South Africa redux: medevac

On April 4 I returned to South Africa thinking I was there for a root canal, which cannot be performed in Rwanda. When the dentist (who's worked on Bono!) took a look, it turned out no root canal needed - but he did have to repair some shoddy dental work done in Rwanda. Aside from the dental appointments, it was basically a second vacation to South Africa. I enjoyed many of the same foods, still marvelled at drinknig tap water and taking hot showers with pressure, and brought even more varieties of cheese back to Rwanda at the end of the ten days.

Partly because I'd told them about my vacation in February, I couldn't bring myself to tell my village I'd gone too South Africa to have my tooth problem addressed. People in my village were aware of the problem and knew I was having trouble, for example, eating corn. Their suggestions for this ranged from having the tooth/teeth pulled to theorizing that my wisdom teeth must be coming in (my wisdom teeth are long gone). I just could not figure out how to explain to a village full of extremely poor people, many of whom have never even been to Kigali and whose only recourse for toothaches is rudimentary extraction, that I went to South Africa on an airplane because of a toothache, all expenses paid. The inequalities there boggled my mind.

HIV/AIDS in Rwanda

On this, World AIDS day, I'd like to share a few statistics about HIV/AIDS in Rwanda.

Rwanda, like other Sub-Saharan African countries, sees the greatest incidence of infection via heterosexual transmission and mother-to-child transmission. Rwanda has a generalized epidemic at a low to moderate level: official records state about 3% prevalence in the country, which is lower than levels in Washington, D.C and lower than all of Rwanda's neighbors. The brunt of Rwanda's AIDS epidemic is in cities: 7.3% in urban areas (11.5% in Kigali and 5% in other urban areas) with only 2.2% prevalence in rural areas.

Rwanda has made great strides in recent decades in lowering transmission rates, through sex and especially from mother to child. The age of first sexual encounter here is about 20, which is older than Rwanda's neighbors. Rates of risky sex are also lower here. During the course of a year Rwanda manages to test about 10% of the population, including required testing for pregnant mothers. ARVs here are free, although the fact that 2/3 of ARV patients are women implies that there are some men who are reluctant to seek testing or treatment. Stigma is relatively low at this point in the epidemic, but it does exist.

The largest and growing risk group is 15-19 year olds in Kigali. Risk factors include that it's a regional transportation hub, Kigali's appeal to young Rwandans looking for jobs, the sugar daddy/sugar mommy phenomenon, and Rwanda's rapid urbanization. The Sugar Daddy issue, in which girls in secondary school receive tuition and other goods like cell phones and phone credit from much older men in exchange for sex and have little power to ask to use condoms, explains the otherwise counterintuitive fact that there is a higher prevalence in HIV among women achieving secondary education: 6.4%.

There are other challenges: some people believe the HIV/AIDS rate is underreported here and may be as high as 10% (and that neighboring countries also have underreported rates). Also, Men who have Sex with Men (MSM) are at a huge risk for HIV around the world, but recognition that they exist at all has been slow to come, let alone services tailored to educating this group and reducing their risk.

Malaria prophylaxis: did you know?

There are three common types of malaria prophylaxis: Mefloquine (a weekly hallucinogenic, see below), doxycycline (daily, also an antibiotic, and with the ironic side effect of increased sun sensitivity) and Malarone (daily, few side effects outside of the hit to your wallet).

Prophylactic pills keep you from getting sick with the symptoms, but malaria is likely still in your blood. After you leave a malaria zone, one type of malaria goes away after each time you have it while the type that lives in your liver should be flushed out with a dose of drugs (which cannot be taken if you have a G6PD deficiency, explaining why Peace Corps requires that obscure test).

The mefloquine (brand name Larium) that I’m on is a weekly pill that is known to cause vivid, sometimes hallucinogenic dreams and/or sleeplessness. I have trouble sleeping the night I take it, but I’ve gotten used to it, dreams of fires and murders aside. Anxiety, depression, psychosis or neurological symptoms such as walking crookedly have been known to develop, in which case you can switch to doxycylcine, a daily pill which has the ironic side effect of increased sun sensitivity. But guess what’s worse than side effects? Malaria.

Poison follow up

Here’s a follow up to the poison post I made last week.

B. says his sister is getting better but still in the hospital. However, they moved the kid to their brother’s house, and he’s recovered.

On the way home from the World Cup third place game, I asked my colleague W. about poison; specifically if he believes it is the cause of B.’s sister’s illness. W. unleashed a lecture about poison, paraphrased from memory below.

“It’s real. It’s powerful. I’m telling you it’s real. There are cases I have heard, you cannot deny them. It is why we cannot allow you to stay with these people who invited you [members of a rural cooperative we work with]. You cannot know what people will do. You must always watch your drinks.”

He told me a few stories about poisoning, which often seems to be the Rwandan term for witchcraft in general. According to W., some farmers put “poison” on their corn. Then, when a thief tries to pick an ear, his hand gets stuck to the corn and the thief can’t move until the farmer returns.

Another story involves a truck driver who suspected his wife was sleeping with other men while he was away. He left poison in the bedroom, and she and the man were stuck “in this way, somehow together, like the man and the corn,” until the truck driver returned home to catch them.

Toothpicks: Rwanda's national post-meal passtime

Rwandans love toothpicks, or kirida. It may sound mundane, but never have I encountered a group of people who so universally love to use a toothpick after a meal. Be it in a restaurant or a middle class home, you will always be offered a toothpick following your meal, usually one of dubious Chinese origins that may or may not break off between your teeth, joining the goat meat or pineapple already stuck there. The simplest box of toothpicks costs only 100 francs, or less than 20 cents. Boxes typically have little holes in the top (the black area, right) so that toothpicks can be shaken out individually in a hygienic manner.

As usual, I get a kick out of some of the imports from China, particularly the "Delightfully fresh and each Vogue" toothpicks and the "Toothy-Fruity" variety with "fruits flowers" flavor tips on one end (click to enlarge):

Even babies love kirida! This is my adopted host sister in Nyanza.

The toothpick craze helps to explain why middle class Rwandans have such great teeth. For poorer Rwandans, toothpicks and other means of dental hygiene are unaffordable. Compounding the problem, raw sugar cane is widely consumed by the poor, meaning that among the other class divides here there is a clear gap in dental health.

Poison

I've known for a few weeks that my colleague B.'s sister is sick. He's even been late to watch a few world cup matches in his own home because he was praying with her. Today on the way back from working in Nyakiliba sector he said we were going to visit her in the hospital in Muhoko sector. Only districts have hospitals, and ours is in Gisenyi, so I asked him, "Do you mean the health center?” No - B. explained that his sister was sick with a mental disorder because she’d been poisoned. The hospital we were going to was a traditional hospital.

I’d heard about the Rwandan belief in poisoning, but this was the first time I encountered it personally. Basically, there are many diseases doctors here can’t diagnose. They lack the technological means to scan a body for cancer and there isn’t a lot of knowledge about invisible illnesses, be they degenerative or temporary. If a doctor can’t diagnose and treat a patient, many times the family (or even the doctor) blames poison, uburozi. “Bamurozi,” they say: they poisoned her. Who is they and why would they want to poison someone? These questions go unanswered. The patient is treated by a traditional healer, an umuganga gakondo, also called a witch doctor. In the case of B.'s sister, the nature of her mental disorder is that she sometimes says things that don't make sense or says non-existent words.

The traditional hospital and witch doctor were not at all what I expected. The hospital was a collection of houses, and the one we entered had several large rooms with 3-4 beds in them and a few small private rooms. All the beds had mosquito nets. Because B.’s family is well off, his sister had a private room. Her son, who is thirteen months old, was with her on the bed. A man came in and talked briefly to B. and his sister; he was well dressed in slacks and a dress shirt. Imagine my surprise when I was told he was the “witch doctor.” According to him, the sister’s condition is improving. After he left, we discussed the child, who has been vomiting and refusing food for a few days and had just vomited up a piece of soap he’d presumably found on the ground. As B. pointed out, the conditions were less than hygienic. Then B. said a lengthy prayer, and we said our goodbyes.

B. is an educated, middle class, religiously Christian Rwandan whom I’ve seen deliver excellent speeches on nutrition and other health topics. Yet he is among many Rwandans who believe in the poisoning phenomenon, and who turn to traditional healers for a cure. He acknowledged that the conditions of the hospital were not clean, and were probably the cause of the child’s illness, but thought that the doctor was healing his sister.