One never knows...

One Never Knows…

Friday is supposed to be a relatively light day at the clinic. That is in contrast to the beginning of the week, when there are generally more than 100 patients to be seen on a given day. For example, this past Monday, we had 114 patients, and on Tuesday, 123. Friday did turn out to be a light day, but only for the two doctors seeing the adult patients; not for me, the doctor seeing the pediatric patients.

I don’t know why there were so many sick children that day. What I do know is that the numbers do not tell the real story. That real story lies not in the quantity of the patients; rather, it lies in the quality, although quality might not be the right word to describe what I saw that day.

The day started with an eighteen month old boy with moderately severe pneumonia. His respiratory rate was in the 60’s (normal would be 20—25/minute). We do have a pulse oximeter at the clinic, so that we can measure a patient’s oxygen level using a transcutaneous probe. This little boy’s oxygen level was 88%. In the United States, the child would immediately be placed on oxygen. Here, our limited oxygen supply requires us to use it only when absolutely necessary. In this case, the child was not in the “absolutely necessary” category. If the oxygen level had dropped in the very low 80’s, or certainly below 80, he would have received supplemental oxygen. However, we don’t have enough of the precious stuff to give it on a continuous basis, even to those who need it.

I will interject a comment here about American modern medicine approach in a similar setting. I believe that too often, we treat numbers, rather than patients. Take, for example, a child hospitalized with asthma or pneumonia. The child is attached to a continuous pulse oximeter to determine his oxygen needs. I have no trouble with that, at least not during the acute phase of the illness. It is more a question of what we do when the child gets better. Clinically, we can see that he is better. He is no longer having trouble breathing. Maybe, in the case of asthma, he is still wheezing, but his energy level is back to normal, as is his activity level. Yet we continue to monitor his oxygen level on a continuous basis. We watch the oxygen level rather than watching the child. We base our medical therapy on that oxygen level. We continue to give him oxygen, even when his needs for that supplemental oxygen are questionable. Let’s say, for example, his oxygen saturation drops to 90-91%. Granted, that is not normal, but does he really need the extra oxygen at that point? I say, no, yet most hospital doctors wouldn’t think twice about insisting that he continue to receive oxygen.

We are lucky, because our supply of supplemental oxygen is both cheap and limitless. Here in Burundi, they are not so lucky. Their supply of most things, including oxygen, is limited. That’s why they reserve those things, including oxygen, for those who really need them.

I digress, but it is my blog, and, therefore, I can digress whenever I feel like digressing. Before I go onto the next case, I will give you follow-up on the little boy with pneumonia. He got better quickly, and went home two days later. I stopped checking his oxygen level once it was clear that he had improved.

Now for the next patient of the day. This one will feature some graphic and possibly disturbing photos. I warn you in advance so that, if desired, you can skip to the next section.

A mother came into my office carrying what appeared to be, from the tiny face, an infant. The baby was wrapped up, so that initially, I did not get a good look at her. All patients are triaged before they come to see me. Triage includes, for the children, weight, temperature, length or height, plus various other demographic information.

I looked at the chart. This was a baby girl of three months. Then I saw the weight: 2.5 kilos (about 5½ pounds). I looked at both numbers. This could not be possible: a three month old baby weighing 5½ pounds. Could the baby have been small at birth because of prematurity? Not here in Burundi: premature babies do not survive in Burundi. The survival rate for babies born at less than 30 weeks gestation is essentially zero. That’s when I made the mother unwrap the baby and place her on the table, so that I could examine her.

I have seen many surprising and shocking things in Burundi. This was above and beyond “shocking.” This was appalling. This was as severe a case of marasmus as I have ever seen, and by now, I have seen many cases. What I saw on that table was a baby who was no more than skin and bones. This was a baby who had been malnourished since birth. I could not conceive how this baby was still alive. Nor could I conceive what kind of organ damage had occurred after such a prolonged period without nutrition. The pictures will give you some idea of what I saw on the table that day.

But how had this happened? How could a three month old baby been deprived of food for so long? Breast-feeding is universal here in Burundi. What had gone wrong? Why had the mother not breast-fed? Or, if she had, why was the baby so tiny? And why had she waited so long to bring the baby to medical attention? Couldn’t she see that something was wrong before it had come to this? Anyone could see that this baby was literally starving to death.

Here is the story: the woman with the baby was not the mother. She was a neighbor who had brought the baby to the clinic. This baby was one of twins. I then asked if the other twin was doing better. The other twin was exactly the same. It was unimaginable: three month old twins, both weighing 2.5 kilos. So why had the neighbor not brought the other baby with her? Because she had come from so far away, and she could not carry both twins. (The trip had taken over four hours, partially on foot, partially in the bus). The mother was at home, taking care of the second twin and another child.

But how had the baby gotten to be like that? That was the obvious question. The mother had been unable to breast-feed from the beginning. I have no idea if that was a result of the babies having difficulty latching on, or simply the mother’s inability to produce adequate milk. It matters not, for the point is that the mother did not breast feed either twin.

There is no such thing as formula here in Burundi, except perhaps for the few members of the elite that live in Bujumbura. The cost of any formula would be prohibitive. Therefore, what did the babies eat? They did not have breast milk or formula, so what then are we left with? The answer is regular cow’s milk, and not much of that either. The mother would go to the store and buy what was presumably non-pasteurized cow’s milk for the babies. I have no idea how much the babies took of the cow’s milk, but clearly not enough to make a difference. I also have no idea how she gave the milk because there are no such things as baby bottles here. Did she give it in a cup? With a spoon? I cannot answer that question.

So there we had a baby closer to dead than alive; a baby in urgent need of admission for nutritional resuscitation. We rarely had babies that young on the malnutrition ward, so we would have to make adjustments in the usual protocol. We had no idea at that point what we would do if we did ultimately succeed in reversing the starvation process. What would happen if we did send the baby home? What would she feed then? That wasn’t our problem at that point. All we knew was that we had to get that baby into the hospital as soon as possible.

I am afraid that’s when my story takes an even darker turn. Any baby admitted to the malnutrition ward has to have an adult (usually the mother) stay with him to give the baby the feeding solution provided by UNICEF. We do not have nearly enough nurses to provide that kind of 1:1 care.

The neighbor could not stay, and, in any case, it appeared that the other twin was equally in need of our malnutrition services. There was only one solution: the neighbor would take the baby back to the mother. Then, the next day, the mother would return with both twins. We repetitively made the neighbor promise that she would convince the mother to do so.

The mother has not returned with the twins. It is now five days later, and there is no sign of her. I have lost hope that she will come. If she has not returned by now, she will not return. Is it possible that she took them to another and closer hospital? Yes, but there is no other facility in all of Burundi that does what we do; none that treat malnutrition in a systematized and appropriate way. What will happen? The twins will die. I wish I had another answer, but there is no other answer. I don’t even know if, under the best of circumstances, we would have turned this around. The baby I saw that day was on the abyss of death by starvation. I cannot imagine her twin was any better.

So who is the villain in this tragic story? Who is to blame? There are no villains, only victims. Yes, I believe the mother should have not let have things to deteriorate to this point. Yes, I believe that she should have sought help far sooner than she did. Yes, I believe that she should have brought the twins back the next day in what might have been a vain effort to save them. However, she is as much a victim in this story as the twins. She will lose her babies. No, what is to blame here is abject poverty, and lacking the means to correct what, in a humane world, should be correctible.

Thankfully, we now go to the lighter side of “a day in Kigutu.” I present you now with a photo of a patient and his mother: this is a 15 month old who had to be admitted to the hospital for treatment of a very large abscess in the right upper chest.

I now present you with a photo of the next patient that I saw that day. This too is with his mother. The patient is a four year boy who also had to be admitted to the hospital for treatment of a large neck abscess.

Try to follow this. I warn you that it gets complicated. The two boys that you see here have the same father. The second mother (the mother of the four year old) was the father’s first wife. She divorced him. The first mother (the one with the 15 month old) is the father’s second wife, but both boys live with the second wife. The first wife is HIV positive, and is being treated at the clinic for her disease. She was at the clinic that day coincidentally. She had no idea that her son would be at the clinic that day. However, she subsequently saw the second wife with the two boys. She grabbed her son away from the second wife, and the two of them had to be separated. Neither the father, nor the second wife have been tested for HIV, nor have either of the children. It is a safe bet that the father is HIV positive, but, so far, he has refused to be tested. The mother of the four year old insisted that her son be tested; we await word on whether the second wife feels the same about herself or her son. The two mothers and their respective children will be placed on the same ward, presumably no more than a few feet apart. We anticipate the possibility of fireworks between the two of them, especially if the father shows up to see his children. Drama here in Kigutu. A final word on the situation: I have no explanation why two children in the same family would simultaneously present with large abscesses, other than the fact that living conditions were presumably less than sanitary.

The club

I have been known by many names here at the clinic in Kigutu: Muganga Petero (Dr. Peter); Muganga-mupfumu Petero (doctor/traditional healer Peter); Muganga-mupfumu-muzungu Petero (doctor/traditional healer-white man Peter). The term mupfumu is used facetiously, for I have no desire to have any association with these charlatans. Regardless of that point, the name I am almost universally known by this year is “Le Roi” (The King). It is a name that I wear proudly. It is the name that everyone at the clinic now calls me. They are correct in doing so, for I am truly “le roi.”

But, you ask, of what exactly am I “le roi?” What precisely is my kingdom? Who are my faithful subjects that offer blind loyalty to their king? And, finally, who made me king? By what line of succession did I assume the throne that I occupy so regally?

I am, in point of fact, “le roi” of the Short Tie Club (more commonly known simply as the STC). Those of you, for whom French is your native language, it is “La Societe de Cravat Court (SCC). Many, if not most of you, are probably unaware of the existence of the Short Tie Club. So what is the STC? To what does it owe its existence? What are its goals, its aims, its desires? Is it a secret club? Or can anyone join? All of these questions will be answered in due time. First, though, a little bit of history is in order.

It all started a year ago, primarily to combat the long-time prejudice of those who wear the short tie. It is well known that the overwhelming majority of people who wear suits do so with what we in the STC refer to as the long tie. That is the normal and acceptable attire in the business world and in any world in which ties are worn. However, in this smallest corner of the world, Burundi, the fashionable attire is the short tie. One is “tres chic” in Burundi if one wears one’s tie in the short manner. I will demonstrate my point by showing you one of the first photos of some of the members of the STC even before the STC came into existence. This occurred in the formative and nascent stages of the club. The historical importance of this photograph cannot be overstated, for it shows three people willing to risk their reputations in a hostile and non-comprehending outside world.

Our motto became “we wear short ties and we’re proud!” That’s when the idea came to me that, for too long, the world has looked down its collective nose at those of us who wear the short tie. We were thought to be freaks and fools. We were thought to be without the slightest sense of fashion. We were pariahs in the tie world.

We needed to organize our collective forces to combat this inherent bias. That was when I decided to form the Short Tie Club: to give a voice and a viable platform to those of us who believed in our mission: our devotion to the wearing of the short tie.

I declared myself president of the club. It was a title that I felt that I deserved, for I had been the one to take the initiative to start the club. I also believed that, by becoming president, I was making myself the point man for the club. I would be the one who would be the object of derision. I would be the person who would deflect the waves of criticism that were destined to come our way. I felt that I had the strength and the fortitude to handle the scorn that was certain to be heaped upon us. It was not arrogance that made me believe this. It was more my unwavering devotion to the validity of our cause.

There is an inherent prejudice in our society against those of us who dare to be different. Robert Frost once wrote, “two roads diverged in a yellow wood, and I took the one less traveled, and that has made all the difference.” We in the STC similarly took the road less traveled, and it too has made all the difference. I am sure that if Robert Frost were alive today, he too would be a proud wearer of the short tie.

Yet, in the beginning of the club, there were those who could not, in the end, take that road less traveled. They defected over to the side of the long ties. I do not blame them. I do not hold a grudge. I wish them only the best, for I know how difficult it is to be the non-conformist in today’s world. We lost several members. It required all my powers of persuasion to hold the club together. I give myself credit that I was able to do so. It was then that I earned the undying respect and loyalty of my fellow members. I was their leader, and I led them into their rightful place in society.

I believe that the STC really came of age at last year’s party at the VHW clinic in Kigutu. It was then that the ties came out of the closet, along with the people who wore those ties. It was then that the short tie became not merely an acceptable form of attire, but a desirable one. People at that party were proud to wear their short ties, as these pictures so graphically demonstrate. First there were six, and then, there were many.

The STC has grown exponentially since that day, and I am proud to report that we have new members every day. We are starting to establish new chapters in cities and towns and villages across the world: wherever ties are worn. We do not proselytize our message or our beliefs. We are not modern-day missionaries, trying to convert you to our way of wearing a tie. Our simple manifesto says to go in peace and to wear the short tie without fear of bias or prejudice.

I know that those who wear the long tie would like nothing better than to destroy our little group. I know that they want us to go back from whence we came. They have used unscrupulous methods in the past and continue to use those methods to discredit us. I warn them, we are here to stay; we will not be deterred from our chosen course. The short tie: now and forever!

Speaking from a personal perspective, the job of president has been an arduous one. I have faced many crises during my tenure. I believe that I may justifiably claim that I have led us forcefully and courageously through all of those crises. The STC has come a long way under my leadership, but it still has a long way to gain full acceptance in the land of the tie-wearer. I know that this may sound immodest, but I believe that I am the only one who can lead us out of the wilderness in which we started our journey. I do not think, as of now, there is anyone with the foresight and the drive who can successfully shepherd us so that we can complete that journey.

That is why in July I made the difficult decision to elevate myself from mere president of the STC to “le roi” (the king) of the STC. I did so, because I believed then as I believe now that the STC is not ready for elections. I believe that one day it will be. Just not now. It needs a strong leader. I am that leader. I hope one day that I will be able to choose a successor. That day has not come. However, I do not want to be known as “le roi” who said, “après moi, le deluge (after me, the flood). I want the STC to continue long after I am gone.

The STC has succeeded because its time has come. Look no further for proof of that than this year’s party at VHW in Kigutu. Just look at the pictures of all the men and women rejoicing in their short ties. The second picture shows "le roi" on his throne surrounded by his faithful subjects.

I want all of you out there to know that you are welcome to join our little club. There are no dues, no rules or regulations other than that one must wear the short tie. Just send me, via e-mail or Facebook, a picture of you in the short tie; you will then be accepted immediately into the club. We do not discriminate against anyone based on sex, race, color, creed, ethnicity, religion, sexual preference, Yankee-lover or hater, tall or short, thin or fat, Burundian or non-Burundian, human or animal, vegetable or mineral. Speaking of animals, here are two pictures of the dear, departed Asman the goat in his short tie. He left us too soon, but not before he posed for these now famous pictures.

I want to give credit to those of us at the STC who have helped make the club the vital force that it is. I know that I am “le roi,” but I could not have done what I have done without their dedication and assistance. The first two pictures are of my son-in-law, Garth Friedrich, a relatively recent convert to our cause. I have invoked the principle of nepotism by appointing him the STC Treasurer. However, be reassured that he will do a very capable job in this all important task. The first picture shows that he is one of us. The second shows him in deep contemplation about the past, present, and future of the STC. The last photo is one of the original members of the STC, my good friend, Dr. Melino. He is my trusted confidante and occupies the vital position of Ministere de Sante (Minister of Health) in the STC.

Malaria

Malaria

I offer the following quote from the Oxford Handbook of Tropical Medicine: “Malaria, a protozoan disease transmitted by anopheline mosquitos, is the most important parasitic disease of humans. As many as 3 billion in endemic areas are at risk of malaria and approximately 500 million clinical cases occur annually. Between one and three million die annually, largely African infants and young children.” That last fact was brought home to me in dramatic fashion today when a nine month old with malaria was brought into the clinic in near death condition. It is possible that we may have saved him, but it is equally possible that he may not survive. His life literally hangs in the balance. More about that child later, but first a brief discussion of malaria is in order.

We who live in a world devoid of malaria cannot possibly appreciate the destructive and debilitating power of this disease. It was only when I lived and worked in Burundi that I did understand that power. It is, at best, a nasty and unpleasant disease; it is at worst, a disease quite capable of killing a child. The numbers (one to three million deaths per year) bear out that statement. The number of children that I have seen with this disease is countless. They come into the clinic with a typical look: a very ill-appearing look; a look which says that everything hurts (which it does); a look which begs for help. I show you one such child.

We, at the clinic, have the means to help these children. We have medications to treat the disease. Most Burundians afflicted with malaria cannot afford these or any medications. The most commonly used medication to treat malaria here is quinine. The cost of one week (the usual course of treatment) of quinine is approximately a dollar and a half. That amount is nothing to us, yet that same amount might as well be a million and a half dollars to a Burundian. That’s why he suffers through his all-too-frequent episodes of malaria without the hope of getting better quickly. That is also true for most of the children in Burundi. It is only a relative few who have access to the services of the clinic here in Kigutu, services that include the dispensing of malaria medication to those who cannot afford that medication.

May 25^th, 2011:

I have seen enough cases of malaria to have a healthy respect for the disease. The case of malaria that I saw today exponentially increased that respect. The child in question was a nine month old boy by the name of Festus Ndayishimiye. The story is that Festus had developed fever approximately one week previously. The mother had subsequently brought him to another clinic two days later for evaluation of the fever. I cannot be sure of the condition of the child at the time, but, according to the mother, his condition had not changed since then. I find that hard to believe in view of subsequent events, yet it is probably true.

The doctor at the outside clinic diagnosed him with “probable malaria,” but did not treat the baby, possibly because the mother could not afford the medication.

Malaria, in its most severe form, is often fatal. I saw that severe form today. The child was brought in virtually unresponsive. He cried only with deep pain. He hardly uttered a cry when we took blood, or even when an I.V. was inserted. His breathing was fast and labored, with each breath coming with an audible grunt. His nose flared out as he breathed (another sign of respiratory distress). Most remarkable was his color. Last year, I learned how to judge anemia the old fashioned way: by looking at the color of a child’s conjunctiva and nail-beds. We did not have a machine last year to test a child’s hemoglobin. This year, we do. That test would only confirm what I saw clinically: this child was profoundly anemic. His conjunctiva and his nail-beds were a chalk-like white. His tongue was white. The blood test confirmed what I saw: his hemoglobin was 3.7 (normal is 12-15). His heart was beating extremely fast (about 130-140 beats/minute) to compensate for his lack of blood. That compensation was ineffective, for the direct effects of the malaria infestation and the subsequent anemia had caused the child to develop something called “acute respiratory distress syndrome.” His lungs were not working. That’s why his breathing was so labored: to attempt to get enough oxygen to his soon-to-be failing body.

The child’s spleen was markedly enlarged, which was further proof that his anemia was the result of severe hemolysis (breakdown) of his red blood cells. I show you now pictures of the child, as he was early this afternoon. I think the pictures will give you an idea of the gravity of the situation.

We did not know for certain that the child had malaria, but the entire picture was consistent with severe malaria. We did a quick blood test which confirmed the diagnosis.

The child was in urgent need of a transfusion, but the clinic is not capable of doing a transfusion. We cannot keep blood on hand, because we do not have the refrigerator capacity of storing that blood. There is an extremely limited supply of blood in the entire country. That supply is distributed by a central source in Bujumbura. The nearest hospital that had the capability of performing a transfusion was in Rumonge, a 45 minute drive down the treacherous mountain path that passes for a road here. That hospital only had Type B blood. If our patient did not have Type B blood, the nearest hospital that might be able to accommodate him was more than two hours further away. It was unlikely that he would survive that prolonged a journey. We were in luck, for the child was Type B.

We had to stabilize him even before we could even think of transferring him. Assuming the mother was correct in her assertion that the child had been in that condition for five days, it was highly unlikely that he had anywhere near adequate fluid intake over those days. He needed fluid, but that was a double-edged sword. Giving him too much fluid, based on his degree of anemia, would cause him to develop certain heart failure. Not giving him enough could cause organ shutdown. We calculated what we thought was an appropriate amount.

We also needed to start treatment of the malaria. That meant loading him with a higher-than-usual dose of quinine, based on the severity of the anemia. We did so in a limited amount of fluid. I should, at this point, acknowledge the skills of the nurses who somehow got a working I.V. into this desperately ill child.

The other problem was that the child had a cough. Severe malaria often causes the child to be immuno-compromised. There was a reasonable chance, in view of the cough, that the child had developed a secondary pneumonia. Therefore, we gave him a dose of Ceftriaxone, a broad spectrum antibiotic.

The good news was that the child was successfully transferred to the hospital in Rumonge. Initially, the hospital was reluctant to take him, because the mother had no money to pay for their services. However, ultimately, they did, and, from what I understand, the child did receive the transfusion. What transpired after that, I do not know. I wait with the rest of you to see if the child did survive the grievous insult brought on by that ubiquitous (at least, ubiquitous here in Africa) parasite that goes by the name of malaria.

May 26^th, 2011;

I have just now received the news that Festus Ndayisimiye has improved. Dr. Melino spoke with the doctor taking care of him in Rumonge, and the doctor reports that the blood transfusion had the desired effect. Festus is now out of danger, and it is expected that he will make a complete recovery.

Festus was lucky. The only blood available to him in Rumonge was Type B. This is a relatively uncommon blood type in the United States, with only about 10% of the population being Type B. Here in Burundi, it is slightly more common: the preliminary research I did shows that slightly less than 20% of the population are Type B. That meant that there was only a one in five chance that the hospital in Rumonge would have blood compatible with Festus’s blood. The next closest hospital with blood was over two hours away. I doubt that Festus would have made it that far.

Festus won his own version of the lottery yesterday. He beat the odds. His 20% chance of survival came home a winner.

The Burundian Chronicles Begin

I arrived in Bujumbura on Friday, May 20^th. For those of who you who don’t know or don’t remember, Bujumbura is not only the capital city of Burundi; it is the only city. The country of Burundi is primarily rural and agricultural, with the exception of its relatively small (approximately 150,000 inhabitants) capital city.

My journey had taken me two days and two nights, but I finally made it to my final destination (actually next-to-last destination, for my final one would be Kigutu and the clinic). It was a far different feeling this year compared to the feeling that I had last year: my first time in Africa.

It all seemed so surreal back then, so out-of-my-scope of personal experience. The sights and sounds and the smells of Africa were all so foreign to me. My daughter, Jessica, age 29, recently spent six weeks in Ethiopia, volunteering at an orphanage. I told her, before she left, that it was impossible to explain in the abstract those sights and sounds and smells; that one had to be there to understand those sights and sounds, and often, for worse rather than better, the smells. She now knows what I mean. Pictures are, as the cliché goes, worth a thousand words, but no amount of pictures or words can tell the story of Africa.

Safaris are amazing and wonderful experiences, and both my daughter and I have done one: she in Kenya, and me on the wild gorilla trek in Uganda. I can even make the unenviable claim that I have placed my entire hand, inadvertently of course, in gorilla shit. It is not a claim I make lightly, nor is it a claim that many people can make. However, one does not have to get that close and personal with the animals to enjoy one’s safari. Seeing these exotic animals in their natural surroundings is both surreal and exhilarating. However, safaris, as breathtaking as they may be, are only a small, and somewhat deceptive slice of African life.

The Africa that both my daughter and I have come to love is the ground level Africa: the one that she experienced at the orphanage in Ethiopia, and the one that I experienced last year and will again this year at the clinic in Kigutu. This is the Africa that steals your heart.

I am not one to romanticize this Africa. Its problems are enormous and profound. Living conditions are more often than not dehumanizing. Too many people here live on the precipice of viable human existence. Yet that takes nothing away from the spirit that is Africa, and the spirit that is the people of Africa. That is why I come back this year, and that is why I will come back every year that I am capable of coming. It is that spirit that draws me here much as a moth is drawn to a flame. Africa is my flame, and I am that moth.

I will post some pictures towards the end of this blog post. Hopefully, those pictures will give you an idea of the spirit of which I speak.

I come to Africa not merely because it is Africa, but also for the work. I do what I do as a doctor here because I need to do it. I do it because I want to do it. And, perhaps most of all, I do it because I can do it. My training, my expertise, my medical skills translate to a setting that is as different from my normal setting as night is from day. I am the lucky one. Most people cannot do what I am doing. Just ask yourself, how many people can take themselves out of their normal world, and do what they do in a polar opposite environment? Not many. Doctors can, and, fortunately for me, that is my chosen profession. It is a profession that I love doing, a profession for which I have a passion.

Now back to the story: I arrived in Kigutu on Sunday, and was greeted warmly at the clinic by my friends and what I consider to be my new family. I felt as if I was home, and, to some degree, I was. This was my second home, and I felt as comfortable, as happy as I do at my home in Los Angeles. The beauty and the tranquility of the place enveloped me. I walked up the hill overlooking the clinic, and stood there, looking down on the expanse of Lake Tanganyika below me, the Congo, across the lake and off in the distance. The scene was profoundly quiet, the only noise coming from the sounds of the children playing in the village below me. The air was clean and pure. I could think of no place I would rather be at that moment.

I show you below two pictures from that hill-top, approximately 4,000 feet above this greatest of lakes. I can only hope that they give you some idea of what I speak.

I then walked down into what passes for the playing fields of Kigutu. A volleyball game was taking place, and many of the children had gathered around to watch. These are children who have nothing, yet, as trite as it may sound, they are happy. They often seem happier than our own children, who have everything. It is these children, with their beautiful faces and wide eyes and lovely smiles that captured my heart. It is they who continue to capture my heart every day that I am here. It is they who are the real heroes of this and subsequent stories of my life in Kigutu. They rejoiced at the mere fact that their picture was being taken. They primped and posed for the camera, and all gathered around eagerly and enthusiastically to see the completed pictures on my camera. I think you get a sense of who they are from these pictures.

We Meet Again

We Meet Again

The Return of the Blog; The Blog, Part II; The Blog Redux; Dr. Pete Goes to Burundi (Again); Burundi on my Mind; Burundi is my Beat; A Long Day and a Long Night and Another Long Day and Yet Another Long Night’s Journey into Burundi; Leave it to Peter; Out of and Back into Africa

Yes, the blog is back. Perhaps you wondered if it would ever make its reappearance. Or perhaps you have not wondered. Perhaps the previous blog entries were of no interest to you. Your interest or disinterest notwithstanding, I am still proud to announce that “Dr. Pete Goes to Burundi” is now ready to make its reappearance in the blog-o-sphere.

I know it’s been a while since you read of my adventures in that small, profoundly poor, landlocked, sub-Saharan African country that goes by the name of Burundi. Yes, Burundi, a country unknown to most Americans; a country for which the term “profoundly poor” does not do it justice. Burundi has the unwanted distinction of being the country with the world’s lowest per capita income. Considering the abysmal living conditions of the majority of the world’s countries, that is quite a claim to fame, or perhaps notoriety would be a better word.

I believe that there are five essentials for any quality of life. Those five would be 1) adequate food; 2) clean, potable water; 3) adequate clothing; 4) adequate housing; and, 5) access to medical care. The vast majority of Burundians are zero for five on those essentials. They literally have nothing. It was to that land of nothing that I was returning. It was also that land of nothing that I fell in love with a year ago when I took my first medical sabbatical here. I return now to do what will be the second medical sabbatical. It is my hope that this second sabbatical will be merely the next in the series of annual sabbaticals to Burundi.

I am, as I write this, a little more than 24 hours from my departure from L.A., the capitol of glitz and glamor. Two days later, after a journey that will take me from L.A. to Miami, followed by an overnight flight to London, which will subsequently be followed by a ten hour flight to Nairobi; then an overnight stay in Nairobi, and, on the morning of May 20^th, a relatively short flight from Nairobi to Bujumbura, the capitol (and only city) of Burundi. It is then that I will be reunited with my Burundian friends and colleagues.

I return to Burundi with a different mind-set than the one I had last year. The trip last year was the great adventure; the proverbial voyage into the unknown; the abandonment of all that was familiar for all that was unfamiliar. This year is still a great adventure, but it is far more a voyage into the known. Last year, I was filled with trepidation in the days leading up to my departure. I wrote, “I have been doing this pediatrician thing for over twenty-five years, yet I still wonder how my skills and my expertise will translate to a medical, as well as a geographical setting that will be completely unfamiliar to me. Let's face it: I have never treated malnutrition, nor malaria, nor disseminated tuberculosis. Is it hubris on my part to think that I can do what I do in a completely different environment, facing completely different diseases than I have ever faced before? Facing children so sick that I may not know what to do? As I get precariously close to my day of reckoning, my fears and anxiety grow exponentially. But, yet, I go forward, and I will encounter what is to be encountered.”

I did go forward last year, and I did encounter what had to be encountered. The experience of being a doctor in a completely foreign setting was initially a very steep learning curve. I was lucky, because I had superb physicians at the clinic that helped guide me up the slippery slope of that learning curve. It was they who helped me learn how to treat diseases that had been unknown to to me: diseases like malnutrition and malaria. But I also found out something about myself. I could take myself out of my medical comfort zone. I could do things that I did not know that I was capable of doing. It is said that an old dog cannot learn new tricks. My experience in Burundi last year would argue otherwise, for this old doctor dog did learn new medical tricks.

I return now ready to face the same challenges that I faced last year, knowing full well that there will be many new challenges this year. I will encounter, if only because this is Africa, medical surprises and shocks. I am sure that there will be many occasions that I will be astonished by what I see. Yet, for me, that is the beauty of doing what I am about to do. Once again, I will challenge myself as both a human being and a doctor. I will be doing what I love to do in a setting where my professional skills will be tested on a daily basis. How fortunate I am that I am able to do that.

Last year, as you probably know, I came to Burundi and to the clinic by myself. No other doctors went with me. However, this year, I have the pleasure of being accompanied by two of the finest and most dedicated physicians I know. Their motto is, have stethoscope, will travel. They are normally shy, but I persuaded them to pose for these pictures prior to departure. They wear their stethoscopes quite well, don't you think?