Hi guys
From kigutu-

a small lushly green hilltop in Burundi, three hours and many bumps along a dirt road outside the city.
It is raining. Hard. The rain is some of the only noise here. Open fields and open sky. And a makeshift hospital. 10 beds very little equipment. As beautiful as this area, the hospital is opposite. for now. I think of Orwell’s short story- “How The Poor Die.” This is the African version some 50 years later. But before this hospital, even less.
this area knew a lot of violence. One of the most violent areas during the burunidan genocide. Only relatively safe since 2006.

At night you can see the lights that look like a city. Across the lake is the Congo. Orange florescent against the black sky. You think it’s a city. Everything you have ever known tells you it’s a city. But there is no electricity here. Or there. It is fisherman holding lanterns in canoes fishing. The light attacts the fish. I wonder if they can swim and if its scary fishing in the second deepest lake in the world in the darkest of darkest nights.

There is misery here. And singing. Usually singing right alongside misery.
Jos is 33 and looks like 65. 60 pounds. she has been here, hospitalized since February 8th. her daughter(in picture-in yellow) is 8 and sleeps next to her mom that wastes away slowly. What will she do when she finally disappears? For now she sings, and dances and laughs all around the compound. And poses for pictures as she sings the Burundian national anthem.

The Burundians. I don’t speak Kirundi. Even if I did it wouldn’t bridge the gap.
They have lived through so much. It is really hard to imagine. And I am outside of it. So far from it. Thankfully.
But physically here. There are a lot of refugees making their way back to Burundi from Tanzania. At this clinic, on top of this hill, every day about 80 people line up to be seen. There are 12 in patients. One is Joselyn. She has inguinal lymph nodes the size of golf balls. She has lost 20 pounds since she got here and we are trying to figure out what she has. Tuberculosis or cancer. We hope its tuberculosis because there is hope there. That we can treat. Cancer, she will die. If its cancer, I am encouraged by the fact that she would die even in the united states with this degree of cancer. That is not true for so many of them. Dumb diseases. Easily treatable diseases. Its like trying to open a door. And all you have a paperclip. But the paper clip has fallen on the floor in a large room that is pitch dark. And even if you find the paper clip you wont necessarily be able to open the door. Even if you figure out the disease, doesn’t mean you will be able to treat it. But you know there are keys that can open the door. A million of them. But they cost money that you don’t have. So you just piecemeal with what you have. And doctors and nurses all around the world have been doing it for decades.
Everytime I think what I would do in the states and then again, what I would do here in Burundi. I always ask the burunidan doctor alongside me if we have such and such medicine. And he always smiles and says “no, we are poor”.

but there are some awesome folks here- the diabetic woman who on discharge is asked how far does she live? “Oh just there, over there she points.” No problem. When we ask specifically, over where? – she names the city. Turns out she lives about a 6hour walk away.


The chronicity is what gets you. The trickle down, little at a time constant nature of it. The ho-hum tuesday afternoon business as usual nature of it all. it is not a famine. not an international emergency by international standards. its just the constant stream of malnourished children that get admitted over here. with TB, with malaria. with HIV or just malnourished. casava bread that sits like a rock in their tummy. not an ounce of nutrition. the kid below is a before and after 2 months of intensive nutrition. It tells the story better than I can.

we are off the grid here. there is rarely electricity powered from the generator. our xray machine is broken and everyone has a cough. the nearest hospital is on strike.


what we do have is man power.
people who care. who know their local community. who are barely paid but paid none the less to daily trek up and down hills to deliver medications. community health workers that hand deliver HIV medications and TB medications to patients.
directly observed therapy. 45 community health workers right now. and when they call to say someone looks especially sick in the community- is coughing up blood, is losing a lot of weight, we send our ambulance along the pot holed steep mountains to go pick them up.
it is a good system. community health workers. accompagnateurs in french. accompaniment. an antidote to despair.
went on some home visits this past saturday. walking through the streets and going into houses and sitting on floors and talking to patients. it is the one thing we can offer for all our lack of equipment and tests.


the 25 year old with shortness of breath who realized before we did that she was dying.
TB with bacterial pneumonia. She asked to be washed clean, taken down to the outside dirt showers before she dies. And she was so short of breath but with an urgency she named names. A string of names for her husband to go tell them she loved them.
And a string of names for her husband to tell that she is sorry.


On two bright notes, one of our HIV patients family runs away from him when he goes home, because they think he is a ghost. They don't believe someone so sick
when they last say him can actually be alive.
We picked him up an emaciated skeleton and now he shadow boxes around the compound.

and I have seen so many malnourished babies. Kwashiorkor. and they recover. food as medicine. plumpy nut provided by unicef. an inpatient ward.
a custodian trained to heat milk, administer plumpy nut and these kids turn around. re-animation.
its pretty satisfying though its ridiculous that so many children are so food insecure.


there will be a roll call of patients who die. Memorize their names. Write them down and put them in your wallet.
If you write them down and live with them and make them matter to your life and your life matters to someone and their life matters to someone, the one who died without so much as a thought in rural Burundi…maybe they can deservedly matter...