Gisenye - Murara Health Centre

In the last week of my time in Rwanda I am lucky enough to get the opportunity to work alongside a fellow volunteer in a rural health centre. I am hoping to do this sort of work in my next volunteer placement so it will be worthwhile getting some experience. I set off by bus on a Tuesday afternoon, headed 3 hours North West to Gisenye, a sleepy lake side town right on the border of Goma, Democratic Republic of Congo. I have a backpack with 3 changes of clothing, and a pair of jandals. It is pouring down with rain when I step off the bus into the dark streets of Gisenye, but luckily a colleague is there to meet me with his motorbike. It means I dont have to walk alone, but does little to help me stay dry!
The following day we set off to the health centre on the back of the motorbike. The little red beast has been sitting in someones backyard for quite some time, and has questionable performance with one passenger let alone two! Nevertheless we eventually make it up the hill heading out of town and soon turn off the main road and begin negotiating the bumpy dirt track. The rain last night has left the holes full of water and despite our careful negotiation I end up with mud all up the back of my legs. We pass an array of houses, some very poor mud huts, but also some fairly nice houses with intact roof's and concrete foundations. Certainly not flash by any stretch of the imagination, but seemingly watertight and warm. The local children are wandering around, playing in the dirt and I hear the all too familiar 'Muzungu! Muzungu!'. Im gonna miss that!

We arrive at the Murara Health Centre at 9am and I get introduced to some of the team. As well as their local language - Kinyarwanda - they speak fluent French. Little help to me. So I smile and nod and try to look friendly and helpful. At exactly 5 minutes past 9 a nurse calls us over to the maternity unit, we have a baby on the way. I stand back and watch as a baby is delivered a couple of minutes after we arrive. I try to look cool and calm as I am secretly shitting myself. My colleague turns to me and says, "thats how it's done, next ones yours'. Mmmhh. We'll see about that.

I have a chance to look around the centre after the drama of the morning. Its fairly large, has about 4 buildings. From the street you arrive at a building that has a pharmacy and 3 consult rooms. The 'reception' is a desk situated on the porch outside the consult rooms. The pharmacy is a tiny room that has boxes scattered over an old desk. No sense of organisation and very little supplies. The consult rooms have a bed, a desk, and again, not much in the way of supplies. I see some iodine, a syringe and little else. The consult rooms don't yet have lighting, power was only installed this week and they are still completing the work. During the day the patient is positioned by the window to utilise natural light. Beyond the consult rooms are the wards where there are about 10 patients in a room. Beyond this is the lab, which is actually quite nice, I think it has recently been refurbished. Then there is the maternity unit, where I end up spending a lot of my time. It is a small building consisting of 3 rooms. The first room is the labour 'suite' I put inverted commor's on that because it really is hilarious to call it a suite. There are 3 beds side by side, but generally more women than that, so they share. There is no linen - the women and families must bring their own. It is dark and cold. Through from here is the delivery 'suite'. There are 2 beds in here, and I am told that at times they have had 3 delivering - one is on the floor. The first thing I notice about the delivery suite is the smell. Kind of like a butcher shop that has not been cleaned out in quite some time. At the end of the bed is a bucket to collect any mess, anything that goes on the floor is swept into a hole in the corner of the room. They sometimes use water to wash off the floor, never any disinfectant from what I saw. There is more in the way of supplies here than in the consult rooms. I see trays of scissors and clamps. A plastic stethoscope.    

Some syringes and viles of medication. Even a drip stand! The power has just been hooked up here so they have lights and the nurses are still very excited about that! I wander on from here to the next room which is the postnatal room. In here there are 7 beds, and the mothers will stay about 2 or 3 days after delivery. The family must come in regularly to feed the women and wash their laundry as they get nothing from the clinic. In the grounds of the clinic there is a large water tank with pipes into the clinics, the water was hooked up about a month ago. Prior to that they had to collect water and carry it to the clinic rooms. I am pleased I was not working here then! Unlikely to have been much hand hygiene going on. There is a toilet block for the patients, I dont even like to walk past it. I see a large furnace for the burning of hospital waste and a large covered well where they will dispose of the maternity waste. There is also a rabbit hutch and some vegetable gardens which are the beginnings of some community projects. As always, there are children running around everywhere, some local kids, some children of patients and also children of staff that have learnt to look after themselves during the day.

   

 

Later in the morning I get to return to the relative luxury of the new lab. To do some HIV testing. This morning we have 30 patients to test. The national average is 12% positive. Lets see how we do! I watch a couple of blood tests before stepping in to have a go. We have no tourniquet, so use a glove tied around the arm. I discover that the women are much easier than the men. Their skin is paler and the veins easier to see. Also their skin is much softer and easier to penetrate. Its quite nerve wracking as these people have never seen needles before. They are frightened. You have to be careful that they dont jump back as the needle goes in. Luckily it all goes smoothly and I get through a few of the patients. The testing is straightforward - a drop of blood on a test strip, results back in 15 minutes. We get one positive out of 30, not good but certainly not bad considering the national average. Today we are at 3%! I am pleased to know that all the patients receive one on one meetings prior to being given the results - regardless of outcome. They will receive education and advice, and if a positive result, they will receive further counselling and support.

The rest of the morning flies by, lunch comes and goes without my knowledge - to be honest the thought of eating here doesn't appeal to me. We do regular checks on the women in the labour suite and at some stage in the afternoon one is ready to go. My colleague tells me to scrub up, and there I find myself at the foot of the bed with gloves, gown and jandals in situ. Shit. Stop reading now if you are squeamish. I am sweating. My stomach feels as though it is slowly making its way closer to my mouth. I feel faint. My colleague tells me he is just heading out to check on someone else. I turn and say dont you fucking go anywhere. The poor woman is on the bed writhing in pain. There is no husband in here. No family. We have no form of pain relief to give her. Not even a panadol. The nurses lack even the most basic compassion you would expect of a fellow human being. One of the nurses here is known to slap the women that yell too much, one managed a difficult delivery by clamping her hand over the women's mouth so she would push harder. Thankfully I dont witness this first hand. I have learnt already that my protestations go unheard.

It seems the water's have not yet broken, yet the baby is coming so the nurse steps in to help out and break the amniotic sac. She tells me to stand back, but obviously I am not quite prepared for the torrent that follows. I get covered from the knees down in amniotic fluid. With my jandals on. Great start. Anyway no time to dwell - once the waters have broken the baby is on its way! I guide it out, turning it slightly to allow the shoulders to come out easily. I place it on the mothers stomach, a nurse clamps the cord and I cut it. I quickly take the baby to a table where I suction its mouth, nose and ears. Wipe it clean. Tie and cut the cord neatly and wrap it up to weigh and measure. It all happens so fast! I dont even know what it is. A quick check tells me I have just delivered a wee baby girl at 2.30 pm on Wednesday 30th March 2011. I breathe a massive sigh of relief before placing the crying bundle into her mothers arms.

The following day passes fairly quietly compared to my first experience of the health clinic. We do another 30 HIV tests. Zero positive today! We have a few consults and I remove some horrendous C-section stitches. We deal with the aftermath of a butchered circumcision. The young boys are encouraged to have it done here for sanitary reasons, and then deal with pain and infection for weeks on end. I begrudgingly learn how to do pelvic exams on the women in labour. Unfortunately a necessary part of the birthing process. The women appear shocked when I take the time to introduce myself and put them at ease before examining them. The nurses would never be so gracious. We check the foetal heartbeats with an ancient wooden bell, and take blood pressure with our plastic stethoscope. No babies are delivered today but we are to head back tonight when typically more are born.



We leave at 3 and have some dinner before heading back to the clinic at 8. Its freezing, dark and quiet. The staff quarters have 2 single beds for the four staff that are on tonight. There is a light in here now which makes things a bit more cheerful. There is also a light in the consult room, but it is necessary to wear head torches as well. The first patient of the night is a young lad with a machete wound on his wrist. He has cut deep and nicked part of a tendon. We dont have fine enough sutures to attempt suturing the tendon so we can only stitch the wound to stop the bleeding. Thankfully we have some local anaesthetic for him. My colleague hands me the needle to do the suturing, but as I watch the needle go in to administer local anaesthetic I realise that I wont be able to do the stitches. This guys skin is like leather and you can almost see the needle bend as it goes in. One of the nurses steps in and in the most brutal way possible, manages to stitch his wound. My every nerve fibre can feel this guys pain despite the local he has been given.

Next we do rounds of the maternity ward. There are four women in labour. On examination some are getting close so we stay on the ward to monitor. There are some spare gumboots so I decide to indulge in them for the next deliveries. I slide my foot inside, to a moist, slimy environment. On second thoughts, I remove my foot, give it a wash, and in true Kiwi ingenuity style, put some gloves on my feet before putting the gumboots back on. Excellent - clean and dry! We check the heartbeat of one baby and find it's a bit inconsistent, but a few of us listen and come to an agreement. We are soon to discover why there was a discrepancy. This women is close so she stays on the table in the birthing suite. My colleague does a pelvic exam and then turns away to get something. Next thing we hear a shout and we all turn to see the baby come.. literally.. flying out. I cant believe that 3 people can fit between a women's legs as we all dive in to catch the baby. Thank god for the umbilical cord which keeps the baby bouncing as though on a bungy. I get busy dealing with the baby as my colleague deals with the placenta - I decide that this is the way our roles will be - I have little interest in placenta. Although turns out - the placenta is another baby. Hence the discrepancy in heartbeats. This little guy also comes out fairly quickly, although we are there to catch it this time! No sooner do we get over this drama, then another woman is on the table wanting to push. Her blood pressure is a bit low and she's tired so we hook up some fluids. Im in the hot seat again. She's struggling. The head is crowning but she has a lot of trouble pushing. I suggest an episiotomy and my colleague kindly steps in to do it for me. We have no scalpel - just blunt scissors. I am soon to put into perspective how painful contractions are. The episiotomy is done in the throes of contraction, one large snip of the scissors. The women doesn't flinch. She may be writhing in pain from the contraction, but she doesn't notice the scissors cut through her. Fuck that. It still takes a couple of minutes for the baby to come out. I guide it out and go through the motions. As I am cleaning the baby I notice something strange with his leg. It looks broken. I take a closer look, check the hips. The problem is at the knee - it appears that the knee joint is malformed. The knee cap is at the back of the knee, and the foot is hence facing the wrong way. This poor woman who has been through so much is soon to discover that she has a disabled child. I also soon find out that the child will not go to the hospital, there is nothing that can be done here. This child will very likely end up a beggar on the streets. It seems so unfair when this tiny, beautiful, innocent child is in your arms.

We have a slight lull so get busy sterilising the equipment. We have exactly 3 sets of scissors and clamps. They get rinsed in the sink, placed in metal dishes, covered in alcohol and set alight. A few minutes later they are sterilised - as best as they will ever be here. We are lucky that they actually have alcohol at the moment. Soon enough we have another woman on the table and deliver another healthy baby. Before the night is out we have delivered 7 babies. One woman walked about 4 hours  in the pitch black from her home outside the village. Another woman was in Goma, DRC, and came across the border on the back of a moto taxi. One woman who was on her 10th baby had been labouring for 8 hours before disappearing, not to be seen again. We manage to get a few hours sleep in between and are so tired we dont mind sharing the single beds with the thin, scratchy woolen blankets. The following day we stay at the centre until 3pm, busy again with HIV testing and consults. By this stage I have lost some of my earlier enthusiasm. The excitement of delivering babies has worn off and all I can think about is a hot shower, and a warm clean bed.