What Came First...

We are all familiar with the philosophical question about the chicken and the egg whatever our views on the answer might be. Well, here in Kigali my answer is the egg came first, at least in theory. About a month ago shortly after my arrival in Kigali my roommates and I were chatting and thinking how nice it would be to grow something in our beautiful yard. Though many different bits of produce came to mind, we were convinced that we were geniuses when we decided we would produce eggs. Obviously we wouldn’t be doing the production, but we could get chickens to take care of and reap the dual benefits of their eggs and their affection during our time in Rwanda.

Convinced of our genius we left for the market on a Sunday morning to purchase three proper egg-laying chickens. With the help of a Rwandan man we quickly found our way to the poultry aisle and they pulled three beautiful chickens out of the box. Some frantic French and a few odd looks later, we were able to explain that we did not want the man to kill the chickens—we wanted to take them home alive. And there we were, three apparently “crazy muzungus” with three living chickens.

We got them home and introduced them to their free range environment knowing that there were plenty of trees in which they could roost and that the walls to keep predators out of our house would be perfect to keep the chickens inside their new home. However, later that evening we were informed by our guard that they needed a home to protect them from cats. His statement was met with a bit of skepticism since he also said we should bring them in to keep them from getting cold. With the threat of three frozen and cat-tormented chickens on our collective conscience, we began conceiving of a way to keep our new pets and egg-layers safe.

It is within this history that the “resource-limited setting chicken coop” was born. The wonderful thing about being in a country like Rwanda is that very little is wasted. So, when rummaging through old furniture at work our administrative staff was very happy to allow us to take the broken filing cabinet behind the project off their hands. A quick stop at the hardware shop gave us the remainder of the supplies we were lacking—chicken wire, nails, hinges, and screws. With hammer and Swiss Army knife in hand, Sally, Sam and I worked to convert the old filing cabinet into a chicken coop complete with fold out doors and run. Extra supplies came in the form of a hair rubber-band, some zip ties, and duct tape. Though these were things that were undoubtedly packed without a clear purpose in mind, I can guarantee that I did not anticipate a chicken coop being a potential use for my roll of duct tape. After toiling away for a couple of hours our masterpiece was complete and our chickens had a new home in which to lay their eggs.

We fell in love with our chickens, despite their apparent lack of chicken sense at times. To express our love, we gave them each a name fitting of their personalities. The white chicken who is the biggest and the bossiest was named Fossey, after legendary primatologist Dian Fossey who pioneered her work with the gorillas while making the locals mad here in Rwanda. The brown chicken was given the name Darwin due to her evolutionary prowess. She was invariably the first to find the water, the food, and the first to put herself to bed. Finally, we have Indiana, the black chicken who is always first to explore territories unknown. His penchant to escape from the gate and venture down the dirt road on which we live earned him the name after the fictional explorer and archaeologist of George Lucas fame. Despite giving them a safe and innovative architectural masterpiece in which to live, and a supply of wheat and corn that rivaled the meals they undoubtedly received before their pardon at the market that day, we were given no eggs.

All of the guards and general workers on the block were abuzz about the three crazy muzungus and their three eggless chickens. Four weeks into the process we had invested time, money, and energy into Darwin, Fossey, and Indiana with no edible return on our investment. Last week, however, our luck changed in a rather unfortunate way. While home eating lunch one day two of our three pets ventured into the house without our knowledge. As we dutifully locked the door and returned to work, we unknowingly locked the chickens in the house. Returning home in the afternoon gave us a surprise of feathers and chicken products all over our house. They had ransacked the kitchen shelves, broken dishes that were sitting out, and left little reminders of their presence all over our floor. Our frustration turned to laughter as we proceeded to clean up the mess and discuss the fate of our poor chickens, when all of the sudden we found it. During their lock in, one of the chickens laid an egg in the middle of Sally and Sam’s bed. The precious offering was, rather ironically, next to a roll of duct tape as if to say thank you for investing all of this time and energy into us.

Since that exciting day the house has been filled every other day with the noises of two proper egg-laying chickens courtesy of Darwin and Indiana. We wait in anticipation for an egg from Fossey, but to be completely honest we aren't entirely optimistic. The grand total is up to fourteen eggs—most of which we will share with the guards for all of their assistance wrangling the chickens when they escape. Though we were anticipating a wealth of eggs from our chickens, they have in some odd way given us much more. Sam was thrilled with the opportunity to use his Swiss Army knife for a practical application. Sally gets a great deal of pleasure watching them peck around the garden all day. And I will never forget the pride that accompanied seeing that first egg in the middle of Sam and Sally’s duvet. In our case the chickens, and their mess, clearly came first. However, without the wait, the egg that was subsequently poached to perfection would not have been nearly as delicious.

Projects

We are a culture obsessed with projects. Americans (more so than others I have begun to realize) love to have something to do, something to work on, or a task to complete. That is one of the biggest lessons I have learned in my four weeks here at Project San Francisco. Project San Francisco (PSF) is the name encompassing the clinic, lab, training center, and research facility that I am working at here in Kigali. It is based in the center of town and has provided care for men and women infected with or affected by HIV/AIDS since its founding in 1986 by Dr. Susan Allen—the Emory physician who is my boss for the next five months.

Originally a grassroots organization, its presence has grown both here in Rwanda and in the international HIV community. The project is funded by grants from the Centers for Disease Control (CDC), the International AIDS Vaccine Initiative (IAVI) and the President’s Emergency Plan for AIDS Relief (PEPFAR) and has become quite the juggernaut of a research group. PSF promotes couples voluntary counseling and testing (CVCT) for HIV and encourages couples to get tested for and counseled about the virus together with the realization that most African couples infected with HIV are co-habiting men and women. If couples are discordant, meaning one partner is positive and the other is negative, PSF follows these individuals for monitoring of their health, retesting of the negative partner, and reaffirming messages of condom usage in efforts of prevention. And, in the unfortunate incidence of a seroconversion (the HIV negative partner becomes positive), PSF performs complex laboratory tests to monitor the genetic linkage of viral strains and the immunogenic factors involved in transmission. Some of these clients of PSF have been living healthily with HIV for in excess of 25 years and have their blood filtered and studied for the presence of neutralizing antibodies to be used in vaccine development. Its role in vaccine trials and its growing role in family planning are among some of the other tasks that we manage here at the project.

Most remarkably, however, are the training and education efforts we have going on here at PSF. Dr. Allen has secured a significant five-year grant to train every government-run health center in Rwanda how to counsel and test couples for HIV over the next five years. Each week nurses come from their centre de santé (health center) in various regions of Rwanda to PSF here in Kigali for a week of didactic and practical training for CVCT. These objectives, of education and health preservation is at the center of PSF mission.

Above is the view overlooking PSF from the building where my office is located. The building straight ahead holds the only Accredited Laboratory in East Africa outside of Nairobi. The building to the right is the clinic building where the clients of PSF are seen 7 days a week by our nurses and counselors. The second picture above shows the walkway from my office to the clinic building. Below is the office that holds the physician and counselors' offices (including mine) that double as clinic rooms when necessary.

For the past twenty-four years, PSF has been a driving force in HIV research and a life force for many of the people of Rwanda. During Dr. Allen’s visit a few weeks ago I realized just how deeply connected the clinic is to the welfare of the people of Rwanda as she shared her account of the events of the 1994 genocide.

There is universal awareness of the horrific events of 1994 in which hundreds of thousands of Rwandans were killed in tribal civil war. I was keenly aware of this incident when I began researching Rwanda as the setting of my summer project. I continue to think about it daily when I interact with patients and try not to wonder who’s Tutsi, who’s Hutu, and who would wield a machete against his or her neighbor if given the opportunity again. Rwanda is a model of post-war reconstruction driven in part by a highly regimented and intolerant government. The official message of the country is that there are no tribes and that there are only Rwandans, but the grenade attacks in the capital and the genocide prisoners in their distinct pink jumpsuits are a reminder that this government-promoted message is only a thin veneer.

Dr. Allen’s story of being trapped in Zambia during the genocide and trying to reunite with her husband and her 3-year-old son who were in Kigali at the time of the incident was harrowing to say the least. The last sentence she heard on the phone from her husband before seeing him in Kenya two weeks later was “we’re never gonna get out of here alive”. Working with the stoic Rwandan physician who is our project director who suffered unimaginable losses to his family in the genocide is a daily reminder of that same horror. And despite the sadness that colors the history of this country and the culture of veiled mistrust that characterizes its present, Rwandans still march towards the future. Dr. Allen’s dedication to this future is why I am proud to be working here at Project San Francisco. At PSF we worry about the medicine and the numbers, but everyone knows that the staff members who worked here before 1994 survived in large part due to her strength and guidance during the evacuation.

Pictured above is the main entrance and garden beyond the gates of PSF. The garden was created as a memorial to the lives that were lost in the 1994 genocide. The black plaque in the center contains the names of those PSF staff members who were lost in this horrible event.

It is with this history that I come to work on my “project” every day. I have been charged with trying to pilot a training program to teach Rwandan nurses how to provide IUDs and implants (long acting and reversible forms of birth control) to their patients. As one can imagine, after mass murder and civil war, Rwandans are eager to rebuild their families. Unfortunately, with a population growth rate easily surpassing other African countries, an unbelievable population density, and the average Rwandan women having 6 children in her lifetime such fertility is not sustainable. As a result, Dr. Allen feels strongly in helping the government develop infrastructure and policy to try to make birth spacing and family planning the social norm. I am happy to be working with nurses who come for CVCT training to assess their knowledge about these methods and what barriers exist to implementation. As I learn more about the cultural and practical barriers to these methods, I look forward to piloting a training program in two clinics—the Centre de Sante Gitega and the Centre de Sante Muhima.

Above is the office that I share with the other ex-pat interns. Below is the view out of our window and the nest of pelicans that live in the top of the tree by the wall.

These are my goals when I come to PSF every day to work on my discovery project. This “discovery project” is a required five-month research endeavor that is a mandatory component of my medical school curriculum. As many of you know, this opportunity for “discovery” was a huge factor that influenced my decision to pursue my medical degree at Emory. Though I am excited about the work I am doing and get even more thrilled as it starts to take shape every day, I realize that my small project is part of something larger.

The work that I am doing on a daily basis may seem frustratingly tedious at times. But a quick glance out my office window to the courtyard of PSF filled with HIV positive women and their many children reminds me that the details I pursue now are a small step towards a larger vision for a bright future here in Rwanda. Though I am proud of the work I am doing and realize it will be a life changing experience in my personal and professional development, I know that it is insignificant in the grand scheme of what happens at PSF on a daily basis. Since starting my work here I have been embraced by the staff at PSF and taught the cursory phrases of Kinyarwanda. In a medical climate characterized by the maxim “publish or perish” it is nice to be around something that has remained. Project San Francisco has endured hardships that are thankfully unimaginable to most of us and has remained a strong presence in the community that is unwaveringly true to its mission. I am proud to be working for and with these remarkable men and women on a daily basis, and I can’t imagine a better place to spend the five months of my discovery project.

Above is Natalie, one of the general workers at PSF who is also my Kinyarwanda teacher. She doesn't speak French or English, but we communicate rather well. Below is one of the wonderful surprises that accompanies working in Rwanda--the beautiful animals that wander through the garden.

Monkey Business

For those of you who know about African tourism you recognize that Rwanda’s biggest attraction is the group of gorillas of the Parc de Volcans. What many people don’t recognize, however, is the abundance of primate species in the country’s lesser-known but equally beautiful national park, Nyungwe Forest. This tree-covered paradise was the location of this past weekend’s adventures as I set out with five other ex-pats to see Nyungwe and its primate species.

Nyungwe Forests boasts as a home to thirteen different primate species representing about 25% of the primate species found in the entirety of Africa. The most famous of these species are undoubtedly the chimpanzees which live in two habituated groups that are available for tourism for those who are up for the challenge. Aside from the flora and fauna contained within the boundaries of the park, Nyungwe boasts as having one of the most beautiful waterfalls in Rwanda that is much more accessible through a ten kilometer trail through the heart of the rainforest.

These were our trip goals, so to speak, as we set out on our adventure to Nyungwe. Six hours later we found ourselves in the park and ready for a challenging hike and the beautiful vistas that came as our reward. In order to access the trail, we walked through rows of tea fields in the tea plantation with a stunning view of Lake Kivu and the bordering Democratic Republic of the Congo. Shortly after venturing into the rainforest, the ferns and freshwater streams that feed them dominated the scenery as we trekked deeper below the forest canopy.

The beauty of the rainforest and the unique sights and sounds it offered us made the rain midway through our journey a welcome friend. It seemed only appropriate to experience the phenomenon for which this magnificent place was named. Then, before we realized it, the mist we were feeling was coming from below, not above for we had reached our waterfall destination. Climbing over some perilously slippery rocks was well worth the reward when we saw the rainbow that donned the water at the top of the falls.

The experience of the waterfall was so incredible that we weren’t concerned when our accommodations were slightly sub par. We realized we had booked a budget hotel but when we showed up at this lodge we found two Africans sleeping in one of the rooms and the other rooms with only four beds for six people. After volunteering to sleep on a mattress on the floor and using a towel for cover, I surprisingly drifted off to sleep quite quickly in preparation for our 4:00 AM wake up call.

Journeying to see the chimps gave us a beautiful sunrise—one that I rarely see unless I am venturing to work for early rounds. And the scenery within the forest was equally stunning. We tracked the chimps down embankments, up hills, along the edge of cliffs, and through boggy bits of mud. Their sounds could be heard throughout the forest and we often encountered their food and bodily remnants but we never caught site of our closest primate relatives. It was the most extreme hike of my life, evidenced only by the fact that I never felt stable enough in my footing to document it with pictures. About three hours into the trek we realized that the chimps were out of our reach for today, so we journeyed back to the road to hike back to our car.

When we finally reached the muddy road that we had parked on I think a mixture of disappointment and relief set in. Of course we were sad we could not see the chimps, but I think many of us were reluctant to venture back into the jungle and that tough terrain so quickly. Just as we started to come to grips with the fact that we would see none of Nyungwe’s famous primates, we stumbled upon a group of colobus monkeys. As we watched these magnificent creatures eat the lichen off the tree bark and teach their young how to cross the canopies of the forest, I couldn’t help but be amazed as to what we were watching.

This sense of amazement mixed with a bit of exhaustion characterized our eventful car ride home. Aside from the friends and conversation, this car ride was especially exciting because we got the opportunity to change a flat tire in the middle of the forest. In fact, we changed the flat using a tree branch we cut down with a Swiss Army knife because the jack was missing the metal pole to act as a lever. After that crisis was avoided we missed a turn and found ourselves on the border between Rwanda and Burundi. The beauty of the roads that wind through the land of one thousand hills is that the paved roads here are so few, it doesn’t take you long to realize you’ve veered off track.

In the end, the pit stop for the tire changing and the detour to the Burundi border left us with a beautiful sunset over the mountains as we ventured from Gitarama back to Kigali. Though we had set out less than 48 hours earlier with a clear plan for our weekend excursion, Murphy’s law took over and our itinerary drastically changed. As a person who does very little without a plan, I was surprisingly calm throughout the entire experience. Yes, it rained throughout our first day's activities but the mist of the rainforest seemed appropriate and made the setting much more beautiful. True, we missed the chimps, but we got to see the amazing colobus monkey in its full group. Similarly, though our tire changing experience was a bit of a surprise, the scenic view off the cliffs into Nyungwe forest was an unparalleled backdrop for mechanical challenges. And lastly, that breathtaking sunset over the mountains would have been totally missed without our detour to Burundi.

This weekend’s monkey business was a wonderful introduction to the Southern Province of Rwanda and the beautiful creatures that call it home. More importantly, however, it was a lesson in flexibility—a life skill that is critical in medicine and, evidently, living in Rwanda.