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In a Constant State of Emergency
September 27, 2004
For the casual observer the recent history of the Democratic Republic of Congo (DRC) can be narrowed down to a few defining outbreaks of violence or disease: violence in Bukavu in March 2004; before that Ituri in July 2003; ebola striking the headlines from time to time.
Yet these events are the tip of the iceberg. All year long the four Doctors Without Borders/Médecins Sans Frontières (MSF) Congo Emergency Teams cover emergencies non-stop. Known by their French acronym, PUC (Pool d'Urgences au Congo), the teams are based in Kinshasa, Mbandaka, Lubumbashi, and Kisangani, and reach across a country the size of western Europe. Charles Kisamba, MD, works in the Kisangani-based PUC (in the northeast of the DRC), which covers the Eastern Provinces as well as the northern zones of the Maniema Province.
"Our PUC in Kisangani is capable of carrying out three simultaneous interventions," says Dr. Kisamba. "But two is more reasonable." By the end of June 2004, they had already received 27 appeals for assistance, with 10 coming in January alone. From those, the PUC carried out 14 exploratory missions, of which six required MSF interventions. Currently, one team is dealing with a measles epidemic in the Yahuma region.
"This started right at the beginning of August when we received an alert from our mobile team in Lobutu, verified by village chiefs and nurses from the local health centers," says Dr. Kisamba. "So we were off to investigate and intervene."
On this occasion, the outbreak was extremely serious, 326 cases in two weeks across four villages, so the team had to work fast to stop the spread. "We quickly set up four diagnostic and treatment centers," says Dr. Kisamba. "First, treating the infected cases and creating isolation facilities to cut the transmission chain, and for the rest, we began a public awareness campaign to inform parents to separate healthy and ill children."
Due to a lack of medicine and education, combined with old cultural habits, people see measles as a mystery, a spell. So they go to a traditional healer. It is only when the healer sees complications he can't deal with that the child is brought to a health center. The death rate for measles can range from 10 percent to 30 percent in malnourished children. "Sometimes it's too late and the child dies," says Dr. Kisamba, "sometimes we can turn the tide."
Measles is one of the biggest threats in the region and is particularly difficult to stop once an outbreak has occurred. "Vaccination coverage is very low, malnutrition is rife, and due to the war, the health system is in ruins," says Dr. Kisamba. "These factors help the rapid spread of disease and children are just not protected."
Battling 13 diseases
Measles is only one of the 13 diseases covered by the PUC. Others include common killers such as cholera, malaria and diarrhea-related diseases, as well as the more unusual, such as ebola, meningitis and the plague.
PUC is also currently preparing an intervention in Dingila in the north of the Eastern Province to deal with monkey pox. The mortality rate is approximately 15 percent. It is virtually unknown to the medical profession and therefore extremely difficult to treat.
"This is an animal pox, for squirrels and monkeys, which can unfortunately be transmitted to humans," says Dr. Kisamba. "Hunters often get infected as well as those who've been in contact with dead animals." Monkey pox causes eruptions on the skin, which are entry points for other microbes, and can lead to loss of organ fluid and electrolytes. This can cause death. With isolation and public awareness, the transmission chain can be cut, but without MSF assistance, the local hospitals don't have the means to correctly treat patients.
Facing a range of challenges
Dealing with little known diseases is only one of the difficulties faced by the PUCs. "There are several levels," says Dr. Kisamba. "The first level of problems concerns infrastructures. Communities are deprived of absolutely everything, a state heightened by the war and the poverty."
A further difficulty comes with dealing with authorities in the field. "Sometimes they cooperate, sometimes quite the opposite because they ask for things that we are not in a position to give them. Otherwise, the state of the roads can be an obstacle, especially in the rainy season. But we try to progress the best we can and with enough determination we usually manage to get through."
The legacy of the front line which until very recently cut a swathe across the Eastern Province, is that the region remains highly militarized. And after years of fighting, insecurity can also be a problem.
"In February," he says, "we had some problems between Lubutu et Walikali with armed groups on one side, and the military forces on the other. Everything is stolen without distinction when you're faced with armed people. They don't know what MSF stands for. In some cases we've just had to cancel a mission and wait for security to improve."
But through all of this, what holds the most fear for him? "Suspected cases of viral haemorrhagic fever," says Dr. Kisamba with a barely a moments' thought. "For this you need a maximum of precaution and good preparation. We do rehearsals before going to the field because if you commit the smallest error, there is no safety net. But we do our job as doctors. We care for the patient and the lucky ones make it."
"In January, I went to Bafwasende to treat and take blood samples from suspected cases," he explains. "They were positive, but for West Nile and Chikunguya viruses, from the same family as Ebola, just less fatal."