I have spent a number of years in sub-Saharan Africa (most of my life since 2014), but my time in DRC in 2020-2021 was unlike anything I have ever known. Among some, mentioning Congo may evoke negative guttural reactions, due to the prolonged conflict, and since Congo is normally only mentioned on western news with respect to the conflict, violence, Ebola, measles, or natural disasters. These issues are all par for the course in Congo, which has known a conflict—and the human and other toll of conflict—in the eastern part of the country for more than 20 years. Ebola is endemic in DRC, and unfortunately the country is vulnerable to natural disasters. For example, a volcanic eruption in the city of Goma last year displaced more than two million persons in May 2021 (on my birthday, which seemed a bad omen). The humanitarian needs are chronic and heartbreaking in DRC and unfortunately there will likely be a continuous high level of need for many years to come.

However, Congo and its people are much richer and more vibrant than the abundant stories of horror. For me, the intensity of life in Congo was palpable. From the moment I arrived, I recall the vibrant colors, intense traffic, markets where you could buy anything, and could feel a charged energy in the air unlike what I’ve experienced before. My time spent in DRC was filled with new friendships, and a deepening understanding of the impact of conflict and violence, of human nature and cultural nuance. I found North Kivu in particular to be a place of contradictions; a province perhaps at the epicentre of the conflict, yet as beautiful as a painting, composed of lush green rolling hills, mountains, and quaint villages. Women dressed in pagne (traditional fabric) dot villages and the countryside in a rainbow of patterns, carrying on with their daily activities.

-Masisi, North Kivu, 2021

In Congo, I felt more than any other time in my life, that the reality was stranger than fiction. Each day brought new challenges, for us and even more so for the population, including severe life-altering and threatening difficulties that no one should have to deal with constantly throughout their lives. Perhaps normalisation of such extremes is a coping mechanism. Perhaps this is the role of myth, and the intermingling of myth and reality that was sometimes palpable; as a means of making sense of this environment, and a way of coping with it.

I have never witnessed such strong resilience, such strength in character, as I have in Congo. Women who are survivors of sexual violence are often rejected from their communities and families due to stigma, yet they continue on, caring for their children often with limited or no support whatsoever (such as socio-economic support). Often, women who have been sexually assaulted while harvesting in their fields, have little choice but to return to them (the choice is between returning to them, or that they and their families starve) highlighting both issues of protection linked to extreme socio-economic vulnerability and food insecurity (and lack of sufficient aid), and a tenacity that one can’t help but wish was not necessary for survival. See (https://www.msf.org/sexual-violence-democratic-republic-congo)

Many families in North Kivu have been displaced repeatedly, sometimes multiple times in one year, often living in informal camps with limited aid available. Sometimes aid takes months or even longer to arrive, even basic necessities such as temporary shelter, food and non-food items. Sometimes it never arrives, or is of poor quality, and often what is available only meets a small fraction of the enormous needs. It is hard to imagine surviving under such conditions over many years. When the security situation degrades (which often occurs), humanitarian organisations have even more limited access in the areas most impacted.

On a more personal note, I find that the longer I spend in such environments, the more that I feel ‘split’ between different worlds/realities. I find it frustrating when people complain about wearing masks or when their preferred type of yogurt is out of stock temporarily. I recognise that this is not fair (everyone likes to have their preferred yogurt and other products ;) ), but please understand that reverse culture shock is not easy to manage. The price of beginning to understand other parts of the world and other people living in it, is that you yourself also change in the process in a non-reversible way.

-Kasaï Centrale, 2021

The views expressed in this article are the author's alone, and are not attributed to MSF or any other entities

From September 2019 until earlier this month (July), I was on my first mission working with MSF (Doctors Without Borders) in Malawi, a small landlocked country in southern Africa. Malawi (formerly Nyasaland) has been independent from British rule since 1964, after which the country experienced 30 years of one-party totalitarian rule by Hastings Banda. In 1993 a new constitution was put into place, ending single party rule. Today Malawi is a multi-party parliamentary democracy, divided into three regions (Northern, Central and Southern), and 28 districts, the subdivisions of which are quite relevant for the health and other sectors given the decentralisation of decision-making and budgets.

It was an extremely busy mission, leaving little time for blogging 😃. The mission itself was quite busy, and the political situation was also constantly evolving. During this period: there were frequent protests over the May 2019 election results; the Constitutional court invalidated the election results in February 2020 due to irregularities (this is the second time a court has invalidated an election in African history); a new election was held in June which resulted in different leadership; and there was quite peaceful transition of power. (see https://www.aljazeera.com/news/2020/06/historic-election-malawi-200626070010661.html)

The MSF Belgian mission has three projects: (1) an advanced HIV (late stage HIV (stage 3 or 4) or AIDS) project in rural Nsanje; (2) a prison project providing TB and other services in Chichiri prison in Blantyre; and (3) a project providing comprehensive one-stop sex worker friendly HIV and SRH (sexual and reproductive health) services to female sex workers in three sites (see https://www.msf.org.za/about-us/where-we-work/malawi) . Things have been especially challenging with Covid-19, in a country which has an extremely weak health system and severe resource constraints (limited hospital beds, challenges ensuring adequate supplies of medicines and other basic equipment, severe human resource for health constraints, among many others). Medical operations have all been adapted to support the Covid response. Unfortunately, the mission will close later this year.

There is so much that I could write about the last year. Perhaps most notably, I've gained a deeper understanding of the extent of the need for quality, non-discriminatory health care, especially for the poor and marginalised (prisoners, key populations, those in remote settings, adolescents, women). Yes, access barriers to health services have been a significant focus throughout my career. However, spending more time in the field and working for a medical humanitarian organisation has provided a better, more concrete understanding of the barriers themselves and their impact, and what needs to be done.

The needs in Malawi are great, multiple, cross-cutting and ever-changing. The health sector relies very heavily on international donors, in a world in which health politics are increasingly complex and many countries have turned inward. Yet, the country manages to make remarkable strides with their limited resources, in the context of HIV and beyond. Malawi is one of the poorest countries in the world, and Nsanje is the second poorest district; yet the country provides national health care for all and without charge (though user fees may be introduced which is a separate discussion). Malawi is also, for example, rolling out more point of care machines at the health centre level to improve diagnostics for advanced HIV. The new National Strategic Plans for HIV and TB, and other policy documents reflect a well reasoned approach to address the needs of a growing (and aging) HIV cohort with integrated service provision, with adapted approaches for specific populations. Perhaps even more importantly, I greatly respect and appreciate the kindness, persistence, and strength of many Malawians I've met, professionally and socially.

photo: The team and I traveling by moto in Makanga, Malawi to get to Chintedza's village

A snapshot of the last year was captured in an article I wrote recently about a trip to Nsanje, which highlights heartbreaking and severe access challenges facing those in remote parts of Malawi, which make me appreciate how unequal and unjust the world is. While there has been significant and commendable progress in the HIV and TB responses, there is still a long ways to go. There is perhaps even further to go, in order to reach any measure of health equity.

AIDS deaths have reduced by 60% globally since the peak. While this progress is significant, many people seem to think that AIDS is over, which this is far from true. In Malawi alone, a country of approximately 18 million persons, each year 13,000 people still die of AHD (Advanced HIV disease). TB is a great contributor to AHD mortality, as are infections and other AHD-related illnesses. This was the case even before Covid-19, along with many socio-economic, quality of care and other barriers. Undoubtedly, there will be significant lost ground due to Covid-19, which is ruinously disrupting all aspects of life all over the world, including HIV, SRH and other health care services. For those with already limted/tenuous access, who facing great economic, logistic and other barriers, the impact of Covid-19 is potentially disastrous, particularly for AHD patients who are generally already in poor health.

For those of you who have never met someone with advanced HIV, it is devastating and difficult to behold (see image in article--link below). Their bodies, and sometimes also their spirits, may be quite fragile. When someone is in an advanced stage of HIV, they may experience a condition called 'wasting' in which they have very little body fat and muscle, with their bones protruding significantly. Someone with AHD typically has a low CD4 count (a key indicator of immune function and HIV progression), and urgently needs high quality services --generally tertiary or hospital care--to ensure they are stabilised, diagnosed with any OIs (opportunistic infections), and initiated onto treatment/switched to second or third line ARVs. A high portion of AHD patients die within the first 48 hours of admission, illustrating that measures need to be taken rapidly, efficiently and by well-trained providers in a setting that has necessary medical equipment, tools and medicines.

The recent article is about some of the access barriers faced by one individual, Chintedza, a chief we were seeking to interview in extremely remote and difficult to access Makanga (an island only accessible by boat, with no cars). Chintedza had previously been in Nsanje district hospital (quite a distance from Makanga), but had thereafter been discharged after his condition improved (we went to visit him some time after the discharge). The time in the hospital was difficult for his family and community, given economic and other barriers; they had difficulty paying for food for the person accompanying him during the hospital stay. The article was from a visit to Nsanje in January, highlighting how difficult things were prior to Covid-19.

To better understand some of the challenges concerning AHD, and how this still impacts lives and communities in Malawi, please read the article in the link below.

The article can be accessed here: (https://www.msf.org.za/stories-news/staff-patient-stories/aids-has-not-disappeared-reality-advanced-hiv-disease-nsanje)

photo above: Bangula, Malawi. Where you board the boat to get to Makanga

photo above: On the boat, on the way to Makanga

The content in this article is the opinion of the author, and is in no way attributable to MSF.

Île de Ngor

One: Don't ever wear white pants.
Ne portez jamais un pantalon blanc.

Two:Boxing matches are extremely important and may result in children (and adults) shrieking in the street.
Les matches de boxe sont extrêmement importants et peuvent provoquer des cris d'enfants dans la rue.

Three: There are exceptional and inexpensive meals down hidden corridors.
Il y a des repas exceptionnels et peu coûteux dans les couloirs cachés.

Four: Goats don't always like the sea.
Les chèvres n'aiment pas toujours la mer.

Five:The disco clubs are crucial for purposes of explaining directions to taxis, especially the one inside the large lion head.
Les discothèques sont essentielles pour expliquer les directions aux taxis, en particular celle a l'interior de la grand tete de lion.

Six: Management of trash is a complex problem, and crucially important for meaningful development.
La gestion des déchets est un problème complex et d'un importance cruciale pour un développement significatif.

Seven: "Nanga def" means hello, how are you in Wolof.
"Nanga def," ça veut dire "bonjour, ça va?" en Wolof.

Eight: The monument of African resistance weights 70 tons and was built by the North Koreans.
Le monument de la renaissance Africain, il pèse 70 tonnes et étais construit par les coréens Nord.

Nine: Senegal's independence was in 1960. Senegal was colonized by the Portuguese, English and French. The Isle of Gorée was an important cite for the slave trade. Today, there are remnants of this darkness and ghosts.
L'indépendance de Senegal, c'était en 1960. Senegal a été colonisé par les portugais, les anglais et les français. Île de Gorée était une ville important pour le commerce des esclaves. Aujourd'hui, il y a des vestiges de ces fantômes et des ténèbres.

Île de Gorée

Ten: Dakar is known for trade in textiles, fish, among other industry, and is very much an international city.
Dakar est connu pour le commerce des textiles, poissons, entre autre industrie, et c'est une ville très international.