Reflections about empty churches, independence optimism, and hospital inefficiencies

I returned from our trip with lots to contemplate and reflect on. Here are a few of my thoughts.

Missionaries, mines and malnutrition in Nyanga

During this visit I was able to experience Nyanga a little more than on previous visits, because I was there on a Sunday, and because I was able to walk around Nyanga a little with Ida. In the past we had usually been too busy working at the hospital to really get out and about. I am glad to have learned more about Nyanga, but sad that what I learned was almost uniformly depressing.

One morning I accompanied Ida on her trip into the village to buy food for the day’s main meal. As we walked along the main avenue, we came across the occasional stall set up outside someone’s house, where a few basic items were being sold: toothbrushes, soap, sugar, coffee. One stall sold second-hand clothes. Fresh vegetables were extremely scarce. I saw one basin of corn flour, one basin of rice, one small table of pilipili peppers, one tiny table with a couple of tomatoes and a pineapple, and two stands with dried fish. I also caught sight of some garlic and onions. There was also a house that sold palm wine, freshly tapped, from a row of gourds suspended on a stick. As we went along we eventually arrived at the actual “market” – a few empty tables in a clearing. Ida assured me that this market was no better stocked than the avenue, and that there was no actual market day. When compared to the overflowing markets in Mukedi and Kajiji, Nyanga, with a similar population, seems a wasteland. I learned from Ida that finding an accompaniment to the daily fufu is a real challenge. Sometimes people come to her house to sell pondu (manioc leaves) or to tip her off that a cow is about to be slaughtered. But more often than not, she relies on her own chickens and rabbits for a reliable supply of meat, and gets her husband to bring whatever he can from Kikwit or Tshikapa.

Ida and Gaspard’s situation is relatively good because they are among the few who have access to cash to purchase the food they need – but most inhabitants of Nyanga have to make do with the bare minimum; children may end up eating just fufu and salt. When I talked with the Médecin chef de zone (health zone director) stationed in Nyanga, he told me that Unicef’s latest survey showed a 14% rate of severe malnutrition among children under five in the Nyanga health zone – a very high number even for Congo. As I walked through the village, I saw several small children sitting listlessly on the ground, looking sick – something that I had not seen in other villages.

Why is Nyanga’s situation so bad? According to Dr. Gaspard, because Nyanga is located in a diamond region, people had gotten into the habit of surviving off artisanal diamond mining and had never developed a farming culture. Now that the diamond market has crashed, they are in trouble. In addition, while many families would produce at least some corn and manioc, people often choose to sell their food for cash instead of consuming it, or convert it into local alcohol for sale. The little bit of money received doesn’t pay for many essentials at Nyanga’s high prices – all goods have to be transported from Tshikapa, 100 km away, by bicycle, motorcycle, boat or large truck. Recall that in Tshikapa, a loaf of bread worth 100 FC in Kinshasa sells for 250 FC; add a markup for the transport, and the salary of a typical nurse at Nyanga hospital who is paid about 8000 FC a month doesn’t stretch very far at all (of course, people in Nyanga don’t buy bread because fufu is cheaper – but the same idea applies to other products).

As Nyanga’s situation started to sink in, Sunday arrived; this was my first time being in Nyanga over a weekend. That morning I got up expecting church to start around 9. I had been told it could start between 9 and 10. That day, it was 11 before anything started happening. Dr. Gaspard and I went, while Ida stayed home. In the back of the church was a big pile of sand. There were wooden benches, which were filthy and had to be wiped off before we could sit on them. The benches were obviously not frequently filled. The church felt like an old, empty, echoing shell. There were less than 30 people present, including only 5 children, in a building designed for about 500. Singing was half-hearted. After living in Congo for a while, I now know that such a situation is highly unusual. Run-down church buildings are commonplace, but are always compensated for by attendance, music and charisma. All the churches I have visited until now, which the exception of one other CMCO church in Mukedi, have been full, with a strong group of children, several choirs even on the most ordinary of Sundays, and energetic, lively singing. As I sat in this church listening to the sole choir accompanied by an out-of-tune guitar, with memories of Nyanga’s “market” and its starving children still fresh in my mind, I started to become angry. Dr. Gaspard tells me that “this is what is happening in all our churches”, that is, they are being deserted by the youth. However, in Nyanga, apparently no churches are well-attended, not even the Église de réveil (Independent churches that have exploded in Congo). Again according to Dr. Gaspard, churches have emptied because people have gotten fed up with their pastors practicing adultery and witchcraft. As I sat there, I asked myself how the people of Nyanga became so bewildered, shiftless, unanimated and dysfunctional. Nyanga has had a large share of missionaries and development workers, including many MCC workers. I wondered what these people would say if they could see this church and this village now. I wish someone would tell them that the churches are empty, the former rabbit projects promoted by missionaries have ground to a halt, and the people of Nyanga are struggling to survive while surrounded by fertile land. I want the situation to be widely known, not so the missionaries will come back and do more of the same, but to promote some serious reflection about what exactly was going on here during the missionary period, that led to so few tangible results.

After the service, I poured out my thoughts Dr. Gaspard and we sat and talked for about an hour. He said that former missionaries sometimes visit Nyanga, but because their visits are announced in advance, the churches usually fill up – there are plenty of former members out there who can be rustled up and can sing a mean hymn, apparently. So outsiders might not know what the reality is really like. And on the topic of missionaries, in his opinion the missionaries didn’t invest sufficiently in people, and in preparing people to truly take over responsibility for churches, schools, hospitals and other structures after the missionaries left. Moreover, he feels that the missionaries taught hypocrisy, by preaching against drinking while drinking surreptitiously in their homes.

I asked him if he thought that contact with the West should end. He answered that none of us are sufficient to ourselves: we all need each other. Perhaps if all missionary and development assistance ceased, people would wake up one day and realize that they need to take responsibility for themselves. But though that would be a good thing, Dr. Gaspard insists that there should always be exchange. The important thing, though, is to promote true exchanges. In his own words, “the hand that gives is bigger than the hand that receives,” and in the past, exchanges tended to be unequal. He doesn’t want to see any more exchanges where one side is always asking for more, hand outstretched. An ideal relationship would focus on investing in people and in their capacity and their ability to manage themselves.

Two weeks later, thoughts about Nyanga keep on circling in my mind. I feel angry, sad, and frustrated, without knowing whom exactly I am angry, sad and frustrated with, and what exactly I should do about it. Disseminating better information seems like the first step, and Dr. Gaspard encourages me to do so … but where to go from there?

June 30th celebrations – a glimmer of hopefulness for the DRC

You can listen to a great Congolese independence song, composed pre-1960, here. This song played over and over again on TV on June 30^th. One delightful evening program showed several “traditionally built” women interviewing some of the original performers and composers of this song, and then dancing to this tune with them, clad in 50^th anniversary print pagnes.

In Kikwit, John watched a huge parade from the balcony of his guesthouse and even managed to sneak a few photos. There was no parade in Nyanga, but since Dr. Gaspard and Ida have one of the few televisions around, several of their friends joined us to watch the celebrations in Kinshasa. It looked like a grandiose day, and following months of roadwork in Kinshasa, the capital was looking better than ever. I was interested in the eight prayers spoken by the leaders of Congo’s eight main religious confessions: Kimbanguist, Muslim, ECC (union of protestant churches to which the Mennonites belong), Salvation Army, Revival Church, Independent Church, Catholic, and Episcopalian. Several asked forgiveness for Congo’s sins; all prayed for protection for the president and his family, and a couple mentioned the problem of corruption. President Kabila gave a long address which we all listened to attentively; he covered a lot of ground and said all the right things, though without much charisma. The parade following his speech was impressive and long. It was curious that the speeches started late because of the late arrival of Paul Kagame, Rwanda’s president, and that the microphone, which had worked fine for all the prayers, suddenly went quiet when Kabila stepped up to it – the first minutes of his speech were marred by loud feedback and frequent cutting out. Later in the day the TV broadcast an excerpt of Lumumba’s fiery 1960 Independence Day speech – the minute it came on, Dr. Gaspard’s attention was riveted, and he kept saying, “That’s a real speech!” I invite you to listen to it (audio only with English subtitles) here.

My feeling is that many Congolese people felt doubtful of what the June 30^th celebrations would amount to, but that most were pleasantly surprised when the day came. I feel a tiny current of hopefulness about Congo’s future that wasn’t there before. When we returned to Kinshasa, the chauffeur who picked us up at the airport took us along the new Boulevard Triomphale – I commented that it looked great, and he replied, “You haven’t seen anything yet, just wait until the next part – this is a real boulevard!” It was the first time I had heard such pride in anyone’s voice about their city or country. I can’t help feeling a little hopeful myself, though it is marred with shame when I read about Canada’s (fortunately unsuccessful) blockade of debt relief to Congo because it might threaten the former’s mining interests.

Hidden leaks at Mennonite hospitals

While in Nyanga I spent a large part of my time helping the hospital lab staff to analyze their lab, in order to determine whether it is breaking even or running at a loss. I had some idea what to expect, because John and I had done similar analyses at other hospitals. It turns out that each month, the lab loses about 67% of its potential revenue, or approximately 120$, because it offers free services to such a large number of patients. Interestingly, even given such a large loss, the lab manages to cover all but 25$ of its monthly fixed and variable costs with its meager revenues. This means that if the lab were to tighten up just a little on the number of free tests offered, it could not only break even but start to generate revenue that would bolster other services at the hospital.

The lab staff and hospital administration had a general awareness that they were losing money, but clearly had no idea of the details of their financial situation. It was interesting to talk it over with them and to see them start to understand their situation from a new perspective.

When something like this comes to light, one way to interpret it is to compare it to a beam in a house that seems firm, but that crumbles when you touch because it’s being eaten by termites from within. But I think it is more accurate, as well as more positive, to say that we have simply gained a better understanding of some of the intangible staff benefits that motivate people to keep working in hospitals even though they aren’t paid a living wage.

A missionary recently told us that he feels sick when he hears people talk about sustainability in hospitals in Congo – he says that first, health care is not a business and cannot be sustainable, and second, churches in the West are well-off and have the obligation to help poorer brothers and sisters, indefinitely if need be. I sympathize with his point of view, but can’t help thinking that hospitals could be a whole lot more sustainable than they currently are, and that such changes would be only advantageous to all concerned. It seems a little condescending to assume that people are incapable of helping themselves and need outsiders to pay all their hospital operating costs; the reality as it seems to me is that outsiders’ dollars are often creatively diverted anyway, that ongoing losses at the hospital are due to mismanagement, inefficiency and lack of follow-up, not just to the poverty of the population, and that when subsidies inevitably end, people will be no better off than before if they haven’t been encouraged to manage the little they have as efficiently as possible. At least, this is the approach that we and the coordinating doctors have chosen to take. Perhaps this sounds condescending too?

A six-stop trip: Kikwit, Kanzombi, Mukedi, Kajiji, Nyanga, and Vanga (June 21-July 9)

What a trip!

It started on June 21st, when we traveled to Kikwit. We stayed there together until the 28^th, for a busy week that included our quarterly meetings with the coordinating doctors, and several visits to Kanzombi hospital. Both doctors were also busy preparing their July medication orders, and we spent some extra time at Zenufa, the pharmaceutical depot, observing the preparation of bills and packing slips.

A few days into our stay we started hearing rumours that travel would be restricted around the 30^th of June, DRC’s grandiose 50^th anniversary independence celebration. Since we had a flight booked for the 29^th, we were a little nervous. In the end, the flight had to be moved to the 28^th at the last minute, though even the flight provider wasn’t given official notice of the closure until just a few days before.

On the 28^th, John and I separated for a week; I accompanied Dr. Gaspard to Nyanga (300 km away), via Mukedi (200 km), with the medication delivery flight. Meanwhile, John stayed in Kikwit and worked with Gogol, Dr. Benza’s assistant, on reporting and computer training, and did some more work at Kanzombi hospital. At the end of the week he flew to Kajiji (1000 km away) with the medication delivery, and stayed overnight to help set up a cell phone signal enhancer antenna – unfortunately without success. The next day, accompanied by Kajiji’s medical director, he flew to Nyanga where Dr. Gaspard and I embarked and we all ended up in Vanga, a Baptist mission with a large hospital where the ultrasound training would be held. Two other doctors joined us there after traveling by road from Kikwit (about 100 km).

We stayed in Vanga three days, just to be present for the first few days of the two-week training and to make sure that everything was progressing smoothly. John and I were graciously hosted by three brothers in a Protestant order (one of whom is a doctor and is teaching the four Mennonite doctors how to use their new ultrasounds). We enjoyed some German- and Swiss-style meals and a beautiful evening Communion service with these men. Our trip ended on July 9^th with an uneventful flight back to Kinshasa.

I find myself feeling very tired and unable to face our regular responsibilities. Fortunately we have a few days off to rest and process the events of the last three weeks. As I look back, I see a higher-than-usual quota of stressful and unexpected events, along with a good dose of intensely thought-provoking conversations and discoveries, punctuated with a few delightful moments.

Unexpected and stressful

Dr. Gaspard hurt his foot (little toe bent backwards after hitting a root while on motorcycle; entire foot swollen) so he arrived in Kikwit a day later than expected after a gruelling and painful day of motorcycle travel.

Dr. Benza and his young daughter both got sick during our time in Kikwit, and had to leave earlier than expected to Kinshasa because of June 30^th closures; we lost a lot of the time with Dr. Benza that we had been counting on.

The cell phone signal enhancer antennas that we tried to set up in Kajiji and Mukedi haven’t worked yet; in both places our arrival to help set up the antennas was unexpected and our stay was too short (1 hour for me and Dr. Gaspard in Mukedi, about 20 hours for John in Kajiji) to be able to really test the devices. For example, in Mukedi, a pole was hastily put together, with the antenna at the top; Dr. Gaspard oversaw a frantic testing session while I reminded him that the pilot was waiting for us at the airstrip and that we were already overdue for departure…

The price to pay for a delicious snack of BBQ pork eaten in a local bar with Dr. Gaspard on the evening before our trip to Nyanga was a bout of food poisoning with fever, diarrhea, nausea and fatigue that overshadowed my first several days in Nyanga. Dr. Gaspard got sick too, though less acutely, but John, who barely touched the pork, was luckily unscathed.

The ultrasound training, tentatively scheduled for the end of July, ended up needing to happen about two weeks earlier; this required us to move very quickly to get manuals printed in Kinshasa, despite looming independence closures, to approve the budget more hurriedly than we would have liked, to deal with a sudden need for cash that we hadn’t planned for, to make lots of convoluted plans to circumvent our cash flow problems, and to make last-minute changes to travel plans to ensure that doctors could all make it on time. Fortunately, it all came together, and the training has gotten off to a great start.

And, saving the worst for last: on the evening of our arrival in Vanga, we realized that we had left several thousand dollars in our guesthouse room in Kikwit two days earlier. The room had already been cleaned and was being occupied by another guest… Fortunately, after some frantic phone calls, the money was retrieved, but not before we had had a really good scare! And even though the money was secure in Kikwit, we still had to deal with the fact that we didn’t have that money in Vanga where it was needed. It all gets very complicated when one lives in a cash-based society where large and small payments are all made with wads of 100-dollar bills or bricks of Congolese francs.

Ahhh… I am relieved that we made it through each of these frustrations, but realize that their cumulative effect has been to wear me out more than usual!

Delightful

During my visit to Nyanga, Ida (Dr. Gaspard’s wife) made delicious donuts that included lemon zest, eggs, sugar, oil, flour, yeast and baking powder. We sat and cut them out together on a low wooden table outside as the sun set, and fried them in palm oil.

The Ghana match was such a disappointment. But sitting and watching World Cup soccer with a dozen of Ida’s and Dr. Gaspard’s friends and colleagues, palm wine in hand, was delightful, and watching the Netherlands beat Brazil was especially so!

I really enjoyed talking with the pharmacy manager at Nyanga hospital. He is exceptionally detail-oriented and is doing several checks on his own initiative to follow the medications more closely. For example, every day he checks the theoretical revenue from medication sales with the money in the cash box (kept by a different person), even though MCC has never asked him to do so. He also does a mini-inventory several times a week of medications kept in the night nurses’ office for midnight emergencies, and keeps track of any discrepancies that would indicate that medications had left the cabinet without being paid for.

In Kikongo, where our return flight made a brief stop, we saw a kitten playing with a clawless river otter cub (an endangered species)! Both animals (along with an antelope and a few alligators) are being raised by a missionary couple. See this article for more details.

Thought-provoking

I’m still thinking… see the next post for some more in-depth reflection about some of the things we experienced on our trip.

John waking up at Kikwit guest house

In Dr. Benza’s office for our quarterly meetings

In Kajiji, trying to set up the antenna

30 June parade in Kikwit

Anicka with lab staff in Nyanga

Lab staff and hospital administrator in Nyanga

Mud bricks being dried for a new building at Nyanga hospital

A nurse administers an IV drip to a child with malaria

Nyanga Mennonite church

Nyanga Mennonite Church from the pulpit

Nyanga Mennonite church, Dr. Gaspard in the back

At Dr. Gaspard’s house on the day of the flight to Vanga

Anicka in the very back of C206 on Nyanga-Vanga flight

Vanga hospital (a major regional hospital) – location of ultrasound training

Learning some theory about ultrasound in Vanga

Trying out the ultrasounds for the first time

Starting to feel comfortable with the ultrasound

John, Anicka, Dr. Nikez, Dr. Friedhelm, Dr. Gaspard, Dr. Shatambi, Nurse Léon, Dr. Ngangula

Congo clawless otter in Kikongo