ICC & the 40th Anniversary Celebration: what someone can do without leaving their home

I want to mention our hosts of this little sejours - "International Child Care" or ICC (see http://www.intlchildcare.org/) is an NGO focusing on Haiti & the DR for the last 40 years. One of the best parts of this week was getting to know members of the American board - ordinary Americans who have been touched in one way or another by Haiti & the challenges there. They are salesmen, nurses, physiotherapists, from all over the US and many had never thought of the world outside their borders before they got involved with Haiti. The American & Canadian members donate a great deal of time and effort to fundraising, while the local organisation and board focus more on programming - with dedicated Haitian staff throughout the country. At the two 40th anniversary celebration, many spoke of their pride in the organization and the lives that it impacted.

ICC has both the Grace Children's Hospital in Port-au-Prince, and community health centers and activities throughout Haiti, with activities like primary care, vaccination, and income generation / microcredit schemes.

Chuck Phelps & Jeannine Hatt acted as our hosts - they've been to Haiti at least twice a year for a number of years, and are very dedicated to the cause. They were incredibly warm and welcoming and put a lot of effort into ensuring that the two 'newbies' - myself and Sarah Kim (another former Pediatrics AIDS Corps doctor) - had a chance to see more of Haiti. (Photo, left to right - Sarah Kim, Jeannine Hatt, Claudy St Juste, Tyler Bloom, Chuck Phelps, Mesa, our driver - lunch stop on our medical tourism day).

Claudy St Juste was the master organizer - what a headache he had to organize 30 North Americans, the details for the congress, all the transport, etc. And yet he was consistently welcoming, friendly and gracious - and clearly dedicated to the organization.


Friday night was the formal celebration, with speeches, a video and excellent Haitian dancing by a group of young adults at least of some of which were former patients at ICC. This photo is the North Americans who came to speak in the conference.

Day 4 & 5 - Congres Medicale

The conference was really interesting. I really enjoyed hearing the Haitian presentations on HIV care, prevention of mother to child transmission, etc. There seem to be many NGOs here providing HIV & other pediatric care, and they are able to do things like TB prophylaxis for children of adults with TB. Haiti is an HIV vaccine study site and Dr Joseph provided an interesting overview of both the study (now stopped due to lack of efficacy) and the HIV vaccine process.

The medical congress was remniscent of being in Burkina Faso (though thankfully, the question period is less painful). We arrived around the scheduled start time, and things got rolling an hour or more later. Each speaker took more than their alloted time, so both days the conference finished 2 hours late.

I gave my talk - on the interaction between parasitic infections & HIV - in French, which was a little painful for me but I think went over well. It was intersting to review the topic in detail.

The congres was at the fanciest hotel in Haiti - perched on the top of a hill, the beautiful hotel was surrounded by lush gardens. Another world from the poverty below.

Haiti, day 3 - "Fete du 40ieme anniversaire de ICC"

"Fete" may be a bit too strong a word for 4 hours of speeches.
It was the hospital celebrating their 40th anniversary, in the ceremony for the hospital staff. The staff really do deserve a pat on the back, for they have a great hospital and clinic. The speeches were followed by a feast - you should have seen the heaped plates!

Driving around this city is fascinating. The roads are really narrow, and the even narrower sidewalks teaming with people and goods for sale. Everything from doves in cages, to plastic chairs, to piles of avocados and oranges. The streets are filled with potholes.

The "tap-taps" are the local public transit system; many of them brilliantly painted, with great names. They are mostly small pick up trucks, with a canopy that has been raised by two feet to allow people to sit on benches along the sides. As in many countries, there seem to be impossible numbers of people in the vehicles.

Electricity is provided by generators - the government doesn't provide it consistently. And water of course is always suspect.

I really like Haiti so far... its got a little of that island feel, and yet the needs are great. I hope to do more work here in the future.

The other benefit to coming here is that I have a renewed excitement for our project in South Africa. It really helps to have a reminder of why I want to do this work and why the benefits can balance the personal costs of being a nomad. (To a certain extent).

These small children, loved by their parents yet with so few opportunities... trying to help them is so important.

Hospital tours

Today was a true ‘medical tourism’ day; we visited 3 different health centres, each quite different. And driving around Port-au-Prince was fascinating.

Our first stop was the Grace Children’s Hospital, run by “ICC”, or International Child Care. (We are in Haiti for the 40th Anniversary of this faith-based NGO - in photo). For their anniversary, they are having “open house” days, where all consultations are free (rather than the usual $2 USD fee). The place was PACKED. They do have a mechanism for waiving fees for those “qui n’ont pas les moyens” (don’t have the means). But with how packed the clinic is today one wonders how many without the means just don’t attempt to go to the clinic (as is so often the case in Burkina Faso).

They have an inpatient ward, where the parents aren’t allowed to stay; it was the first time in my life that I saw a room full of kids with nary a parent in sight. There are enough nurses to do the care, and they are from the old school of believing that kids are better off with restricted visiting hours. One little marasmic girl with big wide eyes, a bit of papular pruritic eruption (an itchy, bumpy, common rash amongst HIV + kids)just held out her arms when we walked over. She didn’t make a sound but what she really wanted was to be held – even by a stranger. Some of the kids were very apprehensive of us but others were just curious and captivated by the white folks.

The hospital grounds are lovely and green, and there is even a playground!!

The second stop was GHESKIO, which is the oldest HIV treatment agency in Haiti – predates the more famous Partners in Health. We had a really lovely, comprehensive tour of an amazing research centre. They are an HIV vaccine trial study site, as well as being involved with a number of other research programs. It seems like a model of locally driven research done in partnership with a western university – and so it has all the funding that this implies. They have separate areas for each area of HIV care – testing counseling, lab (with phelebotomy), ARV treatment, pediatric HIV clinic, pediatric clinic, adherence, clinical trial clinic, STI clinic, family planning clinic, PMTCT clinic. It was crowded and chaotic but seems to be really well organized.
Finally we stopped at the government hospital. Typical for government hospitals, dark, crowded, not too clean. But still better organized and equipped than our hospital in Bobo. They have kids organized by both age and pathology to a certain extent (in Bobo they’re in two groups – older kids, and younger kids, regardless of what other infectious pathology they may have). There were more severely marasmic kids there, and the kids were very sick appearing. It was a odd to be there and not working.

This has been just a fascinating day – but I am sure exhausted! More tomorrow.
Take care
Laura

New country, new adventures!

Well, after a hiatus, I'm making an attempt to get back into blogging again. My impetus is the fact that I'm sitting in a hotel in Port-au-Prince, Haiti, on the first day of a week long trip to learn about pediatric HIV care in Haiti and speak in a conference on parasites & HIV in children.

After a journey that felt almost as long as that to Africa (though it was just two - 6 hour flights), I arrived this afternoon. The warmth was welcome as we climbed out of the airplane. There was a band in the entryway of the airport, like in Tahiti.
In fact at first glance, that's what this reminds me of - a cross between Africa (Burkina Faso) and Tahiti. Despite the higher ranking on the HDI - 154 vs Burkina's 174 of 177 countrires - things seem more run down here. A first example is that the urban roads are much worse - poorly maintained, more chaotic, slower.

Some things made me feel at home - reminding me of Burkina - the women selling deep fried beignettes on the side of the road, the vendors with second hand clothes, the warmth.
The vegetation and the ocean smells, and the cool ocean breeze.

I'm excited for the hospital visit tomorrow.

More later!
Laura

Capacity building & neo-colonialism.

The last few weeks have been obscenely busy.

We had 6 of our South African colleagues here, and had a conference to seek broad input into the planned project. I was the key organiser, though had a ton of help. We got a lot of good feedback on the study, and I think we made progress. However, one of the key issues that will keep reoccuring is capacity (and the lack thereof) and neo-colonialism. Its a challenging problem that i am not sure how we will resolve in this context.

Our South African partners are some of the world's most important TB experts, and its an honour to work with them. Within South Africa, there are few senior researchers in ID, and those that are there are hugely overworked. And worse yet, there are few people coming through the pipeline, particularly in the cultural groups that were excluded / disadvantaged during apartheid.

On the other side, we are a Canadian group that would like to help build capacity, and collaborate with South African's to get this large study off the ground. In our minds, this should be a true collaboration... but our South African counterparts have been victims of many "collaborations"... where they participate, and even spend much effort on a study only to have the data taken and publications (and hence academic credit) written by the developed country researchers. They are - understandably - very leary about entering into partnerships, having been burned before. Groups often go to SA thinking they know what's best in the South African setting, trying to do things in their North American / European way.

... and so i can understand their reluctance, and their unwillingness to be taken advantage of, or be put down by rich world researchers...

but how do we build capacity without taking resources, without imposing our rich world outlook?

We talked about PhD students & post-docs; the South African's stated bluntly that they feel there is no role for Canadian students / post docs. So, we suggested, what about having South African students / post docs involved?... but no, they responded, going on to say that they don't have the capacity to train them themselves.

The balance of offering help without being labeled a 'neo-colonialist' isn't an easy balance, and i think will be a challenge throughout this process even though we're going in with eyes wide open.

Settling in again

I just wanted to write a quick update for those who are checking this and wondering if I'd dropped off the earth...

I've started my new job at BC Children's Hospital. I'm hoping I'll get paid for it too. (long story). But the department seems great, everyone is friendly. Fortunately I can still do some global health - with the South African project i mentioned before. More on that later.

I've found a place to live, and, despite moments of real culture shock, I am thrilled to be here and I hope I can learn a lot, contribute, and find my niche in Vancouver. And hopefully won't have to move again for a long, long time.

The plan is to keep this going - more about South Africa, and the challenges of working there. And about other things I get interested in here.

Thanks for the ongoing interest!
Take care
Laura

Imagine if this happened in Canada...

Flooding: 1,5 million people have been left homeless / cropless / school-less. 250 reported dead (I would guess that's an underestimate). The loss of crops is setting the stage for wide scale famine over the next 8 months.

What, you didn't hear?
Its not making headlines in your city?

Flooding has severely affected people in many of the poorest countries on earth - Burkina Faso, Ghana, Guinea, Senegal, the Gambia, Ethiopia, Uganda, Rwanda, Kenya, Sudan... all countries who can ill afford the damage.

In Burkina Faso, most villages are made from mud brick homes. The schools, the homes, sometimes even the clinics. Imagine what happens when a mud home is flooded.

Throughout the region, families barely scrape by - each wet season that things go well, they almost grow enough food for ever growing families. There are no savings, no grocery stores to buy more food, no social services to pitch in. Now, imagine what happens when the crops are gone. No harvest now, nothing to eat until the harvest next year... but these sorts of floods often set the stage for locust invasions, so maybe next year there won't be a harvest.

I know the flooding is going on because I look for it. If I was depending on CBC for my international news, today I would have read about the value of the loonie, 4 stories on the US - including a crucial story on OJ Simpson (why are we still hearing about this man?), climate change & its effects on North America including a tropical storm that isn't, several stories on the middle east & afghanistan.

And nothing about the entire continent of Africa.

Fortunately despite the rich-world apathy, several NGOs - World Emergency Relief, World Vision, Catholic Relief Services and others - are moving in, trying to do what they can within the challenges of the region.

Imagine the news coverage if this happened in Canada. Or the US. Something to think about.

next: Cape Town!

I've been debating what to do with my blog now that I've left Burkina Faso. After all, I'm not a "burkinadoc" anymore. But I think i will continue this - though likely at FAR less frequent intervals to document my next project.

Well, my current project is finding a place to live in Vancouver - what a nightmare. My choices are too expensive or too small or too run down. Its more expensive than Toronto. ugh.

So today, I treated myself to a haircut - first one in a year - and manicure & pedicure. Nice to treat myself. And everyday this week I've gone for an awesome walk with my uncle - enjoying the hot (for Vancouver) weather - 25C every day. And then spend way to much time driving back and forth between the North Shore and the West side, where I want to live - it takes at least 30 min when there's no bridge accidents.

Anyhow, what is next you ask? Well, for one thing, living in the same city hopefully for a long, long time. I don't want to go through this moving chaos again for a while.

But the exciting thing about my new job is the South Africa project. My Vancouver colleagues-to-be (below - at the top of Table Mountain, in Cape Town) and I will be working with an amazing group of researchers on an enormous, 10,000-child, 20-year birth cohort study. For those of you who aren't medical types, basically it means we are going to follow and take measurements on these kids over 20 years and try to figure out questions like, what are the genetic differences between kids who get sick with TB and those who are just infected? And what about asthma, pneumonia etc? I'm really excited about the project.

Cape Town, South Africa is NOTHING like West Africa. In fact, I felt like I'd already returned to the resource-rich world when I was walking around there. Skyscrapers, fancy restaurants, malls with familiar stores... it all felt very foreign but i sure was loving the seafood!!

While we were in Cape Town for meetings, we did find time to climb Table Mountain and enjoy the spectacular views

So, stay tuned for more updates on my South African adventures - and hopefully some traveling stories too. And the odd entry about life in Vancouver in general. My next trip to Africa will probably be in January, so in the meantime will be preparations and getting things set up.

Thank you for all the lovely comments & feedback about the blog - its nice to know people are reading it. It was a substitute for a journal while I was away and it will be interesting one day to go back and read through things as the year progressed.

Take care & until next time.

winding down

My last days in Burkina were too busy to allow blogging, so I apologize for the silence. I’m actually struggling to keep my eyes open to type this entry.

Wednesday evening we had a going away party for me. When it started pouring rain right at the appointed hour for the party, I was worried that no one would come – rain stops nearly everything in Burkina. In fact, Claire and I had been just about to leave home when the rain started, and as we were all dressed up in our finery we didn’t want to brave the rain and mud of driving there by moto… so had it not been for Bertrand who kindly came and fetched us, we’d have been much later than we were. But our friends braved the rain and the turn out was really good – the 4 counsellors, the 3 Kesho Bora doctors, 2 of the pediatricians, the pharmacist – and of course, Bertrand, Siddiqui and his kids and Amadou. They gave me 3 very nice gifts, and Dr Tamboura – the neonatal ward pediatrician – made a nice little speech.

The next two days were a blur of packing, and tying up an seemingly unending list of details. Why oh why do I always seem to do this sort of stuff in such a rush? Predictably, each task took at least twice as long as I’d anticipated… with Claire’s visit I definitely did not start actively doing the things on my list soon enough. Procrastination makes everything much more stressful than it needs to be.

Thursday I sorted my clothes & toiletries and told Maimouna she could take whatever she wanted of the clothes I turfed; she took them all – if she can’t use them, her sisters or friends can. She filled a bucket with clothes, plonked it on her head and headed home.

Friday was not an easy day. Rising at 6am, we started trying to finish up the suitcases, pack up the kitchen stuff to bring chez Dana, etc. As luck would have it, Friday was the only day of our entire time together Maimouna was really late – wasn’t feeling well. Normally this wouldn’t be a problem at all… but I had counted on her help to get the kitchen finished up. At 9:45 we dropped Claire at the bus; I was sad to see her go, knowing it will be a couple months before we see one another. I really, really enjoyed having her here. After that, stopped at Onatel to pay my final bill – unsuccessful … on arrival I took my number: 648. Unfortunately, they were serving only 522 and not advancing quickly at all, as there was one clerk. I left the money and bill with Julien. It went on and on.

I was worried when I showed up at the airport with my 3 suitcases weighing a total of 43kg – for a flight with a strict maximum of 20kg (can’t even pay extra baggage). Being a regular helps – they were kind enough to wave me through. I feel ridiculous lugging all this stuff to Cape Town for 4 days – but most of it is actually handicrafts and gifts with a few clothes, and a handful of leftover toiletries (the bulk were given away). I also mailed 2 boxes of books and artisanat to Veikko’s.

And then, the time was there… for the last time, I chatted with the luggage staff and went through the worlds craziest airport security (remembering we were going to an area with a simmering civil war): the passengers line up in front of men and women’s doors. You go into a tiny room with the gendarme, and they look at your visa, your plane ticket and ask if you have anything to declare. Rarely, they ask to open your suitcase and they look at the top layer of stuff. They virtually never check the hand luggage. Then, you check in. Then, you go to the security check – the xray machine has been broken for years. So, you hand your hand luggage beside the metal decector, and then you walk through – they are very thorough with making sure that you don’t beep going through the metal detector, divesting you of shoes, belt, whatever it takes. (But you can bring anything in your hand luggage!). After our last trip to Ouaga I realized that I brought a Swiss army knife as carry on – three times! – without it being noticed.

I closed my eyes and rested, and then the plane was there. And my time as a Burkina Faso PAC doctor was over.

At the tailor

Claire and I did something this week I've been intending to do for months... bought clothes. Like everything here, not as straightforward as you might think.

Step 1: Go to the market, look through piles and piles and piles of fabric. Discuss prices. Get followed from one stall to the next by hopeful merchants. Or, alternatively, go to someone's house, and sit on the patio discussing fabric colours and prices.

Step 2: Head to a tailors, and examine posters and photos of clothes models to choose a style. Get measured. Discuss potential pricing.

Step 3: Go back 2 weeks later to check on progress. Worry that clothes won't be done on time.

Step 4: Go back another week later and pick up clothes! Discuss potential pricing. Bring home 5 custom-made outfits (top & bottom) for $60 plus fabric costs.

Step 5: Go home and enjoy new clothes!

Farewell tour for les jumelles Sauve

Claire and I have decided to identify as twins here, since everyone we see asks "vous etes les jumelles?" - here in West Africa its good luck to give twins "donations" so we were thinking of setting up shop outside of one of the grocery stores with the other sets of twins.

This week has flown by and while I worked lots, we still found time to visit the old town and the vieux mosquee. The old town has been inhabited since about the 1400s. The quartier is a warren of mud brick buildings, with sheep, chickens, kids everywhere and fetishes (sites for animist sacrifices), not to mention the sacred catfish pond - so murky that the only sight of the catfish is their mouths and whiskers as they surface for food.

People live as they have for generations, including brewing millet beer from red sprouted millet seeds in hand-made pots, boiled over a mud brick oven for 3 days before setting down to ferment.

After the vieux quartier, we visited the mosque - a mud brick mosque dating to the 18th century. The posts sticking out are steps for cleaning / painting the facade.


After the week flew by, we had another great weekend. Friday night we flew back to Ouagadougou to have a little big city action before leaving. We dined in great restaurants, shopped up a storm and said goodbye to friends...

Saturday we had dinner with Alice Zoungrana, the HIV pediatrician in Ouagadougou - we've worked in many national meetings together. She is a determined, strong person (you may remember my blog about her mother who started the association for widows and orphans back in the 70s).

Since October, we have been using the same drivers in Ouaga for each trip - so I've spent a lot of time in the cars of Augustin (second from right) and his son, Hippolyte (far left). They took my dad and I exploring around Ouaga, have waited through numerous meetings and have even done things like rescuing my errant suitcase from Air France.

As always in Ouaga, they were hired for the weekend. Saturday evening, they took us for a beer at the maquis across the street from the airport, the last stand for a lot of travelers before they hop on the plane . It was really fun to sit and chat while fending off vendors of necklaces, carvings, batiques, sports coats and irons (?!).

Sunday we tried to leave early in the day but realized that our plane tickets were actually for Saturday's flight (yikes!). So we went exploring in a local park where all sorts of youth hang out relaxing - eating, playing drums or stereos (complete with amps & speakers), singing, and dancing. Students use the park as a study hall, escaping the busyness of homes with many kids and little space.

Fortunately, the Air Burkina folks were totally laid back about the plane ticket problem, and we made it back home again on the 5pm flight.

Its hard to believe how quickly the days are speeding by now. Our departure is this coming Friday!

Banfora & the hipppos

We had another great weekend away. Dana joined us for a lovely trip to Banfora, about 90km from Bobo. Its towards the Cote d'Ivoire border and the area is much greener and lusher than where we are. The rainy season is truly upon us, and we are reveling in the cool weather - down to 22C at night, and only 29-30C during the day... in the mornings one can even wear a long sleeved shirt!

We had a great expedition to see hippos on Lac Tiengerela - they were so close we could see their ears moving, and hear them groaning!

On Sunday we enjoyed the waterfalls, the rock formations and the Sunday market - smelly and chaotic as always.

The domes of Kafiabougou are also quite neat.

Now we're back in Bobo for the week.

I am actually finishing up my time in Burkina Faso; next Friday I will be moving back to Canada. I have a really exciting new opportunity at the University of British Columbia, and will be doing research in Cape Town, South Africa. I am really excited about the upcoming events, but it will be sad to leave here before our clinc renovation is even done.

So the other reason why my blog entries have grown sparse is that between trying to get ready to move, spend time with Claire, and still work full time in the clinic, I've had little time for extra things.

Take care.

Happy Canada Day!

We're far from home, with fireworks displays and Canada Day BBQs. But we are will toast Canada's 140th birthday tonight.

People here in West Africa are big fans of Canada - they see us as playing a really positive role in the region. Especially Mali - where the Governer General recently visited to a hero's welcome - but here too.

We're so lucky to come from a country that's wealthy, peaceful, equitable... despite the challenging climate.

Have fun today!

more sister time

The days are flying by... little time to blog these days.

Our current group of interns finished their 3-month pediatrics rotation Friday. We did Pediatrics Jeopardy... weren't sure how that would go here in Bobo but they totally got into it and seemed to really have fun. It was a little distressing to realize they still can't calculate maintenance fluids though...

Actually, their knowledge has really improved. In typical Burkina style, there were speeches at the end... Dr Kientega, one of our colleagues, thanked them for their work and congratulated them on their improvement. And then Masembo gave a little speech saying that they'd been really apprehensive about this rotation but that in the end they learned a lot and found the environment to be a really supportive one.




Friday night Claire and I headed to the Balafons with Sidiki and Amadou, which was fun as alway - I've mentioned them before but here are a couple photos:

The first is Sidiki, Claire and Amadou, the second is the group playing. (For the uninitiated, balafons are xylophones with gourds underneath to project the sound. They are the typical west african musical unstrument.

More later on the weekends adventures!

Traveling part 2: Tiebele

The second part of the weekend trip was to a town called Tiebele, which has really uniquely decorated houses. The shapes of the houses are similar to those in other parts of the country, but the decorations are unique to Tiebele. We stayed in a local-style mud brick auberge, and had a lovely, and cool, night sleeping on the roof.
This first photo is taken in the royal compound, of the king of the Gouramance people. I loved the juxtaposition of modern laundry and traditional construction. The small building in the center is a granary.



This next pic is a village compound nearby... the cows live in the center of the courtyard every night, the people sleep on the roofs in the hot season, and chickens wander all around. You can see the millet fields in the background.

People cook with little outdoor stoves, made from recycled tin - often oil barrels that have been rewelded to make stoves. They use charcoal or wood... there are few trees in the non-protected areas of Burkina.

It was a fascinating weekend for both of us... though i think that the highlight for Claire was finding a stall in the Po market that had about 100 Canadian baseball caps from places like Thunder Bay, Calgary, Aylmer... from goodwill in Canada to a cargo ship landing in Lome, Togo and then by road to Po, Burkina Faso! And one will make the return journey back to Canada...

Take care & have a good week.

Traveling sisters!

Sorry for the silence of the last few weeks - Claire arrived a week ago, which has been really really wonderful - but seriously cut into my blogging time.

She's enjoying the sights and sounds of Burkina, and the slower, simpler pace of life... though downtown Ouaga & Bobo are both hectic.

We had a great weekend going to the Southeast part of the country.

Nazinga Ranch... safari to see elephants, baboons, crocodiles and many cervids. (So, there aren't that many animals to see in Burkina unless you count the urban donkeys, goats and sheep and thousands of chickens) - we even had an elephant charge the motorcycle passing us as we watched them.

More later... Tiebele, the market, and catching up after a year apart!

Pats on the back

Sometimes in this sisyphean task its hard to see if we're actually doing anything good. We work & work but the results seem small.

But today from a number of fronts we got some nice feedback. A counsellor from an association that we haven't been in touch with before came to ask us to see a child, and mentioned that rumor has it in the HIV world that we're doing a really good job. And a counsellor from REVS+, one of the biggest associations, said that their mom's are reporting to them that they are really happy with their care and the work we're doing.

Some mothers are scared to see us as its generally known now that the white doctors see HIV patients only and they don't want to be seen coming into our office.

And, our renovation started finally!!!!!!!!!
I can't say how glad I am that this is finally moving forwards. Actually coming through with something will be important for our credibility here. And it will make our work WAY easier to have a drug room, 3 consultation rooms, a blood drawing / procedure room and a waiting area all our own. YAY!!! Leah has spent many, many hours getting this up and running - she's done a huge amount of work for this. So, by mid-August we should have the CHU-SS / BIPAI Pediatric Day Hospital up and running. YAY!!

AND my sister is coming tomorrow! So its all good for right now.
Take care
Laura

Happy Father's Day!!

Well, as other kids abroad are doing today, I am certainly thinking of my dad - who is working in the NICU on this Father's Day.

I can't do justice here to the admiration & love I have for him but at the risk of embarassing him (and boring other readers) I will try. Both being pediatricians, we share a special bond above the normal father-daughter relationship.

When I started in medicine, I gained a whole new respect for how people outside the family saw him - as a University of Calgary med student and then pediatrics resident, people from every part of the hospital took pains to tell me how much they admired my dad, and how well liked he is.

The NICU is a scary place for most residents - the kids are so sick, the parents anxious and stressed out, and the nurses a force to be reckoned with. At the Foothills NICU though I had an unfair advantage over my colleagues - being Dr Sauve's daughter sure gave me a leg up. How could his kid be anything but awesome? (Well... ) The nurses got a kick out of writing entries in the chart like "Pt. has fever. Dr Sauve junior aware".

I went to Australia thinking that I could be just an ordinary peds registrar. Imagine my surprise when the first thing my new boss said to me was, not hello, not welcome here, but "How is Reg doing, anyhow?"

My first Canadian Pediatric Society conferences were marked primarily with being Reg's daughter too - though now the tides are turning and he's starting to be known as "Dr Sauve's father" in the international health circles!

My dad is so liked is that he is intelligent, wise, kind, thoughtful. I only hope I can live up to his example at work and at home.

My dad isn't as adventurous as I, and I know I have contributed to his quota of grey hairs over the years. Yet he always supports me in what I want to do even if it worries him. From sailing to the South Pacific, to moving to Africa, he is always supportive and even joins me for the adventure! I've been lucky to have him come visit me in the Pacific, Australia, South America and Africa. (Not to mention he was one of the only people who braved the murder capital of America to visit me!).

I hope you all have had a good Father's Day weekend.

Laura

A day in the life...

6am... alarm sounds... UGH... I'm not any better at early mornings, no matter how many days in a row I get up at 6am.

7am... arrive at hospital, squish moto in the crowded Parking, and stumble into the hospital, still half asleep. Say several "Ani sogoma"s to people as I head in. If patients have arrived, start seeing patients.

If no patients, at 7:30am we go to "Staff" or morning report. (At least one of us goes each day). The Intern who was on call over night presents... "3 cases of severe malaria with anemia, 2 cases of severe neurologic malaria, 1 case of malaria with jaundice"...

Discuss differential diagnoses... as far as the interns can tell, every child either has "malaria" or "meningitis"... despite all our teaching and encouragement, their diagnostic possibilities never get any broader.

Discuss death... a common scenario: child arrives, the intern assesses & recognizes that the child is in shock, writes prescription for IV, tubing, fluids, quinine, maybe antibiotics. The parents head out to find the money and then find pharmacies that have the above items. Sometimes it takes 3 hours. Sometimes on their return, the child is dead.

8:30... Sort out the one or two rooms between 2-4 MDs. Start seeing clinic patients. When one child leaves, the next one comes in... so sometimes they come in order of who has the pushiest mom rather than first come first serve. If a kid doesn't come in, we head into the main waiting area and try to figure out which ones are "our" kids without asking anyone if they have HIV.

Draw labs (or help to do so). Search for porter, don't find, so run samples to lab myself. Write ARV prescriptions. Count pills. Weigh kids. Dispense medications, explain medications.

9:30am... A child comes late for their blood draw (or isn't sitting with all the rest and gets missed)... draw blood, run back to lab, beg lab techs to accept the sample after the 9am deadline. Run back to room. Write ARV prescriptions. Count pills. Race to pharmacy to try to get needed medications for OIs. Weigh kids. Watch kids losing weight despite faithfully attending the CREN. Realise that a crucial piece of information is in the other room, 100m down the hall. Dodge slowly moving mothers to get to the other room. Try to take history but unable to because counsellor has gone somewhere and mom doesn't speak French. Look for counsellor, ask her to return to consultation room. Try again to take history. Dispense medications, explain medications. Try to fit in some HIV teaching. Receive lab results & write in chart & file in binders. Realize that the child I've started to see isn't "one of ours" - send them back to wait for the other room, knowing that the consultations in that room are done and that the patient won't be seen before 3pm now. Go back to lab searching for missing lab results. Wash plastic tongue depressors & "single use" ear speculums (at least we only use gloves once!). Bring home hand towel to wash at home.

13:30... wait a minute, how can it already be 13:30?!? Finish paper work, file charts. Head home, desperate for a drink of water & a bathroom break.

Lunch & siesta if at all possible (it really makes the afternoon better!) then some rushed preparation for the afternoon's activities.

15:00... meetings or med student teaching most afternoons. Then, work on designing clinical protocols for us, the health records system, the drug procurement, the lab protocols and partnerships, prepare teaching sessions, find articles for HIV Staff meeting, provide feedback on colleagues work.

17:30 - yoga break (yay for yoga video podcasts!)

19:30 or so - stop working, phone family, do personal emails (wish for more emails from home), watch DVDs, surf the net. Suddenly its past my bedtime and it all starts again. Speaking of bedtime... time for me to say goodnight.

ps... the photos are of a kid from clinic today with Justine in the background, and his attempt at being the photographer with me as the subject.

Books!

This has been a bookish week...

We received a huge box of text & reference books from BIPAI this past week. What a treat! We are really grateful for the references and they will be really helpful.

The English speaking community in Bobo (5 of the 6 BIPAI-associated folks plus our friend Nanette) got together for a book exchange today, for novels and fun books. I've really been enjoying having the time to read more novels in the last year than in the previous several years. Since there aren't any sources of English books here, we trade books from time to time. One advantage is that it gets us reading books that we wouldn't choose otherwise but that are often enjoyable.

Have a safe and enjoyable week.

Quote of the day

I paraphrase a comunity physician from a meeting today:

"Its a bad idea to test kids for HIV because if they're positive, then we'll be obligated to look after them".

Is it not a worse idea to let them die undiagnosed? Or wait until they present with obvious AIDS, at which point they may be too ill to save, or they may end up with permanent side effects? (He seemed to think that preferable).

But part of his point was understandable; they don't want to create a visible need if they won't have the resources to deal with it. So we tried to reassure him that we were happy to look after any seropositive kids he found if he did decide to test kids. On one hand, I can understand his anxiety... but if we don't test kids, we won't know how many resources we need to advocate for.

on being discouraged

I try very hard to celebrate the successes, to be thankful for what I have and I've been really working to keep the positive things focused on the blog lately but as evidenced from the weekend's entry, I'm not always successful.

But it gets discouraging here because everything, every single thing, is so hard. Some days its hard to have the energy to keep fighting the battle.

Why should it take 4 months, >10 meetings with 3 NGOs, 2 UN agencies, 4 MoH departments. 2 hospital departments and two weeks of stalking a pharmacist to get a drug that is provided by the Canadian government FREE for all Burkinabe kids (vitamin A)?

I keep hoping that something, anything, just one thing, will go smoothly, easily. That PlumpyNut will rain out of the sky. That we will get the liquid kaletra before Aimane dies.

We are all trying so hard, working such long days and nearly every weekend and it is never good enough - that's probably whats hardest. Maybe that's part of why most of our local colleagues throw up their hands and say "it can't be done" - like the Vitamin A story (at the beginning, several people told me that Vit A was not available to the hospital, that there was nothing that could be done about the fact that we didn't have it).

We do have victories and despite the fact that i am really discourged, I think, I hope that we are making progress; but none of this comes easily.

Omar & Fofana

OK, so although I have been feeling a little discouraged, we had two kids come in for followup today...

Omar is 13 and he was our very first patient; when we first met him, he weighed 24kg and had severe tuberculosis of his right lung and pleura; his CD4 count was around 120. He is an orphan, and lives with his uncle and grandmother. He stopped going to school earlier this year because he was too sick.

Today, after 5 months of anti-TB therapy and 3 months of ARVs, he weighs 32kg, and doesn't have that skeletal appearance any more. His adherence is 100% and he even asks good questions about his treatment sometimes. He's feeling better, and able to do more. Its wonderful to see the change in him!

The second child, Fofana, is about 2; equally, when we first met her, she was already on ARVs but really malnourished and sickly. She hardly lifted her head, much less played. This morning, she was exploring around our office like a healthy kid, with a mischevious grin and even a bit of a fat tummy.

Those are the things that make this job worth while. Seeing kids start to get better, start to smile and be normal kids again.

Foiled again

So, as feared, the PlumpyNut was just a pipe dream. Its being sent elsewhere in the country (to where a higher percentage of the kids are malnourished).

People from the other BIPAI sites write positive, upbeat posts about their kids who are doing so well on ARVs. That's what I want to be writing, really, it is.

We do have a few successes - one of our malnourished patients gained a little weight last week after weeks of alternating between weight loss and holding steady. And our very first patient who had TB & HIV, who we started on ARVs is gaining weight, feeling better and doing pretty well. And we are helping look after a whole bunch of kids who were terribly sick before they started ARVs and now are doing well.

But what haunts me when I go home at night are the ones who aren't doing well.
In our one room clinic (for 4 doctors) in a cockroach-infested hospital, without nutritional supplements, we continue to watch kids waste away for the forseeable future.

It makes it worse to know that in the other BIPAI sites, they work in fancy new buildings, they have nutritional supplements, PCR, second line drugs, a computerized health record system, other needed medications usually available. They get things like text books, and drug dosing cards. They have receptionists and a waiting area. And nurses. They even have bathrooms! (we have none of the above).

We do have 1st line ARVs, 1st line TB drugs, and a few other drugs - many places in Africa don't even have that, so I am thankful for that. And we can give them vitamin A now!! And we have our textbooks from home, and our own computers.

But often, we write prescriptions for meds that we know the parents won't buy because they can't afford it. We send them to the CREN, knowing they don't get adequate calories there and yet that is the official government system for now.

From a fancy hotel, or a business class plane seat, or a fancy white SUV, its easy to talk about taking things slowly, not "rushing things" or pushing to hard.

But how do you do that when the kids you are looking after are starving before your eyes? While a shipment of PlumpyNut expires because it's not being used. How do you cope with that?
If you think you can change it or that it will change, it helps - that's what has sustained me for the last 6 months. But if there is no relief in sight, what then?

why do i do what i do?

In fact, a good question, one that can be elusive to answer. Some of the reasons include...
... i am cognizant of how very lucky i am, as a Canadian from an supportive, educated family - I've had every opportunity... and i also know that most are not fortunate like me.
... i want to "contribute" something - may sound trite, and it would be laughed off of a med school application... but i am much more satisfied with how i spend my day if i feel its useful in the grand scheme of things
... love of travel & all that it entails, eating new foods, experiencing new cultures, learning about new traditions, trying to understand what makes communities tick
... of all of medicine, its what i find the most interesting
... there is such a huge need; and there are simple interventions that could help - like Vitamin A!
... a deep distaste for winter

My first overseas job was taken on a whim, but back then i realized that there is something about global public health that I find WAY more interesting than anything else whether I'm studying it in a classroom at home or trying to figure out how to balance patient care with resource limitations, and how health systems should work.

After a year here, what has changed? I think all those reasons still stand. I am maybe more realistic about the limitations of foreign aid (though I wasn't impossibly optimistic). I have seen the things I spent so long learning about before coming here... diseases, malnutrition, systems problems, corruption, lack of resources.

With all that, sometimes I wonder, why bother? But what it comes down to is that this is what i think is important, this is what i value. Because even if society as a whole doesn't care much about the poorest of the poor, someone has to. And I know what is out there. I couldn't live with myself for ignoring the problems I see.

I do want to find a way to do this sort of work and yet have better balance because I don't do that well. (though here, I have been doing daily yoga, crafts, eating well, in order to stay sane).

the Central market

For the first time in months, I went to the market today; it was actually enjoyable. I'd stopped going because I was so sick of being harassed by "guides" and sellers of artisanat. To my surprise, I didn't get hassled once, and only a few beggars approached me during my shopping. (Granted, I stayed on the periphery, didn't actually go into the central portion).

In fact, I love the chaos of the market place; the rows of motos, the stalls with everything you could imagine for sale. Things are mostly delivered by hand cart, so you see young men walking by dragging carts piled with pop bottles, or hoses, or any number of things. Men sell non-food items and imported things, and women sell local produce.... piles of lettuce, pineapples, and the foul-smelling sambala (a local spice that smells, and tastes like rank dirty socks). There are big bowls of rice, couscous and millet (like in the photo). The women usually have a toddler or baby strapped to their back with a pagne or running around nearby. Everywhere you look is a wandering vendor with a tray on their head... anything you can imagine passes by if you stay in one place for a while... cell phone recharge cards, toothbrushes, sunglasses and small packets of kleenex are the most common things that young men sell. Girls carry fruit, vegetables or sometimes little baggies of water. The dust is onmipresent. And motos and green taxis are everywhere.

Small kids find white people fascinating, and stare at us with wide, half interested, half frightened eyes. The bold ones come up and shake our hands; the more timid stare from the safety of their mother's pagne.

ahh, urban Africa. We're lucky here because, despite the harassement, Burkina is remarkably safe compared to most large urban centers. You have to be sensible of course, but there are few pickpockets or muggings, and none of the violent robberies so common in southern & eastern Africa.

Dust storm! (again)

As I sit here typing, I suddenly noticed it growing dark. Strange, as it's noon.

I looked outside and was reminded of one of my first days here in Burkina Faso when I sat in the Sofitel and watched a dust storm come over the horizon.

Sure enought, moments later, the wind is howling, the banana trees flailing, windows banging, dust filling the air and covering everything in the house (my poor computer!). Half an hour later, the wind settles as quickly as it started.

The unsettled weather is part of the imminent start to the rainy season... its been really hot these last few days with occaisional wind storms - though nothing like this afternoon's occurance. Thunder rolls in the distance, and I hope for rain to settle the dust (at least outside) and cool things off.

Procrastination and my list of things to do

Why is it that I am surfing the net, painting my nails, writing blogs, etc when I have a huge list of things to do? And rather than doing something that is outright fun, I procrastinate. Ugh! I think part of it is that I subconciously rebel against spending my Saturday morning working. But its not logical, because the list of things to do weighs on me, prevents me from doing fun things. And the internet makes me feel connected with home.

Speaking of connections, last night we went again to listen to the balafons - those evenings make me feel connected with being here in a social way. The loud music, the kids and men dancing, the dust and the glare of the fluorescent light backlighting the band, their dark faces shadowed so all we can see are outlines.

Maybe its chance, maybe its where i am in my life, maybe its the fact that we were starting a new project in awkward circumstances (our intended partners / hosts initially didn't want us here... so we've moved from hostility to acceptance but for me, still don't feel welcome in some ways). My colleagues in Ouaga seem more interested in being friends as well as colleagues... people here in Bobo haven't responded to any of the tentatively friendly moves made, and have made no welcoming or friendly moves. (unless you count the young men downtown who make inappropriate propositions and harass any white woman unaccompanied by a male).

I'm not sure why but I've found it hard to be connected here socially than in other places I've lived. I had this fantasy that I'd meet families like my friends at "Carriere" in Noumea - an extended family that were essentially tolerated squatters beside the gravel pit - though their "squat" had running water, a generator, and 3 buildings plus pig pen, and volleyball court. I had such a close bond with them, and they taught me so much about Wallisian (polynesian) culture. I was always the "papalagi", the foreigner, but i was included in things like family religious occaisions, the family dance troupe, etc.

I guess my friendship with them was karma too though... I worked with their cousin, and the first Friday night I was there... she'd promised to bring some work friends to a family wedding who had backed out, so she grabbed me and two other young, single women who were at the post-work "happy hour" and brought us to Carriere.

That first night, I was so overwhelmed... translating for my non-French speaking friends (from the Cook Islands and Australia), being hit on by good looking young polynesian men but unsure what to make of them, dancing and having my Canadian dancing mocked by the polynesians... but I was hooked. It was the start of a love affair with a family, a culture... in retrospect that night was a life changing event. It set the tone for my time in New Caledonia, and for my love of international health and my views on social justice, racism, poverty.

Anyhow, the wandering introspection has come to an end, and I'm going to tackle the list of things to do... soon.

another week done

With the busy clinics, the weeks just fly by as we cycle from hospital to home to hospital... etc. This week we're at full staff for the first time since sometime in February. I'm really glad to have my colleagues back. It will give us some flexibility to spend more time on the inpatients, and continue to work on our other projects - intern teaching, outreach, the search for the drugs and supplies etc we need to do our jobs, etc. We're aiming to get out to the associations to try to increase testing of kids of HIV positive patients, and ensure referrals of kids who are HIV positive. We also want to work with the inpatient units to increase the testing there. The under 3 ward has started doing more systematic testing - which is just great. They've said they're a little discouraged because there are so many negative ones. But at least then we know they are really negative. And we are finding some seropositive ones along the way too.

It is wonderful to see a few of the first kids we started on ARVs are starting to gain weight and getting better.

Speaking of weight, we have another promise of PlumpyNut - ready to eat therapeutic food - for our kids. I've mentioned before that the majority of the HIV infected kids are malnourished, especially those under about 5 years. The CREN (nutritional rehabilitation and education center) provides some food for those kids but many of them still don't gain weight, and the porridge they get doesn't provide adequate calories. Even if you have all the other parts of malnutrition care working well, if you can't feed the kids, you won't succeed. So we are lusting after PlumpyNut, we have fantasies of being able to give it to our kids...

We've had PlumpyNut waved in front of our noses before but it didn't pan out. So we're trying not to get our hopes up but at the same time, receiving this food would be a revolution in the care of malnourished kids here.

We are getting better at finding what we need. Not having the basic supplies to do our job has been one of the biggest stressors of this year. Its been really hard. However, the upside is that we're learning more from our mistakes than we would have from having the answers handed to us. But at what cost?

Anyhow, its the weekend now, and I'm looking forward to some balafone music, and some relaxation to get ready for the week ahead.

Happy birthday small, blonde & sisterish!

It's a big milestone birthday for someone very dear to my heart today... a little hard to believe!

This year has been one of growth and learning for her, and she's learning more about her talents as a teacher and healer and about herself. She is very creative. I am really proud of her.


I haven't seen Claire since July and I miss her terribly. She's actually coming out to visit in a few weeks and I am really excited to have her here with me for a while - for her to see what it is I am doing, and why this all is so important.
But also, because, well, its been way too long since I've seen her!

ps... the photo is on the path near our childhood home in Calgary, when Claire, Dad & I took a walk out there in July before i headed to Africa.

Siesta

One of the things I love about the pace of life here is the siesta - something that is rigidly adhered to. I am a much more productive person in the afternoon post-siesta and actually end up working more hours, more effectively... otherwise my eyes droop and I spend half the afternoon fighting sleep. Now, my work schedule of the last few weeks has played havoc with my siestas (I've been working through to 14:30 then starting again at 15:00), but in general I'm DEFINITELY a fan.

Because of the heat, people get up early here - the normal work day starts at 7-7:30. All "fonctionnaires" - that is, salaried people - have a lunch break from 12:00-15:00 or so. During those hours one cannot do anything... banking, groceries, post office, phone company - everything is closed (except the onmipresent handicraft sellers). Even the fruit, basket and whatever-you-can-imagine vendors on the sides of the roads are usually flaked out, under a tree or in the shade of their wares if possible.

It's the height of rudeness to call someone during those hours unless its a true emergency.
Everyone heads home for lunch - normally the biggest meal of the day - and then rests for 1-2 hours. Work starts up again after the heat decreases a little and usually goes to about 18:00.

How civilized!

the Nightlife of Bobo Dioulasso: "Farafina Love"

For the second week, I went with two Burkinabe friends to "Farafina Love" (farafina means "black person" in Djoula), the "quartier populaire" live music spot with weekly balafone & tam tam music.

The highlight of the evening was the main dancer... all of about 3 years old, he was dancing up a storm for at least an hour - and he was still dancing when I became tired and decided to head home! With bushy hair standing on end, he was happy as a clam dancing with the grown-ups - once and a while heading over to beat a little on the tam-tam and then heading back out to the dance floor. And boy, did he have some moves. Some of the grown-up men danced too; they were but a side show to the star though. Towards the end he was joined by a little girl, who looked to be about 18 months old... more awkward with a few wipeouts but really enthusiastic (though she got tired of it after a couple songs).

Its a real community event, with a row of chairs & tables where people (mostly men) sit and have a drink, but then tons of people (who can't afford the $0.50 sodas) standing in the background listening. It hasn't rained in several days so the dancers were stirring up a fair amount of dust, and piles of burning garbage on the sides of the road added to the haze. There is one fluorescent light that is behind the musicians, so their faces are in shadow.

Today was hotter than usual, and even at 11pm, its still hot enough outside that in t-shirts everyone is sticky and hot. I am thankful for my air conditioner!

made it through

I wish I were better at highlighting the good parts of the week... but in my writing - in part because this is my only journal - it often works out that the things i am trying to work out, the things I am frustrated about, are what I talk about in the blog so it sounds more grim than it really is. Let me assure you, there are lots of good things that happen here, small gains and successes, happy moments.

Everyday enroute to and from work I pass 3 elementary schools, and I love the chaos of the healthy kids, running around, yelling, playing with huge white smiles. Its common to see little boys walking along hand in hand, and they look so cute! Its nice to for me to see!! In fact, a good number of the kids on ARVs are really well and resemble those kids... the counsellors tell of before they were on treatment and how they were so ill, so malnourished.

This morning, we had to tell a mother that her and her son are seropositive. Her child is 3, and is severely malnourished, has thrush, and maybe TB. The interns did her HIV test without counselling or consent, so we had to do pre-test counselling, redraw the test and this morning broke the news. The woman had an eerie lack of response, very flat. Based on the history, it seemed she suspected something, as she told us about her husband's girlfriend during the pre-test couselling.

The other day we had 2 seropositive mother who we told that their 18 month olds are negative - which is great. Both mothers took the news calmly, and a few minutes later, burst into tears. Tears of relief and joy, that their child was not infected.

What a busy week. I am really glad my colleagues will be returning over the weekend. I definitely rushed through some things that i would like to have spent more time sorting out, especially with our hospitalized kids.

The funny thing is, some of the feelings of being out of control relate to the system, or lack thereof. On most kids, I have to register them, find their charts, do vitals, draw blood, dispense medications (except ARVs). Even though we do certain things on EVERY child (find chart, weigh & measure the child, get a temperature, count the remaining pills that are left, ask for contact details and look for old CD4 results if its a new kid), the counsellors help only if I ask them explicitly for each task, for each child.

The counsellors get annoyed with us because they want us to just write prescriptions without any information except the last script... but some of the kids end of having had no CD4 counts for >1 year (the standard of care in North America is every 3 months, while the WHO recommends every 6 months at a minimum), some kids have major adherence problems, and many are significantly malnourished but keep coming for refills without having their problems addressed week after week. In the long term, we wouldn't do those kids any favours by just writing a prescription even if it means we might finish earlier.

The families wait in a common waiting area with the kids for general pediatrics consultations, and at least twice a day - today it was 3 or 4 times - we have kids come in, I start asking questions and it becomes clear that they are not for our clinic and then send them away. We don't want to make it too obvious that the toubabs are only looking after HIV infected kids because people may be reluctant to come if that is known widely. They are supposed to come into the room in order of arrival. But the aggressive mothers slip in without waiting their turn. Sometimes there are disputes amongst the mothers about who arrived first and who's turn it is and both today and wednesday we had a yelling match in our doorway. I can think of lots of ideas but either they are not easily implementable or not really acceptable to the counsellors.

We are hoping to renovate a space so that we have more than a 1 room clinic; it seems to be stalled for unknown reasons. But I dream of having a registration desk, a waiting room just for our kids, a room for drugs & procedures, and more than 1 consultation room for 4 physicians. I dream too of having the drugs we need, HIV test kids and the malnutrition supplies we need. At least we have ARVs.

Alas, not in the forseeable future. They are waved under our nose, we get our hopes up, and then they don't materialize. Over and over, for various reasons. I remind myself of the successes (vitamin A!) but there's so much more yet to work on.

whirlwind

The balafone music on Friday night was great fun, and really relaxing. The best part was watching the 10-12 year old boys getting up and dancing. Interestingly (for a toubab), there were no women or girls that got up and danced. mostly it was adult men, but there was a little group of boys who got up from time to time... they really got into it although they always stayed right together. The maquis was essentially a bunch of tables and chairs on the side of the dirt road, so as taxis and motos went by they spray dust over everyone.

Saturday after seeing the patients, we went to pay our respects to the deceased patient's family. It was the first time I'd been into an ordinary, "upper middle class" home. We drove 15 minutes off the paved road, into sprawling quartier populaires and met the aunt in the market near their house. The market is a collection of roughly tied together stands consisting of a table with a little grass sunshade; many of the stalls look like they'll be toppling over any minute. From the market we walked another 5 minutes to their compound which was made up of an enclosure containing several goats and chickens, and 4 one- or two-room buildings for the husband, each of the 2 co-wives and the adult kids. (Polygamy is legal and common here especially in the older generation). We sat down in the living room, which had 2 couches and a huge religious picture, a cross and a the grandfather's commendation certificates hanging on the walls. There was also a moto in the living room. Its the tradition here to give money to the grieving family, so we did that. The family was really touched that I (the toubab doctor) took the effort to go out there and I was thankful i could help them in their grief.

I am seeing about 17 patients / day, and we've had quite a few new ones this week - just my luck! They take quite a while to see. The "morning" clinic goes 7am-2pm every day since i'm on my own. I'm getting better at drawing blood at least from big kids (have been passing off the little kids to the nurses, in part because of the time it takes!).

We've met a nurse on the under 3 ward who is passionately interested in malnutrition care and so once my colleagues get back hopefully we'll be able to work with them to systematize the care. The unforunate thing is that i suspect getting the refeeding formula will be like getting the Vitamin A... it is available but at great effort.

That's a lesson i've been coming to realize over time: the difficulty in fixing a broken system. The doctors & nurses are skilled, intelligent people. But they are discouraged and unmotivated because (1) they work in a really crummy environment; (2) they don't have the tools they need; (3) even things that are available are a hassle to organize (eg, Vitamin A); and (4) they get paid poorly if at all - one of the junior doctors makes only $50USD / month. I can understand where their lack of motivation comes from in a way... I tried to convince the nurses in the neonatal units that hand washing would be a good thing... their response was "we don't have working incubators, so what's the point"... but the incubator issue is really a sign of all the other things that don't work. People get tired of fighting against a system broken on so many levels. Even after only 6 months, i can definitely understand that.

Some days I'm envious of my friends and colleagues that work for NGOs where they can set up their own system rather than trying to be an extra hand within someone else's system (or lack thereof).
anyhow, 6am comes very early... so I'd best sign off.
Take care
L.

Mother’s Day for a motherless daughter

I am blessed by having an amazing family. My father is incredibly supportive, loving and encouraging even when I’m doing things he sort of wishes I wouldn’t (like moving to Africa). He is one of my most important mentors, and even though I sometimes groan, it makes me proud every time I hear “so you’re Reg’s daughter… he is such a wonderful man / doctor / teacher / whatever”. My sister is creative and loving and caring, and passionate about life and we have such an important bond. From my aunt in Toronto I have learned about being brave enough to do what your heart calls you to do, even if its unusual, despite the challenges, and my aunt & uncle in Vancouver have taught me about working towards balance in busy careers, and are wonderful friends.

But its Mother’s Day to day, and since Dec 1992, it has not been a favorite of mine, but rather a time of introspection, remembrance and also of grief. It seems incredible that it was 15 years ago that my mom was sick, having chemo, surgery and then more chemo. I came home for the summer, to be closer to my family and by August, it was clear that the chemo wasn’t helping and it stopped. I went back to school in Victoria and at the end of that term, was called back to Calgary. The pain of that fall was compounded by the fact that my then-boyfriend’s (and still one of my dearest friends) mother was also ill. In a 1 week period – bits of which I can still remember like they happened yesterday – his mother died, we grieved, had a funeral, I was called home, my mother died, we grieved, had a funeral. So many people came to me and mentioned what she had meant to them and I was touched and comforted by their words.

I was 21 years old, my sister was just 15. The day before she died, my mother apologized to me for what she was putting us through, for leaving us. Those were among her last lucid words that I remember. (Other than complaining about the leadership convention that was selecting Ralph Klein as leader of the Conservative party and predicting dire consequences from his leadership).

Even though it was so long ago, and I have many important role models, mentors and friends and a precious relationship with my dad and sister… I still do miss my mother. I wish she could see me now, having made it through my education, and following my dreams. I wish I could ask her advice on things, I wish I could know her now, as a woman, as a wife, as a mother; now that I am older, hopefully more mature. I remember that she was intelligent, fun loving, passionate, opinionated. She was a great cook, a hard worker, and a natural leader. I have so many questions for her, every day. When she was in her late 20s and unmarried, did she ever despair of finding the “right” person? What was it like for her as a nurse in a time of lack of equality for men and women, such division between doctors and nurses? How did she cope with being an immigrant in a time and place that was hostile to foreigners?

I won't ever have answers to those questions, or many others. But I will always remember her, and cherish her memory. And every year, Mother's Day will be one of her days of remembrance.

A tough day

Today was my busiest day yet - I saw at least 17 kids (it may have been more), including 3 new ones (which take a while).

We have a new counsellor, and the growing pains are a little challenging on these busy days. She's not got the hang of translating, and with nearly each sentance, I have to ask alternately "could you translate that into Jula" or "what did she say?" Sometimes the mothers understand a little French so can reply to my questions directly... but I sure can't understand the response! (Other than a few key words). She also doesn't know how to do the counselling. However, she's really nice and I'm sure things will come together.

The other reason it was tough though was that we had our first death over night so the first thing I saw on coming in was her aunt, waiting to give me the news. A child I knew would likely die; her family had her baptised on the weekend because of her grave state. But it is still just devastating for this family, who had already lost the mother and father of the child, and are now losing her. Tomorrow, Fatu and I will go to pay our respects - we just couldn't today, too busy. One always wonders if there wasn't something else we could have done. But it would have had to have been done months before I met her, I think.

Tonight, I'm off to listen to some balafone music in one of the quartier populaire's with Suzanne's Malian friend, Siddiqui. We've been planning this for 2 months but for various reasons it kept getting put off. But after such a day, I think listening to a little local music will be great.

Have a safe, fun and relaxing weekend

On my own

I've knowing this week was coming for a while now. But somehow it snuck up on me. For the next 10 days, I am the only pediatric HIV physician in Bobo Dioulasso. Leah is on vacation (at her brother's wedding), and Suzanne, Dana, Prof Nacro and the other GP who sees a few HIV+ kids are all in Ouaga today, and tomorrow head to Romania for the BIPAI network meeting.

This is frightening - both because of the amount of work, and because I will have no one to talk through cases with over the next week. I'm not sure why that helps, but often telling a colleague about a case out loud helps me work out what I think is best to do. Today I saw at least 12 kids, (might have been a few more), 4 of whom were new which means a much longer interview as we get as much baseline information as we can. And Pr Nacro was here seeing a few kids this morning. The last few weeks we were seeing up to 25 patients on Fridays. Yikes! I'm hoping there are mostly patients I already know as new patients take much longer.

We have been doing our own blood draws lately... after 3 years without sticking a needle into a kid, I'm getting back into the swing of it which is good. (I've always had a lot of anxiety about drawing blood and starting IVs... i find it hard to focus when the kid is screaming, the parents are upset etc.) There is a downside though... of the toddlers are all starting to associated white doctors with being poked. So once we've drawn blood from them, they're impossible to examine. We go within 3 feet of them, and the wailing starts. The language barrier doesn't help - kids under about 8 never speak French.

This week is going to be all about relaxing evenings and looking after myself; a key to dealing with the stressors here. Other than reading my email, I didn't do any work on returning home. I decided to limit the work to an 8 hour day. So I knitted, read and did some cooking. I am doing yoga every evening now, from a podcast I found, which is great.

inspirational colleagues

We work with 3 (hopefully soon to be 4) volunteers in our clinic who are really inspiring; Fatu, Justine and Dala (left to right - seated in our one room clinic). They get a stipend but I think its really small. But Monday through Saturday they are there from 7am to 2pm rarely with a break.

They work for an "association" - a local HIV related NGO, called REVS+. This is a group that was started here by people living with HIV/AIDS for people living with HIV / AIDS. They have foreign funding (and even a Canadian CUSO volunteer) but they are really Burkinabe through and through.

These intelligent, motivated women saw a problem in their own city and decided to do something about it. REVS+ provides monthly food supplementation (donated by World Food Program - though there is never enough), infant formula for mothers who choose not to breastfeed, some medicines for opportunistic infections. They organize testing days, educational sessions, support groups and income generating activities.

But the HIV Counsellors is one of the most interesting programs. There are about 45 counsellors working in various health care facilities - maternities (birthing centers), clinics and the hospital. They help with voluntary testing and counselling, adherence counselling, social support, drug distribution, and a myriad of other tasks. Until we started, the pediatrics counsellors had the only record system for children with HIV in Bobo; they have a series of notebooks with the names of kids and why they came written in order of their visits (so its hard to find any given entry if you don't know the date they came in). Now that we're here, they also act as our translators - and we would be absolutely lost without them. They translate both language and culture - for example, letting us know that the mourning period (time when a new widow is unable to leave the house) is 40 days, or the best way to ask a certain question. And we're going to train them to take the height / weight and vital signs.

Sometimes they wonder why we are so detail oriented (who cares about development or TB history, anyhow), why we want to know certain things. And we frustrate them when we're not willing to prescribe antiretrovirals to Pr Nacro's patients without knowing anything about the child.

But it is such a key relationship, and we are really lucky to have them working with us. And the city is lucky to have such a system that provides services to various health centers.

A totally Burkinabe initiative - the kind of development that is more sustainable than a foreign idea imposed on Burkina.

Granola, "More with Less" and Fair Trade

This morning I made a batch of granola, out of my “More With Less” cookbook. Cereal here is really expensive - $7 / box for mediocre, weevil-infested no-name cereal. But there are oats, and I’ve been intending for months to make granola. It’s a hot job because it requires the oven to be on for 45min. But now I have breakfast cereal for the next several weeks.

Flipping through the cookbook though got me thinking… the premise of the cookbook is that people in North America / Europe should reduce their consumption of over-packaged, high fat, high protein, high sugar foods. Hard to argue that. But I paused this morning, thinking, I am living in Africa, where the effects of rich world overconsumption are stongest. And in fact, one thing that I have realized is that rich world overconsumption includes the rich in poor places too. Even on a salary which would be very modest in North America I can have a lavish lifestyle compared to those around me. And I do; I drink imported coffee, eat canned tuna, buy fancy French cheese, have a computer and internet access at home. While 40% of the children in my clinic are stunted or wasted or both.

The CBC Radio “Dispatches” podcast from April 17 had an article about chocolate. And the fact that much of the mainstream chocolate is produced by virtual (or actual) slaves, often by children. They even featured a discussion on child slaves trafficked from Burkina Faso (which sadly had a seemingly unending supply of uneducated, impoverished families with nothing to eat with multiple children to feed) to Côte d’Ivoire to work on cocoa plantations.
(As an aside, you may find something interesting on the April 30th edition too).

I knew about these things long before I lived in Africa. I tried to buy fair trade, to live relatively simply, to commute by bike / transit rather than car when possible. Most of my friends are the same. But living (albeit in a protected way) it is something else entirely.

So the question that arises – yes, but is there anything one can do?

I think there is; I think if everyone tried to make some effort, we could make a difference… for example…
- buy fair trade coffee and chocolate and other goods; support stores such as “Ten Thousand Villages” and don’t support stores with exploitive practices.
- become aware of the issues, support global NGOs
- encourage the government to work towards their commitments of 0.7% of GDP to go towards foreign aid (both Canada and the US donate much, much less than that).
- act locally – volunteer, donate to your local food bank, plant trees
- decrease your carbon emissions – walk/bike more, drive less, lower your thermostat / raise the temp of the AC, avoid over packaged goods

Some food for thought (its better to be doing something than wallowing in guilt!).

Un peu de repos

This week has been our busiest yet. In fact, with one more day to go in April, the month has been record breaking for us. We now have 115 patients registered (about half are Nacro's) and had 143 patient encounters (that is, seperate visits). After our days in clinic, I spent the afternoons and evenings getting ready for a regional pediatric HIV care planning meeting that Suzanne is going to. We were only invited to the meeting 1 week ahead of time, and I suddenly had to sign over everything that I've been doing to Suzanne in such a way that she could represent us as well as possible, and seek the answers to a number of issues. In having to compile everything I've done in the last 6 months, I realized I've actually done a lot of work. Sometimes it feels I have little to show for it. But I do think we've made important progress.

Even though I know that Suzanne will do a good job, it was really hard to let that stuff go; I'm really invested in it and wanted to follow it through to the end.

Over 40% of our kids are moderately to severely malnourished (that is, less than 2 SD below the mean weight for age) and a third are stunted (less than 2 SD below the mean height for age) and a third are wasted (less than 2 SD below the mean weight for height). Some of them, its their illness(es). But for some, its that the family doesn't have enough to eat. In either case, we have nothing to give them but advice. All the ARVs in the world won't solve that problem. But what to do? We are waiting for the Clinton Foundation donation which was promised to be bringing nutritional supplements... but it seems to be totally stalled.

One of the things I struggle with the most is the feeling of guilt. Every day we are face to face with how much privilege we have, and how little people here have. On my salary (which is 1/4 - 1/3 of what I would be making at home), I am incredibly wealthy here. Several of our patients are trying to feed multiple children, pay school fees, buy medicines and pay for doctors visits all on less than $1 / day. If the adults are to get treatment, it costs $10 / month plus the lab testing. Thankfully pediatric HIV care is provided for free.

But what about the little boy I saw yesterday who has some sort of congenital heart defect (not HIV)? How do I tell his family that the only way he'll get better is with surgery that, even if it were available, wouldn't be affordable?

What about all the families who spend the last of their money on the hospital fee for a hospitalization and then have no money for medicine? (everything must be paid for up front).

And what about the one legged elderly gentleman that asks me for money every time I go to the post office. And the young paraplegic man in a wheelchair who also lurks by the post office, and alternately asks me for money and to buy his postcards. And the two mothers with toddler twins who beg outside the grocery store. And the two mentally ill people who live under the tree on the corner near the hospital with their hair matted, often having battles with their voices.

I don't have an answer; those faces haunt me.
But when the economy is so weak, and there is corruption, and lack of motivation amongst most health care workers (at every level) and lack of productivity due to malaria and HIV etc, and an inhospitable climate that has marginal food growing conditions, and the country is landlocked.... its hard not to despair sometimes.

Other times I think, I am working on it. We are making a difference, even if its only to a few children. Me and my colleagues (including Pr Nacro) are doing the best that we can, working long hours and trying to give high quality care to the HIV infected & exposed kids. Sometimes we can even visibly help them; this week I treated a girl for really severe thrush and cold sores and it was wonderful to see her back in followup feeling better. It is a sort of instant gratification that helps make the job easier.