We boarded the overnight train in Mombasa knowing about the possibility of massive delay (and derailment), but hopeful that the law of averages was on our side. After a fitful night of interrupted sleep, I woke confident of our on-time arrival. The train is a great way to travel for a view of the country and certainly beats simply popping in an out of airports. Though great, the views can last a bit long at times, as the African train slows and sometimes stops briefly in smallish towns where the locals, especially the children, take an interest in the passengers. On more than one occasion we noticed the local kids racing the massive locomotive as it began to build speed on its way out of town. These barefoot children maintained pretty impressive speeds on the rail yard gravel.

As excited as we were to get into the field and start reviewing potential pilot sites, we still had a pretty reasonable backlog of information gathering and analytical modelling to complete in Nairobi. A friend of mine got us into the “members only” Nairobi Club, a delightful colonial leftover that provided us with a warm workplace much more like the fraternity house of my academic years than the office cubicles that had stolen the summers between them. Despite the workload and a super office, our time in Nairobi had to be very brief. Our solidifying agenda revealed Uganda as the country we would spend the most time visiting, and we still planned to visit a Ugandan surgeon in Rwanda and possibly an innovative Congolese doctor in Goma. We looked at flying to Kigali, but interregional African flights are terribly expensive and not particularly air worthy. The cheapest alternative is to spend the night on a bus, but bad roads and limited visibility had us nix that idea for safety reasons. This meant finding a network of connecting day buses that let us inch our way around Lake Victoria and into Rwanda.

While Shannon was busy coordinating our continental bus transit, I met with Dr. Tom Raassen, a native of Holland who has spent the last 30 years helping the women of East Africa. Besides treating thousands of fistula sufferers himself, Tom has also trained a sizable population of surgeons throughout the region. When I met Tom in Accra in April, he agreed to meet with me in Kenya and, despite a very busy schedule, he kept to his promise and sat down with me at the Nairobi Club. This meeting turned out to be one of the most productive of the trip as Tom shared his expertise in capacity building and helped me better understand fistula center infrastructure requirements and how to rapidly facilitate human resource development (especially in terms of surgeon training).

Shannon managed to get us the last two seats on a 14 hour bus from Nairobi to Kampala that left the next morning. With an afternoon to spare, we went to visit my friend Becky Chinchen, an American who runs a social business called Amani ya Juu. Amani was borne from Becky’s experience in Liberia. Having fled the country during the devastating civil war, Becky set up a very small operation in Kenya that sought to create peace and reconciliation through textiles. With a huge heart, a sharp mind, and a keen eye for quality, Becky built her little venture into an export driven women’s empowerment movement operating in several countries and continents. The grounds of Amani are the most inviting I have experienced in Africa and Becky says she “just wanted a peaceful place for the ladies to work.” Amani hires refugee women to produce high quality fashion and accessories that are not only saleable in western markets, but are actually on the high end of the quality spectrum. Amani pays these women 3 times the minimum wage and even encourages them to start their own businesses employing other women to produce products for sale to Amani. Not only was everyone we saw glowing with happiness, but they also leapt up from their sewing machines when we entered the production room and proceeded to surround us with a joyful welcome song.

The comfort of our afternoon with Amani contrasted greatly with the next morning’s transit to Uganda. Stuffed into the last seats of a roller coaster bus that bounced hundreds of pothole-ridden miles, we arrived in Kampala with a rainbow of bruises more varied than the stamps in our passports. After a day of waiting for our next bus, we boarded the luxury liner to Kigali, which was much better than our trip to Uganda, except for the “American Boy.” Instead of the quiet roar of a diesel bus, which drowns itself out, we were treated to a Nigerian film about that blared loud sound from a cracked speaker for over 3 hours. The rest of the passengers loved the film but the “Welcome to Rwanda” sign, was a long awaited visual cue that this comedy/drama classic would soon end. When we finally arrived in Kigali, we needed to set up camp and get to business.

As a social entrepreneur on the go in East Africa, I would say the first step upon arrival into any new town is to establish an “office.” Step 1 is getting a local SIM card to slide into your phone. Africa is a “pay as you go” market for everything from shampoo to liquor, meaning you only have to purchase the amount you intend to use. (I discovered this last year in Tanzania when a women I wanted to photograph talked me into giving her some money for the picture and then proceeded to buy one Coke and one serving of gin in a small plastic bag which she quickly opened and poured into the Coke.) With phones, this means you can buy a phone number via the SIM for about $1 and then charge it up as you need it. Step 2 is finding a place to work. Electricity is a must, internet is a nice-to-have and a comfortable environment is a supreme luxury. We found office utopia in Kigali’s Bourbon Café at the Union Trade Center. I typically avoid such Americanized places when travelling abroad, but at this point wireless internet and overstuffed chairs seemed a reasonable balance to our bus rodeo.

We headed down to Butare meet a Dr. Ignatius Kakande, a Ugandan surgeon who produced a brilliant presentation on surgical challenges in Africa. I had only communicated with Dr. Kakande over email and he invited us to visit him at the University of Rwanda. Our intent in the 2 hour trip was purely to meet Dr. Kakande, but upon arrival, we were quickly sent to see Dr. Jean-Baptiste Kakoma, a Congolese doctor and Head of the Obstetrics and Gynocology at the university. It didn’t take long before our collective enthusiasm for helping women with fistula exploded into an impassioned hand-waving discussion of how we might work together to change the face of fistula in Rwanda. Our tour of the facilities revealed two young surgeons with some fistula training and experience who were both interested in learning more as well as a physical infrastructure facility in need of support. We met a few fistula survivors in the small and crowded post-operative recovery ward. This hospital in Butare handles a consistent, albeit small, flow of fistula patients and the entire staff seems to believe that significant expansion of activities is possible with a little outside support.

We excitedly took notes and reviewed the site thoroughly, noting infrastructure gaps and potential opportunities. Unfortunately, the Hospital Administrator was not in the office, which limited a full scale site analysis. But we did find out that EngenderHealth had visited Butare in May and having gathered all the info we could, we rushed back to our regional office (Borubon Café) to follow up with our friends at Engender.