink, no exam table, no light except rom the doorway and a small window with no glass.  I was so grateful to my certified dermatology nurse practitioner Ted Scott back home who had donated 2 powerful lights, of which one always stays in my pocket. This was part of the 90 percent of Rwanda without electricity. At first, because the press of the crowd was so great, they wanted me to see any patient in need but I insisted that I would only see skin problems. That was a wise move since I have not done any general medicine since 1985, when I had to cover the military hospital ER as a pediatrician.

I had the assistance of a terrific medical student, Brian. He had just completed his second year and had zero knowledge of patient care or dermatology. Nevertheless, he interpreted for me as the steady flow of patients was unabating.

I had no paper. No one had a piece of paper- so I took my Nakumatt receipt and in tiny handwriting, enumerated every case. In the four hours that I saw patients without a break (they did bring sodas at 1PM) I saw 36 patients. The pediatrician in the next room saw 30- and his cases, including a toddler with previously undiagnosed Tetralogy of Fallot- were more complicated than most of mine.
I saw everything from multiple cases of tinea versicolor ( called “Ise” and pronounced ee-say in Kinyarwanda) to abdominal stretch marks after pregnancy to tinea capitis to atopic dermatitis, mostly infected, young and old, usually impetiginized, to a thyroglossal duct cyst in a 4 year old (that went to the ENT resident) to AIDS associated eosinophilic folliculitis with the IRIS phenomenon, to  chronically infected leg wounds that had only been treated with short courses of oral antibiotics without resolution. The medical record consisted of a “blue book” type 8 inch square paper book which had been cut in half (I bought one at Nakumatt for 15 cents). If I was lucky, in somewhat clear handwriting there might have been a date, a diagnosis and a treatment on one of the pages. More often, the book only had the patient’s name in it.

Brian and I devised a system. He called in the patient, asked what the skin complaint was and with the help of Ted’s light, checked the spot, and any other areas as needed. Then I gave the diagnosis, with a quick explanation of its nature and treatment which Brian ably interpreted to the patient. Then, because I am not licensed in Rwanda, Brian wrote the date, the diagnosis and the treatment in the little half-book. I had no difficulty with the diagnoses. The treatment was another matter. Like many American patients, people feel cheated if they don’t emerge from their encounter with a prescription. On the other hand, there is no spare cash for effective over-the-counter remedies, even if there were a nearby store where such things could be bought. Luckily, the Barry Wood ministries had supplied us with antibiotics and steroid cream and ointment so when we wrote our treatment in the half-book, the book could then be given to the pharmacist. It might mean only a 5-day supply of antibiotic or a 15-gram tube of medicine, but it was something. Of course, followup would be back at this local clinic with a nurse. In case of a severe problem, the nurse could write a consultation in English or French to our local Nyamata hospital, but then would come the challenge of transporting the patient to and from the visit. It would be at least a day’s walk just one way if a moto wasn’t used.

Exhausted and hungry, but exhilarated by the sensation that we had offered something to these desperate people, we doctors made our way through knots of people that had to be turned away because we just couldn’t see everyone who showed up. That’s when I experienced the only rudeness I have received in Rwanda.  An elderly woman leaning on a tall stick for balance shoved me on the shoulder as I walked with the doctors. She uttered a harsh, scolding cry as I quickly waked away. I understood her frustration but could not communicate my sorrow that I could not help her.

We gathered in a small room at the smaller clinic building. Dr. Stephen gave a summary of the day’s success and noted that the collection of doations from the doctors and  medical students paid for the bus, the meal and 50 Mutuelle cards for the most impoverished. The medical supplies not used would be left for the clinic. And then I was asked to say a few words.

I explained that this day was the holiest day in the Jewish calendar, Yom Kippur. Normally Jews spend the day fasting and praying for forgiveness of sins. This was the first day I can remember in my adult life that I did not spend in reflection, whether at home or in a synagogue. Nevertheless, I felt caring for sick people was too important for the ususal activities. I finished by saying the Sh’ma. Then Dr. John, the Pediatrics professor spoke, referring in his prayer of thanks and blessing of the participants to “Adonai.”

We then ate the festive meal as you will see in the photograph on Facebook French fries, spaghetti, boiled potatoes, a chunk of chewy beef on a bed of rice and a tablespoon of African spinach. For most of the participants, this lunch at 4:20PM was the first meal of the day, and they cleaned their foil containers.
By 4:45 we were back on the bus. Normally I would have been let off at the gas station in Kicukiro, but I don’t like to walk by myself after dark, and we were not going to reach the gas station in time. So I rode all the way into downtown, arriving at 6:45. First stop for me, Nakumatt, where I bought  plastic wrap to have in my backpack to at least waterproof my computer for future downpours if I am caught again.

I called Taxi Rene who was busy but sent a friend. Saturday traffic was much lighter and only took 25 minutes to get back, then went  straight to sleep as I was exhausted.

Friday, October 7
This was Susan the chef and Christine the sous chef morning. I made a pot of oatmeal, which is called porridge in Rwanda. The local custom is to make it a drinkable gruel. Here we spooned it into coffee cups and sweetened it with golden raisins (a dollar a small box but a delicious luxury for me) and grown sugar. I had bought a round challah at FRULEP and slices of it were eaten with the porridge.
For lunch I attempted to make chapatti. I only had pizza flour and the recioe called for both wheat and white flour. I have not found any wheat flour in Rwanda. The receptionist and accountant Louise brought a rolling pin and a wooden disk but I did not roll them out thinly enough and I also had trouble with the skillet despite oil- it was either too hot or not hot enough. The omelets were more successful and everyone liked the canned mushrooms I got at the Italian grocery store. I chopped zucchini and onions but again had trouble with the saucepan so they were greasy yet people enjoyed them. I also got a wheel of Rwandan gouda cheese which to me tastes more like Muenster. This was cut into slices. Only Christine had cheese in her omelet as most Rwandans don’t eat a lot of cheese and we weren’t sure they would like it. 4 oranges cut into slices made a fine dessert.
After lunch I worked on my Skin Signs of AIDS talk then got a ride from Dr. Joseph to the 24 hour grocery store downtown, Nakumatt. There are numerous money changers in the area so I was able to change my American hundred dollar bill for a fistful of $3 bills – 2000 Rwandan Franc notes (there is no denomination higher than $6). In a 3 story complex there are small boutiques, money changers and a Western style coffee shop, Bourbon coffee, with free wifi and the most white skinned people I have seen in one place in Rwanda, all using electronic devices. I had a hot chocolate for $2.50 and enjoyed my Droid which would not normally be used except for texts because calls are $3 a minute and internet is also outrageous.
Then I browsed Nakumatt- like a small Sears with groceries. I was looking for a poncho or waterproof jacket- none. I briefly toyed with buying a shower curtain and cutting a hole for my head but decided that would be ridiculous. No giant plastic garbage bags or even plastic sandwich bags. I ended up with 3 bags of cookies for the doctors on the bus the next morning, since I knew many of them would not have eaten breakfast. Taxi Rene picked me up and then we endured a 40 minute odyssey of rush hour. For all his pains the fare was $12 which probably barely covered his gas.

Wednesday, October 5
Went to HDI in the morning and there was still no chef. Once again Louise came to the rescue and prepared a delicious lunch of rice, fried potatoes, and a tomato vegetable sauce.
Christine, the HDI intern from Sacramento and I decided we would make lunch this Friday. The menu: omelets with cheese, cut-up tomatoes, onions and green peppers and chapatti. I found a recipe for chapatti on the Internet and went to the Italian grocery store down the street looking for inspiration. I found pizza flour and a can of mushrooms. There were no eggs there and we have no refrigeration for cheese so I left the purchase of eggs and cheese for Friday morning.
I spent the day working on the scar lecture and some preliminary work on the Skin Signs of AIDS lecture for next week.  I walked all the way back to Dr. Joseph’s just before dark at 6PM. I have been stopping by a small grocery store the past few days to buy a bottle of water for about 60 cents which helps break up the long walk. In the evening, Betty, Josh and I walked down the road in front of their home for about a 10 minute stroll to a small grocery store to buy milk and rolls for evening tea and breakfast. Dr. Joseph’s sister Lydia is visiting and has a lively, outgoing personality. Even though I don’t understand the Kiryarwandese conversation the body language and vocal inflections provide some insight into the conversation.

Thursday, October 6
It’s no different in Rwanda than anywhere else for professionals: we depend on our cars to get to work and when a car is not working it is challenging to get around. This morning Dr. Joseph needed to go downtown, but had no functioning vehicle. He diverted the taxi that normally would have picked up Josephine by the airport, then me on the way to my 8 AM lecture at Nyamata Hospital, with the result that Josephine and I arrived 30 minutes late. This time I had texted Dr. Stephen and then called him when we were 5 minutes away, and valiantly he rounded up the troops so that once again by the time I had finished my lecture at 9:30, the room was filled.
I need to tell you for a moment the sacrifices the staff, especially Dr. Stephen, are making when it comes to attending these lectures. They take an hour out of their work schedule (the physical therapist, the ophthalmology technician, numerous nurses, the hospital pharmacist as well as the physicians) and they have to make up that time. It is a tribute to their dedication to learning that they continue to attend the lectures despite the impingement on their work schedules. And Dr. Stephen takes top marks in the dedication category. He had ward rounds to make on 20 patients this morning and who knows what else yet he and Josephine patiently went through our 6 consultation patients this morning (2 siblings with vitiligo, 2 premature boy-girl twins born a week ago by C section to a mother with malaria, both of whom had fevers and one of whom had yellow staph pustules on the abdomen, 2 women with pomade and papular acne, and a woman with facial dermatitis and AIDS with a low CD4 count) until noon.
Dr. Stephen is also in charge of a Christian Medical outreach program with a group of doctors and student volunteers who go to a neighborhood clinic usually staffed by nurses and treat patients using donated medicines. Those patients who are so impoverished they can’t afford the $2 yearly premium for government health insurance, “Mutuelle,” are provided insurance cards. The donation I made of about $30 US, which he requests from each doctor, pays for the volunteers’ transportation and lunch, subsidizes these expenses for the students, and buys the Mutuelle cards. This outreach program takes place on Yom Kippur, when normally I would be sitting in Temple Solel and atoning for the sins of the past year. However, this is not a normal year.
On the way back from Nyamata Hospital we stopped at FRULEP, a grocery store the size of a 7-11, where I bought an onion, some fruit juice boxes (one for the taxi driver, one for Josephine), raisins for the oatmeal I will be making for breakfast at work tomorrow (the raisins cost $6 for 6 little boxes but I really wanted them for the oatmeal) and oranges for Betty and Joseph. Next door is a French bakery called Tante Olga and they had round challahs so I bought one. Since Josephine will be away from the office tomorrow I gave her the first slice. While cutting it I said the Hebrew blessing for bread and she joined me in the “Amen.”
There is a new man in the HDI kitchen named Charles. He made a creditable lunch of fried potatoes, rice, sautéed green bananas in tomato sauce and chewy beef in tomato vegetable soup.
I spent the rest of the afternoon working on the Skin and AIDS lecture and reading the New York Times’ obituary of Steve Jobs. Creative genius, rest in peace.
Set out for Dr. Joseph’s at 4:30 PM. Huge gusts of wind  werestirring up dust clouds and lightning in the distance foretold a massive downpour. Although my shoes and pants were soaked and muddy,  I hoped the umbrella had protected the backpack with my computer in it. Unfortunately, the backpack was soaked through and when I pulled out the computer, water ran out of it. I quickly plugged it in hoping the warmth it generates would dry it. Sad to say the left upper screen has been ruined with water damage but it is otherwise functional. As soon as possible I will look for a plastic poncho.

Tuesday, October 4
We were 15 minutes late for the 7:20 AM lecture due to the late arrival of the taxi. The staff meeting room was deserted but people drifted in and there was a full house by the time the lecture was over. I was only able to get through the bacterial part of the talk but it seemed to be well received.
At the end I asked, “Are there any questions?” and a bespectacled gentleman piped up, “What is the mechanism of ocular cataract development in atopic dermatitis?”
I told him as far as I knew that it might be genetic or traumatic or related to steroid use and that the most common type was the posterior subcapsular type.  I told him I would research it further. After a lecture on bacterial infections of the skin, where I only briefly touched on atopic dermatitis and secondary infection, I was glad I recalled that little tidbit of information on cataracts I had studied for my Pediatric Dermatology boards in 2004!
Dr. Stephen and his colleagues had amassed a stack of charts and in the subsequent three hours saw six interesting patients with nodular and papular acne, a nonhealing leg wound since 1994 that had been unsuccessfully treated with antibiotics in the past and which recurred after surgical excision (I’m thinking  atypical mycobacterium or deep fungus), elephantiasis in a patient with AIDS, secondarily infected dermatitis, now improving after antibiotics, and a chest and shoulder scald burn after a week of treatment.
Then it was back to HDI where receptionist Louise cooked a lunch of rice, fried potatoes and peanut sauce.  The electricity was out at HDI so I walked back to Dr. Joseph’s home and worked until 10 PM on my lecture on scars.

Monday, October 3
Typical Rwanda day, rolling up and down like the “Mille Collines” or Thousand Hills.  Got into HDI at 7:15 am to find that Emme, the chef, had not returned. The receptionist and an assistant washed the mugs from Friday, boiled the water and reconstituted the powdered milk, then heated it for tea. The receptionist then went to the center city to take her written test for her driver’s license. About 1PM Christine, the HDI intern from Sacramento, and I were wondering what to do for lunch. I had seen a sign for a restaurant operated by a tourism trade college just a 10 minute walk up the street, so we decided to check it out.
What a delight! For 2000RF (about $3.50 US) there was a buffet served in a spacious cafeteria like setting with big windows wrapping around the seating area overlooking a valley. Most of the other customers were businesspeople and students served as waiters and buffet servers. We began with a fish soup, suspiciously like canned cream of mushroom but with the saving graces of little pieces of fish and a subtle curry seasoning that took it into delicious. The hot buffet had  chafing dishes with cut up vegetables, green bananas in tomato sauce, rice with the ubiquitous carrot flecks, French fries, the least greasy so far, pinto beans with green tomatoes, beef on the bone (mostly bone), well done but not overly chewy slices of pork and vegetable broth to put over the top. For 80 cents more a selection of sodas was offered- I had my favorite, Eau Gazeuse (seltzer or literally gassy water.) Three people were back at the office and although they had to go foil trays they were unsure of what to do with them so I went down the buffet line making my choices and they filled the containers (guess they didn’t want me to sneak out with a trayful of meat). The student lovingly and painstakingly crimped the foil top around the paper lid. This took several minutes. Then there was a search for the correct paper bag. Several were tried, one finally was chosen. But wait! You can’t leave without the 2 stubby bananas!
Total cost for 2 meals with soda and 2 to-go meals $17.  Christine paid for her lunch and I bought mine and the to-go boxes.
I get back to the office and administrator Louise has returned from her driving test. She tells me that the MONTHLY budget for lunches 5 days a week for up to 7 people at a meal is $15. The meal we ate on Friday wrecked the budget. If Emee doesn’t return by tomorrow she will hire someone else.
Finished my talk on Bacterial, Fungal and Viral Infections of the Skin and was out the door at 4:45. My goal: to walk back to Dr. Joseph’s house, where I am staying, before nightfall at 6 PM. A steady rain doesn’t defeat me as I use my sister Patricia’s red Cornell Medical School umbrella to shield me from the downpour.  It takes exactly 75 minutes to get home.

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