Andy, a graduate student, and I have been working with the Community Health Department at KCMC to help prepare their MD1's (first year medical students) for their longitudinal community health experience. It is a great idea, and I wish my medical school had offered such an experience....years ago.
The MD1's spend 1 Thursday every week in their 1st 2 years of medical school with the Community Health department. Students are placed in groups and paired with villages in the Kilimanjaro region. Initially, they are required to do a community assessment of their village- interviewing the village health leaders, some families, and the health facility- and form recommendations based on their evaluations. Last week, the students presented their findings, and it was a great way to hear about the villages bordering KCMC hospital. Andy and I had each gone with a group to a specific village, so we had a chance to see 1 village closely.
My village was on the road to Kibosho, a rather large village with 12,000 inhabitants, it contained 7 primary schools, 123 local bars and 2 health dispensaries. We went to visit one dispensary. Dispensaries are the most basic level of health facility, and are ubiquitous. Tanzania has a goal of having 1 dispensary every 5 kilometers. This dispensary was privately run by a church, and contained all the essential parts: outpatient area, pharmacy, lab, 6 inpatient/maternity beds and 1 delivery bed. The dispensary was very clean, but it was also very quiet. The entire hour we were there, we only saw 2 patients come through. The villagers say that private dispensaries are not popular because they charge money for medications and services. Usually it is quite minimal- $1 for medications, $5 for a delivery. But this amount is enough to keep people away. We see this at KCMC hospital, where people don't want to pay the $12 fee for a regular delivery and try to stay at Mawenzie hospital (where it is free).
This village also has a local healer, and we were lucky enough to interview him. He practiced from his home, a nice house with a very nicely manicured lawn and driveway. His entire waiting room was filled, and we (the 4 medical students and I) squeezed into his treatment room the size of a closet with 2 babies, 1 child and their anxious mothers. Local healers practice in different ways- some are herbalists, some are spiritualists and a few are quite frightful (see the recent news of albinos afraid for their lives given the high value of their body parts http://www.timesonline.co.uk/tol/news/world/africa/article6901688.ece ). This local healer used to be an engineer until about 15 years ago when he had a vision, literally. He was driving down a lonely road in central Tanzania when he was forced to pull over by a vision in the sky. This vision told him to start healing people in his village, and he continues to get his treatments through visions. As he was talking with us, he was creating suspensions in bottles (he wouldn't tell us what it was) to give to the babies and child. He gave 1 teaspoon to each, and waited 5 minutes. Then he gave the suspensions to the mothers to take home. I admit I was rather conflicted- especially seeing infants given suspensions of unknown yellow liquids, when it sounded like they had some colic. Should I have offered to evaluate the infants with my western medical background and provided my allopathic-based diagnosis and treatment? Who am I to say that my treatment would work better? It definitely would be less mysterious and more standardized. I was surprised to see the mothers willing to pay $1 to the local healer, but not to the dispensary. The healer was not surprised, and he gave us a few stories of people who failed to be healed despite weeks of therapy at the hospital and who were only cured after visiting him. Of course, this conflict of therapies occurs in the U.S. all the time. My patients would tell me about how their Homeopathic doctor, or their Naturalist finally treated their problem after countless visits to my colleagues had failed. I wonder how many of my patients had similar experiences. I assumed that this local healer would be cheaper, or offer services at nights/weekends, or spend a long time with his patients- none of these were true. But he was definitely a popular alternative to the dispensary, or to the long journey to a larger health facility. With so many health facilities lacking basic medicines, laboratory tests, or essential supplies (like blood pressure cuffs or delivery kits), local healers can be an attractive alternative in health care. As we were leaving at the same time as the patients, we heard the mothers thank the "doctor" for his help.
Sumera
Tuesday, December 15, 2009
Brief trip to Rwanda
Jeff had a quick visit to Rwanda recently. It's always helpful to get some perspective on suffering. Here is a brief email received from him:
"I made a quick. somewhat last minute trip to Rwanda with Nathan Thielman to help him with a project on emergency obstetrics teaching here. Yesterday, we visited a few hospitals and also had the oportunity to visit two genocide memorials here in Kigali and in a town close by called Nyamata. I had read of many accounts of the Genocide in 1994, and the smaller ones over the past 40 years that lead up to it. It was something else to ride through the beautiful landscapes here and imagine it strewn with corpses. The world sat by and watched as 1 million people were systematically killed. It was sobering to say the least. We are going to Gisenyi today which is on the border with Congo. We are visiting one of the district hospitals there that has a particularly high maternal mortality rate."
More details to come....
"I made a quick. somewhat last minute trip to Rwanda with Nathan Thielman to help him with a project on emergency obstetrics teaching here. Yesterday, we visited a few hospitals and also had the oportunity to visit two genocide memorials here in Kigali and in a town close by called Nyamata. I had read of many accounts of the Genocide in 1994, and the smaller ones over the past 40 years that lead up to it. It was something else to ride through the beautiful landscapes here and imagine it strewn with corpses. The world sat by and watched as 1 million people were systematically killed. It was sobering to say the least. We are going to Gisenyi today which is on the border with Congo. We are visiting one of the district hospitals there that has a particularly high maternal mortality rate."
More details to come....
Monday, October 26, 2009
Return of the Learners
This week, the medical students returned to their duties at KCMC. It is an impressive thing to watch so many students fill the campus. Knowing that the medical school opened its doors in 1997 shows how quickly it has become established. Initially, there were only 10 students per class. However, it quickly became apparent that this low number would not help the severe physician shortage in Tanzania. Before KCMC College started its medical school, the only other government sponsored medical school was Muhimbili in Dar es Salaam.
When we arrived last year, it took Jeff and I a few months to finally realize a few things about KCMC hospital and medical school students:
1. The school year starts in October, not in august/September like American medical schools. The reason this matters is that when we arrived in July, instead of joining a new group of students, we landed in the middle of final exams for the entire hospital campus (all the schools: medical, assistant medical officer, public health, residency program, nursing, allied health, you name it). It threw us off for a few months. When Tanzanian students want to come to the US, they get thrown off their usual schedule as well, or may lose almost a year waiting to apply to US based residencies.
2. The medical school class size has undergone a massive increase in students due to a government mandate. At KCMC, this has included the creation of a brand new beautiful medical school facility right next to the hospital. What’s needed are instructors to fill the facility. Currently, the attendings (consultants they are called here), or senior level faculty, not only see patients, perform surgeries, oversee residents and teach students on the wards, they also provide lectures on basic science relevant to their specialty for other students. Because there are not enough faculty, the residents have to teach as well. Helps put the teaching issues at American medical schools in perspective.
3. The medical students, who used to number 10 per class year and now average 100 per class year, all have to rotate through KCMC hospital. The hospital has stayed the same size. So now this week, there are 18 new 5th year med students who have joined our hospital rounds on the OB/GYN floor. Last year’s class had 10 students per rotation, and that already added to the crowd of 10 3rd year medical students and 10 AMO students every rotation. We all don’t fit into the morning report room, so the latecomers stay in the hallway, hoping to at least hear the report if not see it. Students have to be extra assertive to make sure they are able to get necessary experiences in. Most medical students, right after they graduate, have to be able to perform c-sections in remote regions (usually without supervision) when they serve as Medical officers. I hope these students make the extra effort.....
4. The medical students follow the British system here, so they can start medical school straight after high school and earn their medical degree in 5 years. So most of them have not had any undergraduate experience or real-world health care experience before starting the path towards becoming a physician. Is this a good thing or bad thing? After our past year, I don’t know if undergraduate study is necessary. It is a nice thing for most undergraduates, especially if they are not footing the whole bill. In a country like Tanzania with such a paucity of doctors, with such poverty, it makes more sense to get students through the education system earlier.
5. The government pays for most residents to go through residency, but that is after requiring 1 year of ‘medical officer’ work in rural parts of Tanzania. In fact, similar to the US system until the 1960’s, medical students do not have to do residency, and after their 1 year of ‘medical officer’ work, they can stay on as a medical officer indefinitely. The government salary is even less than what US hospital residency officers make- and amounts to about $400 per month. I once calculated after a particular grueling shift in the hospital as a resident in America that I had earned $1.20 per hour. No matter what minimum wage was at that point, I knew I had earned less. I see the residents here working hard, making even less, and I feel bad now for complaining.
There are differences from what we were used to in the US medical system. But the things that matter most- trying to keep people alive, women delivering safely, newborns healthy- are the same. And that is why we became physicians in the first place.
Sumera
Sunday, September 6, 2009
5 Lives
Rounds on the ward last week:
Wednesday. First patient- routine patient with fibroids and heavy bleeding: plan for hysterectomy. Second patient, gasping for breath. So many people here die gasping for breath. KCMC hospital is the referral hospital for 11 million people, so the hardest, most desperate patient cases end up here. Gasping for breath leads to miserable deaths. Air hunger, dyspnea, shortness of breath, respiratory fatigue.....little relief for them when there is only one ventilator available in the hospital for non-surgical patients, no morphine. She had been admitted that morning at 26 weeks pregnant with shortness of breath. Known HIV positive patient on antiretrovirals, still a very young woman. Oxygen saturation low (56%) pulse high (160). Suspected PCP pneumonia, but no prior xray and no blood work. Lungs sounded horrible. Declined admission in the ICU as there were no beds, at least no beds for an HIV positive person at that time. Quick bedside ultrasound: Twins at 26 weeks, looked normal- surprising that they were moving with such a low maternal oxygen saturation. Perhaps in the last agonizing throws themselves. The patient received oxygen, antibiotics, lasix just in case, steroids. She looked a bit more comfortable with slightly rising oxygen levels. On to the rest of the patients and plan to check on her in 10 min. The next room, second patient collapses and is not breathing. Pulse 50's . Pupils fixed. Oxygen level 65%. Blood pressure normal. Her neighbor tells us she had a severe headache that morning with a stiff neck and fever. We start A,B,C's (airway, breathing, circulation)......IV.....O2....Bag mask ventilation and a call for anesthesia. Reviewing the record, she had been treated for malaria for the last 10 days at an outside facility. 25 weeks pregnant, single fetus. Live. After a few minutes of bag mask, she breathed a little on her own , but not normally. Anesthesia intubated her and took her to the ICU and she was able to get the one ventilator overnight. As the second patient was being intubated, the first stopped breathing as well and rapidly progressed to pulselessness. A,B,C's, Bag Mask ventilation, CPR, No defibrillator.....15 minutes of CPR, Epinephrine and Atropine, no response, pronounced dead at 11:15.
Back to the ICU: The second patient had normal oxygenation on the ventilator but showed signs of brain death so was extubated and died in the morning. The neurologist said it was likely a subarachnoid hemorrhage.
Justice is the ethical principle that ethical theories should prescribe actions that are fair to those involved. Most commonly in medicine we speak about justice when it comes to allocation of resources. For instance, it is unfair for the rich to have access to life saving drugs or technology in the USA when the poor do not. Or, questioning whether it is ethical to spend 2 million dollars saving one person when 100 die for lack of immunizations that could have been saved with that 2 million dollars. The two cases above are not about our commonly applied notions of justice because justice is most commonly applied and described within the boundaries of a country or a state, sometimes ethnicity or religion or another possibly arbitrary boundary or group identity depending on where you live and what your leaders believe. That is: it is ok to withhold the treatment for X condition for the person in Juarez Mexico, but in El Paso, Texas it would be unthinkable if not illegal even though I could have a conversation with my Mexican neighbor from my back porch in El Paso.
I called out to the residents and nurses for many things when we were handling the above two patients. The one thing I did not call for when these women were dying was a scalpel. I like calling for the scalpel. It usually means some solution to the problem is coming. Typical surgeon. In the US, with these patients, it would have been near the top of the list. Airway, breathing, circulation, scalpel........ Get the babies out fast. For each passing second of cardiac arrest, the baby has a smaller chance of survival. In fact, you even help the woman by removing the baby quickly to facilitate CPR. I didn't call for the scalpel because I knew these babies would not, could not survive here in Moshi and the chances for the mother were dismal either way. There are no ventilators for babies, no NICU, no surfactant, no neonatologist. So, 5 lives, 5 deaths. 2 mothers 3 fetuses- minutes from being babies. Fetuses in Tanzania. Babies in the USA. No overlapping circles of justice.
Wednesday. First patient- routine patient with fibroids and heavy bleeding: plan for hysterectomy. Second patient, gasping for breath. So many people here die gasping for breath. KCMC hospital is the referral hospital for 11 million people, so the hardest, most desperate patient cases end up here. Gasping for breath leads to miserable deaths. Air hunger, dyspnea, shortness of breath, respiratory fatigue.....little relief for them when there is only one ventilator available in the hospital for non-surgical patients, no morphine. She had been admitted that morning at 26 weeks pregnant with shortness of breath. Known HIV positive patient on antiretrovirals, still a very young woman. Oxygen saturation low (56%) pulse high (160). Suspected PCP pneumonia, but no prior xray and no blood work. Lungs sounded horrible. Declined admission in the ICU as there were no beds, at least no beds for an HIV positive person at that time. Quick bedside ultrasound: Twins at 26 weeks, looked normal- surprising that they were moving with such a low maternal oxygen saturation. Perhaps in the last agonizing throws themselves. The patient received oxygen, antibiotics, lasix just in case, steroids. She looked a bit more comfortable with slightly rising oxygen levels. On to the rest of the patients and plan to check on her in 10 min. The next room, second patient collapses and is not breathing. Pulse 50's . Pupils fixed. Oxygen level 65%. Blood pressure normal. Her neighbor tells us she had a severe headache that morning with a stiff neck and fever. We start A,B,C's (airway, breathing, circulation)......IV.....O2....Bag mask ventilation and a call for anesthesia. Reviewing the record, she had been treated for malaria for the last 10 days at an outside facility. 25 weeks pregnant, single fetus. Live. After a few minutes of bag mask, she breathed a little on her own , but not normally. Anesthesia intubated her and took her to the ICU and she was able to get the one ventilator overnight. As the second patient was being intubated, the first stopped breathing as well and rapidly progressed to pulselessness. A,B,C's, Bag Mask ventilation, CPR, No defibrillator.....15 minutes of CPR, Epinephrine and Atropine, no response, pronounced dead at 11:15.
Back to the ICU: The second patient had normal oxygenation on the ventilator but showed signs of brain death so was extubated and died in the morning. The neurologist said it was likely a subarachnoid hemorrhage.
Justice is the ethical principle that ethical theories should prescribe actions that are fair to those involved. Most commonly in medicine we speak about justice when it comes to allocation of resources. For instance, it is unfair for the rich to have access to life saving drugs or technology in the USA when the poor do not. Or, questioning whether it is ethical to spend 2 million dollars saving one person when 100 die for lack of immunizations that could have been saved with that 2 million dollars. The two cases above are not about our commonly applied notions of justice because justice is most commonly applied and described within the boundaries of a country or a state, sometimes ethnicity or religion or another possibly arbitrary boundary or group identity depending on where you live and what your leaders believe. That is: it is ok to withhold the treatment for X condition for the person in Juarez Mexico, but in El Paso, Texas it would be unthinkable if not illegal even though I could have a conversation with my Mexican neighbor from my back porch in El Paso.
I called out to the residents and nurses for many things when we were handling the above two patients. The one thing I did not call for when these women were dying was a scalpel. I like calling for the scalpel. It usually means some solution to the problem is coming. Typical surgeon. In the US, with these patients, it would have been near the top of the list. Airway, breathing, circulation, scalpel........ Get the babies out fast. For each passing second of cardiac arrest, the baby has a smaller chance of survival. In fact, you even help the woman by removing the baby quickly to facilitate CPR. I didn't call for the scalpel because I knew these babies would not, could not survive here in Moshi and the chances for the mother were dismal either way. There are no ventilators for babies, no NICU, no surfactant, no neonatologist. So, 5 lives, 5 deaths. 2 mothers 3 fetuses- minutes from being babies. Fetuses in Tanzania. Babies in the USA. No overlapping circles of justice.
Monday, August 3, 2009
When crying is a good sign
I was called to assist with a potential neonatal resuscitation. I didn’t know anything about the patient, her pregnancy history, or her labor issues. I barely had time to put on a white coat and gloves. Peeking into the c-section room from the hallway, I could see the mother with her arms outstretched, and two physicians scrubbed and already starting the surgery. I checked to make sure the ambu bag, oxygen tank, the infant warmer, and the suction tubing were all functional. But I didn’t need to- - the midwife was two steps ahead of me diligently checking over everything. The Labor ward was quite calm, different from my U.S. experience where any potential resuscitation would be surrounded by an atmosphere of nervous tension. Or maybe it has always been just MY nervous tension that I have brought to the labor ward.
When I peek again into the c-section room, another physician has scrubbed in, and I wish I had time to find out the mother’s pregnancy and labor history. Three physicians scrubbed in for a c-section is not a good sign (unless they are teaching new residents). The baby is pulled out, but doesn’t make a sound as it is wrapped in a cloth and rushed to the resuscitation room. We open the cloth to find a limp, wet, slightly blue baby who is not breathing. There are suddenly six hands trying to stimulate, warm, dry, cajole, suction and assess the child. We all try to take a different part of the baby- one person is drying, one person is suctioning, one person is getting the ambu bag ready. I realize that I haven’t looked at the newborn resuscitation algorithm in two months, and in that time I have been travelling, writing grant proposals and scheduling courses and so my algorithm retrieval sections of the brain are sluggish. But with six hands that all know something about resuscitating a baby, I’m hopeful that we can get the baby to cry.
When is a cry more desperately needed than in the first few seconds of life? The three of us (two doctors, one nurse) are all working feverishly to get this baby to cry. In most other settings, we try to dampen a baby’s cry (during vaccine injections, ear checks , late night awakenings, long airplane flights).
After the first seconds of stimulation and assessment , the ambu bag is used, the mask is snug on the baby’s face, and someone is giving positive pressure ventilation. Not me, though. I have taken my hands off the baby, and I notice that she is a girl. A beautiful baby girl, perhaps the mother’s first baby. The other doctor doesn’t know the mother’s history either, as he was called at the last minute also. After just twenty seconds, the baby starts to sputter, fight, and get agitated. And then she belts out a huge cry, a howl of indignation.
Yes!
We three adults finally exhale, smile, and start talking. The midwife takes over completely, as she has years more experience in what the newborn baby needs now. But I stand and coo over the crying baby, happy to hear her. I remember that the c-section room is just across the hall, and perhaps the baby’s mother is also hearing her baby cry for the first time. I think about hearing my children’s first cries, and the relief I felt. It is enough to make me cry as well, and I leave the room quickly.
I still hear the baby crying as I leave the labor ward. What a great sound.
When I peek again into the c-section room, another physician has scrubbed in, and I wish I had time to find out the mother’s pregnancy and labor history. Three physicians scrubbed in for a c-section is not a good sign (unless they are teaching new residents). The baby is pulled out, but doesn’t make a sound as it is wrapped in a cloth and rushed to the resuscitation room. We open the cloth to find a limp, wet, slightly blue baby who is not breathing. There are suddenly six hands trying to stimulate, warm, dry, cajole, suction and assess the child. We all try to take a different part of the baby- one person is drying, one person is suctioning, one person is getting the ambu bag ready. I realize that I haven’t looked at the newborn resuscitation algorithm in two months, and in that time I have been travelling, writing grant proposals and scheduling courses and so my algorithm retrieval sections of the brain are sluggish. But with six hands that all know something about resuscitating a baby, I’m hopeful that we can get the baby to cry.
When is a cry more desperately needed than in the first few seconds of life? The three of us (two doctors, one nurse) are all working feverishly to get this baby to cry. In most other settings, we try to dampen a baby’s cry (during vaccine injections, ear checks , late night awakenings, long airplane flights).
After the first seconds of stimulation and assessment , the ambu bag is used, the mask is snug on the baby’s face, and someone is giving positive pressure ventilation. Not me, though. I have taken my hands off the baby, and I notice that she is a girl. A beautiful baby girl, perhaps the mother’s first baby. The other doctor doesn’t know the mother’s history either, as he was called at the last minute also. After just twenty seconds, the baby starts to sputter, fight, and get agitated. And then she belts out a huge cry, a howl of indignation.
Yes!
We three adults finally exhale, smile, and start talking. The midwife takes over completely, as she has years more experience in what the newborn baby needs now. But I stand and coo over the crying baby, happy to hear her. I remember that the c-section room is just across the hall, and perhaps the baby’s mother is also hearing her baby cry for the first time. I think about hearing my children’s first cries, and the relief I felt. It is enough to make me cry as well, and I leave the room quickly.
I still hear the baby crying as I leave the labor ward. What a great sound.
Tuesday, June 2, 2009
Rallying for Safer Motherhood
This is the 1st time that I’ve participated in a Safe Motherhood event that featured a clown wearing stilts.
We drove out to Karatu in the Arusha Region more than 3 hours away from Moshi. We went with Mackrine Shao, Regional Coordinator for the White Ribbon Alliance (WRA). The International WRA has gained a lot of positive attention, with celebrity and political endorsements (Sarah Brown, wife of England’s prime minister Gordon Brown, is WRA’s patron, and names associated with WRA events include Melinda Gates, congresspeople and actresses). WRA-Tanzania, I’m proud to say, is quite an energetic national association.
Mrs. Shao is the epitome of a dynamic activist who seems to thrive on the sorts of political and community outreach that takes legwork.
Literally.
One Saturday morning in Karatu we celebrated Safe Motherhood Day. Although Safe Motherhood was celebrated on April 23 in other regions of Tanzania, Mrs. Shao had to postpone this region’s celebration until the District and Regional offices were ready to participate. The initial small group of participants met at the health clinic in high spirits. There were students from a youth band, a dozen NGO volunteers, our family, Mackrine and Kate (a visiting MPH student) who started the approximately 5 km rally through Karatu. By the end, we had about 100 students, 20 townsfolk, the District Medical Officer, the District Assistant Secretary (guest of honor), a theatre group, acrobat troupe, and the man on stilts.
There were a few speeches interspersed between informative entertainment. In a village where maternal and newborn death is a common tragedy, it was interesting to see the topic brought to attention with humor and honesty. Most such events in the U.S., where maternal mortality is rare (11 per 100,000 live births) are filled with powerpoint presentations, earnest lectures, and an aura of sadness.
In Tanzania, the maternal mortality statistics range from 578 deaths per 100,000 live births (Tanzania Demographic and Health Survey) to 950 deaths per 100,000 births (WHO). However, tracking maternal (and newborn) deaths is incredibly difficult- considering that about 53% of women deliver at home, with a traditional birth attendant or a relative, there are many uncounted deaths. If a woman dies on the way to the hospital, her death is not counted by the hospital. The village council is supposed to keep track of deaths and births for each village but it depends on the village, we are told. Frequently, a woman who dies from a postpartum endometritis 2 weeks after delivering is not counted among the maternal deaths.
The KCMC-Duke Women’s Health Collaboration contributed with a demonstration of emergency obstetric techniques. First, Mackrine had to reassure us that we could bring out our anatomically correct demonstration mannequins including a female pelvis and a newborn. We wanted to emphasize to the crowd the importance of delivering with a skilled health worker. Of course, we are just figuring out which health workers are actually skilled in emergency obstetrics- but women still have better odds of getting help with complications if they deliver at a health facility rather than at home. (The argument women give is that the health facilities are so understaffed and undersupplied, they would rather deliver at home knowing that there are no supplies or skilled workers, rather than travel great distances and pay money they can’t afford to deliver in similar circumstances).
To the great delight of the clapping crowd, we safely delivered the baby through the pelvis. Then the women volunteers took the newborn, wrapped in a kanga, and performed a celebratory dance around the stage to the music of the band. The man on stilts disappeared sometime during the presentations, and I don’t’ know if he was from the band, the acrobat troupe or the theatre group. However, he wasn’t needed to keep the crowd interested. After a long morning of speeches, skits, dances, and demonstrations, the rally ended quietly with many thank you’s passed around. By 2 pm, we had packed up our car for the 3 hour drive back to Moshi. Hopefully the rally made an impression on the women watching like it made on us.
I would love to download pictures and video from the day, but I will have to wait until our internet connection is able to handle it.
We drove out to Karatu in the Arusha Region more than 3 hours away from Moshi. We went with Mackrine Shao, Regional Coordinator for the White Ribbon Alliance (WRA). The International WRA has gained a lot of positive attention, with celebrity and political endorsements (Sarah Brown, wife of England’s prime minister Gordon Brown, is WRA’s patron, and names associated with WRA events include Melinda Gates, congresspeople and actresses). WRA-Tanzania, I’m proud to say, is quite an energetic national association.
Mrs. Shao is the epitome of a dynamic activist who seems to thrive on the sorts of political and community outreach that takes legwork.
Literally.
One Saturday morning in Karatu we celebrated Safe Motherhood Day. Although Safe Motherhood was celebrated on April 23 in other regions of Tanzania, Mrs. Shao had to postpone this region’s celebration until the District and Regional offices were ready to participate. The initial small group of participants met at the health clinic in high spirits. There were students from a youth band, a dozen NGO volunteers, our family, Mackrine and Kate (a visiting MPH student) who started the approximately 5 km rally through Karatu. By the end, we had about 100 students, 20 townsfolk, the District Medical Officer, the District Assistant Secretary (guest of honor), a theatre group, acrobat troupe, and the man on stilts.
There were a few speeches interspersed between informative entertainment. In a village where maternal and newborn death is a common tragedy, it was interesting to see the topic brought to attention with humor and honesty. Most such events in the U.S., where maternal mortality is rare (11 per 100,000 live births) are filled with powerpoint presentations, earnest lectures, and an aura of sadness.
In Tanzania, the maternal mortality statistics range from 578 deaths per 100,000 live births (Tanzania Demographic and Health Survey) to 950 deaths per 100,000 births (WHO). However, tracking maternal (and newborn) deaths is incredibly difficult- considering that about 53% of women deliver at home, with a traditional birth attendant or a relative, there are many uncounted deaths. If a woman dies on the way to the hospital, her death is not counted by the hospital. The village council is supposed to keep track of deaths and births for each village but it depends on the village, we are told. Frequently, a woman who dies from a postpartum endometritis 2 weeks after delivering is not counted among the maternal deaths.
The KCMC-Duke Women’s Health Collaboration contributed with a demonstration of emergency obstetric techniques. First, Mackrine had to reassure us that we could bring out our anatomically correct demonstration mannequins including a female pelvis and a newborn. We wanted to emphasize to the crowd the importance of delivering with a skilled health worker. Of course, we are just figuring out which health workers are actually skilled in emergency obstetrics- but women still have better odds of getting help with complications if they deliver at a health facility rather than at home. (The argument women give is that the health facilities are so understaffed and undersupplied, they would rather deliver at home knowing that there are no supplies or skilled workers, rather than travel great distances and pay money they can’t afford to deliver in similar circumstances).
To the great delight of the clapping crowd, we safely delivered the baby through the pelvis. Then the women volunteers took the newborn, wrapped in a kanga, and performed a celebratory dance around the stage to the music of the band. The man on stilts disappeared sometime during the presentations, and I don’t’ know if he was from the band, the acrobat troupe or the theatre group. However, he wasn’t needed to keep the crowd interested. After a long morning of speeches, skits, dances, and demonstrations, the rally ended quietly with many thank you’s passed around. By 2 pm, we had packed up our car for the 3 hour drive back to Moshi. Hopefully the rally made an impression on the women watching like it made on us.
I would love to download pictures and video from the day, but I will have to wait until our internet connection is able to handle it.
Tuesday, May 26, 2009
Sleepless in Moshi
The strangeness of the last 10 months is difficult at times to fully process or appreciate. Sometimes the writer's block is profound. Sometimes the drivel that comes out on the paper is so bad or comes from a place so bleak that it must be summarily squashed and hence one of the many reasons for the long delay in writing on this blog. After working in low resource settings on many short stints over the last 12 years, I thought there would be minimal difference between the way I internalized these short term experiences and those that one accrues over a longer stretch. I was wrong. The summation of many and varied exposures and the continuous exposure is fundamentally different and should be considered carefully ahead of time by those contemplating it; for there is no taking it back. And our situation is tame by most global health standards. We work in a place where there are only dozens of maternal deaths a year. There are many places that are worse. Losing track of time as we develop this or that program and submit this or that grant. The strain on family and relationships. The vagaries of new professional relationships. Concern over the loss of skills and future potential as a physician in the States. Thoughts of reintegration in to that system and moving on.
Few thoughts and recent patients:
1. Humility: I can remember my first exposure to a large number patients with obstetric fistula in Niger . Leaking of urine from a fistula causes fistula dermatitis. This can look exactly like secondary syphillis (condyloma lata) . After I had cancelled a few patients for surgery because of what appeared to be a rampant outbreak of syphillis amongst our fistula patients, I was promptly educated by an older and wiser colleague who told me what this really was. I sheepishly rescheduled the patients and learned a good lesson. We recently took a young woman to the operating room who was dying of something. We knew not what. She was thin and wasting away. Gaunt, tired. She began speaking of her own death. She had an abdomen full of ascites (fluid) and a large pelvic mass. We chose to operate to make a diagnosis in case this was a treatable type of cancer. We made an incision and on opening the abdomen found what looked like cancer everywhere. Her blood count was too low to try to remove all of this and there was only 1 unit of blood available in the blood bank. She likely would have died on the operating table if we tried to remove the tumor. We took a few biopsies and closed her up thinking there would be no hope for her. I was convinced like never before this was some terrible malignancy and hoped at least it would be one that could be treated, because every day she was closer to death. We pleaded for the pathologist (who already has a backlog of 6 months of cases to read) to give us an answer quickly. In 4 days (a miracle) we had our answer. It was Tuberculosis. We were all elated and once again I was humbled by the variety of ways a patient can manifest a disease and my limited exposures in the past. We began treatment and just three weeks later she was on her way home looking 100% better.
2. One of our patients we brought from Berega (see prior blog) is still here at KCMC. She has a rectovaginal fistula and underwent a loop colostomy to divert the flow of feces. She also has such a small bladder after her prior bladder fistula repair that she leaks constantly anyway. She needs surgery that cannot be done here for lack of a few instruments and expertise. She leaks stool now on to her abdomen through the colostomy instead of between her legs. Perhaps the lesser of two evils for her. There is no supply of ostomy bags, so she wraps a kanga around her to compress the stool and hide its odor for a while and then changes it a few times/day. Noone will take her at this point and we've been asking friends and colleagues to come with the appropriate expertise to help. She may be like that forever.
3. We have at least 4 women on the service dying of cervical cancer. A terrible way to go with bleeding and foul smelling necrotic tissue coming from the vagina. Intractable pain from metastases to the bone. No morphine to ease the pain.
4. 3 recent patients with choriocarcinoma which is nearly 100% curable, but we don't have access to the chemotherapy drugs they need. sent a few to Dar Es Salaam recently to the cancer hospital. Have to decide at some point how much is it worth spending to try to save the life of an individual woman in her prime. Is it $200, $300, $500, $10,000? If we spend $2000 in Blue Jean Ball funds on one woman do we deprive 10 women in the future of some local life saving therapy that we can't afford at that time.
5. 16 year old came in two nights ago at 32 weeks pregnancy with a intrauterine demise (stillbirth) and seizures. She had been treated for days at an outside facility and presented too late to do anything. She passes away yesterday morning. She was an orphan herself and no relative or friend was with her at any point in her labor or death.
Many more interesting and devastating stories, but time for bed.
Our team is going to a sugar plantation tomorrow (employs 10,000 people) to teach the ALSO emergency obstetrics course at their hospital.
A recent article by
Denise Grady at the New York Times
http://www.nytimes.com/2009/05/24/health/24birth.html?_r=1&em
Few thoughts and recent patients:
1. Humility: I can remember my first exposure to a large number patients with obstetric fistula in Niger . Leaking of urine from a fistula causes fistula dermatitis. This can look exactly like secondary syphillis (condyloma lata) . After I had cancelled a few patients for surgery because of what appeared to be a rampant outbreak of syphillis amongst our fistula patients, I was promptly educated by an older and wiser colleague who told me what this really was. I sheepishly rescheduled the patients and learned a good lesson. We recently took a young woman to the operating room who was dying of something. We knew not what. She was thin and wasting away. Gaunt, tired. She began speaking of her own death. She had an abdomen full of ascites (fluid) and a large pelvic mass. We chose to operate to make a diagnosis in case this was a treatable type of cancer. We made an incision and on opening the abdomen found what looked like cancer everywhere. Her blood count was too low to try to remove all of this and there was only 1 unit of blood available in the blood bank. She likely would have died on the operating table if we tried to remove the tumor. We took a few biopsies and closed her up thinking there would be no hope for her. I was convinced like never before this was some terrible malignancy and hoped at least it would be one that could be treated, because every day she was closer to death. We pleaded for the pathologist (who already has a backlog of 6 months of cases to read) to give us an answer quickly. In 4 days (a miracle) we had our answer. It was Tuberculosis. We were all elated and once again I was humbled by the variety of ways a patient can manifest a disease and my limited exposures in the past. We began treatment and just three weeks later she was on her way home looking 100% better.
2. One of our patients we brought from Berega (see prior blog) is still here at KCMC. She has a rectovaginal fistula and underwent a loop colostomy to divert the flow of feces. She also has such a small bladder after her prior bladder fistula repair that she leaks constantly anyway. She needs surgery that cannot be done here for lack of a few instruments and expertise. She leaks stool now on to her abdomen through the colostomy instead of between her legs. Perhaps the lesser of two evils for her. There is no supply of ostomy bags, so she wraps a kanga around her to compress the stool and hide its odor for a while and then changes it a few times/day. Noone will take her at this point and we've been asking friends and colleagues to come with the appropriate expertise to help. She may be like that forever.
3. We have at least 4 women on the service dying of cervical cancer. A terrible way to go with bleeding and foul smelling necrotic tissue coming from the vagina. Intractable pain from metastases to the bone. No morphine to ease the pain.
4. 3 recent patients with choriocarcinoma which is nearly 100% curable, but we don't have access to the chemotherapy drugs they need. sent a few to Dar Es Salaam recently to the cancer hospital. Have to decide at some point how much is it worth spending to try to save the life of an individual woman in her prime. Is it $200, $300, $500, $10,000? If we spend $2000 in Blue Jean Ball funds on one woman do we deprive 10 women in the future of some local life saving therapy that we can't afford at that time.
5. 16 year old came in two nights ago at 32 weeks pregnancy with a intrauterine demise (stillbirth) and seizures. She had been treated for days at an outside facility and presented too late to do anything. She passes away yesterday morning. She was an orphan herself and no relative or friend was with her at any point in her labor or death.
Many more interesting and devastating stories, but time for bed.
Our team is going to a sugar plantation tomorrow (employs 10,000 people) to teach the ALSO emergency obstetrics course at their hospital.
A recent article by
Denise Grady at the New York Times
http://www.nytimes.com/2009/05/24/health/24birth.html?_r=1&em
Friday, February 27, 2009
After a Devastating Birth Injury, Hope
This is the title of a New York Times article this week. You can read the full article at:
http://www.nytimes.com/2009/02/24/health/24hospital.html
Denise Grady, a New York Times reporter, accompanied Jeff, Brandi (our wonderful Global Health OBGYN fellow) and Dr. Masenga (OBGYN physician at KCMC and expert fistula surgeon) to Dodoma in central Tanzania. They held an obstetric fistula surgery training camp, sponsored by AMREF and helped with funds from the Blue Jean Ball (http://bluejeanball.mc.duke.edu/index.html). Denise Grady's article describes the problem facing girls/women with fistula quite well.
http://www.nytimes.com/2009/02/24/health/24hospital.html
Denise Grady, a New York Times reporter, accompanied Jeff, Brandi (our wonderful Global Health OBGYN fellow) and Dr. Masenga (OBGYN physician at KCMC and expert fistula surgeon) to Dodoma in central Tanzania. They held an obstetric fistula surgery training camp, sponsored by AMREF and helped with funds from the Blue Jean Ball (http://bluejeanball.mc.duke.edu/index.html). Denise Grady's article describes the problem facing girls/women with fistula quite well.
Saturday, January 10, 2009
“Tangu lini?” we ask the boy child. Since when?
He is 16 years old, but because of HIV, and malnutrition and social factors that we could only guess at due to our limited Swahili, he looks barely 10. His body is skinny, and he weighs less than my 8 year old daughter. The bumps on his face are like little pieces of yellow-red gum that’s been chewed up into small varied globs and stuck there in haphazard fashion. How long have the bumps been there? For 10 months. Looking through his medical chart, we only find one other mention of the face lesions (although the undecipherable handwriting of the physicians makes it difficult to know this for sure). Two months ago, the physician referred the boy to dermatology clinic where he was diagnosed with molluscum contagiosum. This link shows a picture of another child with molluscum: http://www.cehjournal.org/extra/53_05_01.html.
The referral note from the dermatologist didn’t include any treatment options, or the boy’s probability of improving or being cured. We ask the boy if the dermatologists said anything to him about the diagnosis, or prognosis but he shakes his head no.
We flip through the child’s medical records to see what we can offer him. He is obviously very embarrassed about his face lesions. The only question he asks the nurses is whether we can offer him any cure for his facial disfigurement. He doesn’t ask us, the doctors, directly. He only nods respectfully and offers single word responses. He appears shy and modest, and he has no family members with him that we could question. The nurses tell us that he lives in Moshi with his mother, who runs a business and never comes to his clinic appointments. His HIV status was discovered during an admission to the hospital 10 months ago due to sepsis. Actually, his CD4 count has significantly improved, from 350 to 770, in the last 10 months. But this disqualifies him from the only simple treatment for his facial molluscum- antiretroviral (ARV) medications.
Later that morning, we see a 12 year old cachectic boy with HIV, vomiting, and severe ascites (abdominal swelling) with unknown social situation (Are his parents dead or alive? Who are the different people who claim to be his guardians? Has he been given any of his ARV medications since his HIV diagnosis was made 15 months ago?). The next patient is an 8 year old girl living in an orphanage who has had worsening mental status over the last few weeks despite taking her ARV medications, and who can barely stay awake, stand, or control her stools when we visit her. What is causing her to get worse? Who will pay the $80 cost for her CT scan (luckily, one of the doctors)? Once we know the diagnosis, is there anything we can do about it?
So many mysteries, so many unanswered questions. The one certain thing is that prevention is the best cure. Now, in Tanzania, we have the chance to have HIV-free children born to HIV positive mothers thanks to PMTCT (Preventing Mother To Child Transmission) programs. The latest guidelines call for all pregnant to be screened for HIV at their first antenatal clinic visit, no matter what remote part of Tanzania they live in. Those found to be HIV positive are to receive certain ARV medications starting at 28 weeks of pregnancy, with a more intense ARV regimen during labor. If a pregnant woman doesn’t seek care in time, or doesn’t receive this regimen for whatever reason, the newborn baby is to get ARV medications for 28 days. And with this approach, the number of children with HIV related horrible, complicated medical issues will be drastically reduced. It is definitely not an easy task. Most pregnant women in Tanzania are now being screened for HIV during pregnancy, but only a few who qualify are actually receiving guideline-based ARV medications. Either the medications are not available, or the proper combinations aren’t available, or the hospital staff do not know about the changes, or the patient’s condition doesn’t allow for it.
Before PMTCT was initiated, the Ministry of Health in Tanzania estimated that 72,000 babies a year were infected with HIV by through pregnancy, deliver and breastfeeding. That number could be reduced to less than 8,000 by following the latest guidelines. Although the nurses and staff of the HIV clinics and pediatric wards are working hard to improve the lives of children with HIV, the best treatment is prevention.
I don’t know if we will ever be able to clear the 16 year old boy’s face of molluscum. But because of his plight, we will work harder to ensure more pregnant women receive full PMTCT services and medicines so future children are less likely to have to live with such stigma-inducing diseases. I can’t convey such a complex message to the 16 year old, even if I could speak fluent Swahili. I hope the Dermatology clinic has something more to offer him.
He is 16 years old, but because of HIV, and malnutrition and social factors that we could only guess at due to our limited Swahili, he looks barely 10. His body is skinny, and he weighs less than my 8 year old daughter. The bumps on his face are like little pieces of yellow-red gum that’s been chewed up into small varied globs and stuck there in haphazard fashion. How long have the bumps been there? For 10 months. Looking through his medical chart, we only find one other mention of the face lesions (although the undecipherable handwriting of the physicians makes it difficult to know this for sure). Two months ago, the physician referred the boy to dermatology clinic where he was diagnosed with molluscum contagiosum. This link shows a picture of another child with molluscum: http://www.cehjournal.org/extra/53_05_01.html.
The referral note from the dermatologist didn’t include any treatment options, or the boy’s probability of improving or being cured. We ask the boy if the dermatologists said anything to him about the diagnosis, or prognosis but he shakes his head no.
We flip through the child’s medical records to see what we can offer him. He is obviously very embarrassed about his face lesions. The only question he asks the nurses is whether we can offer him any cure for his facial disfigurement. He doesn’t ask us, the doctors, directly. He only nods respectfully and offers single word responses. He appears shy and modest, and he has no family members with him that we could question. The nurses tell us that he lives in Moshi with his mother, who runs a business and never comes to his clinic appointments. His HIV status was discovered during an admission to the hospital 10 months ago due to sepsis. Actually, his CD4 count has significantly improved, from 350 to 770, in the last 10 months. But this disqualifies him from the only simple treatment for his facial molluscum- antiretroviral (ARV) medications.
Later that morning, we see a 12 year old cachectic boy with HIV, vomiting, and severe ascites (abdominal swelling) with unknown social situation (Are his parents dead or alive? Who are the different people who claim to be his guardians? Has he been given any of his ARV medications since his HIV diagnosis was made 15 months ago?). The next patient is an 8 year old girl living in an orphanage who has had worsening mental status over the last few weeks despite taking her ARV medications, and who can barely stay awake, stand, or control her stools when we visit her. What is causing her to get worse? Who will pay the $80 cost for her CT scan (luckily, one of the doctors)? Once we know the diagnosis, is there anything we can do about it?
So many mysteries, so many unanswered questions. The one certain thing is that prevention is the best cure. Now, in Tanzania, we have the chance to have HIV-free children born to HIV positive mothers thanks to PMTCT (Preventing Mother To Child Transmission) programs. The latest guidelines call for all pregnant to be screened for HIV at their first antenatal clinic visit, no matter what remote part of Tanzania they live in. Those found to be HIV positive are to receive certain ARV medications starting at 28 weeks of pregnancy, with a more intense ARV regimen during labor. If a pregnant woman doesn’t seek care in time, or doesn’t receive this regimen for whatever reason, the newborn baby is to get ARV medications for 28 days. And with this approach, the number of children with HIV related horrible, complicated medical issues will be drastically reduced. It is definitely not an easy task. Most pregnant women in Tanzania are now being screened for HIV during pregnancy, but only a few who qualify are actually receiving guideline-based ARV medications. Either the medications are not available, or the proper combinations aren’t available, or the hospital staff do not know about the changes, or the patient’s condition doesn’t allow for it.
Before PMTCT was initiated, the Ministry of Health in Tanzania estimated that 72,000 babies a year were infected with HIV by through pregnancy, deliver and breastfeeding. That number could be reduced to less than 8,000 by following the latest guidelines. Although the nurses and staff of the HIV clinics and pediatric wards are working hard to improve the lives of children with HIV, the best treatment is prevention.
I don’t know if we will ever be able to clear the 16 year old boy’s face of molluscum. But because of his plight, we will work harder to ensure more pregnant women receive full PMTCT services and medicines so future children are less likely to have to live with such stigma-inducing diseases. I can’t convey such a complex message to the 16 year old, even if I could speak fluent Swahili. I hope the Dermatology clinic has something more to offer him.
Subscribe to:
Posts (Atom)