A Tale of Tele-Education: Mouth Matters

(by Ted John)

A big part of our ministry in Burundi is medical education, a topic which has been previously written about and most recently here. A couple years ago, there was a major change in re-structuring the medical school curriculum such that med students would do nearly all of their clinical rotations at our hospital (whereas it was only about a third of their clinical time with us in previous years). Awesome! This continuity and increased face time had many positive implications, including more opportunities for building relationships at a deeper level and for medical education and discipleship. 

Not surprisingly, this transition also came with some added responsibilities, including the organization and teaching of more coursework, much of which was previously taught elsewhere by others. Thus, there has been increased time and effort putting together resources, creating PowerPoint presentations, and organizing courses to fulfill the med school curricular requirements (especially if it’s the first time a course is being taught at Kibuye).

It makes sense that the pediatric course would be taught by pediatricians, and we are thankful that the knowledge and expertise was contained within teammates on site. It’s no small task to organize a 75-hour pediatric course! But what about the courses for which we don’t have the specialties represented here at Kibuye? For example, Cardiology, Psychiatry, ENT, PM&R, Dentistry, Ortho, and the list goes on. Well, nowadays with modern technology, it’s possible to do this creatively in the truest sense of tele-education and distance learning using a combination of audio and/or video recordings and live video conferencing, often in both English and French.

I am certain each course has its own story behind it, but I will share a little about my personal experience of how I (a general surgeon) ended up organizing a 2-week, 15-hour dental course (“cours de stomatologie” in French), implemented and completed in December 2021.

Med student courses are usually taught in the hospital chapel

Back in August 2021, not long after I returned to Kibuye, I remember having a conversation with one of our teammates about how the dental course had been postponed due to the challenge of finding instructors. Then I thought about my dentist friends in the U.S., many of whom I had befriended when I was a med student at the University of Michigan (which also has an excellent dental school!). So, I contacted some of these friends (big thanks to Amy, Dave, and Ben), who all expressed interest in being part of the development of this course.

What went into putting this course together? In a nutshell, these were the major steps that occurred during the subsequent 3 months (in mostly chronological order):

•         Determine educational content based on provided learning objectives and context
•         Organize the material into 1-hour lecture blocks
•         Divide work amongst presenters
•         Create PowerPoint presentations
•         Translate English slides into French, if applicable
•         Pre-record each presentation as a video, in French if possible
•         Write quiz/test questions for each lecture (and translate into French)
•         Coordinate selected lectures over live video conferencing (Zoom) over different time zones
•         Proctor, grade, and submit results of quizzes and final exam

Dr. Ben Kang giving a lecture on inflammatory diseases of dentistry over live video conferencing (Zoom)

Things didn’t always go according to plan due to unforeseen circumstances, and an element of flexibility was required. For example, on the first day of the course, we had planned for a live Zoom lecture, but earlier that same day, lightning struck the hospital and damaged the Wi-Fi equipment. As a result, I had to re-arrange the schedule and show a pre-recorded lecture instead. It also happened that there was a concurrent anesthesia course, so the schedule had to be adjusted a couple times such that there was no overlap.

Dr. Dave Chiu giving a lecture on the temporo-mandibular joint

In the end, the content was delivered, even if not in the originally planned order, and all the students passed the course successfully (which I’ll take as a surrogate measure that some learning has taken place!). I even recognized the top performing students with a new toothbrush each.

I also gained some cultural insights about teeth and dental care in Burundi. For example, have you ever thought about what people in other countries and cultures do with their baby teeth? Most Burundians apparently throw it under their legs (described to me in the manner of hiking a football) and say the phrase, “nyamanza tora iryinyo ryawe unsubize ryanje ryiza,” which rougly translates as “a small bird will take your tooth and give you another (permanent tooth) that’s better.”

While I was glad when the course was over, it was definitely meaningful and worthwhile to be able to be part of teaching and equipping these future medical doctors with basic dentistry knowledge. Since it was the first time teaching this course, there was more upfront time and energy invested in content creation. But in future years, we should be able to use the same didactic content, and focus our attention instead on how to make the course better.

Group photo with all 46 students at the end of the course

What’s next? Well, there's actually a 45-hour "synthesis" course already underway, which is being coordinated by Eric and taught by many of our teammates. After that, I'll be coordinating a new 45-hour trauma / orthopedic course, currently being prepared for a tentative start date in mid-February. It’ll be a bigger undertaking than the dental course, but thankfully we have a French textbook as a reference and 5 surgeons involved (one of whom is an orthopedic surgeon who will be visiting Burundi at that time).

Looking back at my own med school days, I can say that I took the courses and the quality of education for granted. Funny how God is using my role as an educator now to give me a new perspective and deeper appreciation for anyone and everyone involved in medical education.

A Glimpse Into Daily Life

(by Michelle Wendler)

I've been doing a weekly interview with one of the local women to find out what daily life is like here in rural Africa. Here are some things I've learned.

Sleeping: 

Most villagers have a wooden bed frame with a mat made of reeds placed on top of it. To make it softer they might put down banana leaves under the mat. The majority have blankets but not the very poor. It's been cold lately...dropping into the low6 60's and even 50's at night. I'm cold on my warm mattress and with my comforter. When I asked how they stay warm at night she said they clutch their clothes around them and are very happy when the sun rises. 

There are no cribs for infants, they co sleep with the parents. The bed is placed against the wall and the baby sleeps between the wall and the mother, with the father on the other side of the mother. The mother will create a barrier between her and the baby so when the baby wets, it doesn't get her wet. 

Eating:

Most people have two plates, one plate for the children to eat off of (at the same time), and another for the parents and very small children. But very poor families will all eat off the same plate. An interesting side note; if your father-in-law visits, the daughter-in-law cannot eat off of the same plate. But his grandson can. And the daughter-in-law is supposed to be quiet in his presence and only speak of things that are important. 

Upper class families will have a table and chairs, but lower income will sit on boxes or small wooden chairs. But poor and upper class will always have at least one chair in case a visitor comes.

The majority of the population here in rural Burundi eat two meals a day. The rich can eat 3x per day, and the very poor, usually only one time per day. Unless you are very wealthy, breakfast is only consumed by small children (under school age) and is usually a small portion of the previous night's dinner that has been set aside and kept overnight in a small container. Refrigeration is unheard of here. Most school age children go to school hungry and eat their first meal at lunch time. 

Beans + one other side (corn, salad, sweet potatoes, potatoes, bananas and rice...(rice if you are rich) is what is eaten for lunch and dinner 98% of the time. Meat will be eaten sometimes only 2-3x per year at Christmas, New Years and maybe Easter. 

Water is the main source of hydration, but it's not purified. Many kids have stomach and digestive issues because of this.

Most people can't afford things like eggs, milk, and other fruits and veggies because they cost too much. Sometimes 11 people can live under the same small roof...kids, relatives, workers etc and it would be expected to give everyone the same portion. 1 egg costs around 500 fbu and the daily wage is around 3000 for those who have a job. Many are just farmers who live off what they grow.  If you have many mouths to feed, an egg by itself isn't going to satisfy but it might break the bank. I asked about the possibility of people raising chickens for their own eggs, but that would require a chicken coup, food for the chickens, and medicine. All that on the front end...when most people can't afford the next meal. The woman I was interviewing said that if someone is given a rooster which costs around 15,000 fbu, they would most likely take it to the market to buy a lot of "filler" type food instead of having one small meal of meat. 

Hygiene:

No showers or baths around here. Sponge baths. Not everyone can afford soap. After you clean yourself you rub on palm oil. The wealthy use margarine (Blue Band) or lotion. I have been using their version of margarine (Blue Band) and my skin feels amazing. 

Marriage:

If a couple wants to get married, their family / church / neighbors / elders traditionally ask them: 

1) Do you have a blanket?

2) Do you have a pot?

3) Do you have a bed?

These three items are considered necessary for starting a marriage.

Child care:

At age 5, the kids start to carry infants (2 months and beyond) on their backs. If the parents are too poor to afford a child care helper, then the kids stay home from school to help watch the younger siblings so the parents can work in the fields.

Status:

And lastly, a sign of wealth here are shoes / flip-flops / sandals. Those who own shoes are considered upperclass. 

I hope to do more of these interviews in the future and will share what I learn about the lives of our Burundian brothers and sisters. 

 

COTW: Tuberculeus Adenitis, PEPFAR and Education

 (from Eric)

Over the weekend, some of us were talking about the recent lack of medical blogs.  This is largely driven by the fact that, when you've done something daily for several years, you start to think "what is there to talk about?  It's just everyday normal stuff."  Not only is our daily work not-normal for the majority of this blog readership, but we in the daily grind need fresh ways to "see" what is around us, particularly when it proclaims goodness and hope, though the white noise of the everyday threatens to drown it out.

So, in that spirit, our first Case of the Week (COTW) in the last 11 months.  =)

My first morning back on Internal Medicine last week, my students guided me to the bedside of a new patient.  A young man in his early thirties, he had swelling on both sides of his neck that was quite painful, in addition to multiple weeks of fever and poor appetite.  Just before coming to the hospital, he had gone to a local nurse-run health center, which had tested him for HIV, which was positive.

The students wanted to know if I knew what was causing this neck swelling.  Yes.  Yes, I do.

Note the swelling on the side of the neck and the skin breakdown where it had been oozing.

Painful swelling of the lymph nodes on either side of the neck muscles in an untreated HIV+ patient with a couple weeks of fever and poor appetite in Burundi is about 99% certain to be Tuberculosis.  In fact, he even had the classic matted appearance and evidence of past oozing fistulizations which are typical of TB. We put him on TB medications (which are free) and contacted our HIV nurses to come and get him into the system to start ARVs in the next couple weeks (which will be free).  He slowly started to feel stronger and we let him go home yesterday, but he'll return in a week to start HIV medications.

***

For me, this guy is about as simple as my cases get, but I peel back the veneer of a To-Do list checkbox and find a number of things to celebrate:

1. THE PATIENT: This young man is probably going to do great.  Yet without a proper diagnosis and the medications for his problems,  he would likely die, from his TB alone, even more so from HIV.  His TB is curable.  With proper treatment, he can live a long and healthy life with his HIV.  It is a changed life, and I got to be a part of it.

2. PEPFAR: I don't think that most Americans are aware that the US has spearheaded the largest global health effort against a single disease (until Covid) via PEPFAR, which is the US President's Emergency Plan for AIDS Relief.  It was started in 2003 by George W. Bush, and has continued since then.  This fund has provided care in over 50 countries and is estimated to have saved over 20 million lives, largely in Sub-Saharan Africa.  The US is not extraordinary in regards to foreign aid compared to other rich countries, but PEPFAR is a great example of something America has done that has truly changed millions of lives.  

15 years ago, medicines for HIV would likely have been unavailable for this young man.  Around 10 years ago, it was found that, if someone is well treated with ARVs for their HIV, their ability to spread it to someone else drops dramatically, which has caused policy makers to try to get everyone with HIV on treatment, since it was prevention as well as treatment.  Now, though considerable challenges exist in implementation, the difference feels palpable to me.  Yes, this guy came in with previously undiagnosed HIV, but these cases feel increasingly uncommon.  This is a very good thing.

3. EDUCATION: I don't know the mental image of the above story that automatically comes to you.  But if it didn't include the white coats of at least 15 trainees or various stripes (medical, nursing, allied health), then it wasn't accurate.  All of this was an opportunity for these growing professionals to see a problem that they should be able to correctly diagnose and manage the next time.  HAU currently has hundreds and hundreds of graduates that trained at Kibuye that are now working all over the country and the region, and this was another small moment to help them to do that future work better.

First Term Tidbits

(reflections from Jenn and Michael Harling, penned by Jenn)

Kibuye team sending us off in prayer. 

We left Burundi for home assignment one month ago. We were with family throughout the holidays and have settled in Greenville, SC where we will spend the next five months. In addition to spending time with family, we attended a debrief at SIM* afterwhich, thanks to grandparents, Micahel and I were able to spend 24 hours alone to have a "mommy daddy date."  While we couldn't discuss everything that was going through our minds, a subject that we both had been mulling over was the fact that we agree that we not only "survived" our first term, but feel like we "thrived."  How did this happen? Short answer, God's grace and mercy.  Long answer, below:

At SIM home office for debrief

1. While the Holy Spirit continues to do work in our lives in identifying sin and refining us daily, a huge lession we learned during our transition from passport country to our host countries (France and Burundi) is this: It is essential to have our identity firmly established in Christ, not work. Before our international move, Michael grappled with this extensively, as he described in this wonderfully-written newsletter.  I highly recommend you click the link and at least skim it. (Bonus, see a picture of little Amelia and Madelyn at the bottom). Michael's difficulty with this and his idolization of work led him to be an irritable and grumpy person a lot of the time (HIS words!) and blinded him from the fact that indeed his identity was not in the right place. We aren't perfect people - God is still doing wonderful work on our hearts, but we are immensely grateful that the Holy Spirit made this evident before we even left Greenville.  

The way I struggled with this issue is that when we arrived to Kibuye, I wanted everyone to think I was super smart. The problem was, I wasn't super smart in many things including malaria diagnosis and treatment, all-things-malnutrition, and many other things not to mention performing in an underdeveloped setting. I'm thankful that this desire to have a good outward identity coincided with our journey through the Mentored Sonship Program (see number 3).  By the work of the Holy Spirit, I saw that I was too concerned about what others thought of me and not fully accepting of my acceptance and identity as a daughter of Christ.  We are sons and daughters of Christ primarily, put on earth to do His will.

2. A second key thing is that, thanks to our great pre-field training we received at SIM and MissionPrep, we were strongly encouraged to walk into our host country with a learning attitude.  This helped us to determine quickly that we needed to have discernment of what is controlable and what is uncontrolable in our context.  Of course there's the caveat that in reality nothing is in our control ultimately.  So I use the word "control" here to mean the things which we can affect due to our efforts. I'll give an example.  There are no ventilators in our hospital except for the anesthesia machines used in the OR. If a patient were to need ventilatory support, it's up to someone to manually compress the bag of air that is connected to the tube going down the trachea to ventilate the lungs. Would it be physically possible for Michael or me to spend all night at the hospital bagging the patient so that hopefully the lungs/body would improve enough so that we could stop in the morning. Yes, we are physically capable of staying awake more than 24 hours. But that's not sustainable by any means. So in that case, it's truly uncontrollable. And as miserably hard as that is to accept, we have to.   

3. Mentored Sonship Program - this is a program that is mandatory for all those who are going to serve with Serge. It is "a one-on-one mentoring program designed to help you truly live out the power of the gospel in your daily life."  We went through this program during our first term, it was truly transformative and it's timing was essential for us. You can learn more about it here. 

4. Another huge thing we found extremely helpful and key in many interpersonal relationships is that you need to let the small things go.  (That's not to say there isn't a place for conflict, there most certainly is!  In fact one of the Sonship lessions talks about peace making (healthy conflict) vs. peace keeping (unhealthy avoidance).). But, for example, is there something that's done a little different than you would do it but in the light of eternity has no weight? It's probably ok to let it go. This is key for living in a group of ex-pats who have to live together in a little community, see each other and interact together every day, and depend on each other every domain of life all while living under the stress of cross-cultural living, cross-cultural working, and living thousands of miles from friends and family. Grace is huge; Grace is necessary; sometimes it's best to let the small things go. 

5. Happy wife, happy life. Jk. But kinda not.  Being on the same page in marriage is SO important.  By the grace of God, Michael and I have a strong passionate calling to do what we do where we do it. I won't dwell on this issue, but it's something we've seen play out in a great way in our cross-cultural lives. 

___

I'll say this again, we aren't perfect! Did we have struggles during our first term? Yes. Was it hard to be so far from family and friends in the United States? Yes.  Did we feel a need for this home assignment and some time away from the field? Absolutely.  But by God's grace, we had an excellent first term and we are so grateful for that. We are thankful for this home assignment but also are excited to return to Kibuye to continue the work there. 

*If some weren't aware, we are also using this HA to transition from SIM to Serge.

Merry (late) Christmas from the Harlings ◡̈ 

Homecoming

 (from Eric)

We arrive in Bujumbura late Sunday night, crawling to our hotel beds with an intense relief coupled with a wonder at how we have been underestimating the amazing phenomenon of laying down and stretching out your legs to their full length.

Four in the morning.  I'm awake for no reason other than that it is dinner time in the US.  Laying on the bed in the pitch black, I hear the call of a Robin Chat that has no business to be making noise at this hour.  I'm smiling because I had forgotten about the birds.

Six in the morning.  I still haven't fallen back asleep and Rachel and the kids couldn't be woken up by all the Robin Chats in the world, so I decide to sneak outside.  The hotel is on the edge of Lake Tanganyika, and maybe I'll go sit on the beach.

As I walk by the pool, a flock of terns soars overhead, and then a solitary African Kite.  I pass by what I have always thought of as a mango tree, though I've never seen it bear any fruit.  I walk out to the beach and notice that the incredible rise of the lake level (over 2 meters!) that we had been experiencing when we left in June has finally started to recede.

African Kite (from an online image)

The sky is gray in the early morning and so is the water.  The surface on a lake this big is never totally calm, but it's pretty close this morning.  Dotted around in the distance are fisherman who have spent the night on the water, fishing mostly for tiny ndagala that you eat whole after they have been dried or fried.  The boats are spread out in every direction, usually in pairs.  I know that soon, they will head into shore.  One of the pair will have an outboard motor and will tow its partner in.

Lake Tanganyika fishermen out on the water (from an earlier visit)

Behind me, a pair of security guards are next to a sleeping dog and chatting indistinctly in Kirundi.  The words are too low for me to try and understand, but the familiar cadence falls on my ears from the first time in over six months.

Closer in, about a hundred feet offshore and another hundred to my left, I see a dark silhouette above the water's surface and realize with a start that this is what I was hoping to find.  A hippo is silently making its way down the shoreline in my direction.  He ducks underwater but surfaces again thirty feet closer.  I'm sitting on a small rock wall that encloses a little cabana where hotel guests can share a drink.  When the hippo is directly in front of me, an incredibly long ribbon of dark lake birds rises from the water and flies over it in a huge V that has devolved into a zigzag.  

The only picture I actually took this morning

I suddenly realize the hippo has turned and is heading quite quickly towards me.  He's still a ways out, but remembering the nearby sign which correctly describes the hippo as "l'animal le plus dangereux en Afrique", I decide to swing around and watch from the other side of the rock wall.  As I lean forward on the wall from my new vantage point, I feel a quite sharp pain in my right palm.  I look down to confirm what I had suspected, that I had accidentally put my hand down on a intozi, or pincher ant.  I wince and shake out my hand.  The hippo stops 25 feet from the shoreline, changes direction, and continues down lakeshore toward the Congo border.

I realize that the restaurant is probably open, and decide to go and find a cup of coffee.

***

So many things that I have slowly come to know well.  So many that remain mysterious.  Calm.  Routine. Surprise.  Wonder.  Beauty.  Majesty.  Pain.  Wild?  Yes, but it's such a familiar wild.

It's good to be back in Burundi.