Bits and Pieces

Over the past few weeks, I’ve traveled from Santa Cruz to Cuzco, passing through small towns, large cities, Lake Titicaca, the Bolivian-Peruvian border, Machu Picchu, and points in between. Below are a few anecdotes from my travels that I think illustrate some of the more interesting aspects of life here.

El Duende

As the sun set in Santa Cruz, it had begun to rain. Tropical location aside, Bolivia’s elevation means that the July winter in Santa Cruz can be cold. Alex, Cindy, and I had rushed to nestle under a small overhang, avoiding the spray while crossing our arms to ward off the cold. Cindy was keeping their daughter Aisha close by. Alex would later tell me that this was the first time in his three years in Santa Cruz that he could remember seeing his own breath.

“Do you see that hitching post across the street?” Cindy motioned to me as we waited for the micro-bus to arrive. I glanced to the opposite corner where a small lone wooden post stood fixed into the modern street tiles. There was what looked like a head carved into the top of it. Together, she and Alex told me the story of a young man, a hundred years ago, who having been denied permission to marry his beloved, stood nightly across the street from her window. There he carved her face into that same hitching post, as he watched her and wasted away from grief. They say his ghost still haunts the area.

“Are there many stories like that around here?” I asked.

“Oh sure,” Alex replied, “But here, they’re not stories. These things happen.”

“Bad husbands, adulterers and drunks,” he continued, “They see the black widow when they’re alone. Often it’s in a church. She comes dressed all in black, covered from head to foot, with a veil over her face. She’ll appear, approaching them silently, staring accusingly. They can’t see her eyes, but they know. Sometimes they try to lift her veil to see her face. Maybe they see a skull. Maybe they don’t. Every single one passes out and wakes up alone and frightened.”

“And this actually happens?” I responded incredulously.

“To people I’ve known,” Cindy answered matter-of-factly, “Of course it’s more so in the rural areas, and there it’s mostly el duende.”

“’El duende?’ I don’t know the word. What is it, some kind of Chupacabra?” I asked, referring to the Mexican legend of a short creature with a spiky back that mutilates cattle, sucking their blood until they die.

“Not really, no, though it is a short little creature, about three feet tall. El duende wears a long white robe made of roughly woven indigenous cloth with a hat so ridiculously wide-brimmed you can’t see his face. His hair is long and snow white. He loves beautiful and pure things. That’s why he steals little girls with blonde hair and blue eyes. Only children can see him. In the rural areas, when several children all share the same imaginary friend, speaking to the air and listening as though they hear a response, the parents take notice.”

“Especially the ones whose children have blonde hair and blue eyes?” I quipped.

Cindy looked at me directly, got the joke, smiled a little, but wasn’t biting.

“It’s very uncommon for rural children to have blonde hair or blue eyes but not unknown. When a little girl disappears, the parents immediately begin searching the woods. If they’re lucky, they find her, alone, crying, on a perfectly clean mat, surrounded by the finest fruits and flowers of the forest.”

“El duende loves only the purest things. It won’t keep a girl once she cries too much or wets herself.”

I was hooked. I was even starting to believe a little bit: “So if it’s only children who can see it, does it ever hurt adults? What about the girls who aren’t found?”

“It depends. Some women are actually married to el duende,” Cindy replied.

“What?!?! Married to el duende? How does that even work?”

“In the smaller towns. These are women who live in large villas on the edge of town. Usually they’re widows or escapees from violent marriages. No one ever sees them work but somehow they always have more than enough money to live. They’ll walk through the village streets holding conversations with empty air. If anyone asks, they’ll say that they’re talking to their husband.”

“Sometimes violent former husbands who have been forced by popular opinion or the law to leave their wives will try to return home to regain them. When they do, an argument usually ensues. The next morning, the woman will wake up, covered from head to toe in bruises. With his history and the sound of the argument to condemn him, rather than face prison time, he usually flees town.”

“El duende keeps his brides.”

Help Control the Pet Population?

Bolivia and Peru are places full of hospitable people, large four-course lunches, and stray dogs that are cute until the moment their barking, car-chasing, and fornication begins to irritate. They represent every breed imaginable, with adorable bright wide eyes and lolling tongues. Some are well kept. Some are fed occasionally by quasi-owners who otherwise leave them alone to roam the streets. The rest bother with humans only to eat their trash, bark at them, or chase their cars in a way that defies their apparently missing sense of self-preservation. Sometimes the dogs form packs. Together they chase females and yowl into the night. With all the barking, I expect Alex could count on his fingers the number of full nights he’s slept since moving to Santa Cruz.

Feral though they are, it’s still hard to find these creatures intimidating. This is probably because they seem so pitiable when the copulating’s done.

For as long as his erection remains, the male is trapped by the female. There’s something a little ridiculous about the sight. Unable to withdraw, he tries desperately to extricate himself. He flips around, facing the opposite direction. There both dogs remain for minutes at a time, bum touching bum, the female patiently exasperated, the male pawing the ground uselessly in occasional furious attempts at escape.

Alex tells me this extra time helps ensure that the first dog is the most likely to impregnate.

The rest of the pack sits back, barking, yapping, and occasionally fighting over who goes next. When the first male finally gets away, the female makes a mad dash for freedom. The rest of the pack chases behind with the winner of the last round of fights in the lead. The former leader usually stays behind, dazed and trying to recover his composure.

The Flota Infomercial

Inter-city buses here are called flotas. They work a little differently then back home. In order to ensure a full complement of passengers, they can be flagged down along the road at any time. The seeming hitchhikers who board pay a fraction of the fare and sit in whatever space is available, including the floor of the aisle. I’ve been forced there myself on occasion. It’s not as comfortable as you’d think.

Other times, passengers ask to be let off early. This has led to an interesting phenomenon:

“Yes, the ultimate information book! Learn all of these essential words in English, including numbers from one, uno, ten, diez, one-hundred, ciento, to even one million, un millión! Also parts of the body, the arm, the foot, the face! There are also basic instructions for important software, Microsoft Word, PowerPoint, Windows, and more! And all of this for only seven Bolivianos!”

I had just started to drift off into sleep, when from the corner of my eye, I saw the man in the second row, seated directly in front of me, begin to stand. “Why did I sit so near the front where the shouting would be?” I asked myself. Inwardly, I began to groan, preparing for the oncoming onslaught.

“Today, as a special offer only we are also presenting this other book, the complete geography and history of Bolivia! Yes, with this book your children can learn the history, location, capital, and major industries of every province! It also contains relevant biographical information about major government figures, including every minister and the president!”

Every sentence ended with an exclamation mark. Not since the first episode of Amazing Discoveries aired in the early nineties had I seen anyone so excited about a new product. I tried to tune him out, despite a slightly unexpected nagging interest in the second book, politely refused the not-to-be-missed opportunity to flip through a sample copy, prepared myself for the final onslaught:

“And for all this, how much would you expect to pay? Today only we are making the special offer of one book for seven Bolivianos! That’s right, either book for only seven Bolivianos! Or, if you act right now, you can have both for just ten! That’s right! One for seven Bolivianos, or two books, containing all this information, including English vocabulary, software, geography, history, and more, for only 10 Bolivianos!!!”

He kept going for a while, nearly exploding with feigned enthusiasm. A few people bought the books. At about $1.25 for both, it wasn’t a bad deal. Eventually the salesman called to the driver for a stop. He left the bus, likely hitching his way back along the ten or twenty kilometers he’d just traveled from town.

With the salesman gone, I reflected to myself that this was better than the last time. On a bus of less than twenty people, that man had spent nearly half-an-hour shouting about the wonders of his new cures for both impotence and prostatitis.

Teacher’s Strike

Having crossed the Peruvian border the previous evening, my tour group had just dropped me off near the central square in Puno, a medium sized town on the shores of Lake Titicaca. A large crowd had gathered in the central square, with banners megaphones, and creative home-made t-shirts. A protest was about to start.

I was hungry. I raced ahead of the plaza to find a restaurant. Behind me, the crowd began to approach, filling the street ten abreast until there was standing room only next to the walls on either side. “Así! Así! Así!” they cried, the Spanish equivalent of, “Yeah, that’s right! That’s so right!”

I still couldn’t make out what they were protesting. Pushed to the side, I asked someone nearby. “They’re teachers,” he replied, as if that explained the matter.

As the crowd marched on, a chorus of beautiful female voices, began singing. They had the consistency of a choir on key. The sound was distant and pleasant, growing louder as this new group approached. I listened for the lyrics, hoping to learn more.

“Presidente mentiroso, ahora te jodiste,” sang the melodic chorus.

Literally translated it meant, “Lying president, now you’ve f---ed yourself!”

These were some angry teachers.

I stopped a few and asked them to explain. “The president announced two weeks ago that the national education system will be privatized. He’s a liar, he breaks all of his promises, and if he doesn’t change, we’ll get a new president!”

In the meantime, the other teachers continued to sing: “Si no nos pagara, eso no nos importa. Con sueldo, sin sueldo, la lucha continuará.”

If you don’t pay us, we don’t care. With wages or without, the fight continues!

Usually it’s the students who start revolutions. I felt like it was nice to see the teachers taking up the slack for once. More realistically, I was amazed to see so many citizens concerned so strongly about public education that they took to the streets to voice their support. At my best guess, I was seeing at least three thousand teachers marching. “If only people back home cared as strongly as these people do, things would be better,” I thought to myself.

“Privatisation of education is horrible,” I told them in broken Spanish as I ducked into a restaurant for lunch, “Good luck to you!”

Hundreds more passed by the restaurant window until finally with a last giant effigy of the president, his eyes crossed out with large x’s, the demonstration passed.

Of course there was more to it than that.

For the past few weeks I’d been hearing stories of massive strikes in Peru disrupting transport much as the bloqueos had in Bolivia.

The Peruvian president was a man known for breaking his campaign promises. He’d been elected before and done none of what he’d promised. This time, a few years after leaving office, claiming that he’d learned his lesson and matured as a leader, he had successfully sought re-election.

Once in office, he began pulling the same technique again, pandering to the more powerful blocks in an effort to avoid rocking the boat. Faced with an inconvenient former policy that had created teaching jobs by allowing anyone with a high school education to seek work in education, he’d tried a two-pronged approach to fix the nation's problem of countless teachers of questionable quality.

The first prong, mandatory skills testing for all teachers, with rewards and consequences implemented to enforce quality made some sense. Hoping to cut his own costs and liability though, he’d also suggested a second policy, relocating responsibility for the administration of the educational system to the community level. Communities here are the smallest unit of government administration. They oversee populations of no more than a few thousand. The second prong failed uproariously. By creating hundreds of completely autonomous boards of education, he was in effect creating a de facto privatised educational system.

Thousands of teachers who already feared the new controls now had an excuse to run amok in their students’ name.

Within the first week, as demonstrations gripped the country, disgruntled teachers seized control of the airport in Cuzco, Peru’s tourist centre, and one of its largest cities. No planes landed or left. Other teachers were soon blocking roads, throwing rocks at any cars or buses that tried to pass.

It soon became hard to distinguish between dedicated teachers and self-serving protesters who threw rocks by day and drank themselves silly in bars by night. Public opinion was confused and consternated.

Luckily for me, by the time I arrived in Peru, the demonstrations were beginning to fade. Though I'm unsure what, if any, the final resolution was, this demonstratoin was the only one I've seen in my two weeks here.

Democracy in Action

I arrived in Bolivia one week ago. I'll be travelling between here and Peru until August 3. For those who would like postcards, please don’t hesitate to leave a comment on the blog or to send me an e-mail.

Bolivians value their democracy in a way that could shame an American. When things aren't going well, they don’t vote for change. Instead, they go out and form a new government. From 1825 to 2003 they had 192 different governments, an average of roughly one every 11 months. In case anyone was starting to feel complacent, they went through about another three by 2005. The current President, Evo Morales, swept into power after a wave of popular protests paralysed most of the country. With Morales at their head, the growing middle class and the indigenous peoples, who comprise most of Bolivia's population, came to power through a new weapon, Los Bloqueos, Bolivia’s greatest contribution to democracy to date.

Los Bloqueos are roadblocks. Individually small, their strength lies in their numbers and the people manning them. They operate on a wider scale than the one or two roadblocks raised by native protesters in Ontario a few weeks ago. They are simple, non-violent, can be built quite literally from twigs, and with little effort can completely cripple a country. Two years ago, Morales had come to power on the stength of a popular movement, willing to block traffic to all major centres with trees, old furniture, whatever was to hand, and sheer force of will on the part of those manning the blockades.

The effectiveness of this strategy wasn't lost on the rest of the country, Morales' opponents included. Like Pandora's box, once the demons were out, there was no putting them back.

My first stop in Bolivia was a visit with my old friend Alex and his family in the town of Santa Cruz. When I arrived at the central bus terminal in La Paz one week ago, I had already been through four flights, two luggage check-ins, five countries, and one night of fitful sleep in the airport of the world’s highest capital. Waking up after shifting position at four thousand metres above sea level feels a little like running the hundred metre dash head first into a wall. The slightest movement causes breathlessness. The act of waking up itself is an invitation to the type of headache only a hangover can produce. With a taxi carrying me to the mercifully lower altitude of the bus terminal, all I had left to overcome was the long ride to Santa Cruz.

I arrived at the bus terminal at 6am, travelling pack, suitcase of gifts from Alex's family in Canada, carry on bag, and phone number for Alex’s wife, Cindy, in hand. I was already looking forward to the end of the upcoming twenty hour bus ride. By 6:30, I had tried to purchase tickets from about a dozen different bus lines. Every single one refused. Some of them had signs: "No hay salidas por bloqueos." No departures due to blockades.

By 7am I was watching the crowd of stranded shivering passengers around me on one of the terminal’s many television screens. The blockades had started the previous evening, isolating the capital city, and leaving hundreds of travelers stranded. Miners, upset at their working conditions, were trying to draw the governments attention to their plight. The average Bolivian miner dies from massive dust accumulation in the lungs ten years after he starts work. I'd like to say that at least the money is good but the region around Potosí, Bolivia's minig capital, is also the poorest in the country.

By contrast, the region around Santa Cruz is the richest. Soon after the miners began their blockades, the peoples of Santa Cruz and Cochabamba, which lay halfway between me and my destination, set up their own blockades. Tired of the government's socialist transfer payments siphoning their riches into the poorer areas, they were demanding more administrative autonomy.

Of course there was more to it than that. The Collas in the west near La Paz disliked the Cambas near Santa Cruz. The feeling was of course mutual. The indigenous population was disenfranchised and wanted more from the Spanish descended families that effectively ran the country. These families were themselves none too pleased with a socialist government, which kept trying to reposess tracts of unused land from them for redistribution to the poor. Essentially, everyone had an axe to grind, the government was the target, and the roads were simply collateral damage.

I for my part naïvely asked a hotel owner to give me a room at a discounted rate, since I would certainly be leaving by that evening when the blockades ended. In the evening, all that had changed were the signs in the terminal. They now read, "No hay salidas por bloqueos. ¡No insista!"

No departures due to blockades. Don’t insist!

After two days of waiting, I took a flight to Santa Cruz. It was great to see Alex and Cindy again. Their new daughter Aisha is adorably cute and has already mastered her fist word, "Dog," which she uses to refer to any animal she sees, people included. Alex and Cindy planned us a day trip to a nearby resort in Samaipata. By now, the nationwide blockades were lifting. Watching the news as we left, we learned that five families had taken it upon themselves to start a new series of blockades. Upset by the government's plan to take their unused land and redistribute it to the poor, they had hired the same families who stood to benefit from the policy to man blockades for them all around the city protesting it.

Bolivians really do love their democracy. They will not only defend others' rights to express themselves, but also demonstrate on their opponents behalf. So long as they’re paid for it. Land redistribution or a few dollars in pocket with which to feed your family, for the poor of Santa Cruz it was win-win.

Home Again

I arrived back in Toronto almost two weeks ago. Classes resumed on Monday this week. It’s been a hectic but wonderful opportunity to catch up with friends, family, and my wonderful girlfriend Rachael. There are several more blog entries I had been hoping to write. Unfortunately, as the obligations of life back home are beginning to take hold, I’m still hopeful they will be done but I don’t know if or when.

In the meantime, I’m living with my family until next week, after which I move in with some old friends downtown:

40 Ulster Street
Toronto Ontario
M5S 1E3

647-895-5548

Thank you all for sharing in my experiences these past few months. Those of you who are in the neighbourhood, please feel free to drop me a line anytime. Hope this finds you all well. Looking forward to seeing many of you again very soon. All the best!

Bone Rot

Another Tuesday morning meeting. Amna and I sit side by side trying hard not to fall asleep. As Mzungu medical students, our actions draw more attention than they normally would. The minutes of the last meeting are read. The number of patients seen by each doctor is announced. Unsurprisingly, most have been seen by residents rather than fully-trained surgeons. When even the executive head of a department earns only a few thousand dollars per month in the public service, most physicians try to spend as much time as possible at their private clinics. This leaves a group of semi-trained residents to guard the trenches of medical care without supervision, equipment, or support.

As happens every week, one of the consultants complains about the lack of clinical work from his fellow surgeons. As happens every week, the chairman notes his concerns, agrees with him, points out that little can be done at present, and expresses hope that something will be done eventually – Three weeks later, one of my neighbours, a middle-aged woman who was once this same consultant’s patient, will describe to me a case of semi-benign neglect suffered at his hands. She was briefly paralysed and is now forced to wear a brace for the rest of her life. The irony surprises me only a little. The system is difficult.

The meeting continues. Amna and I try not to fall asleep.

"What is the situation for Operating Theatre 7?" asks the chairman.

"Mr. Chairman, as you know, Theatre 7 was meant to open on Monday," responds one of the consultants. "Unfortunately, this has not yet happened."

"Though the original problem has been fixed. Results from samples in the theatre show that it is still not clean of anaerobic germs. We have asked that it be properly cleaned again and new samples taken."

Another doctor feels the need to clarify. "Mr. Chairman, the problem arises because there is a trash heap smelling of feces outside the theatre. It has been dumped there by The AIDS Support Organisation next door. Also Mr. Chairman, stray dogs have taken to perfuming the theatre’s outer walls."

It would be funny if the results weren’t so tragic.

The various wards declare their numbers of patients seen, discharged, admitted, and transferred. With the central operating theatre closed for nearly a month, the number of patients awaiting treatment is growing constantly. Every week the bottleneck is supposed to be cleared. It never is. It will be almost another month before the situation is rectified.

Reports come in from the nursing units in the different wards. "Sister, how fares your section?" the chairman asks the nurse in charge of the central ward, 2CO. "Not good," comes the reply, "We are severely understaffed."

"Sister, how many staff do you need?"

"We need at the very least eight to be able to care for those with spinal injuries and others requiring constant care."

The chairman addresses her with the Luganda word for healer: "How many staff do you have Musao?"

"Mister chairman, we have eight but two are on leave and may never return and two have spinal cord injuries."

In a room full of spinal specialists, some snicker at her casual diagnosis.

"What do you mean spinal injuries?" comes the forcefully benign reply.

"Mr. Chairman, one has a slipped disc, the other has weakness and can not bend her back without excruciating pain."

The snickering dies.

"Musao, are there any other difficulties?"

The question is a little incredulous. What other difficulties could there be?

"Yes. One of the remaining four is pregnant."

There is nervous laughter in patches throughout the room. The chairman pauses. He knows the difficulties. He wishes they would disappear. Beyond comforting words, he is powerless to help. "So, in fact, you have three nurses to perform the work of eight?" he asks.

"Yes, Mr. Chairman." The nurse takes a deep breath. She is steeling herself for the inevitable lack of support. After a short pause, she continues. "Mr. Chairman, we have all been working double and triple shifts for several weeks. I fear we shall be unable to continue."

The understatement in her next words lands with all the subtle dark humour of a mortar round striking a balloon factory:

"Mr. Chairman, we are very tired."

More words. More promises to raise the matter with the administration. Cold comfort without the power to effect change.

It would gain more sympathy if it hadn’t become routine.

Rounds on the Orthopaedics Wards

Three weeks before this meeting I assisted on my first surgery. It was almost accidental. The attending physician had me inadvertently providing the extra pair of hands needed to allow him to go somewhere more profitable. On the way to the operating theatre, I stopped with Dr. Otiano, one of the residents, to collect blood from the hospital blood bank. "Have a look in that fridge there," he said, pointing to the far wall. "All of the blood supply for the entire hospital is in there."

"You mean this fridge?" I asked, "That can’t be right, there’s only one unit."

"No. That’s probably right," he replied with a smile of stoic dejection, "There’s always a shortage."

To add insult to injury, the unit was AB positive, a type of blood useful to less than four percent of the population. "Sometimes some of the departments hoard their own," he continued, "You go ahead to the theatre. I’ll try to find more."

Unfortunately, this is a recurring story at Mulago, Uganda’s largest, proudest, most well-equipped hospital. Hundreds of well-trained physicians, nurses, and support staff, people in whose treatment I would be confident in any Canadian hospital, left to work without beds, tools, drugs, finances, support, or in some cases, even gauze.

On a recent visit to the Pediatric Infectious Disease (PID) clinic, Amna and I found a similar story. Children waited in crowded rooms for nutritional support, lab work, clinicians, and counselors. Bright cheerful paintings of animals played on the walls. A teacher gave English lessons to a group waiting seated on the floor. Thanks to the AIDS pandemic in Sub-Saharan Africa, PID is synonymous with HIV. Every child there was HIV positive. Every single one.

We were visiting through Canadian Feed the Children (CFTC), our medical class’ official charity. Money made available from charitable groups has allowed this clinic to increase its capacity several times over in recent years. It is still not nearly enough.

Infected children need more than drugs to survive. They need adequate food and resources to keep them healthy while the drugs take effect. How do you provide food for infected children when there is not enough for their siblings? How do you counsel teenagers, patients who have lived with HIV since birth, about their budding sexuality? What do you do for families too poor and too far from a clinic to receive treatment?

As we walked past the lesson, our nurse guide made an announcement. I caught the Luganda word for "We thank you," before a scattered applause began. What had we done to deserve such a reaction? "She’s just informed them that you are Canadians who have helped by making donations to support this clinic," Christina, CFTC’s Country Director, told us. Too stunned to reply, we watched the lesson continue.

"We are moving forward in Uganda," the teacher intoned.

"We are moving forward in Uganda," the children repeated.

"God, I hope so," I thought to myself as pat of me wanted to laugh and the rest to cry.

Sadly, HIV is not the only burden overwhelming Uganda’s limited health resources. Earlier this month, I manned an educational booth with Jacqui, the chief physician in Mulago’s Casualty – British for Emergency – department. We tried to teach children the basics of first aid, the ABCs: Airway, Breathing, and Circulation. In Canada, the goal is to teach people how to stabilize friends and family until they can be rushed to hospital. Here these lessons seem sadly impotent.

Jacqui

In Canada, if someone stops breathing, one helps with mouth to mouth resuscitation. Here, with a bleeding victim, mouth to mouth is an invitation to infection. Our booth had pictures of masks used for protection from infection. They are both unaffordable and unavailable in Uganda. Other first aid lessons seemed equally inept. To avoid spinal injuries, if someone hurts their neck or back, Canadian children are taught not to move them until help arrives. Sadly, with no public ambulance system, in Uganda help will never arrive. Moving the injured is a necessary evil.

Jacqui is a vibrant woman, cheerful, quick, and no-nonsense, someone with whom I would be honoured to work one day. Soon after we met, she asked me in frustrated disgust, "Do you know how many quadriplegics we could save if we just had proper spinal boards available?"

I empathised. Throughout June and July, as mangos, avocados, and a local olive-like fruit called Jambuya were all in season, broken necks from falls out of trees had become so common that the orthopaedics residents had begun referring to them as "Mango Syndrome."

For Jacqui, the lack of understanding, funding, and support has become almost unbearable. "It’s a silent epidemic," she told me, referring to injuries. They are the third leading cause of death amongst the young in developing countries. We see them as the inevitable result of poverty. They are anything but inevitable. Were they the result of some virus or bacteria, we would be hearing as much of injuries as we do of HIV, TB, and Malaria. As is, very rarely does anyone stop to consider how many everyday mishaps, quickly treated and discharged at home, become life-altering for the poor.

Case in point, Osteomyelitis. It is a disease almost unheard of in Canada. In Uganda’s hospitals, it is seen every day. A cut becomes infected. Through neglect and poor conditions, the infection spreads to the bone. There is some pain and swelling. This fades. Most patients don’t seek medical care. Transport costs to hospital are too expensive. The infection consumes the bone, leaving it so brittle it snaps. Broken shards spread in the wound. Some of them regrow, combining into a weak, misshapen, useless core. Left long enough, the only available treatment is amputation.

It’s something I’ve seen first-hand. My first surgery was on a thirteen year old girl. Arriving calmly in the operating theatre, she seemed nervous but not scared. As Dr. Otiano arrived with the blood for which he had been searching, we both made our way to the sinks to prepare.

When we returned, the girl was anaesthetized and draped. The young woman I had seen was gone. In her place, an anonymous arm poked out from under green sheets. "So," I asked, remembering with confidence the girl’s nervous but reassured appearance, "what’s our plan of attack?"

"Oh," Dr. Otiano replied, "A simple amputation from just above the elbow."

First Surgery

During the surgery, we made small talk while arteries, nerves, and muscles were severed. I reminded myself about clinical detachment. The arm was anonymous. The girl was not. When I could, I placed my free hand over the green draping, feeling the spot where her stomach rose and fell, reminding myself that a person lay beneath. When the procedure was done, the arm was discarded into a shining steel bucket.

We paused for a break. Sitting down outside, Dr. Otiano completed his paperwork. Soon, we were scrubbing for our next surgery, a young boy.

"What’s this one?" I asked with forced casualness. Observing the movements of my hands under the water, I felt a sense of gratitude and shame I had never felt before.

"Amputation. Lower-right limb. Just below the knee," came the reply.

Après la Mort, la Vie Continue

Rwanda is beautiful.

The Country of a Thousand Hillsides – Le Pays des Milles Collines – it gives the impression of a rumpled blanket, covering the fitful sleep of a slow unseen giant. The countryside is a patchwork of sloping banana tree fields and vegetable patches, dropping down into tea plantation valleys. The wispy clouds above are complimented by the green of the tea leaves below, a deep, pleasant, and relaxing colour. It’s almost enough to make one forget the nauseating stop and start of the curves in the road, and the steep unforgiving drop just a short driver’s error away to the left.

Just across the Ugandan border, the road provides its own stern warning: the charred skeleton of a petrol truck, lying at the bottom of a hundred-foot black scar. The smoke has mostly cleared as we drive past.

Rwandan Landscape

Our driver continues obliviously onward, treating the speedometer like a bungee cord as he bounces between sixty and thirty kilometers per hour at every bend. The speedometer is likely broken anyway. It has been my experience that in poor countries, they always are. Exhausted from several days of travel, I curl up in my seat, resigned to whatever fate has in store.

I am in Rwanda at the invitation of my friend Aska, a Polish medical student I met in Cambodia last year. She is on an International Federation of Medical Students exchange at the University of Butare in the south of the country.

Arriving in the capital after a ten hour bus ride I am soon informed that the last bus to Butare has already left. I find an alternative route on public transport. Four hours and several dozen stops later, I saunter into a restaurant in Butare, a dusty mess with a large backpack. Thankfully, Aska is there waiting with friends. She’s already entertained them with the story of how we met, traveling on the roof of a pickup in Cambodia. My ragged entrance seems appropriate.

They invite me to join them at a dance club. Émanuel, a Rwandan medical student in his final year of studies, is warm and friendly. He seems to take a special delight in looking after foreign visitors. As the girls gyrate their way to distant corners of the club, he stays behind to make sure that Laurent, a French student, and I are both comfortable. We’ve both been awkwardly practicing our respective versions of the white man shuffle. Surrounded by the kind of booty-shaking that can only be seen in Africa, our lack of rhythm draws attention.

We are soon joined by other enthusiastic Rwandans, men and women who are happy to offer words of encouragement, "No, no. Don’t worry so much. Relax! Have fun! Just feel the music. … Much better!"

This is Rwanda. At first glance, it is a country beautiful, friendly, and open. Old men pass the time playing Igisoro, a subtly complex game of sixty-four stones in thirty-two piles. Women sidestep around puddles and people, carrying snack trays for sale. Children shout "Bonjour Mzungu!" at passing foreigners. An exception amongst poor countries, the government passes progressive laws, and the people actually follow them. Every motorcyclist wears a helmet. Taxis even carry an extra one for their passengers. Every major road is paved with barely a pothole in sight. Plastic bags have been replaced by environmentally friendly paper ones. In the hospitals, volunteers dressed in pink clean and tend the grounds.

"Il y a un esprit de développement ici." – "There is a feeling of progress here," I told a Rwandan named Émile when he asked what I thought of his country. He had just been telling me about the genocide. Émile is a Tutsi. He survived by moving from one hiding place to the next. Several members of his family weren’t so lucky. "Après la mort, la vie continue" – "After death, life continues," he replied.

That is also Rwanda, a country littered with genocide memorials and mass graves, a country in which only twelve years ago, men, women, and children butchered men, women, and children.

After World War II, European civilians could claim they were unaware of the genocide in their midst. In Rwanda, there is no such option. With the limited resources of a poor country, the Hutu massacred the Tutsi with whatever was ready to hand: machetes, hoes, and clubs. For a hundred days, people murdered from sunrise to sunset, stopping only for food and rest. It was hard work. Those Hutu who refused to help were often massacred alongside the Tutsi. Unable to escape, victims were gathered in groups to watch and await their turn.

The volunteers in pink do not work voluntarily. They are génocidaires, former participants in the genocide. With limited resources and countless accused, Rwanda relies on traditional courts. Every week, businesses close so that the population can convene to hear evidence. The guilty are usually sentenced to public service. It has been twelve years since the genocide ended. The lists of accused are still long.

Génocidaires at the Hospital in Butare

I gave a talk in January at a synagogue, contrasting the Cambodian Genocide with the Jewish Holocaust. "How can you begin to compare such atrocities?" I was asked. Here I didn’t have to. The Kigali Genocide Memorial Museum had already done so, with displays of the mandatory identity cards that labeled Tutsis, the propaganda that dehumanized them, and the tools that killed them.

The Hutu Ten Commandments, a document widely circulated by the Hutu Power movement before the genocide, exhorts all Hutu: "Show no mercy to the Tutsi!" It forbids marrying Tutsi, frequenting Tutsi businesses, or showing kindness even to Tutsi within one’s own family. Substitute Jew for Tutsi and the commandments provide a good summary of the Nuremberg laws of Nazi Germany.

The museum contains displays of other genocides from the Armenians to Nazi Europe, from Cambodia to Yugoslavia. The Children’s Memorial in the basement is a darkened room in which the names of children are recited in an overwhelming seemingly endless list. If it were filled with the lights of flickering candles, it would be a perfect replica of the Children’s Memorial at Yad Vashem in Jerusalem. There is even a hallway paying tribute to righteous Hutus who risked their lives to save Tutsi. At its centre is a quote from the Talmud in English, French, and Kinyarwanda, "He who saves one life, it is as if he had saved the world."

There is an eery feeling in the museum, a sense that though we know nearly nothing of the history of these people, they know us and ours well. That feeling is confirmed by a glass plaque in the final display, the museum’s central unspoken message:

"When they said ‘Never again’ after the Holocaust, was it meant for some people and not for others?"
     –Apollon Kabahizi

It’s a valid question. While Interahamwe militias manned roadblocks, scouring throughout the country for Tutsi to kill, the United States government actively blocked the United Nations from sending troops to intervene. Until the bodies were piled so high that dump trucks were required to remove them, US officials refused to use the word "genocide." Under international law, that word would have required them to do something to stop it.

France was worse. President Mitterrand was so closely linked to the Hutu Power movement, its leaders referred to him affectionately as Mitterahamwe. Before the genocide, French troops helped in identifying Tutsi. As the genocidal government collapsed, France unilaterally created its own UN mission under the banner of humanitarianism. New French soldiers arrived enthusiastically, expecting to save lives. Many quickly became disillusioned as they provided a safe retreat for fleeing génocidaires.

After publishing One Boy at the start of this month, I was asked, "It’s great to say you should care but practically what action can you take?"

It’s a difficult question. I spent much of my time in Rwanda thinking on it. Here is my answer: Care actively. Become interested enough in the injustices you hear about at home and abroad to learn about them.

We are active in the things we care about. Governments act on the issues of greatest concern to voters. Corporations act on the needs and demands of consumers and shareholders. We are voters, consumers, and shareholders. When we care as much about an injustice as we do about the environment, health care, and gas prices, corporations and governments will take notice.

We want a simple solution, a path that has already been laid for us: Click a link. Sign a petition. Buy a product. The small solutions are good but they don’t absolve us of the need to educate ourselves. Learn. Don’t stop because a practical direction is unclear. The first step is understanding. Solutions won’t immediately follow but the next step will.

Lt. General Romeo Dallaire, a Canadian who led the United Nations Peacekeeping force during the genocide, has said repeatedly that with only four thousand troops he could have ended the slaughter. Subsequent military analysts have agreed with him. No country was willing to send those troops. We in Canada had the resources to help. We chose not to do so. The Belgians, who composed most of the troops in the UN mission, withdrew days after the killings began.

"Riskless warfare in pursuit of human rights is a moral contradiction. The concept of human rights assumes that all human life is of equal value. Risk-free warfare presumes that our lives matter more than those we are intervening to save."
     – Michael Ignatieff

Four thousand troops could have saved eight hundred-thousand dead.

I met two Australian UN workers this week. They were on leave in Kampala from Southern Sudan. I asked them about the situation under the current peace agreement.

"Peace agreement?! There’s no peace and no agreement. Most of the groups didn’t sign it. Many of the remaining groups, Janjiweed and others, might as well be working for the government. No worries though. There will be peace in Sudan. It’s coming just as soon as they’ve eliminated or pushed all the undesirables across the border."

"Après la mort, la vie continue."

Unfortunately, neglect, apathy, and genocide do too.

As for the Rwandans, the government while coping with the same problems of poverty faced by its neighbours, has done a miraculous job of keeping both sides living peacefully side by side. Artwork in national galleries more often than not has titles like "Reconciliation," "Peace," "Compassion."

Rwandan Art

The Tutsi still remember the murder of their families. The Hutu still mistrust and fear the Tutsi. Witnesses set to appear before the traditional courts still disappear. So do former génocidaires. Nevertheless, the Rwandans are moving forward. As Émile told me, "Most génocidaires were poor and angry. They were told to kill, coerced to kill, and they killed. They did not know what they were doing. If one of these now understands his actions and wants forgiveness, we must forgive." After all, what alternative is there?

"The only conclusion I can reach is that we are in desperate need of a transfusion of humanity. If we believe that all humans are human, then how are we going to prove it? It can only be proved through our actions. Through the dollars we are prepared to expend to improve conditions in the Third World, through the time and energy we devote to solving devastating problems like AIDS, through the lives of our soldiers, which we are prepared to sacrifice for the sake of humanity."
     –Lt. General Romeo Dallaire, Shake Hands with the Devil

Life in Kampala

Providing a break from heavier subjects, the lighter side of life in Kampala.

Mobile Phone

Ladies and gentlemen, as seen on countless Kampala street corners, the world’s most mobile phone:

World’s most Mobile Phone

It’s even got wheels.

The Equator

“Hey Australia! Which way does the water in your toilet drain?”
&tab;–Bart Simpson

Thanks to the valuable scientific knowledge in The Simpsons, many of us learned that while water drains counter-clockwise in our Northern Hemisphere, it drains clockwise in the Southern one.

So, I’ve been asking myself ever since, what does it do at the equator?

About a ninety-minute drive from Kampala, there are three small water basins set up at the equator where one can try the experiment oneself. The first basin is about ten meters into the Northern Hemisphere, the next directly on the equator, and the last about ten metres into the Southern Hemisphere.

At the exorbitant charge of nearly three dollars, I opted not to try the experiment.

Standing at the Equator

Luckily for science, weeks of staring at my bathtub drain, which according to the GPS unit I borrowed from the Injury Control Centre at 0º 20.63’ North latitude is pretty near the equator, have yielded the following result:

Counter-clockwise about half the time, clockwise the rest.

Purchasing Pants

Arriving for our first day at Mulago hospital, Amna and I immediately noticed a problem. We were underdressed. Luckily, with much haggling, used clothes are available here at very reasonable prices. This is part of a general trend throughout Africa. When second hand clothes dealers in rich countries are overstocked, they ship in bulk to Africa at discounted rates. These clothes are so cheap that local manufacturers are often unable to compete, effectively destroying domestic garment production in many countries. It’s a twisted irony. Clothes that were donated to help the poor rob them of employment.

I’ve been told that in some places these shipments are called “Dead white men’s clothes.” The logic is that no one in their right mind would give away perfectly good clothes for nothing. When nearly everyone is poor, fashion is a non-issue. Besides, 1970s polyester dries more quickly in the sun than cotton blends do.

About a week before my departure I had been telling a friend about this problem. “Really?” she’d responded. “I don’t want to donate clothes just to have them cause problems overseas. Which groups are responsible?”

It was an astute question. “I’m ignorant,” I replied. I’ve heard of the trend but I don’t know if it’s Goodwill, the Salvation Army, or what. Once the local clothing manufacturers are wiped out, I’m not even sure if the process could be stopped without leaving whole countries without clothing. I haven’t done the research.”

Back in Kampala, Amna, some friends, and I investigated Owino market, an amorphous heap of wooden and tin stalls stretching endlessly through the downtown core. It is a place so full of pickpockets that even local Ugandans dare not bring more than a few small bills with them inside. The sight of three potentially rich foreigners started a ripple through the shopkeepers. As the word, “pants,” escaped my lips, I was surrounded by eager men with measuring tapes, proffering me endless pairs of Khakis.

One of them had a green Value Village tag on the waist.

Value Village, j’accuse.

Pants Shopping at Owino

Shylocke?

Ugandans are a religious lot. Muslims drive taxis with Bismillah emblazoned on the front. Christians pepper their buildings with biblical references. For the New Testament Scholars there are frequent Agape Health Clinics. For those who prefer Hebrew, there are The Haggai Nursery School, The El-Shaddai Guest House, and the Shekhinah Prayer Centre. In my opinion though, there is one Hebraic business here that inadvertently tops the list:

Shalom Moneychanger

Yes fellow Israelites, you read correctly. Despite all our hard work to move beyond the stereotype, he changes money at a business called Shalom.

The World Cup Downtown

"Which team are you supporting?"

Right after "How are you?" and "Where are you from?" it’s the most common question I’ve been asked here. Wandering the streets of downtown Kampala after sunset, one often feels like a fish swimming between human islands that stand thirty men deep. The focus is always the same, a single small television screen resting in a shop window, above a restaurant counter, or even someone’s flat. The men trail out as if queuing in a bread line, never moving, always waiting and attentive. Often the TV is muted, as someone in the crowd has brought a radio from which the commentary can be heard in Luganda.

The rule here is solidarity. Though Uganda did not qualify for the World Cup, the teams to support are all African.

"Ivory Coast but they didn’t do so well. Now they are out," I responded one day in surgery, "What about you?"

"What about me?!" was the laughing response, "My skin is black, I support Ghana!"

By this time, with an impressive win over the United States, Ghana was the only African team left. Riding a matatu as the sun set this evening, I was perplexed. The van had stopped short. It was turning away from its usual route.

"Conductor, stage!" I called, asking to be let out. Amna and I exited, strolling around the ever denser downtown television islands as we approached the core. It soon became clear why the matatu had stopped. People filled the city’s central artery, shoulder to shoulder on Kampala Road. They stood calmly, expectantly, staring upwards into the distance.

We followed their gaze up to a large billboard, advertising the greatest public service I had yet seen in Uganda. It was broadcasting the World Cup game. In the streets of Kampala, thousands of Ugandans stood side by side, silently cheering the Ghanaians as they struggled with Brazil.

Already late for our dinner meeting, we stopped. I can not describe the energy of that moment, thousands of people together in the heart of a major city, happy, expectant, and hopeful.
The game was nearly done.

"Hey Mzungu!" someone called from the side of the road, "Who do you support?"

"Ghana!!" Amna shouted with a smile, "I am in Africa! Who else?"

Ghana lost that night. Still I wish that I could have bottled that moment. Never have I seen so many strangers so happily united, stoic in a single hope.

One Boy

I noticed him on the first day in Loubugumou. To the dozens of children not in school, the sight of two white people with clipboards was the most exciting event in months. They let us know by gathering round, asking us endless questions in Luganda that we could not understand. We answered with English that was equally incomprehensible to them. Together we made a game, a vain attempt to start them on the road to literacy, calling out letters printed on the bottom of a water bottle or scratched in the dirt.

Letters in the Dirt

One boy had come with the others to pay his respects. He looked to be about ten years old, leading a group of two or three younger children for whom he had decided to be responsible. He was unlike the others. When he saw what my digital camera could do, he made no attempt to see endless pictures of himself. Instead, he hurried to find a young girl of about four, carrying her back so that she could join in the fun.

He stayed longer than the others, smiling, drawing doodles in the dirt that covered our pickup, and raising his shirt to reveal a protruding lump the size of a small fist where his belly button should have been.

I stopped watching the passing motorists. "Amna," I called out, in my calmest possible voice, "I know I’m not qualified to tell but does that look like an umbilical herniation to you?" Translated into English, umbilical herniation means "Intestine pushing its way out through the belly button."

"Oh yeah. It’s easily treatable. We used to see them at the clinic in Ghana all the time."

"You’ve seen these before?" I asked, "So, without treatment, what’s the likely outcome?"

There followed a look that spoke with silent finality.

In theory, every Ugandan has access to universal health coverage. It remains only a theory though. Coverage extends to those able to afford travel to the hospital, medications that are almost forever out of stock in the public wards, and lost time helping to support their families.

To the best of my knowledge, eighty percent of Ugandans work in subsistence agriculture. With luck and hard work, they grow what they need to feed their families, with a little remaining to buy clothes and tools. With poor luck, transport costs, and unexpected hospital bills the average Ugandan family will begin to lose what little they have.

I looked over at our guide, Jerome.

"Amna, do me a favour," I asked with forced casualness, "Ask Jerome what would happen if we told the boy’s parents that his problem is both potentially dangerous and easily treated."

She returned a moment later. "He says the problem is common here. The parents will expect you to transport and treat him yourself."

Here was my dilemma: Similar things happen every day. It wasn’t a revelation to me. I had known the statistics for a long time. Thirty thousand people die every day from hunger and preventable illness. Every day. Six thousand are children. Though I knew this indirectly, until that moment those children had always seemed like someone else’s responsibility. There I stood, a budding health professional with the resources and connections to whisk this boy away to the side of a well-trained surgeon and back again.

Was it my responsibility this time?

I continued counting motorcyclists, trying to decide what to do. I opted to wait for an opportunity to check with some of the doctors from whom I’ve been learning in Kampala.

The response came during rounds of the hospital the following day. "It’s quite common here," I was told, "Generally, you don’t need to worry about it unless the bowel becomes twisted or the blood supply is interrupted. Then it’s serious. Actually often the larger hernias are safer than the little ones."

"Oh good," I said, feeling both surreal and relieved.

On the drive back to Loubugumou, I considered this re sponse. The boy was in no immediate danger. I had dodged the responsibility. There was nothing I needed to do. Still, I had not dodged the question.

Between malnutrition, unsafe water, and poor sanitation, these children have far more than umbilical herniations with which to contend and no reliable access to health care with which to do so. In a country with supposedly universal health coverage, they are the rule not the exception.

What if the boy had needed treatment urgently? What difference if I poured my resources into treating this one child? Did he deserve it more than the others?

Worst of all, what kind of a system would prompt me to ask such a question?

The resources exist to protect all of these children. In Canada alone, we spend more each year on ice cream than we do combating global poverty. If the numbers were reversed, proper nutrition, safe water, and actual health care could be made available to every one of them, not only in Uganda, but also in several other countries as well. I’ve read it before. Somehow though, when I reach a Baskin Robbins or the frozen foods section of a Loblaws, it always seems so distant.

Having had two weeks to think about it, I’ve come to some conclusions. The resources exist. We have the power to make them available. That boy is no more my responsibility now for having been right in front of me than he was before.

He was always my responsibility.

The trade, economic, and political imbalances that lead to extreme poverty are subjects wide enough for several books but the central point is this:

There is a global system that allows for this kind of poverty. Canada is powerful enough to help change that system. We can influence our government to represent the causes in which we believe – We have the power to change that system. "It’s not my fault," "It’s not my responsibility," and "I’m only one person," are about as valid an excuse for apathy as "I was only following orders."

When we arrived in Loubugumou the following day, the children were there, happy to see us. We began our observations as they laughingly clambered over the pickup truck, shouting and joking in Luganda. Several of them were running around without shirts nearby in the tropical heat. This time, I noticed what I had not seen before: countless umbilical herniations, only smaller.

"All that is needed for evil to prevail is for good men to do nothing."
  –Edmund Burke