Monkeypox in the Democratic Republic of Congo

Things you do not encounter on a run in Boston

2009-02-23T10:01:00.000-08:00

1. Man with a spear
2. A large spotted pig
3. Two little goats
4. Mother hen with baby chickens (Stephen calls them chicken nuggets)
5. 20 village kids screaming, laughing, and running to keep up with you

I do love it here

7 women and 4 women

2009-02-15T07:52:00.000-08:00

Feb 7th Part II
Following that bit of public humiliation, we did get a chance to go see the Lodja General Hospital. This is one of the largest hospitals in the region and was interesting to compare to the Kole General Hospital. It is about the same size as the Kole Hospital, but while it has similar facilities and infrastructure, is sadly lacking in basic supplies even compared to Kole. The sum total of the equipment diagnostic lab for the whole hospital is a couple of glass slides for blood smears, some syringes to use as pipettes, an ancient microscope and a hand cranked centrifuge in a vise clamped on to the end of the table. There were also a couple of pairs of rubber gloves that the lab technicians wash and re-use every day.

While we were all still trying to wrap our heads around the diagnostic lab (and of course I’m lost in thought immediately planning on what we can do to get supplies out there), we stumbled into the dim ward for female internal medicine. If “The Biggest Loser” or “America’s Next Top Model” is your version of reality, I would suggest not reading any further. But for the hearts and minds and souls inside the people here, this is unfortunately a very real part of their existence. The only patients in the ward were seven women, lying listless on the cots in the ward. All of them were victims of violent rape, who had come to Lodja hospital to have their vaginal fistulas repaired. This is horrifyingly common in Congo, where in addition to the rape, prolonged rape over days, gang rape, machetes, guns or other sharp objects are used to internally eviscerate the woman. This guarantees that she will never again carry a child, and will be physically marked as a victim, because she can no longer hold her urine or sometimes even her inner organs. There was a small child, about a year old, standing in the middle of the ward and screaming in anguish. It was about all I could do not to join him.

The doctors said there are 40 cases of this coming into the hospital a month. The surgeon donates his services for free to repair these fistulas and offer the women some chance at re-integrating, but there is no mental health or emotional services. Folks at the hospital are doing the best they can to struggle through this gruesomeness done to humanity, and communication of these things with the rest of the world is something I hope we can contribute. I debated about not even posting this part of the trip as I’m not sure I wanted to inflict this on family and friends, even second hand. I was wondering how much of this description is me just trying to pass on the ghastly burden to others so I don’t have to keep custody of it. But I think at the end, communication to the rest of the world about the conflict in the Eastern part of the country and how it is rending the societal fabric is important and I desperately hope may have some small impact.

We visited the maternity ward next. I was confused for a moment because it was introduced as the maternity ward, but there were no newborn infants to be seen. Just four women on four cots. But the doctors explained that all four women had stillborn infants. They had problems with the labor out in the village, with no health care facilities available for miles and the only transportation is by walking. So by the time they had gotten to the hospital it was too late. Four women, four births, and four deaths. And that was the end of our day.

Scopolomine hangover

2009-02-15T07:51:00.000-08:00

Feb 7th
I didn’t sleep at all last night (too much work to catch up on for the lab back at home, and calls with my family). So by the time we met downstairs at 5:30am to head out to the airstrip, I’d lost 100 IQ points and was operating on autopilot. I was a little worried about this flight, since this is the one last time where we came fairly close to crashing (OK, Mom you probably just shouldn’t be reading this blog at all). In October, we ran into one of those massive Central African thunderstorms, and started skirting around the outside edge, until we ran low enough on fuel, that we had to go back in, under the very low ceiling. We were skimming the tops of the rainforest, pilot pulling up the terrain map and looking for a place to set down, with our light aircraft being tossed through the clouds and lightning striking a couple hundred yards away. But after some initial obsessive checking with the pilot and the MAF folks about the weather this time, we got everything/everyone on board. This flight was quite smooth, and as always, an amazing experience to fly over hundreds of miles of densely packed triple-canopy rainforest. Our study site is far, far in the interior, and the distance and remoteness become palpable as one flies over this vast expanse of jungle.

Since I revisited the contents of my lunch on that rough flight the last time, I applied a prophylactic transdermal scopolamine patch this round. I’ve used these for scuba diving before (but only ½ or ¼ of a patch), but I went the whole hog this time. It probably wasn’t a very good idea, because between the drugs and the lack of sleep, I was so disoriented, I wasn’t sure what my name was. It’s a good thing we have such a supportive study team, because they dragged me through the day as I was trying to pin the tail on whatever purple donkeys I was seeing (kidding about the purple donkeys – mental capacity was diminished but not quite at hallucinogenic).

I got my bearings later in the day, which was fortunate, because we were a little blindsided by a Congolese meeting. I probably should have expected because this has happened before. Congolese scientific meetings are a funny animal. They are always late (sometimes 1-2 hours), but incredibly formal. Everyone gathers in a hot stuffy room, sometimes without any power, sweats it out for an hour or two until some VIP shows up, and then proceeds as if it were a convened session of the UN. Luckily for this meeting, we were the VIPs (and were late), so we skipped the sweaty part. Unluckily, we thought we were walking into an informal discussion with some of the lab folks in the health zone, only to be led into a conference room with a U shaped table, a dozen MD’s and scientists and the heads of both the Lodja Health Zone and the head of the whole Sankuru district. After introductions with formal titles they all stared at us while they waited for us to begin our presentation. In French. Sans any pre-prepared powerpoint slides or distracting visual aids whatsoever. After a few minutes of exceedingly uncomfortable silence I got up and gave a speech about our study and why we were there, what our research goals and scientific interests were. I would like to now apologize to all French speaking people for that transgression against their beautiful language, but at least Stephen was there to jump in when it got really ugly. The health zone doctors were quite gracious and pretended not to mind. I loved it that they all stood up and addressed the Head of the Sankuru District as literally “The Number One”. I’m thinking I might institute that policy in the lab…

7% is not close to target goal

2009-02-15T07:47:00.000-08:00

Feb 6th
Our last full day in Kinshasa. We had this trip a bit heavy on the back end, with 4 or 5 meetings planned for today. Our first meeting was at the CDC offices with the staff of the HIV programs. They are doing a great job with the programs in Kinshasa, with 37 clinics supported and prevention, testing and counseling programs at many locations in Kinshasa. They also just got a USAID grant to triple the capacity, add nutrition support to the program for HIV positive mothers, and increase the prevention of mother to child transmission. However, like everything in Congo, some parts break down. They have a very popular call center/HIV hotline, with calls coming in all over the country for HIV prevention, testing an d treatment advice, but they can only take 7% of the calls, because the call center is located on the outskirts of Kinhsasa (where rent is cheap), and power is off there more than on. They lack a backup generator, so can’t take any calls when the power is out. These things are really tough to see, when a program is 90% of the way there, and is then hampered by some small thing that wouldn’t be an issue in the US, but can cripple a program here.

After CDC, we went down to the dockyard to see a boat that is currently being refurbished for a zoonotic diseases project. This a project run by the Global Viral Forecasting Initiative, who has this boat, leased from USAID to carry a team of epidemiologists, lab workers, doctors and public health workers up the river networks of Congo for several months. Along the way, they will collect human and animal samples for identification of viruses which are jumping species and could be viruses of epidemic potential. We are working to provide equipment and lab advice on how to outfit a mobile field lab on this boat. It’s a large boat, but setting up the lab will be difficult, given that a person on the tall side (like me) can’t stand up straight in the inside without whacking my head (which I did several times). No bleeding, though and I got my tetanus booster recently :)

After the boat, we spent a couple of hours getting our medical and research supplies together at the National Research Institute, and loaded up to take out to the airfield. While I thought hauling all this stuff to check in at United was amusing, pulling out all the boxes and getting them loaded in the 95 degree heat and humidity was quite the opposite. We had 792lbs of weight just for the supplies. Each box weighs between 40-50lbs, so I got quite a workout. Of course, just as we finished up, a high-ranking official from the Ministry of Health showed up to talk to Prof. Muyembe. He grabbed me to be introduced as I was going back into the lab. Now, I normally don’t get taken very seriously here anyway, being female and on the younger side, but sweaty, sunburned, and panting from hauling boxes around did not do much for a formal and solemn presentation. Next time I’m going to let Stephen be in charge and I’ll just be his secretary.

We got back from the airstrip and had a meeting with a USAID-funded local NGO. The head of this program was a missionary doctor in Vanga (where we refuel on our way out to Kole or Lodja - above is a picture just outside the Vangs airstrip). ||Mom, stop reading here.|| He had been in Congo for several years when the rebels came through during the war. He packed his wife and children on the last flight out of Vanga as the US Embassy was closing down their mission and evacuating all personnel. He decided to stay behind as the doctor at the Vanga hospital and endured 18 months of occupation, while trying to salvage the hospital, stripped bare from looting, and continue patient care as the whole country was a war zone. He was an incredibly humble person and had seen things that most people couldn’t envisage in their worst nightmare, yet he decided to return to Congo to continue this work and has built an amazing program here. While he was telling us his story he mentioned something about “almost losing his ears” I didn’t quite follow and thought maybe hearing loss from gunfire, since there’s no frostbite in Congo, until as we stood up to say goodbye, it dawned on me that he meant the rebels almost cutting off his ears for his defense of the hospital. It’s stories like this that leave me with absolutely no way to respond – how can you even start to wrap your mind around it?

It was a very good meeting, and in addition to hearing about his work here we learned that there is an organization that is taking over the USAID grant for the health zone we work in out in the interior (Sankuru district). The headquarters for this NGO are about a quarter mile away from my lab in Boston. It’s truly amazing that we come halfway around the world to find out about a potential partnership with our (practically) neighbors in Boston. It sounds like we could do a lot to coordinate the logistics of the research study together with this NGO and provide some real benefit to the region.

Kinshasa/Là-bas

2009-02-05T14:38:00.000-08:00

Tonight at dinner we went to a nice restaurant (nice by Kinshasa standards). A beaten down area, back alley, grimy, trash filled area; stepped into a tiny elevator where the lights went out before the elevator could shudder and groan with the effort of starting up a claustrophobic shaft. We all held our breath in the dark until we stepped out on a beautiful top floor restaurant with a view of the river. Kinshasa is like that, full of contrasts. In some ways it is a good middle ground between the two worlds – Western and opulent in some areas yet destitute and bedraggled for the most part.

Looking out across the river to Brazzaville, I could not help but to thank God for where I was. I had a hard time focusing on dinner, and difficulty trying to talk to an important collaborator with the study at Kinshasa School of Public Health, due to the constant refrain in my head. I’m here, I’m here, praising God that I’m here, but with every day more painful as it draws me closer to the day I leave. I’m not sure why it has taken this many days to arrive in my mind, but I am now hearing a constant drumming of where I am. On African soil. On the African continent.

There is a tension in being in Kinshasa, in being stuck halfway between two worlds. It becomes more pronounced each time, as I have a better understanding of where we are going. My mind has already departed my body and I am out in “Là-bas”, le interior, in the thick of the jungle. I am in the heat and the humidity and the smells and the people crowded, yet I sleep in a comfortable bed in a hotel and eat at a restaurant overlooking the city. It is easier to just be in the interior and be where I am. The other world falls away, and yes, it is painful and full of suffering, but at least I am fully there.

I am in Kinshasa, I am headed out to the rainforest the day after tomorrow. I’m trying to hold onto each moment here as they slip away. I feel invisible bands tighten across my chest as I try to grab onto things that are painful; the beggars in the alley around the restaurant, the burning trash on the curb, the angle of the corrugated metal shack that shelters a family within.

Back in Kinshasa Feb 09

2009-02-03T23:20:00.000-08:00

OK – I’m going to do better about blogging this trip – the last few trips to Africa, I have been fairly negligent – it gets to be routine for me, but I forget how foreign and exciting this is to family and friends. The trip this far has been pretty standard. I am getting used to landing in Kinshasa and actually look forward to those first few steps off the plane. There’s something about the disorientation of having crossed several timezones in a few hours, being in transit for 36 hours straight and walking off into an entirely different world that I am not part of yet I love. What a change from Boston and the 25 degree weather to the humid reaches of Central Africa. The first few steps are permeated with the sensation of walking in the heavy air, thick with smoke from the trash fires and dizziness of being on a different continent yet feeling right at home.

Kinshasa is pretty much as we left it, slum after slum, punctuated by the isolated area of the diplomatic Gombe district. Optimistically, I notice more lights (electricity) as we travel through the shanty areas, and am grateful that all 18 boxes of medical supplies made it through several legs of the flight. This time the briefing at the embassy took a more somber tone, however, with the economic crisis reaching to even this forgotten corner of the globe. The Congolese Franc is devalued against the dollar and tensions are rising in the street (according to the Embassy) – quite a few incidents against Americans in the last couple weeks, but none ended up violent or fatal. I don’t sense much of a difference in the tone on the streets after a day here, but am reminded that this is not a safe place and keeps me mindful of my surroundings.

Today was fairly uneventful, some greetings with friends at INRB (the National Research Institute), some time at the US Embassy and meetings with the USAID representative and Centers for Disease Control reps in Kinshasa. The USAID meeting was actually interesting, because the main focus of the project is conservation of tropical rainforest and biodiversity. While these topics are of strong personal interest to me, they have never been areas that have particularly interacted with infectious disease research. So it was very engaging to have some discussions about how conservation efforts might intersect with infectious disease research and how global emerging infectious disease surveillance impacts our view of the environment and conservation efforts.

Tomorrow we hope to meet with the Mission Aviation Foundation, Catholic Relief Services and other organizations that can assist with work on our non-profit organization. So much of the communication in Congo is face-to-face personal interaction and stepwise identification of the structure and contacts here. It is slow work, but despite the pace, feels like the most critical and significant aspects of what we do here. I’m trying to enjoy Kinshasa, but am so ready to go out to the field and back in a place where I can integrate with the community, rather than travel in lead-lined embassy vehicles. As always, the otherness of being a Westerner in Central Africa grates, but in between that I do take a pause to breathe, thank God for where I am, and take it all in…

Congo River

2007-07-14T07:08:00.000-07:00

We then went to the river, bordering DRC and the Republic of Congo. There was a gust or two of breeze, which was a relief from the oppressive, thickly humid air, and a brief respite from the trash fires.

Medical Clinic in Kinshasa

2007-07-14T06:49:00.001-07:00

We visited a local medical clinic – it was actually quite clean and well run, for the DRC. The INRB driver told us that Mama who runs it (everyone is Mama in Congo), keeps it clean, and does not overcrowd the tiny 6 foot cells that are the hospital rooms.

The pharmacy for the clinic

One of the rooms

The operating suite – there is a small steam sterilizer for instruments, but to imagine having surgery in that room…

The next room we visited held a tiny, tiny new baby – one or two days old. The mother looked about 16 and had malaria. She could barely lift her head off the pillow, and as the clinic staff handed her the baby for us to take a picture, I could only lower my camera in respect. There is no photo of that room.

Back out of the clinic onto the streets of Kinshasa

A Kinshasa neighborhood

2007-07-14T06:41:00.000-07:00

Sorry – I am behind in posting. The solar power only works a few hours a day here in Kole, and the internet is even less stable. So back to Kinshasa….

After the zoo, the INRB drivers took us to out into the streets of Kinshasa. The poverty, filth and disease and are anguishing beyond description – the pictures will have to suffice.

Kinshasa by Day - the Kinshasa Zoo

2007-07-09T11:46:00.000-07:00

Our first foray out of the hotel or INRB campus. Le jardin biologique was not quite as romantic as it sounds. Perhaps it was a nice zoo or botanical garden twenty years ago, but today a sad series of caged monkeys and some reptiles.

Some cages were empty

The monkeys

And others...

Alive, not stuffed

Also not just a mantle decoration

And a Library in the middle of it all (no books)

Kinshasa by Day - INRB

2007-07-09T11:24:00.001-07:00

Next morning. Our driver picked us up and we went to the Institut National de Recherche Biomédicale to get our supplies ready for the flight to Kole.

This is the office area for the study.

Sorting supplies. We had a maximum of 833 kilos that we could take on the single engine Cessna from Kinshasa to Kole - including 5 people, luggage and 17 boxes of supplies. We came in at 826 kilos. I was a little nervous about a 7 kilo tolerance when the matter in question was whether the plane would crash or not, but I am posting from Kole, so yes, we made it…

First glimpse of Kinshasa

2007-07-09T11:22:00.000-07:00

The drive from the airport to the hotel was long – 30 minutes over roads in disrepair, but no worse that some of the streets in Boston. However the sights from the van were jaw-dropping. I have traveled in third world countries before and seen abject poverty, but nothing like the slums we drove through. Tent cities and shacks strewn together with bits of corrugated metal and cardboard. Glowing specks dotting the side of the road were campfires or candles to provide some light. Hoards of people were milling around, sifting in and out of the slums, disappearing in to the pea soup of smog and soot. Traffic was like what you would expect if you crossed Italian drivers with Guatemalan road rules (i.e. no rules). Most cars were 20-30 years old, some looked like bits of scrap metal pieced together on wheels with lights, steering and brakes all optional. The vans would have round holes cut in the metal for windows and 20 people packed inside, so upon passing one you would see faces jammed in like they were staring out the windows of a submarine.

We were shuttled directly into the hotel, closed up and imperious perched high behind its walled compound. Metal detectors at every entrance and armed guards patrolling outside the walls. It looks like a war zone from outside, yet I feel like the guilty privileged to be shut in a fortress to block out the seething misery of humanity we have just driven through. To be bedding down in a western-style hotel (albeit the style unchanged since the Belgian colonial rule 47 years ago), eating a full dinner… hypocritical seems like a generous assessment.

Tomorrow our driver meets us at 11am to tour some of the areas of the city and go to the Institute Recherché National Biologie – their NIH.

Landing at the airport - Kinshasa, DRC

2007-07-09T11:18:00.001-07:00

As we flew over the Kinshasa, I could barely make out the houses below – I thought there was some kind of dense ground fog, but as we got closer to landing, and dipped into the murky air, all the light from above went out and everything was suddenly a shadowy greenish grey glow. The passenger next to me explained that it was always like this – partly from the humidity, and partly from the wood burning fires and piles of trash being burned. The combination of humid heavy air along with the soot got trapped in the valley, giving a perpetual smog that makes LA look fresh and clean. As we dropped down onto the runway, it was cracked concrete, with brackish fields extending out into the gloom. Outlines of palm trees were barely visible at the edge, but nothing of the city appeared in the fog.

We climbed the stairs out of the plane and started towards the airport. Not much like the US – swarms of people covered the tarmac, while the officials tried to keep them away from the passengers. To enter the airport, we had to show our passports to demonstrate we had come from the plane and not the rabble swarming the tarmac. Security and passport control was not as bad as expected, although the sight of doctors and nurses in white coats to check everyone’s international yellow cards for proof of vaccination seemed straight out of a polio epidemic 60 years ago.

As we rounded the exit through security and came into the baggage hall, there was a crowd of about 100 - all men – yelling and shoving. The police were trying to keep back the porters and drivers trying to make some cash, while the rest of the hall disintegrated into chaos. At about 90 degrees and sweltering with a din and an odor that assaulted all of the senses, it was overwhelming.

We had a nerve-wracking quarter of an hour, as we couldn’t find the embassy expeditor. My colleague and I stood trapped in the hall packed between passengers, security guards and the yelling crowd. We knew we would get searched and shaken down for as much as they could get out of us without embassy personnel. We tried the cell phone, but it had gone dead. I stood there sweating – weather if was from the heat or nerves I couldn’t tell. Finally we located our escort and headed to claim our bags.

The entire flight clustered around an ancient baggage belt for an anxious 20 minutes while they tried to get the baggage machine working. When it finally started, they stacked the bags so close that when a bag rounded the corner it would catch on the rusted metal, and back up all the bags behind it while the conveyer kept moving. The baggage handlers were afraid they wouldn’t get it started again, so they wouldn’t stop the machine. Luggage piled up and started shooting off the belt into the crowd. A few people would get crushed – others would throw the suitcases back on to the belt and so on until the next backup a few minutes later. After retrieving the luggage from the melee, we finally met the embassy expeditor and headed to our van.

Sorry no pictures - I didn't think the airport paramilitary would take kindly to la touriste snapping photos of the airport.

Stranded in Paris

2007-07-09T10:14:00.000-07:00

Yes, I know, quelle terrible! But really, after the overnight flight to Europe and no sleep, I was just really ready to get to the DRC and start the study. Air France delayed us two hours, we missed the connection, and then another three hours in the re-booking line. The next flight out wasn't for two days. So after 4 more hours of talking to every airline that flies to Kinshasa, my colleague and I accepted our fate, and went into Paris for a bit.

First post - MPX in DRC blog

2007-07-09T08:08:00.000-07:00

Hi all,

I'm a poxvirologist, and I've been studying monkeypox (MPX) for the last 7 years. My lab http://www.wi.mit.edu/research/fellows/rubins.html is at the Whitehead Institute http://www.wi.mit.edu/, at MIT. Together with many collaborators, I've been planning a field study to collect samples from human MPX cases in the Democratic Republic of Congo. We are working with many many wonderful collaborators at USAMRIID, UCLA, INRB in Kinshasa who have set up a network of studies in the DRC. However this blog is not so much about the science - that will unfold as we start to publish these studies in the scientific journals, but mostly about my experiences here, for family and friends.