Rabies?

Rabies?

Wendesday, 7 November 2007

I got bitten by a dog around noon on Monday, the 22nd of October. Sistebol and I had left the village of Ioko a few hours before, and were approaching the next village of Elema-Impata. The first hour of trail was through dense forest, with the next 30 minutes or so trudging through knee- to waist-deep water of the inundated Lokeli River.

When we neared the village, the dense forest gradually gave way to slashed-and-burned agricultural fields on either side of the trail. We started passing villagers going to and from their fields carrying machetes, hoes, and baskets filled with manioc tubers or firewood. I saw the three dogs ahead on the trail, but had little choice but to pass through their huddle. Sistebol went ahead without incident, with me close behind. It was only once I had passed that one turned back to bite my leg. When I turned around I didn't even know which of the three had bitten me.

Sistebol was surprised, and several passing farmers and children seemed so too. Several people gathered around as I cleaned the wound with my water bottle. Blood flowed cleanly from the wound, directly from the muscle that showed below the skin. The bite wasn't very broad, just a bit deep. No major veins or arteries. I dabbed it dry, applied some antibiotic ointment, and put on a band-aid.

Of course, as any foreign traveller in Africa is trained to think, my first concern was the possibility of rabies. Sistebol was nonchalant: "Don't worry, the dogs around here don't have rabies, they have tetanus!" Oh great. At least I know I have an effective vaccination against tetanus. We continued our trek, and I changed the bandage and ointment regularly over the coming days.

This incident happened on my first actual vacation from LuiKotal. The destination was Lokolama, which is the only town of any consequence in the area. Aside from our Camp, Lokolama is the only place where any of the villagers that work for us are able to acquire any consumer goods like machetes, buckets, soap, or clothing. It is also the seat of various governement offices, so our camp maintains relations with many of the officials based there. I had heard a lot about this great metropolis over the months at Camp, so was determined to pay the place a visit.

In order to leave my post for a few days, I had been training our interim Camp Manager, Babs, for a couple of weeks. Things at camp were to be fairly calm during the week of my absence, so Babs would mostly just need to manage its day-to-day running. It would be good practice for her, and we would have the opportunity to discuss any problems before they got out of hand. (In fact, this is precisely how it worked - things went relatively smoothly, Babs was able to learn from the things which didn't go well, and I was able to help clear things up when I got back.)

Well Lokolama is about 83km from Camp. From Lompole, which is a 20km walk from Camp, the local people generally make the trip in two days. Elema-Impata is often the halfway point, though Ioko is also feasible. Both days of walking are very long, and the trail ranges from bad to horrendous. Some stretches are good enough to pedal a bicycle on, but most bikes are just used as overburdened carts with people pushing the loads along the same route most people walk.

So Monday I got bitten by a dog en route around noon, and we arrived in Lokolama shortly after sundown. Tuesday was my touristing day, when I saw the sites of the city and greeted every single government official there. The regional leader, "le Chef de Secteur" invited Sistebol and I for breakfast "a votre honneur" on Wednesday, and then we started the walk back. We got back to Ioko that night, after around 40km in about 9 hours of non-stop speedwalking. Thursday we kept walking, and I left Sistebol in the last village before Lompole. I got back shortly before 3pm, and wanted nothing more than to just keep going to reach camp. I greeted the villagers, was fed a small meal, picked up my tent, and continued on my way. It was another day of about 40km by the time I pitched my tent at Penge, which is a small clearing about an hour before the Lokoro. Friday morning I walked the last hour, yelled at the top of my lungs for a while, and waited for someone from camp to show up in the dugout canoe to take me across the river. After waiting for over an hour, it was clear that nobody could hear me, so I left my bag and started swimming. The water was high, so it ws a good 30 minutes of swimming within the inundated forest before I could even touch bottom, with frequent breaks holding on to trees to catch my breath. I stumbled the last kilometre or so into camp, soaking wet, arriving about 48 hours after leaving Lokolama. Someone went to fetch my bag on the far side of the river, and I spent the rest of the day relaxing, recovering, and treating my wounds.

I had been away for exactly one week. The whole trip constitutes enough of an exciting adventure to warrant its own blog entry, but this one is supposed to be about rabies so the trip gets abbreviated to one long paragraph. Sorry. I may or may not get back to that later.

On my weeklong trip, the dog bite was really just one little ailment among many. My feet had plenty of blisters, my arms and legs got loads of other scrapes, cuts, and bites, and my guts had been periodically rebelling against me. While travelling as well as once back at camp, I spent every evening applying ointment and bandaids to various wounds. The dog bite was just one among many.

Back at camp, though, I read a bit more about rabies. It seems that the vaccine (which I got some doses of but not all) offers somewhat of a shield, but that immunity is impossible. It also seems that the incubation period can vary, depending on health, the pre-exposure vaccines, and whatever else, and can be as long as a year. Post-exposure treatment can be taken any time during the incubation period and eliminate the possibility of the bite incident leading to rabies. Once symptoms start to appear, it is too late for treatment and, as one of the books describes, "a slow painful death is inevitable."

The first symptoms are apparently some tingling around the wound, and general pain in the affected limb. Well of course I immediately started noticing that my leg was sore, and that the bite spot hurt. Yeah, all the other cuts and blisters and overworked muscles and joints hurt a bit too, but they wouldn't indicate anything besides a tired body.

One way to determine if rabies is present is to monitor the dog for a couple of weeks. I started writing a letter to Lompole, asking our collaborator there to ask the people of Impata-Elema to let me know if any dog turned up dead in their village within a couple of weeks of my bite. The letter wouldn't be sent to Lompole until Monday, when the porters came with our food transport.

I discussed the dog situation of the region with our local workers. They said that rabies isn't common, and several of them pointed out spots where dogs had bitten them. I asked about the dogs in the village of Impata-Elema, and they said the place probably has 150 of them running around. The village probably has around 40 homes, so I assume this is an overestimation of of the dog population, but the conclusion is that there are too many dogs for the villagers to really keep track of any of them. The dogs are used for hunting, so they have a lot of contact with all of the local wildlife, particularly anything that is on the ground. Based on this, I assume that if any nearby village's dogs were to end up with a few rabid individuals, Impata-Elema is the most-likely contender.

This is basically all the information available to make a decision. The decision basically comes down to two choices: do nothing, or leave camp to go for the post-exposure treatment. It basically comes down to weighing the risks. Given the information, it appears that risk is low. The bite wasn't that nasty, and rabies isn't common in the area anyway. Low as the risk may be, however, it is not zero: the possibility of rabies remains. And given the consequences ("slow painful death is inevitable"), I came to the decision that the risk warranted my evacuation.

This decision was not an easy one, and was not taken without a lot of thought and discussion with a couple of my campmates. I got back from my trip on Friday morning, read about rabies on Friday night and Saturday afternoon (in different books), and finally decided to contact my travel insurance company on Monday morning. My time at camp was to last another six weeks, and I had a number of big projects to accomplish still. So both professionally and psychologically, I wasn't ready to leave yet. Monday was a sad day.

This was the first test of Camp's means of emergency evacuation. I started with my travel insurance, since I needed to convince them to pay the flight bill. It took several phone calls, numerous agents and supervisors, and way too much explanation of how stupid they were being. "Before we can authorise an evacuation, we need you to consult a medical professional who agrees that your case could be improved with an evacuation"; "No, I need the evacuation so that I can get to the medical professional." Ridiculous. The satphone had hundreds of dollars wasted on such stupidity that day.

Eventually they agreed that I needed to be evacuated to seek medical attention, but they couldn't figure out how to evacuate me. In the end it was me organising the plane out, with the insurance company just contacting them to promise payment. The plane was scheduled for the next morning from the Ipope airstrip, 27km from camp. I had packed my things quickly in between phone calls, and sent them ahead with the porters. Andrew and I left around 5pm with one of our plant experts, Kabongo. We did most of the walk at night. In one of the knee-deep stretches of inundated trail, I got a massive electric shock up my left leg from the Nina, one of my favourite meals (the electric fish). We got to Lompole around 10pm, and everyone in the village had already gone to bed.

A few people were awoken, and we ate some rice. Andrew and I were totally beat, and shared my little tent for the night. Finally crashing after midnight, it was the latest Andrew had ever stayed up in the Congo.

We were up by 5:30 on Tuesday morning. A number of people came to greet me, all in shock at my sudden departure, and all sincerely disappointed. Given my position as everyone's boss around here, I've had, at times, tenuous relations with pretty much everyone. When it came down to it though, I was touched that the people genuinely respected me, despite the official role I was obliged to maintain. Yeah, it was often pretty frustrating to work with these people, but in the end we all understood one another. I was certainly disappointed to be extricating myself from their lives so suddenly.

Eventually we left for Ipope, with several people coming just to see me off. Andrew and I sat in a house for a while as we waited for word of the plane's progress, and our local friends came and went. We started the walk along the last two kilometres once we heard the plane overhead; it was waiting on the airstrip when we got there. At perhaps a dozen adults and fewer than 20 children, this was by far the smallest crowd I had ever witnessed at the airstrip. I got a couple of last photos, and got in the co-pilot seat. I was the plane's only passenger.

The flight was uneventful, with beautiful weather. The plane's GPS had been removed for repairs, so it was interesting for me to observe the pilot navigate visually with his maps and compass bearings. The forest has no roads and few major rivers, so landmarks are extremely limited. We made one stop at Semendua for gas, and arrived in Kinshasa by mid-afternoon.

The insurance company had asked the pilot to organise an ambulance to pick me up, but this would have been overkill. Instead, the GTZ sent a driver, Serge, over and we went to the Centre Medical de Kinshasa. (I walked into the lobby, and two teenage girls who were waiting there litterally broke out laughing as they stared at me - this was a precurser of what was to come in Kinshasa as people saw my huge beard.) One doctor sat down with me and talked about rabies, and basically said that the protocol is to watch the dog for a while. The CMK had no other means of testing or treating rabies. He called a veterinary doctor he had worked with in the past, and made me an appointment for the next morning.

Serge then took me to a bakery so I could indulge in a baguette with cheese, a chocolate eclair, and an apricot pie. I pigged out in the jeep as he navigated the rush hour traffic to where I'd be staying. The residents were surprised to see me show up, but they took me in. The house is my director Gottfried's, and it is currently occupied by a German couple, Kristian and Julie - Kris works at the GTZ. I finished my eclair, ate their leftovers, and we went for cold beers.

I went with Kristian to work on Wednesday morning, leaving by around 6:15 to beat the traffic. I did a lot of loitering around the GTZ office, as well as a bit of internet when one of the computers was free, and eventually convinced a driver to take me to the vet clinic.

The place was a joke. It basically consisted of a couple of rooms with people sitting at tables, with all the doors and windows wide open. I was directed to the bench in front of the Doctor, who opened his briefcase to get the information. The doctor had a facial expression and hand movements that reminded me of Mr Bean. The briefcase was basically filled with little scraps of paper, one of which was the folded insert from a Verorab treatment. He said it would consist of five shots over the coming 28 days, with a sixth one after 90 days, and that he had the shots available. A woman brought over a thermos to show me that yes, there was indeed a stock of them being kept refrigerated. He needed $420 though, and no, insurance or credit cards were not accepted. What a ridiculous proposition.

So I got my first shot on Thursday morning, when I returned to the clinic with a stack of American bills. This was November 1st - the 10th day since the dog bite. The first shot was a serum, whereas the next four are vaccinations. I don't really know what this means, exactly, except that the first one was really big and made my arm hurt for the rest of the day. 5ml into the muscle. My next appointment was for Monday, and three more were foreseen over the rest of the month. If I didn't want to stick around Kinshasa I could just pick up the remaining doses and take them with me, but they needed to be kept refrigerated (not frozen) to ensure their viability.

So Monday would be my next appointment, and I could leave town anytime after that. I changed my outgoing international flight for the following evening. I spent the weekend enjoying the company of Kristian and Julie, meeting several of their friends each day. Friday we even went to an expat party, so I met a few dozen diplomats, aid workers, and other random white folks with jeeps who live in Kinshasa. On Saturday we went to the market to get fresh produce for the week, and on Sunday we lounged around most of the day. Sunday night we went to a concert of Congo's foremost musician, Werrason, though we were so tired by the time he finally graced the stage sometime after 11. All in all, it was a good weekend.

On Monday I first went to the market to find a thermos, and settled for a funny purple one from China. I got to the vet clinic around 3:30, and the doctor was waiting for me alone. Everyone else had gone home, but he knew I'd be back. He also wanted me to exchange a bunch of the American bills I had paid, since many had little rips in them. I got the shot, we exchanged bills, and he gave me the three remaining syringes with vaccine vials for my thermos.

Tuesday was my last day in Congo. I checked my bags at the Air France office downtown in the morning, and accompanied the driver on a few of his other errands. I searched for lunch with Julie, who had also come to the GTZ for the day, and finally settled on the restaurant next to the office where I had been twice already. Kris joined us, as did Gaby, a friend who was at LuiKotal for several months. A kid walked by selling shoes, and I bought a pair - I'd been trying on such shoes all week, to no avail. Another kid repaired my other shoes, whose previous repair job had finally come apart again.

Before I got the ride to the airport, Julie and Kris and I went for a last round of drinks at a stall around the corner. It was a pretty anticlimactic finale, but entirely relaxing. At least we had had the Werrason concert on Sunday night, which was even preceded by a couple rounds of (excruciatingly pitiful) pool games. I headed to the airport Tuesday night.

So now I'm in Europe. I arrived in Paris this morning, Wednesday the 7th of November. I spent a few hours repacking my luggage, and I left the majority of my belongings at a storage place in the airport. I then flew to London's Luton airport on EasyJet, and took a bus downtown. I'm spending the night at the Museum Inn Hostel tonight, and will be paying the University College of London's Travel Clinic a visit in the morning. As a British citizen, I should receive free treatment, as long as they decide to admit me on the spot. My intent is not only to get more-professional attention to the rabies situation, but also to get the standard post-tropical screening that is necessary after an experience such as I just had. It remains to be seen what they'll decide to accord me.


The conclusion of all this, though, is that my time in the forest is now over. I still had a lot of stories that were unwritten, given my lack of adequate time to write while at Camp. I'd still like to share them, but as time goes by they may just get dropped. Sorry. We'll see.

The other thing is that I can no longer receive emails at LuiKotal. Anyone wishing to write me should revert back to my hotmail address: professionalnomad.

As for my travel plans, my first plan is to see what this travel clinic says tomorrow. From there, I probably won't stay too long in London. My trans-Atlantic flight is from Paris, so I'll be back there soon, and I certainly need to make a pilgrimage to Amsterdam while I'm in the area. My mom wants me in New Jersey for American Thanksgiving, which is realistic but not definite. But sometime around then is likely. Then what? Any suggestions?


-Ryan à London