Thanks

Brandi and Scott arrived last week. Brandi Vasquez is, as far as I know, THE first, official Global Health Resident in Obstetrics and Gynecology…..EVER. Thanks are due to the Department of Obstetrics and Gynecology, the Hubert Yeargan Center for Global Health, the Duke Global Health Institute, the Blue Jean Ball Committee (and BJB donors!) and Covidien HealthCare for making our presence and work here possible. They have accepted the challenge to support global women’s health on a level previously uncommon if not unheard of at other institutions. Special thanks also goes out to Stryker Surgical and Cardinal Health for their very generous donations to our work here.

Women’s health has languished in the corner of the Global Health house for too long. The Safe Motherhood Initiative has been labeled an “orphan initiative”. Women’s health care has largely taken a back seat to other pressing issues such as HIV. Very little improvements in maternal healthcare have been realized in sub-Saharan Africa in the last 15 years and we are far from on track to reach Millenium Development Goal number 5 of a 75% reduction in maternal mortality by 2015.

“No Woman Should Die Giving Life”.

A nice little saying that warms the heart, but has done nothing to save the lives of millions of the poorest and most under-represented women on earth.

“Since the human race began, women have delivered for society. It is time now for the world to deliver for women.”
Another little feel-good dittie that has gone nowhere. When will this “time” be that mothers are valued enough to prevent their untimely death at the moment when life seems most precious?

Thanks to the generous donations of many of you, we are planning to hold the first combined Advanced Life Support in Obstetrics and Neonatal Resuscitation Courses in a referral hospital in Tanzania on November 3-12. Improvement in emergency obstetric care is the third of three core health-sector strategies designed to reduce maternal morbidity and mortality. We are all excited about the prospects for disseminating this information and technology locally and regionally. Thanks to all who have seen us through to this point and who continue to support us.

The question of Malaria

I am pleased to report that Barney survived his experience at the Vets and returned home to us as good as new. The total bill was 250,000 Tanzania Shillings which is about $210 USD. This was for blood work, three electrical stimulation treatments (still not sure what those were for) and 2.5 weeks lodging with food. A good deal, all in all, especially when compared with the $250 my brother-in-law just spent on one visit to the Vets in the states for a check-up and a few shots for his new puppy. This also happens to be the full cost to surgically repair a patient with vesicovaginal fistula in many sub-saharan African countries (see www.endfistula.org and more on this topic later).

We were in Bukoba two weeks ago helping to teach the first ALSO (Advanced Life Support in Obstetrics) Course in Tanzania. The flight across lake Victoria from Mwanza was truly spectacular and surprisingly uneventful given that we were flying in a plane that was older than I am with pilots who were half my age. The course was a success. We trained over 40 people in caring for obstetric emergencies and hopefully generated some interest in the widespread dissemination of this teaching throughout Tanzania. The maternal mortality ratio (number of maternal deaths/100,000 live births) in Tanzania remains high at 500 - 900 depending on who's counting. This compares to about 12 in the US.

Towards the end of our week there, I began to feel sick. Chills, Sweats, a pounding headache, muscle aches and fatigue. I nearly passed out giving a lecture on post-partum hemorrhage. Our kind hosts insisted that I go to the hospital in Bukoba to get evaluated. There was no question in anyone's mind, except for mine, that I had malaria. I had been living in Moshi (where the rate of malaria is felt to be quite low) and had been taking Mefloquine for prophylaxis. That said, there is a widespread propensity to make the diagnosis of malaria for anyone with concerning symptoms. I have seen the same in Niger and suspect that this practice is widespread wherever malaria has been common in the past. I had some blood tests done at the hospital. They showed moderate anemia and possibly an atypical infection, viral or......MALARIA! The smear for malaria was negative. I took the pills for malaria, of course, and over the next few days, slowly began to feel better: A scene that has played itself out countless times in Africa and elsewhere: Treatment for malaria when the diagnosis was almost certainly something else. I returned home to Moshi and, feeling a bit weak still, I had the lab tests repeated at the Duke lab and they were normal. Significantly abnormal labs at the Bukoba hospital were likely wrong, leading to assumptions that were also likely wrong. Laboratory issues that people here deal with all the time. No anemia, no abnormal white blood cell counts.... Probably a viral illness. Something my immune system had never encountered outside of East Africa.

The reasons for overdiagnosis and treatment of malaria are many and complex. People are dedicating their careers to figuring this out. Most providers here have seen dozens if not hundreds of people die from malaria. To be wrong about the diagnosis and withhold treatment leads to disaster. To diagnose and treat malaria when it is actually something else that will resolve on it own is somewhat of a self fulfilling prophecy. Treat for malaria...patient gets better...must have been malaria. It reinforces the practice of treating liberally in the absence of data or with data that is suspect. Fortunately the treatment is fairly benign and most people get better. I have spoken to a number of people here who say that they get malaria many times a year and keep the medications on hand and self treat at the first signs of fever or malaise. Have to wonder what this all is doing to the efficacy of the drugs.

Ear drops

Our 11 year old is sick again. He has already missed 2 days of school, and it is only the second month since classes started. This time, he started crying and clutching his ears at 9 pm on a Sunday night. Naturally, I was sure this was a delay tactic to avoid getting ready for bed, until I looked in his ears with the otoscope. A bulging ear drum full of pus and blood stared back, one side only slightly better than the other.

Our medicine cabinet here in Moshi is impressive. It was impressive in Durham, but it has reached new heights of prevention. And thanks to a yard sale, all of our items are organized into Tupperware boxes. Since we were to be one of only a handful of faculty doctors on the compound, and not knowing what is available in Tanzania, we came prepared. We have antibiotics, anti-inflammatory, anti-viral medications, steroid creams, antifungal creams, antifungal tablets, tablets in german that were donated to our cabinet and that required a google search to identify.

However, we forgot ear drops. Luckily, there are many pharmacies in Moshi town, and I went to one of the biggest. They seemed to have all sorts of medications, prescription and non-prescription. However, the ear drops are a problem. I go through my list of choices: Auralgan- no. Cipro Otic- no. Cortisporin Otic- no. Let’s look at the generic names to see if anything sounds familiar. I mentally kick myself for not learning the Swahili term for “ear drops” or “antibiotic drops”. I have learned how to say “are you having contractions” “does your head hurt” and “is the baby moving”, which are only useful in a Labor Ward.

Finally, they emerge with a tiny little tube of some ear suspension medication I had never heard of, but it was sealed, and had a Pfizer label and tetracycline and steroid ingredients. I paid 11,500 shillings for those ear drops (about $10), and as I left the pharmacy, I did some mental math. It costs 15,000 shillings (about $13) to have a vaginal delivery at KCMC, and we are told that countless women could never afford to deliver there. I just spent almost that much to buy a 4 ml tube of symptom control for my son.

Barney update: Barney is still at the vet’s office. He is getting his final electrical stimulation, and he will return on Sunday. The vet says he is better- we’ll see what that means.

Return on Investment

A pervasive challenge in Obstetrics is how best to monitor the fetus to ensure “fetal well being”. The ultimate goal is to end up with a healthy baby after delivery. One can listen with a stethoscope like device, a hand held doppler or with continuous electronic fetal monitoring. One can perform an ultrasound. The ability to do this well is a challenge in both low and high resource settings. In high resource settings, we over utilize fetal monitoring and this results in inconvenience and discomfort for the mother, a higher rate of cesarean deliveries and other unnecessary interventions. I have been tempted on occasion to hurl the fetal monitors from the heliport at Duke. In low resource settings, there is often no fetal monitoring. This is almost always due to resource limitations, training and personnel shortages. This paradoxically results in higher rates of cesarean deliveries because obstetric providers cannot reassure themselves that all is well and the smallest of things can prompt an “emergency cesarean”. In our first two months here, we reviewed at least a dozen fetal or neonatal deaths that might have been prevented with fetal monitoring. The loss of a pregnancy is hard on everyone: the patient, her family, the nurses and the doctors. The staff at KCMC were eager to prevent this from happening again and we had discussed some practical means of doing so on a few occasions. It might seem like an easy solution to simply monitor all women in labor or perform a cesarean delivery on all high risk patients. Not a simple task on a ward where there are two patients to a bed and a single nurse looks after 40 patients.

It is rare in medicine that you see teaching efforts bear fruit immediately. We taught the ObGyn residents how to perform and interpret continuous electronic fetal monitoring on Thursday morning of this week. We encouraged its selective use in only high risk patients because of significant resource limitations. That afternoon, a woman presented on referral from a local district hospital. She had experienced eclamptic seizures and had a dangerously high blood pressure prior to transfer. On arrival, she was quickly stabilized and magnesium sulfate was administered to prevent further seizures. A decision needed to be made about delivery: Attempt to induce her labor and deliver normally or expedite the process with a cesarean delivery. Already deemed a high risk patient, the residents performed what is called a non-stress test on the fetus with the single electronic fetal monitor system on the labor ward. They had never personally performed this test. The fetal heart tracing was ominous: Late decelerations with no variability followed by a few minutes of bradycardia (slow heart beat) A sign that the fetus was in trouble. This was the kind of tracing one might see in a textbook illustrating what a fetus looks like prior to intra-uterine death.

A cesarean delivery was performed. Dr. Tina Oneko from pediatrics was on hand to resuscitate a floppy looking baby. We have since visited this healthy looking child in the nursery. Her name is Grace.

Barney

We adopted a dog in Moshi. His name is Barney. Barney is a mix of a Rhodesian Ridgeback and a Boxer. He’s gentle and fun and BIG. A good dog to have around the house at night. His original owners just returned home to Australia after a 6 year stay in Moshi. A few days after they left, Barney began to look ill. I thought he might be depressed, missing his real parents. He stopped eating and appeared listless. He usually eats anything and is full of life. The local veterinarian made a house call and after a few injections, I was hoping that Barney would be on the mend. He was not eating his usual rice and dried fish dinners so I made a stop at the store to see if I could get him a special treat to perk him up a bit. Looking through the aisles at the store, I noted a host of options for the discerning pet owner. A small store in Moshi, which clearly caters to the expatriot community, had at least 6 forms of dog food. A single can of food was about $2.25. A two weeks’ size bag of dried food cost about $22.00. The average family of four in Tanzania eats for a week for under $10. In the USA, $33,000,000,000 (billion) is spent annually on pet care products, including $14.2 billion on dog food alone. The GDP of Tanzania was about 49 Billion in 2007. The health expenditure per capita in Tanzania is about $50. I spent more on one veterinarian visit and some pet food than the average Tanzanian spends on health care in a full year.

Barney started to look more ill last night. He was panting and could not stand on his own. We lifted him in to the car and drove him to a German veterinarian who lives 17 kilometers away in Machame. The sun was beginning to set as we left Moshi behind. I had promised myself not to stray far from Moshi at night: No street lights, uneven, unmarked pavement, a host of pedestrians and animals on the shoulder and huge trucks with variable safety features. After a ride part way up the foothills of Kilimanjaro, we arrived at the vet’s home and coaxed Barney from the vehicle. He was able to walk to a small clinic down the hill from the doctor’s home. The lab was well equipped with a microscope, hematology and chemistry analyzers and a decent operating table and lights: The envy of many hospitals and health centers in the region. The doctor was efficient and courteous. Not once did he ask how I would pay. It was assumed that I could pay and that I would pay. I thought of the countless patients in hospitals throughout Africa that night who were deprived of testing and treatment because they could not afford to pay. My newly adopted dog was receiving better care than many if not most human patients can get. Was it right to expect treatment for my dog when my patient could not receive the same? Should I allow Barney to languish ill and go pay the hospital bill for the patient in room 25? Would there be some perverse justice in that? This is not a moral dilemma unique to Africa. The 50 million uninsured people in the US can attest to the difficult decisions surrounding healthcare in the richest country in the world. The relative scale of the moral dilemma in Africa, however, is, simply put: HUGE

Late in the Day

She had been bleeding for weeks. It seems an insignificant afterthought to me now that she never knew her diagnosis. Is it better to die with or without the knowledge of what kills you? She had a few visits to the doctor. What was done for her was unknown. She was pale and confused. Profound blood loss leads to shock: The body prepares itself. Non-essential tissues constrict blood vessels in deference to the brain, heart and other essential organs. The hands and feet are cool and clammy. Ultimately, the brain and the heart have nowhere to turn for oxygen and an inexorable series of events occurs that lead to death. There’s panic, hunger for air and system wide suffocation, then delirium. Is there suffering at this point? It certainly looks like suffering. Flailing arms, retching, gasping….clinging to a loose piece of rock that has detached itself from the face of this earth and only has yet to fall to the ground. We happened upon her when it was late. Late in the day, late in the course of her illness and too late to make a difference. The gasping and the flailing stopped and she lay still. There was nothing notable otherwise. She had been so pale that her now increasingly dusky appearance was barely noticeable. She could have been asleep. Asleep with no breathing..no pulse. A B C’s. Airway, breathing, circulation. IV’s, Fluid, Oxygen, Blood, Epinephine, Atropine…… and the blessed return of pulse, blood pressure and…… breathing. Semi-consciousness returns. Did she have any idea what was happening? Did she have some last fleeting thoughts of her six children. Down again, 1,2,3,4,5,6,7,8…… Breaths, more fluid, more blood, more drugs…….Up again…A continent of vast resources and potential. Motherhood stolen from countless children. Children stolen from countless mothers. She died later that evening. My thoughts returned to a patient in the US with nearly the same condition who survived……. No flailing, retching or gasping. No broken ribs and near death experience. I remember the discussion I had with her about “worst case scenarios”. If she only knew.

Schistosomiasis

August 25, 2008

Over the last few weeks, I have been working with various teams on different hospital wards. The medical service beds are commonly full, (10 beds per room) and so additional beds and patients are placed in the middle of the room (3 can be accommodated). If those are full, they are placed on cots in the hallway. If those fill up, then they double up patients on one bed.

I was surprised that more patients on the medical ward, during my rounds, have complications from schistosomiasis than from HIV. Probably because KCMC has an excellent endoscopy program( an endoscopy costs about $12) and so patients are referred here from other centers. Schistosomiasis (also known as Bilharzia) is the disease caused by a blood born fluke (trematode) of the genus Schistosoma. Snails are the intermediate hosts. Adult schistosome worms were first discovered in an Egyptian patient in 1851 during an autopsy carried out by Dr. Theodore Maximilian Bilharz.

The Medical Ward room I rounded in had 3 female patients with end stage complications from schistosomiasis. They all had liver failure, and I palpated their spleens almost to their pelvis. 2 of them needed endoscopy to coagulate their bleeding esophageal and stomach veins. One patient had 5 liters of fluid drained from her abdomen, and yet she still had such significant ascites, she looked like she was carrying a term pregnancy. All of the women were 20-30 years old.

The Male Medical Ward room had 3 teenage boys, all recovering from bloody vomiting. They also had presumed schistosomiasis. Presumed because the tests required to confirm are prohibitively expensive. At some point once the chronic manifestations occur, there is no cure. It is difficult to predict that point for any given patient.

From the Schistosomiasis Control Initiative (http://www.schisto.org):

Light infections with schistosomiasis can be asymptomatic, and many people may live their lives without knowing they have ever been infected. However, globally, up to 120 million of the estimated 200 million infected people are believed to be symptomatic, and as many as 20 million may well be suffering severe consequences of their infection. The annual deaths associated with schistosomiasis are estimated at 20,000.

The first obvious symptom of infection is blood in the urine (hematuria). Early signs of morbidity which manifest in school age children are anemia, impaired growth, impaired development, poor cognition, and substandard school performance. However none of these signs and symptoms are due solely to schistosomiasis, and so a diagnosis on clinical presentation is difficult.

In terms of Women’s Health, schistosomiasis can wreak havoc on the female genital tract. Diagnosis is made by the presence of schistosome eggs and/or worms in the upper and/or lower genital tracts. Possible consequences include hypogonadism, retarded puberty, infertility, cancer, ectopic pregnancy, anemia due to chronic blood loss, miscarriage and preterm delivery, increased risk for sexually transmitted diseases (including HIV), and vesicovaginal fistula.

The most common method of transmission occurs when humans wade or swim in lakes, ponds and other bodies of fresh water which are infested with the snails. Thus, children and fisherman are at high risk of being infected. The parasite, when present in the water, bores through the skin and enters the bloodstream. The bladder is a favorite site of infestation. And in some endemic areas, a diagnosis is made based on observing blood in a child’s urine.

According to the Carter Center:

Schistosomiasis can be controlled now by one of the great miracle medical discoveries of the 1980s: the oral medicine praziquantel. Now that costs of the medicine have dropped from more than $2 USD per dose to 18 cents, great strides can be made in treating schistosomiasis.

Studies of those treated show that within six months of receiving a dose of praziquantel, up to 90 percent of the damage due to the schistosomiasis infection can be reversed. In the past, praziquantel has been used successfully to treat millions of people at risk for or infected with schistosomiasis in Brazil, Egypt, and China.

Too late for my patients, but there is hope for other Tanzanian children: August 29^th is the official start of the mass deworming project in the Kilimanjaro Region, the first to occur in a few years. All school age children will receive praziquantel and albendezole (to treat other worms). Only one dose is needed (more is ideal, but only one is required). This will also be paired with a massive immunization campaign.