Ups and downs

Today was definitely a bipolar sort of day...

The down part was my morning in neonatology, where 25% of admissions die. They have 15 broken incubators (old ones donated by a French hospital in Dijon that didn't need them any more... unfortunately, since they're old there's no one to maintain them even in France, much less here!), a few cribs and a working bili light. And a sink, table and scale. During the day now the ambient temperature is OK for the prems - its above 35C... but at night it sometimes goes down to 16C which is less than ideal without working incubators.

But worse then the lack of equipment is the lack of making the most of what they do have. And medications not being available because the parents can't afford them. An example of the former... (sorry, this is very medical)... a 5.3kg baby was born on Friday by cesarian section... and from then until this morning the baby got neither food (as mom is in post-op) nor IV glucose (because the interns / nurses didn't think of it)... so by this morning the baby was barely responsive and jittery all at the same time... and then when this information came to light, instead of urgently infusion some sugar, the intern kept flicking the kid's heel to try to get him to react... for 15 minutes. Despite my repeated pleas to start giving the dextrose (which by fluke we happened to have right on the examining table). (For those non-pediatricians... very large infants are at high risk of having very low blood sugars and need frequent feeds and sometimes IV sugar to prevent severe low blood sugar and even brain damage). It was really frustrating!

So after that very depressing morning in the neonatology ward, I had a really uplifting meeting with Pr. Nacro, the chief of pediatrics. Basically, we reaffirmed that we're on the same page for priorities and goals with respect to treatment of HIV + children... and most importantly that he will let us start seeing the HIV patients as early as next week to start decreasing his clinical load and prepare for the inlflux of kids that we expect to get once we start wider scale testing up and running.

Next week!!!!!!!!!!!

(Actually, I'll be in Ouaga next week, so it will be Leah and Suzanne who likely will start).
Pr. Nacro can be a little hard to communicate with at times but he is really on top of things and is such a dedicated worker. And he has the connections that without which we would never, ever make any progress.

So suddenly, I expect life to get quite a bit busier. And I'm all for that! Observing in someone else's unit is OK... but its often hard to not do things our way, to just accept the way things are done. Whereas we can provide whatever level of care we want in our own practice. And we can continue to work towards ameliorating the standard of care in the service in general. But that requires interest on the part of the local staff, which can be a challenge.

One other encouraging story is with respect to Vitamin A... at Johns Hopkins we learn a lot about how Vitamin A is the wonder drug, the most cost-effective child survival intervention there is. Here in Burkina Faso, it is theoretically given to kids every 6 months on vitamin A campaigns (with excellent recorded coverage rates.... I have serious, serious doubts that they are as high as they say they are!). Because its given (in theory) in peripheral clinics to all kids, its not available in hospitals. Even for kids with measles, severe malnutrition or vitamin A deficiency.

When I arrived here, I kept trying to prescribe it with limited success. Kept talking about it, suggesting it etc. Apparently the staff went to Pr Nacro to ask "what is she on about" and he totally supported me (thankfully!) and they started to believe it.... then we managed to borrow some Vitamin A from a peripheral clinic so we can at least give it to the malnourished kids. And people are thinking of it a bit more now. And the other staff pediatricians - especially the Urgences doc - are encouraging the med students to give it. So, I think vitamin A is making its way into CHU-SS.

I have to get excited about baby steps... because that's all we have. Overall, during the last few weeks it has been really discouraging to keep trying to get things organized, but the renovation of the transitional clinic space is going to be a long time in coming, the translation of our curriculum is delayed, the national committees for training and guidelines are excruciatingly slow, and I haven't the foggiest idea how to deal with the corruption and need for "motivation".... so to have a few positive steps is really, really exciting. Maybe, just maybe, we're getting somewhere.

La Guingette

I actually did something that was just for fun this past weekend! It was lovely. I - we - need to do more that's just for fun.

Dana, Siddiqui (Suzanne's Malian friend) , Suzanne, Allison and I all went out the La Guingette, which is a small protected forest around a river area about 15km from Bobo. The trees are so big... most of the trees around here are small as there is really extensive deforestation. So it was great to see enormous ceibas, and lots of other ones. In the dry season here, most of the grass is brown, and the trees are generally looking spares. La Guingette though is green and lush looking... though without the lush tropical smell that I usually associate with this sort of forest... I guess that comes with moisture.

It doesn't rain - at all - between the end of October and the beginning of June; so the only things that are green are either very hardy, or watered either by a spring like at the guingette or a hose, like my garden. (My garden is currently flush with green beans and zucchini).


A few people have expressed disbelief that i actually ride a motor bike... so for those disbelievers, and now that i have a helmet carried all the way from Calgary, here is the photo of 3/4 of us on our motos at La Guingette (I'm the one in the middle bearing an unfortunate resemblance to Marvin the Martian).

We have a workshop in Ouagadougou scheduled sometime in the future to help develop norms & protocols for the treatment of HIV in children... I was all set to head out on Tuesday morning, when at 6pm Monday I got a call from my Ouaga colleagues saying that it was postponed by 6 days. First thing Tuesday morning, I changed my plane ticket, rescheduled drivers in Bobo & Ouaga and Dana changed our hotel reservations. Not even an hour later, it was pushed back another week... I am embarrased to contact everyone again! We are anxious to get going with this, though, because we won't be designing the HIV training curriculum until the norms & protocols are set... and training health center physicians may get way more kids on therapy than we can achieve here in the 'big city'.

At the workshop I was at 2 weeks ago, several of the people working in various parts of pediatric HIV care said that one of their biggest needs was "motivation"... at first I didn't quite understand what they were refering to... then, I didn't want to understand it. One of the problems with trainings, meetings and even getting referrals is the lack of "motivation"... if health care workers aren't paid a "sitting fee" / "per diem" to go to a meeting, they won't go (or, if they do go, they won't remember it). Even if they've had the training on who to refer for HIV care (as one example), they won't refer patients unless they have "motivation"... in other words, a fee provided for each referral. A prevention of mother to child transmission study here found that initially they were getting no referals of HIV positive pregnant women. Once they introduced "motivation", the referrals started pouring in.

So then the ethical dilemma... without "motivation" we may not get referrals... but how sustainable is that? And how appropriate is it to use funds that way?

On another note... we are trying to come up with a way to improve severe malnutrition care but one of the big problems is finding a sustainable source of the refeeding supplies. One has to buy them from UNICEF. On paper, the government officially supplies them... but in reality, they're not available. (So, if anyone knows of funding groups that are willing to contribute a certain amount per year for severe malnutrition refeeding supplies, let me know!)

Anyhow, all the best - enjoy your week.
Laura

Long awaited groundbreaking ceremony!

Well, the big day (well, one of them) is here... we and 500 of our closest friends gathered at the site of the future COE for the groundbreaking. According to Mark et al, the Burkina groundbreaking was the biggest ever - and it was bigger than some of the opening ceremonies!

Francophone West Africa is a place that is VERY formal; nothing is simple. All of the people had to be in place before the important guests (BIPAI visitors from Houston & the Minister of Health and his entourage). There was even an honour guard of nursing students. Pictured above is the stand for the "honoured guests" which, besides us BIPAI folks included the Minister of Health, the Governer of the Province, the assistant Mayor, representatives from many government departments, including military, police, and others.

There was a musical group and dancers, which is certainly de rigueur at any African ceremony. Some of the women in the women's dance group danced with babies in their arms or on their backs, very appropriate for the groundbreaking of a children's center.

Of course, local people came to see the spectacle.... and in true Burkinabe style there were soon people selling food and drink to the waiting crowds. Also seen wandering through the field were a cow and a donkey! The speeches were, well, speeches. Everyone professed a lot of ethusiasm for the project and were excited about have a regional center of excellence here in Burkina. After that, the crowed walked over to where the first ceremonial stone was laid, and then trees were planted by 6 honoured guests along the side of where we will be building.

The day was completed by a luncheon (which consisted of grilled chicken and beef brochettes... it was all about the meat!) and then a visit to one of the local associations, Association Espoir pour Demain (hope for tomorrow), which is one of the primary groups providing psychosocial, nutritional and educational support to kids infected or affected by AIDS. The dynamic president of AED is a friend of ours, and we hope to continue to collaborate with her.

We all really hope that this catalyzes pediatric HIV treatment here in Burkina Faso and in West Africa.

window onto Burkina life

I took the bus to Ouagadougou again & back again for another meeting. It’s a neat window into life here. The bus station is chaotic (though not too crowded until shortly before the bus goes), with motos and suitcases and boxes everywhere. The ‘upscale’ buses like the one I usually take only fit stuff in the holds; some of the other bus lines have stuff stacked on top too.

As we drive through the countryside, its remarkable how much different the landscape looks now that the dry season is upon us. Instead of being a clear, intense blue, the sky is hazy, the blue partially obscured by the dust hanging in the air. The trees still have leaves but the grass, bushes & old crops are all brown now. Piles of harvested cotton lay by the side of the road, ready to be put in bags & loaded onto trucks. Many of the vehicles are totally overloaded; I saw one bush taxi (mini vans or sometimes small buses) so packed with people that in each row of seats there were a couple people standing… but the roof is to low to stand, so they are bent nearly double. What a way to spend a several hour drive! We passed one bus with a little herd of 4 goats on the roof; they must have been tied up there though nothing was visible from below, just 4 goats trying desperately to stay upright at 80km/hr. Some of the bush taxis have people riding on the roof racks, or hanging off the back too.

Half way there, we stop in a village called Boromo where there is a rest stop place. As soon as the bus pulls in, vendors run towards it with their goods. The thing Boromo is known for are these little sesame snaps (sesame & honey) and there are dozens of girls & young women selling those. But other women have soft drinks, apples, bananas, beigniers (like an unsweetened donut – tastsy when they’re very fresh). Young boys sell small packages of Kleenex… “Lotus” brand, so as you get off the bus, you have a fistful of ‘lotus’ waved in your face. Once the first wave of vendors finishes, the beggars start making the rounds. Some disabled people, plus boys from the Islamic schools (I’m not sure why, but begging for money / food is part of what they do when they go to Islamic school). The boys run around in little packs, often holding hands or with their arms around one another. Its such a relief to be outside, but usually after a few minutes, I get a bit overwhelmed with all the attention and duck back into the bus.

I have to say though, although its an interesting cultural experience, 3, 5-hour bus rides in a week is too many. I was pleased to be reunited with my suitcase and the dvds, chocolates etc that it held.

Now that the dry season is established, we’re starting to have occasional water cuts in the mornings; thank goodness for my large water filter which means I always have enough for cooking / drinking. It makes one more aware of water use, that’s for sure!

Urgences - the 'intensive care unit'

Despite some jet lag and 3am awakenings, I've been back to the hospital this week. I'm impressed with the work my colleagues have gotten done over the last few weeks. While we are physicians - with no business or admin training, our jobs are mostly administrative... Leah has organized most of the renovation of 10 rooms of the pediatrics ward to use for our transitional clinic - getting quotes on items, liasing with architechts & building managers and the head of pediatrics. Suzanne has been spear heading getting terms of reference agreed upon by the various sides and will be liasing with the maternity care people to ensure that kids get referred. Dana has been working on getting our translated curriculum reviewed - and in between they've been helping out on the wards.

I've taken on some of the lower profile, less 'sexy' parts - lab, monitoring & evaluation, training sessions. With my informatics, ID & public health training, I'm the only one trained to do the job I'm doing right now!

The Urgences is a difficult ward. There are about 14 beds, but 2 kids / bed. The room is small, chaotic and noisy. Although since it is the critical care unit there are more staff, and its easier to get urgent things done. There are several cases of malaria, meningitis, and malnutrition. A couple kids with chronic health conditions for which there is no treatment here - one two year old child with an unknown congenital heart lesion that would have been echoed, likely surgically managed and followed carefully in resource-rich settings. The parents are doing their best for their kids but often follow sometimes harmful traditional therapies before the last-ditch hospital visit... like the kid today with coma (likely from meningitis or severe malaria with neurologic involvement - a daily occurence here) who's parents took him to a traditional healer who recommended ?sitting him in very hot water to rouse him... so now he has not only potential brain damage but 2nd degree scalds to buttocks, 'private parts' with little chance of keeping them clean, dressing them properly etc.

On a positive note, with our incessant questions / suggestions about use of vitamin A for malnutrition, the Urgences ward managed to 'borrow' some from a district health post. It appears that vitamin A is provided for free to the CSPS' but not to the hospital. The pharmacies don't carry it as it rarely sells (and they are businesses above all) - therefore, in the hospital they haven't been giving it even to kids with kwashiorkor & marasmus. So we have a temporary solution, anyhow.

So, like all weeks some ups and downs... I'm trying to write a more balanced blog with both good & bad presented... its easier to sound more negative than I really intend to be. I'm off to Ouaga again for a national level planning meeting with ESTHER, another big NGO. The "Center of Excellence" groundbreaking is scheduled for next week - hooray!

Back to Burkina Faso

I write this post at 5:45am, a time I don't normally see... but thanks to a 7 hour time difference, I've been wide awake for 3 hours already and finally decided to give up on wooing Morpheus and do some work (so instead, I'm writing in my blog).

I had a wonderful trip home - though much more hectic than I expected. In my 4 city tour of Baltimore, Calgary, Victoria & Vancouver, I was able to spend time with friends and family and start thinking about what lies ahead for me. One of the personally tough things about this job is the social isolation - its quite a switch from being a student and having little time to do my own thing, to having all the time in the world - yet somehow I still have trouble finding time to do some things! It was a pleasure to see everyone I spent time with - sadly I ran out of time to see everyone I'd hoped to see.

While I was home, I got to see the new Alberta Children's Hospital - it is an incredible place, so high tech, so huge. But the friendly people are the same. The parent areas seem just great - places for the parents to go unwind a little from the stresses of being in hospital, better palliative care spaces, parent beds in every room (and most of the rooms are single rooms).... (I can't help thinking of the hospital here, with 6 beds to a room about twice as big as the individual patient rooms at ACH; grungy walls, no sinks for washing hands, cockroaches on the bedside stands, no work areas or private places to have discussions with the families...)

Its been good to have some time to reflect on the last 4 months, and get prepared for the next few months. During my absence, things have been moving ahead nicely. We'll have the groundbreaking next week, and I think the renovation of our temporary space is imminent. It also seems that the BIPAI HIV curriculum in French is not too far from being finished. In an hour I'll head back to the hospital; I think I will spend the mornings this week in the other wards that I haven't seen yet.

I think we're lucky that we have some motivated local physicians who have been working really hard on their own to get treatment going for children with HIV; hopefully with the injection of personnel (us), drugs (from Clinton Fdn) and our infrastructure support we'll really make a difference. Because at the end, we are doing this for the ?2000 local children with HIV, most of whom are not receiving treatment.

All the best in 2007; I hope it is a happy & healthy year for you & your loved ones.