The peripatetic pediatrician

The ongoing struggle in Burkina Faso

2008-09-15T16:03:00.004Z

I haven't written anything about good old Burkina Faso for ages.
Out of the initial four MDs that were there, only one remains - she's really dedicated to West Africa and really perserveres despite everything.

Here is an article from the Houstone Chronicle about Suzanne's ongoing work - the patient mentioned was diagnosed and started on treatment about a month before I left Burkina.
http://www.chron.com/disp/story.mpl/headline/world/5986438.html

Reading it makes me quite homesick for Bobo Dioulasso - the work was often so frustrating and discouraging, and yet there are moments of triumph, and that is the work I feel so passionate about.

The stakes are so high. It makes it hard for me to relate when people here complain about not having weekend access to fancy tests (as happened this weekend on call), and about the "lack of resources" in one of the worlds richest - and best funded - public health care systems. Our system can always improve, and there is needs for more and more. Despite being in a city where there is a lot of relative poverty, we are really lucky. If someone comes here in from the street they can get the same care as everyone else because its not based on what you can pay.

In the year since I've been back, I haven't seen one child who was severely malnourished. Not one who died because basic health care services weren't available, or because they couldn't afford $4 worth of antibiotics and supplies.

We can always work for better, but we really are the most fortunate of countries. And we need to protect that at all cost.

Heading home

2008-06-20T11:45:00.002Z

Well, I can hardly believe it but this 2 month stint has gone by, and in a couple hours I'll be headed to the airport. I've nearly finished the task for fitting my life back into suitcases. Again. As I was packing I was cognisent of the fact that i have way too many warm weather clothes here - I hadn't realised that not only is it cold here, but there is no heating in most places. Brrr! So I only wore the warmest clothes I brought, other than the few days in Uganda. Ah well, live and learn.

Take care & I'll be in touch again soon.

Mbekweni & Fairyland

2008-06-18T16:00:00.009Z

I spent the day today working with the home health workers from Drakenstein Hospice, doing home visits into the townships and informal settlements of Mbewkeni and Fairyland (a cute name for a dismal looking place), as well as to a farm (to visit the farmworkers).

The home health worker, Myrtle (wearing the vest, right), was really amazing. She used to have a better paying job in a private hospital and gave it up to work for hospice - she is amazingly dedicated to the families she works with. She brings food to them every visit out of her own pocket - little things of yoghurt, or a sandwhich. She sometimes pays for gas out of her own pocket to bring kids to the hospital in town when they need to go. Here, we are measuring and weighing one of our little patients.

The thing is - I think they're all like that. Doing amazing work with few resources, just a lot of caring and love.

Some of the mothers / grandmothers / aunties we talked about in rounds have been really amazing, taking in other orphans and looking after their own and other kids. Others struggle.

One family (a grandmother, her son and her 6 or 8 grandkids) had been doing really well, with a small meat selling business in a container. (containers, like shipping containers, are often used here as little shops). About 2 weeks ago, during the xenophobic attacks, her shop & home were attacked, her husband shot, and all her furniture, fridges & freezers stolen. So now they have no income, no food, nothing. (Incidentally, they are not foreigners!).

It was a day when the inequities of life here were so blatant. The photos are taken beside some shacks, just 25 m from a train track. We visited a daycare - basically a one room shack liket he ones you see in the photo, with 9 or 10 preschool kids wandering around. These two little kids on the left were not in the daycare - they came to see the commotion and watched as we gave out little things of yoghurt, so I had to give them some as well. The big brother could hardly carry the little brother strapped on his back.

It was an exhausting but illuminating day.

Hermanus

2008-06-17T11:48:00.002Z

Last weekend I visited our landlords cottage in Hermanus, a whale watching town about 2 hours drive from Cape Town. What a beautiful area! With mountains on one side and the ocean on the other, we had lovely walks along the beach. One of the highlights was seeing some early Southern Right whales breaching and playing in the waves. Usually they're not around for another month!

There seems to be some lovely restaurants and shops in the town as well, although we ran out of time to do any poking around in the town.

Its really lovely to do some exploring of the region.

Pediatrics Ward

2008-06-05T14:10:00.003Z

I spent yesterday with the pediatricians in Paarl Hospital, the secondary level hospital that provides care to the children in the Drakenstein Valley. Its actually split over two sites, one depicted above, the TC Newman / Paarl East Hospital, and the main hospital. I spent the morning on rounds with the house doctors (residents / registrars / locums) in neonatology, the main children's ward and the gastro ward.

The hospitals look a little run down but they have MUCH more available than in other places I've worked. One chronic problem they have is a shortage of doctors, including consultant pediatricians. The ones they have work SO hard! They were really friendly & welcoming, and enthusiastic about our study.

The big problems there? Acute respiratory infection, gastroenteritis, malnutrition. Prematurity and low birth weight as well. They do have access to the usual tests and antibiotics and some of the high end ones - there were 3 kids on Vancomycin & Meropenem (the really big guns).

The day provided a real boost for my spirits, to remember what it is I am doing here.

The "what else"

2008-05-31T15:14:00.001Z

This has been a quiet week - I've been working on our pilot protocol, mostly sitting by myself at a computer. Not so exciting!
Maybe this is a good time to think about what I am doing here at all.

Did you know that 10 million children under the age of 5 die worldwide every year? And that the number one killer is pneumonia. Why does that happen?

Its a whole lot of complicated things working together - a combination of malnutrition, crowded living environments, smoke in the home, genetics, delayed presentation to health care services and maybe incorrect treatment when kids get there. And the spectre of HIV looms over all. Our study is looking at trying to tease apart some of these factors. For example the organisms (viruses, bacteria, etc) that cause pneumonia don't happen in the same frequency as in North America so we need to know which ones are more important here.

Part of our study that I find interesting is the "ancillary care" ... the idea is that we can use a study and its infrastructure to help improve care outside of our study. Communities aren't necessarily excited to participate in research - for really, what benefit does it give them. When you're living on the edge, helping science isn't that interesting. But the "what else" can hopefully be an avenue where we DO something other than study. Where we can provide (hopefully) a tangible benefit. That's what we're aiming for anyhow.

Wine Tasting

2008-05-26T19:25:00.005Z

There are hundreds of wineries around this region of South Africa and since driving around by myself to taste wine just doesn't seem like a good idea, I took a tour, where we visited 3 wineries (4 if you include the cheetah project where we didn't taste wine).

It was nice to get out of town and explore some new places. The town of Stellenbosch, where the main campus of Stellenbosch University is, seems to be a really beautiful little town with gorgeous Cape Dutch architechture. We also visited Franschhoek, a French town founded by the Huegenots, which has lots of nice little stores and restaurants.

It provides such a contrast to the way we've been thinking about the wine regions... for the last month, I've been thinking of alcoholism, the troubles of the farm workers, the "dop" system (a long outlawed system where workers get part of their wages in alcohol instead of money)... this is the other side of the coin. You would never guess there were any challenges at all from the descriptions of the tour guides.

At any rate, it was a beautiful day and we had some lovely wines - the expensive ones were in the price range of R50 - about $7. I bought a bottle of Sauvignon Blanc on sale for R10 (just over $1)! And while its not as complex as some, it's a tasty wine (I opened it tonight to have with dinner).

Salud!

new troubles

2008-05-22T19:50:00.003Z

I'm glad to be back in Cape Town; but it saddens me to hear about the terrible xenophobic violence that's going on in other parts of the country. People who have fled disintegrating economies or war in their country of origin and seek refuge in the wealthiest corner of this troubled continent and are now chased away.

Wealthy parts of Cape Town is an oasis of peace, but also I am in a position of privelege - the people being targeted are not (relatively) wealthy academics but the poorest of the poor. Just down the street is plenty of violence, just not targeted against foreigners.

It seems to my uneducated eye that this ties back again to the difficult history of this region and Africa in general.

Its front page news here ... but i wonder how (or even if?) its covered elsewhere in the world.

Source of the Nile & Chimp Sanctuary

2008-05-21T18:38:00.005Z

I took a rare few days of tourism over the last few days, which has been lovely.

A group of us went to Ginja, where the Nile starts its long journey from Lake Victoria. The drive up was green and beautiful, and it was neat to see a window on Ugandan life passing villages from the highway. I was surprised to find out there's a full-on mall here - they can't be escaped!

This is "the" source of the Nile - what used to be a spring in the lower right hand corner was overtaken by the lake after a dam was built, but you can see the clear water welling up from the edge.

We got to see lots of various birds - kingfishers, egrets, cranes, weaverbirds. And even a troupe of monkeys.
In the mouth of the Nile there were lots of men in fishing boats like the one shown here...

We also took a walk in a protected forest and stopped at some rapids, where we had coffee in a lovely riverside lodge. By the way, the coffee here has been generally excellent. Strong, dark roast - yum!

A few days later, a different group took a 45 minute boat trip to Ngamba Island, which has a big chimpanzee santcuary - a group of 45 chimps that have been confiscated from smugglers or orphans found with their parents poached live on the island. On one small tip of the island, their caregivers live, and funds are raised for the food, vet care, etc by having tourists come see them.

We learned about the chimps, and then saw a chimp feeding, where they come to get their thrice daily fruit. It was just great watching them catch the thrown fruit, squabbling over it, and chowing down. The caregivers know them all (and their personalities) well. Next time I'm in Uganda I'll try to go back - you can stay overnight there and go for a walk in the chimp enclosure in morning.

Its been a lovely break here, and early tomorrow morning I'll be heading back to Cape Town. I'm looking forward to getting back into a routine again.

Until next time!

Research and sub-Saharan Africa

2008-05-18T19:42:00.000Z

The first days of the conference have been long but interesting (at least, parts of it). I was not as excited about the dozens of slides of graphs of green and red dots that demonstrate the results of microarrays and various molecular technologies.

But there was a great review of the state of the art of malaria research, TB and novel HIV vaccine targets.

The workshop on building research capacity in Africa was great though. The perspectives ranged from very accomplished, well funded, well respected researchers to very disillusioned people saying essentially “the man with the key is gone” (a uniquely Ugandan way of saying the problem is out of my hands). While some speakers complained that there was no funds available for Africans to contribute to research, a Sudanese physician and research leader (who sits on review boards, trains students and is involved in international research) who sits on funding review boards remarked that he feels that there is much potential funding that African researchers don’t get because of a lack of quality proposals.

One message that came through loud and clear that one of the needs was in teaching African medical students, residents and health workers about how to write a good proposal, execute a study and then write it up which is the goal of one part of an upcoming UBC – Makerere collaboration. The lack of skilled mentors was also mentioned as a concern. So it seems like an ideal time for UBC / CICH to be working on such a project.

Rainy season

2008-05-18T19:37:00.000Z

Its rainy season here in Uganda, and this morning lived up to that. Rain fell in sheets, and at first there was still sun shining on the leaves giving a surreal look. In the afternoon the clouds disappear and it becomes sunny and hot again.

Everything is so green and lush here, with spectacular flowers throughout the resort; beds full of birds of paradise, and amazing varieties of hibiscus. Right now its still the tail end of the dry season in Cape Town so its brown and dry there.

People are gathering for the keystone conference, which starts later today. When I am registering for these things I’m always enthusiastic but when the time comes I am reminded that I find networking really stressful. I don’t know anyone here, so I don’t have that to fall back to. Ah well. Another AFLO.

To have a break from the artificiality of the resort, I went for a great (but warm) walk through the town of Munyonyo. Its really not a big town, but there is a church, a health centre, a primary school and even a pre-school. There are only a handful of shops with no one selling anything by the side of the road. I only saw a couple wandering merchants – one with bednets, and another with bowls. Small kids waved and shouted “mzungu, mzungu, how are you” just like I remembered from my previous trip to Uganda. Some seemed frightened of me, others were excited to say hello – but no one came up to me, they all stayed in their yards and shouted and waved.

back to the origins

2008-05-13T19:57:00.001Z

The first African country I ever visited was Uganda, back when I was a resident – several lifetimes ago. Tonight, I returned, and some things seemed familiar but so much has changed – here in Uganda and even more in my perspective.

I was excited to be back to somewhere warm (Cape Town is really cold) and, well, African. The drive to the resort took about 1.5 hours, through just crazy (very slow!!) traffic, with overloaded matatus (minivan shared taxis, each PACKED full of people), boda bodas (motorcycle and bicycle taxis) and trucks. By the sides of the road or in one-room businesses just beside the road, in the dark, life was going on in full swing – people sitting around kerosene lanterns drinking or eating, women walking by carrying big buckets on their head and a baby on their back, hair stylists, pool tables, etc etc… it was such a neat snapshot of suburban society here.

The resort where the conference will be was not what I expected though – its just HUGE and really fancy. But some things still don’t work as you expect despite the fancy surroundings to act as a reality check.

The other fellow in the shuttle asked me what my ‘area of research’ is and I floundered a bit – I need to come up with a 2 or 3 word statement to describe my “area”. Child survival is just way to broad, but I don’t have any other slick idea.

Anyhow, I’ll be conferencing for a few days then on to Mulago Hospital to meet some of our Ugandan pediatrics colleagues.

Cheers

On keeping in touch

2008-05-10T11:19:00.003Z

So, the upside of moving around is all the great friends I've made in many countries. That is one of the beautiful things of living and working overseas.

The downside is that it is sometimes hard to keep in touch with people. Compared to my first times working abroad, it is much easier to do these days with email and the web.

However as I have only brought my work computer to Africa I am missing a bunch of email addresses. If you haven't heard from me in a long time it could be because I lost your email address. Please either add a comment or email me at my 'temporary' address "burkinadoc 'at' yahoo.ca" and I will respond from my real email address.

Thanks!
Laura

Humbled, as always, by our local colleagues

2008-05-10T10:52:00.003Z

Our nascent study, tentatively called “Drakenstein Child Health Study” (not too catchy – suggestions are welcome!) will be in the Drakenstein valley, an area with rural areas and farms (wine growing) and some urban areas. I went out to spend the day with Jenni, our anthropologist who did the first stage of the community engagement and meet some of our colleagues out there.

We visited Emporium of Care, which I described last time, Drakenstein Hospice and a local pediatrician’s farm.

Drakenstein Hospice is an NGO in transition. It traditionally provided classic hospice care – helping people die with dignity and trying to alleviate their suffering as much as possible. In the pre-ARV era AIDS was a universally fatal disease causing great suffering and hospices were crucial parts of the care. But today with increasing access to ARVs, Drakenstein Hospice is finding that the needs are changing and so the leaders, Elizabeth and Maria, are working to open Butterfly House – that will support people living with HIV / AIDS. Income generation, day care, pre-school, education, food supplementation & nutritional education are all planned as part of this new program.

They’ve invited me to spend more time with them, and I think that will be a great opportunity to learn more about the community we’ll be working in.

another new home

2008-05-08T16:47:00.000Z

Somehow, the flight between Western Canada and Africa never seems to get easier; Vancouver to Cape Town feels really quite long. But I have survived another journey, and am excited for this new adventure.

What a difference from the last time I lived overseas. Sea Point, the neighbourhood I live in, could really be anywhere in North America or Europe. The first couple days I had trouble with my internet access so I walked along the beach to an internet café with free wireless that wouldn’t be out of place in Vancouver. At Pick & Pay, the local grocery store around the corner from my house, one can get everything, from breakfast cereal to all sorts of pre-packaged food.

I did feel like I was in Africa this afternoon when I staged a sit-in at the car dealership that is trying to fix our car, and I heard the list of excuses of why the car isn’t ready. I extracted a loaner car out of them… I definitely feel a bit nervous driving on the left after several years though.

South Africa is such a study in contrasts. I feel like I will need to spend time doing some things like home visits with the hospice program to really get a feel for the South Africa that most of the citizens experience. Its odd, a bit uncomfortable, to be in this rich enclave yet knowing that most of the people live in extreme poverty.

I’m not sure exactly how often I will be writing in the blog; much of what I will be doing is computer work – writing a proposal. That process won’t be interesting to write about in a blog! But as I do learn things, and have new experiences I will try to keep it up to date.

Take care & keep in touch!

the Emporium of Care

2008-04-20T18:49:00.004Z

In a disused boiler house, Nils Groebler and his colleagues have built the Emporium of Care - what started out being an ARV treatment program now has ARV treatment plus income generating activities, skills development, VCT, spiritual care, a playroom for kids and the newest project is a community garden. The tables you can see in the foyer are part of the tea shop - a place for PLWHA (People Living with HIV / AIDS) to sit and chat with people who really understand what they are going through.

To me this is the ideal of where we should be aiming for HIV treatment programs - without an income and food, all the ARVs in the world won't help. The Emporium of Care really tries to be a holistic community and care centre.

Robben Island

2008-04-20T17:55:00.009Z

I arrived home two weeks ago already, but didn't have the time / energy to return and add my photos. In a few weeks I'll return to Cape Town for 2 months - and I expect that my blogging will increase again since I will have more time to do that sort of thing. And interesting observations to make!

Cape Town from Robben Island; with famed Table Mountain in the background. (I climbed that once).

Robben Island: the notorious Western Cape island prison, for political prisoners during the struggle, including Nelson Mandela.

The visit to Robben Island was excellent. For me it was an emotional thing, to see the quarry where the leaders of the struggle spent their days, moving rocks from one place to another and yet still teaching each other to read, and leading the struggle. To see the cell, where Nelson Mandela spent so many years of his life. To see how truly shamefully we humans are capeable of treating one another on the basis of the colour of someone's skin.

A Canadian colleague recently mentioned that in the late '80s / early '90s he was hardly aware of what was happening in South Africa. From what I remember, it was hardly covered in the western media so you had to be interested to know what was going on. I remember it - seeing news footage of riots in Soweto, hearing of the school strike, seeing masses of youths doing the toyi-toyi.

But it didn't seem real, in a way. But when I now am spending time in South Africa, I am humbled by the strength and determination of those involved in the struggle.

The ex-political prisoner who was our guide talked about how the guards worked to 'divide and conquer', driving wedges between prisoners using access to 'luxuries' such as newspapers, extra meat. He showed enlarged mockups of the cards that ruled everything in their lives.

Even in prison, there were huge differences between how the apartheid-defined racial groups were treated. I just have so much trouble understanding how an entire country was run on those bases for 50 years - true democracy only started in 1994 in South Africa!

As I continue to work in South Africa I will surely learn more about it; but as a privileged, white foreigner will never be able to truly understand.

Anatomy of a collaborative study

2008-04-01T17:11:00.000Z

I’m here in South Africa for two workshops on the development of a huge planned study. Its challenging to bring together such diverse groups to work on one study, to communicate and truly collaborate. And the politics can be such a minefield, often tough to negotiate – though for now its not me who will be doing that. Again the time “before independence” defines a lot of how people relate and its hard for the foreigners to sort it all out. We’re often making inadvertent blunders. Luckily we have two young South Africans on our team, to help us negotiate all that.

The site visit yesterday was just great. It was so helpful to see to a certain extent what the level of care is like here, and what is available. The Drakenstein valley is really beautiful, in a basin surrounded by mountains with wineries all around. The hospital & HIV clinic we visited was much better resourced and better developed than what we had last year. The “Emporium of Care” provides a variety of health care services, social support, spiritual support and income generating activities. Its just a really neat holistic facility. Our conference badge lanyards were made by the beadwork project from there – www.kidzpositive.org

Yet the health care workers all talked about being discouraged with the system and how draining it is. I wonder if part of that is the fact that there are such riches here.

I’ve been struggling a little with what my role really is; I’m not an expert in any area and I sure don’t have any experience in designing and implementing any large study much less one of this scale. So I find myself wondering what I can really contribute.

The anthropologist that has been working with us has been really good – although she’s just working on her Masters, she’s worked on a number of prior studies in the area, and in other parts of Africa.

One of the challenges has been to establish “community participation” and “community driven” … no one in the core group (especially of the Canadians) has actual experience in doing that in low and middle income country settings. Yet how you go about community engagement is different if you are selling / engaging them on a study that is essentially already designed is quite different from really finding out what the community wants and studying that. My public health hero, Dr. Bang has taught us about projects that ultimately fail when they didn’t take into account the community.

Anyhow, there are no easy answers, that’s for sure. We’re all learning incredible amounts along the way though.

Welcome to Cape Town

2008-04-01T17:08:00.000Z

The last blog entry that I wrote related to a trip to Haiti. How I’m onto the next big project… a tri-university collaboration in the Western Cape, South Africa.

I’m writing this first update from South Africa, halfway through a 10 day visit. The weather has been just beautiful – this is a great time of year, not too hot (about 26-30 in the day) and sunny. (In Vancouver there is snow!)

We arrived last Thursday, and spent the next two days delving into a psychosocial pre-workshop.

Sunday I went with some colleagues to Robben Island – the prison where Nelson Mandela stayed for 18 of his 27 years in prison. It’s a national historic site now. I really enjoyed the trip although it was pretty exhausting – even as a foreigner its hard to understand Apartheid and how it affects everything here. But to hear the stories of political prisoners is really moving. How can a society heal from the wounds of such discrimination and of so many years of oppression of the majority of the people? People here refer to the end of apartheid as “independence” and the time since as “since democracy”.

Cape Town is a strikingly beautiful city and it’s a little hard to come to grips with the poverty that lies underneath the city that looks like any Western port city – Vancouver, San Francisco, etc (but with sun!). The waterfront is a quaint area of lovely restaurants and shops nestled in a working harbour. Table Mountain is the anchoring landmark for the whole city. There are malls with all sorts of fancy shops.

Yet… nearby are places where people live in shacks cobbled together with whatever they could find, no electricity or running water. There are towns that have some of the highest rates of fetal alcohol syndrome in the world. The culture of violence is incredible and effects everyone from the bottom to the top of the social ladder. The poverty is pervasive in this society, yet hidden from view. There are such riches, yet 6% of kids don’t get to go to school at all. There are some amazingly brave and resilient people and some that crumble under the pressure. It is a country of contrasts, of dichotomy and I think it will take my whole career to even scratch the surface of how it all works.
What a learning experience!

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

2007-12-02T19:45:00.000Z

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

2007-12-02T19:22:00.000Z

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"

2007-11-28T22:30:00.001Z

"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

2007-11-28T00:25:00.000Z

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!

2007-11-26T22:37:00.000Z

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.

2007-10-29T04:25:00.001Z

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

2007-09-26T05:52:00.000Z

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...

2007-09-25T02:50:00.000Z

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!

2007-08-01T23:46:00.000Z

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

2007-07-14T18:49:00.000Z

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

2007-07-10T21:00:00.000Z

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

2007-07-08T21:04:00.001Z

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

2007-07-03T08:53:00.000Z

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!

2007-07-01T17:27:00.001Z

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

2007-07-01T16:58:00.000Z

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

2007-06-28T20:50:00.000Z

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!

2007-06-27T20:18:00.000Z

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

2007-06-18T14:34:00.001Z

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!!

2007-06-17T20:25:00.000Z

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...

2007-06-14T20:25:00.000Z

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!

2007-06-10T22:22:00.001Z

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

2007-06-05T17:51:00.000Z

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

2007-06-04T22:19:00.000Z

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

2007-06-04T13:53:00.000Z

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

2007-06-02T22:22:00.001Z

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?

2007-05-31T20:09:00.000Z

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

2007-05-30T14:27:00.000Z

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)

2007-05-26T12:56:00.000Z

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

2007-05-26T11:58:00.000Z

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

2007-05-25T17:52:00.000Z

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!

2007-05-19T16:18:00.000Z

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

2007-05-19T16:06:00.000Z

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"

2007-05-18T22:51:00.000Z

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

2007-05-18T17:55:00.001Z

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

2007-05-15T21:34:00.000Z

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

2007-05-13T10:00:00.000Z

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

2007-05-11T19:24:00.000Z

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

2007-05-10T19:23:00.000Z

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

2007-05-05T17:12:00.000Z

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

2007-05-01T20:06:00.000Z

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

2007-04-28T16:50:00.000Z

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.

Vitamin A victory!

2007-04-24T00:46:00.000Z

Well, its been a number of months since I realized that the most cost-effective child survival tool wasn't being used at CHU-SS.

The administration of Vitamin A (which costs a few cents / dose, and is given for free by the Canadian government) is one of the cheapest interventions there is. It can make a huge difference in the survival of kids with severe malnutrition, and measles.

When we first arrived, no hospitalized child was getting vitamin A for any reason; I was told "its not available to hospitals"... after months of digging around, interviewing people and trying to understand the system, it seemed that Vitamin A is in fact available to the hospital. But only if they ask for it. And no one has asked recently (if ever). It took dozens of phone calls, meetings in Ouaga and Bobo and today a near sit-in in the office that distributes it. But today I was the pround recipient of 1503 hard-earned but free vitamin A capsules. Hopefully enough to last us until our order theoretically arrives with the next order in June.

The other part of the battle has been with the hospital staff. They too believe that vitamin A is only for vitamin A distribution campaigns. But with Pr Nacro supporting me, I've been trying to encourage the physicians and interns to realize that it is a key part of the treatment of severe malnutrition. I have Dr. Sessouma, the pediatrician in charge of the Urgences ward on my side too, which helps.

It may seem small, but as a Johns Hopkins alumnus, it is an important accomplishment for me!! (For those of you to whom that doesn't make sense... it was Hopkins researchers who played a huge role in establishing vitamin A as a child survival tool, and anyone who studies public health there learns very much about vitamin A over the course of an MPH).

Attack of the termites

2007-04-24T00:33:00.000Z

For a moment this evening I thought I was back in Noumea. I looked around my dining room and there were dozens of termites flying around, knocking off their wings and falling to the ground wiggling. ugh. (In my extremely termite infested apartment in Noumea, they would fly up into the hanging paper lampshades, knock their wings off and then fall onto my kitchen table). They're small, only about 1-1.5cm long, and a mm or so wide. But they make up for their small size by the volume. I guess its with the mango rains that they're coming out. At night now, outside you can see thousands hovering around any light source. I don't know how they get it, given my place is totally screened. Its just one of those things about living in a hot climate.

I'm in one of those frustrating cycles... i can't sleep at a reasonable hour because I'm worried about how much work I have to do... and then am exhausted in the day when I am trying to work. So its 12:40am and I'm still wide awake, and I know that the 6am alarm and the hectic clinic, followed by meetings, and a number of administrative tasks will make tomorrow a long, long day. And that just makes the insomnia worse!

I'm glad we're busy in clinic though. And over the next little while I think I will be passing a number of my jobs onto other people which should make things a little easier. Although I'm loathe to do so, being really interested in most of what I've taken on as responsibilities.

Mango rains

2007-04-22T16:17:00.000Z

Its the hot season here - and as someone who generally likes warm weather (you'll not hear me complain about a 30C day at home), even I am hiding in my air conditioned room in the hot part of the day, often exceeding 40C. But this is also the time of year of the mango rains, or little rains - little rainstorms that are much less frequent than in the wet season, that often just dampen the ground and quell the dust a little. But we've had a few wonderful, glorious rainstorms - its just pouring rain right now, and the beauty is that everything will be wonderfully cooled off afterwards, and the garden loves the rain. People say that the mango rains make the mangos sweeter. The other day I had to ride my motorbike home in a similar rainstorm and was actually cold - it was wonderful!!!

Its a quiet weekend for me - catching up on paperwork, knitting, reading, emailing and talking with folks at home on Skype. After the very long days and stresses of the week, its great to have some down time.

Take care.

an ethical dilemma

2007-04-20T18:05:00.000Z

Well, this week has been our busiest yet with Pr Nacro away. We are seeing about 10-12 patients / day that are new to us (followed by Pr Nacro); each one takes a while because we can't just prescribe ARVs without knowing anything about the child. Plus, our followups. We're up to about 15 or so patients / day, sometimes more. We're seriously limited by space in our 1 room clinic. Each morning we seek out a free consultation room because we can get through many more kids with 2 rooms.

From about 8am - 10 or 11am each day one of the pediatricians does consultations. So patients come and line up (and its a shared waiting space with our patients for now). Between when the morning doctor finishes and when the on call intern starts (which can be 4 hours or more), there are no physicians to see acutely ill patients. Sometimes the nurses see the most critically ill patients, but even things like stiff neck & fever (in the middle of meninigitis season) waits for the intern. So, often we get patients at our door wanting us to see them and generally, we refuse. On one hand, they're sick and they need to be seen. On the other, there is a system in place (of sorts) that we don't want to disrupt; also, our mandate is to care for the HIV infected and exposed kids, and to help on the wards. If we start seeing those patients, we may have negative systemic consequences. On the other hand, we feel terrible about making them sit and wait for the intern.

My last patient of the day was a child who accidentally got into our "line" - neither HIV infected or exposed; however the patient was so sick that I decided to see him anyhow. It was a 3 month old refered for poor feeding. The child weighs 2.8 kg; which is what he weighed at birth. So, I did the history and physical, wrote my first admission orders in 3 years (it was so routine in residency!). Then comes the dilemma of how to execute the orders. The mother of course had no money for the medicines and infant formula (mom has minimal breast milk). We scrounged up most of what we needed from hospital supplies. And I went out and bought 2 cans of infant formula and brought them back. 3 hours after leaving the supplies etc with the nurses, I checked back and nothing had been done since I left; the baby hadn't been fed, no oral rehydration solution had been given, nothing. I stood in the ward until we got things going.

The thing is... there were 10 other kids in the Urgences ward, as sick. Some can't afford their medicines either and just go without. The wards are full of kids who's parents can't pay for their medicines.

So ethically its tough. On the one hand, I want to do good to my patient (who I shouldn't have even been seeing). I can't sit and watch him die because his mom can't afford the $4 can of formula.
On the other hand, what I am doing is unjust. I am not paying for all of the kids, and some are going without medicines and food because their parents can't afford it. Also, foreigners stepping in to buy some kids drugs is not sustainable and potentially weakens the health care system.

And what is really unjust is that some of these children are dying for lack of $2-3 worth of medicine. That the system (imposed by the World Bank and the IMF) demands that the poorest people in the 3rd poorest country in the world pay for their own health care costs - something that Canadians, with all their privilege and all their disposable income for SUVs and TVs etc etc etc, don't have to do. The economic theory is that health services will be more valued and health care usage will go up and quality will improve with a pay as you go system. In fact, several studies here in Burkina suggested that the exact opposite happened when Burkina instituted those changes.

These sorts of things tear me up.

Designing systems

2007-04-18T21:50:00.000Z

Another busy week for us (yay!); we’ve run out of health records folders, having bought out the store’s whole stock. Our 1-room clinic is starting to be too small, as despite the fact that there are 2 or 3 MDs in clinic each morning, we only have 1 room and the few times we have more than 1 patient in there, it just doesn’t work.

While Pr Nacro has done an amazing job at caring for 300 kids with few resources, things aren’t very systematic. I think if you asked him, he’d say he’s too busy to be organized. The HIV counselors keep track of the patients by date of visit in notebooks they have, and he has a pile of the last 6 months of CD4 results in random order. And the rest is in his memory. One of the neat things is that the HIV counselors have decided they like our index card system and are adopting that, so with time we’ll have all of the kids recorded at least on an index card with name, date of birth and whether they’re on ARVs. That’s a start!

So, we’re trying to systematize things to create better flow of information between the various doctors and health care workers caring for these kids – in a health care system which doesn’t have a culture of keeping chronic health care records. The challenge is, we’re trying to do it without any real experience in a resource-poor setting or guidance. So, while I know what’s in the literature, what’s taught at public health school and have some idea from that, I am – we all are – learning lots of things from our mistakes…. Creating patient care forms that are comprehensive but as short as possible… figuring out our own adherence plan and disclosure strategies that are culturally appropriate… figuring out how to get things done in a system that seems to be designed to be as difficult as possible.

On top of that, there are lots of clinical lessons… how to manage things with few tests and fewer drugs. And most importantly, not very much experience. (Our PAC colleagues in the other countries have had 8 months of clinical work to get a handle on that issue but we’re getting there now too). But the experience will come with time, and each day we are in clinic I am thankful that we have gotten this far.

Good Friday

2007-04-06T23:11:00.000Z

Well, for us it certainly was a Good Friday - not a holiday here in Burkina Faso (the Easter Holiday is Monday) but it was our busiest clinic day so far. While the busyness is a little stressful, it is a good kind of stress - I am really glad to have lots of patients, and to be getting into the swing of things. We have some routine patients, some challenging ones - and every day we learn a lot.

Our first patient, Omar, came in for a follow up today. He was our very first patient, Dana & Leah looked after him over the Christmas holidays on the ward, with TB & HIV, very malnourished. He is 13 but weighs only 24kg... he is WAY shorter than me (which is very stunted for a 13 year old boy!) Since we've been caring for him, he started on TB drugs, improved a little, started on HIV drugs, improved a little more. Today in follow up we started him on iron (for anemia) and for the first time, he asked "what is this medicine for?". I was glad he was asking the question... here too often, people don't ask those questions.

Our new administrator, Julien, seems really good - it is GREAT to have him. He has lots of good ideas, and is MUCH more skilled at many of the admin stuff than we are. And he's enthusiastic, and dedicated to the cause. He's worked for HIV organizations in the past, and has experience as an HIV counsellor.

Its SO wonderful to feel like we're making progress. A lot of the initial work was necessary but not so obviously helpful... now, we're actually caring for kids. And its great - even if I worry about the kids, I am SO happy to be at the point where we can care for our own patients, institute our own organization, start systematic adherence counselling, and followup up etc.

Have a safe & blessed Easter weekend.
Laura

Raining mangos

2007-04-02T09:02:00.000Z

Its a long weekend here - one of the lunar Muslim holidays that everyone thought would be Friday, but on Thursday it was declared that the holiday would be Monday throwing scheduling into chaos. So, i've had a nice quiet weekend, doing stuff around the house, knitting, reading, writing letters, etc.

The weather is odd today - its down right cool (the BBC website says 30C). OK, maybe not - but I can sit outside at 9am without sweating! The sky is cloudy and the wind is blowing clouds of dust around. And in my garden its raining mangos - many of the early mangos that are getting ripe are getting blown out of the tree. (All of the ones in easy picking height are still hard as rocks).

One of my colleagues, Suzanne has just headed back to the US for her holiday; perfect time to get away from the heat. And Dana is coming back after 2 months of working in the other COEs. I am looking forward to hearing about her experiences in the COEs that are up and running. And our other very exciting news is that our administrator is starting Tuesday; he seems like he will be great. And act as an important liaison between BIPAI and the Ministry of Health, helping negociate the cultural landmines that we keep finding.

Little by little the bird builds its nest!

Three children

2007-03-31T16:51:00.000Z

Clinic is getting busier by the day now - which is great. Friday was the first day that we really could have used 2 rooms; the renovation and expanded space will be very welcome when they're ready.

Three kids this week demonstrated why I'm here...

The first is a 6.5kg 2 year old orphan... now, for you non medical types, the average 2 year old weighs 12kg. She was admitted and diagnosed with HIV this week. When we brought her some medicine on Friday afternoon, she looked at us with huge bright eyes and smiled, and offered her hand to shake like a polite Burkinabe child. But she was so skinny, its hard to imagine her being able to walk; she gives a new definition to "skin and bones". Thats where they sometimes start.

We also saw a 10 month old with thrush (which you shouldn't see after the first few months of life); but growing well, developing normally who needs to start treatment. His mom was treated in pregnancy but just took a few doses here and there... so adherence will be a challenge. When we talked to her about the medicines & reasons for them, it seemed like all the information was new to her... either she didn't know, didn't understand, forgot. She feels unable to tell her husband about her HIV status and that is another barrier to successful treatment.

That's common here; women fear being beaten, turned out of the house, ostracised. So many women feel unable to tell their husbands about their infection. Hiding the infection, and the drugs, makes it really hard to ensure compliance.

The last kid, 1 year old, was brought in by an educated mother who had been tested in pregnancy and found to be positive. Despite starting on triple therapy to prevent transmission, the baby was infected and has been chronically ill from the beginning. Started on ARVs at the age of 6 months, and clinically is doing poorly; malnourished, chronic thrush, can't even hold up his head or sit up unassisted. Basically, is clinically failing and will need second line drugs that we don't yet have.

All three of these cases give different management challenges. Social challenges - not enough food, literacy, violence against women, HIV related stigma. Medical challenges - how to manage things with few resources for testing and only a limited selection of drugs.

But I have to say the other reason we're here is this: the kids who do well on therapy, who go from deaths door to being normal, healthy kids. We are also doing followup visits for kids who are doing well on ARV therapy; and they are healthy, smiling (unless the white doctor gets too close), normal kids. That part is great and gives us hope for the first three kids. I'm looking forward to when a few of the kids we start on ARVs start rebounding like that.

lack of resources or lack of effort?

2007-03-28T19:59:00.000Z

Monday, the intern on call presented a case of marasmus (severe malnutrition). He didn't check for low blood sugar, hypothermia, nutrient difficiences, didn't give oral rehydration or feed the child. We talked - for 1.5 hours - about the WHO's 10 steps to recovery from severe malnutrition. I thought they understood (it is not difficult).

Today - Wednesday - the intern on call (a different one) presented a case of marasmus. He didn't check for low blood sugar, hypothermia, nutrient difficiences, didn't give oral rehydration or feed the child.

When I tried to insist on preventing hypothermia, he had the gall to say "we don't do that here"... they don't do it because they don't have any systematic way of treating severe malnutrition. And they have the results to vouch for that with VERY high mortality. Thankfully, Pr. Nacro came to my defense (as he has done on several other occasions) and basically said, "these americans may seem to have crazy ideas but they're right - we are NOT doing this well and the WHO guidelines are correct".

Why tell this story? One of the challenges of the pediatrics department (that I have seen in all parts of health care here) is this inertia, this attidude of "well, we're a very poor country, we don't have any resources - of course we have bad outcomes". I want the interns to make the most of what they DO have. Because it would take 30 seconds to explain to the mother why its important to keep the baby warm & dry. And that doesn't require any fancy machines, expensive drugs or anything but the mom. Because an even easier intervention is to administer a dose of vitamin A. Because we can do better with the resources we have - if we make the effort.

In fact, Pr Nacro has often lamented that those attitudes are one of the downfalls of this country. He's not at all like that - in fact, he hopes that people will learn from out example, from our "can do" attitudes.

Another example is Vitamin A. When I arrived, I was horrified to realize that none of the children with severe malnutrition (much less any one else) received regular vitamin A. Asking around I was told "well, its not provided to hospitals - they only provide it to peripheral clinics". I thought that was a little odd, so over the last few months I've been investigating.

In fact, its not automatically provided to the hospitals.

But it is available if you ask for it. No one asked, so no one gave them the vitamin A. I've asked, and I am hoping we will receive a temporary supply in the next few weeks. In the mean time, I got some high calorie formula to use that is on the verge of expiring. I'm not gonna turn down free formula!!!!!!!

I sure am learning a lot. And if I can learn to inspire effort in this batch of interns, that will be a HUGE success.

not much to report

2007-03-27T21:04:00.000Z

The last week has been rather mundane in a nice sort of way - going to the hospital, doing sign over rounds, seeing a few patients. Home for lunch & siesta & then work on other projects for the evening. I LOVE being able to have a siesta... and I can work much longer days than if I just struggled through in this heat (its HOT now). Generally I'm working 7:30-12:30 and 2-7 or thereabouts.

We have a new group of interns. They're actually quite a bit better than the last group; they manage to get more of the relevant information on history and physical exam. Although all of the interns we've worked with so far seem to be happy with a differential diagnosis with 2 things on it. No matter what the problem.... sometimes its MUCH more complex than that!! So one of my goals is to try to get them to think more broadly and realize there are diagnoses other than malaria, meningitis, pneumonia and prematurity. For example, a child with fever and jaundice gets a differential diagnosis of "malaria with jaundice, or viral hepatitis"... they are happy once they've thought of the most obvious possibility.

Its HOT now, even I (with my aversion to air conditioners and cold air) am using my air conditioner daily; at 7:15am this am as I walked into work, I was sweaty... this will continue for at least another 6-8 weeks. ugh.

Anyhow, take care & keep in touch
Laura

Back to the grind

2007-03-20T19:31:00.000Z

After a lovely vacation, I'm back to work again (actually, have been for over a week already).

Last week we finally had the long awaited workshop on pediatric HIV guidelines - now I have to spend some time working on the draft to get ready for the next workshop. I'm glad the process is moving along. The participants were mostly public health folks, who had much to say about formatting, style and questions of organization of health services, but little to say about medical dilemmas or controversies. I was hoping to have some active discussion about a few issues, but in the end it was just Alice & my ideas that were kept.

This week I'm back in clinic, and I'm enjoying that. No exciting or complex patients yet, which is OK as we get the hang of things.

When I think back, I think we have really accomplished a lot over the last 7 months, even though at times it seems we're hardly moving.... Leah was reviewing what we've done so we can orient our new administrator (HOORAY - administrative support!!!!!!!) and we realized that from August when we had no connections, no idea about the situation in Bobo (besides the national level statistics that are published) and really weren't welcome in the hospital we have managed to:
- learn about the practical situation on the ground of pediatric HIV care, in part by visiting every public health clinic (~30) in the Bobo area, assess their pediatric HIV care needs and let them know of our program and visiting every local association (~10) who provides services for familes & children with HIV to find out what they do and let them know what we do
- built liaisons with the department of pediatrics (most important), the lab and pharmacy at CHU-SS as well as CMLS (Committee Nationale pour la Lutte Contre le SIDA)
- participated in general pediatrics care and in Suzanne's case, general internal medicine
- built partnerships with the Burkina Faso HIV branches of UNICEF, Clinton Foundation, WHO, ESTHER (a french NGO) and to a lesser degree, WFP, Helen Keller International, PSI, SOS Children's Villages
- built a health records system & monitoring and evaluation plan
- organized a renovation of 10 rooms of the pediatrics ward for an HIV day hospital
- figured out a source of ARVs and cotrimoxazole
- helped push forward the national pediatric HIV training agenda (by first participating in the norms and protocols).

Sometimes we have struggled to know what we are supposed to do - how do you start a new program in a challenging environment? What do you need to do to make those partnerships. And while there certainly have been challenges, delays and inefficiencies along the way, I am pleased that we are making progress and that we are helping strengthen the Burkinabe health care system. Every day I learn new lessons. I hope these next few months we can increase our numbers, complete the renovation, and continue to work on our education mandates - both ward-based education of the interns and national level guidelines and training.

I appreciate the support given to me by those at home. The comments and emails are really encouraging.

Association des Veuves et Orphelins de Burkina Faso (AVOB)

2007-03-17T11:16:00.000Z

I think this visit deserves its own blog entry. My friend and colleague, Alice (on the right) invited us to a film (during FESPACO) about her mother (center), who started AVOB in 1974. It was such an inspiring film that we arranged a visit to the Association.

I should explain what often happens to a woman here when her husband dies. His brother has the right to all of her possessions – house, moto, savings, everything. He can choose to take her as his wife if he wishes. He can also turn her & her children out on the street, without any of the possessions they worked so hard to have – even if it’s the woman who earned them. In fact, its against the Napoleonic Code, but it’s a long standing West African tradition that few women can challenge.

So, when Mme Kaboré’s husband died leaving her with 8 children aged between 5 and 25, she suddenly became aware of these difficult issues. She decided to do something about this travesty, and formed AVOB – and its been her passion for the last 30 years.
Mme. Kaboré is not your average woman – M. Kaboré had been a high ranking government official, and she learned to read and write, drive a car and be active in her community long before that was common. All 6 of her daughters (as well as her 2 sons) are university educated – in a time when less than 15% of girls even went beyond 6th grade!!!

AVOB provides:
* legal support (and moral support) for women contesting their loss of possessions in the courts
* literacy training – a CRUCIAL activity, as only about 30% of adult women are literate here.
* vocational training – sewing, weaving, and other income generating activities
* a kindergarten for the orphans
* a free family planning clinic
* a free pediatric care clinic
* an HIV voluntary counseling and testing service is about to open
* nutritional support – this program has been phased out for lack of resources, but they provided an important relief source during some of the famines (Burkina has famines on a sadly regular basis).

Not bad for a nearly 80 year old woman (in a country where the life expectancy is below 50!)!! Mme. Kaboré at one time did lots of traveling to seek sources of funding for her activities but as she ages she is in declining health and isn’t able to do that so AVOB is facing critical funding shortages and is cutting back on some of their activities.

This is a group with 30 years of history, started by a Burkinabé woman, for Burkinabé women. It is such an important group, I’d hate to see them fold. So, one of my reasons for writing this blog entry – do you know of a women’s group, or some service group who would be interested in donating to or working with AVOB?

One of the challenges here, in the world’s 4th poorest country, is that the needs are never ending. Everywhere I look there is an outstretched hand. But this group has a well established history and excellent track record. And they serve an extremely vulnerable group in this society.

Exploring Southwestern Burkina Faso

2007-03-17T10:50:00.000Z

Well, I’m writing this entry after my dad’s departure – it was great to have him here. Some of the highlights of our trip:

International Women’s Day Celebrations – the First Lady of Burkina Faso was in Bobo to celebrate International Women’s Day – a huge event here. The Boulevard de la Revolution was blocked off and every women’s group imaginable marched, dressed in matching outfits. There were the Handicapped Women’s group (in their wheelchairs), Women’s groups from various towns & provinces, the Widows & Orphans group, a few HIV women’s groups, the female high school students, church and Islamic groups, the market women’s group, etc etc etc. My dad was particularly struck by the pride with which even the Street Cleaners group marched. They all shone – it’s the one day of the year where the incredibly hard work of them women gets recognized, in a society where when have few rights but much of the responsibilities of looking after the families needs.

Banfora – a town 85km from Bobo, in a relatively green valley with a set of waterfalls, and rock formations. There is irrigation in this valley so it was remarkable to see vast green sugar cane fields when the rest of the country is so dusty. There is a hippo pool, where we sat in a very leaky pirogue and watched hippos frolic (seriously!)

The sites of Bobo Dioulasso including the grande mosquee - a huge mud mosque - the old town, with its sacred catfish pond (more accurately at this time of year, puddle of green slime), nearby villages and the market.

The best restaurants of Ouadougou – I’ve realized with this visit that Ouaga actually has a number of very good restaurants. Often when I’m there, as a single person I just stay in the hotel for dinner (not too safe to go walking around at night). But with my dad, we arranged taxi service and took advantage of some of the farther away restaurants – many of which were just great. Gondwana was a highlight, with its Mauritanian “case” (traditional home) design, and lovely artwork everywhere. The lasagna at Verdoyant is still a favorite though.

Everyone was excited to meet Dad – the patriarch of a family is a position of really great honour. So, from hotel staff to my guards, everyone was THRILLED to have dad here. We were even presented with a chicken, by my gardener - the photo is my dad and our chicken in my storage room. (The guard did the dispatching). Since Dad's departure, everyone has been asking if he’s made it home safely (and he has).

All in all its been a great visit. Thanks so much, Dad!!!

FESPACO

2007-03-08T14:10:00.000Z

My dad arrived on Monday 26 January - its been really great to have him here. He spent the previous 3 weeks touring Mali & Burkina Faso with ElderTreks - an adventure travel group for older travelers. He really had a great time, saw lots of eye opening things. I think its been fascinating for him to visit Mali & Burkina, two of the poorest countries in the world but with amazing culture, traditions and history.

Every second year, Burkina Faso hosts the pan-African film festival, called FESPACO. Since it coincided with my dad's first week here, we went up to Ouaga for it. I've never seen Ouaga so lively (or filled with so many foreigners) - the restaurants were packed, the hotels all full.

We saw about 10 films, mostly in English. A couple notable ones were "Le presidant a-t-il le SIDA?", a Haitian film about AIDS, "500 years later", a british film about the effects of slaverly on Africa and the African diaspora and "Death of two sons", a film about a Guinean peace corps volunteer who was killed in a bush taxi crash, and his host family's son who was the unfortunate unarmed gentleman killed by a hail of 42 bullets by the NY police in 1991. The top photo is my dad in front of one of the festival venues.

It was fun to finally do some tourism in Burkina Faso, and I enjoyed visiting some of the various associations - picked up some handcrafts from a handicapped people's association, a women's association, and a young men's association (for former street kids / impoverished youth). We also visited a Mossi museum a little ways north of the city. The landscape is starkly flat and dry as you head north of Ouagadougou.

We stayed in a hotel I've stayed in several times before, and the staff were THRILLED to meet my dad. He was the honored guest of the hotel. When it came time to leave Ouaga, our driver even came out just to say goodbye to my dad. We also enjoyed several really lovely restaurants; the bottom photo is at Tiebele, one of the nicest restaurants in Ouagadougou.

Distributed zoo

2007-03-04T15:57:00.000Z

Its been a while since I've written; things have been quite busy, between work and my dad's visit - he arrived 26 Feb. More on that later.

Last Saturday Suzanne and I visited Bobo's "Distributed Zoo" - some of tourist attractions of Bobo Dioulasso. The first stop was the tortoises who live at the Hotel Agouta. I'm not sure where they originate from, or why they live there, but there is a male and a female. We found the female eating from the burning garbage pile, her face black with soot.

Then we went to the Sacred Catfish Pond. Really. There is a sacred catfish pond here. I didn't have the heart to take a photo of the gelatinous green water. But we fed the sacred catfish and paid hommage to the ancestors - the water was so murky you couldn't see them until they broke the surface.

Our final stop was the Bobo Zoo. Oh dear. It the prototypical horrendous old-style zoo - most of the cages have long since disintegrated (the animals reportedly starved to death). There are 3 primates left - a chimpanzee and 2 smaller monkeys. Their food mostly comes from what visitors bring - we brought several bananas, carrots and bread. The door is broken off the chimp cage, so you can go right in there with her; she is kept in by a chain attached to her neck. If you reach out to her, she "grooms" your hand; her hands are remarkably human-looking but very rough. What a life she has.

Anyhow, I will write more about my dads visit etc. later.

Take care!

Laura

Our first 4 patients!!!!!!!

2007-02-20T19:58:00.000Z

This was a huge day for us: after 6 months of work we finally started seeing our own patients. We had 4 new patients today; 3 HIV infected and one HIV exposed. As any first day of something new goes, it was hectic and disorganized. But, we started finally. The Burkina Faso Pediatric AIDS Corps doctors have worked incredibly hard at building the relationships we need to get permission to do this. We have found sources for medicines, consumable medical equipment and the supplies. We've figured out how to estimate as best we can lab and drug needs and are trying to make sure those needs are met. We have developed a health record system (that has some glitches to work out) based on the forms used in the other Baylor countries. We have built liaisons with peripheral clinics and groups of Persons Living with HIV & AIDS.

One of the biggest challenges is knowing the theory of what to do (first needs assessment, then collaborative planning, then find the resources needed, then start & reevaluate)... but having never done it before its hard to know if we are doing in right. Its very trial and error. But we are trying our best, even if it isn't always quite right.

I want so much to provide the best possible care for these kids, given the limited resources, and the systemic challenges. I hope we can do it but at times I despair. We still have an enormous task in front of us, and many more long, long days. We will keep working at it anyhow.

workshop cancelled - AGAIN

2007-02-15T20:32:00.000Z

I went to Ouaga on Tuesday for 2 things; a 3 hour meeting with Clinton Fdn, UNICEF, CMLS and representatives from a number of hospitals and a 3 day norms and protocols workshop that has been scheduled and cancelled every week since my return from Canada.

In both cases, the CMLS invitation letters didn't go out until the last second, so that the required people weren't present.

Despite that, we continued with the Clinton Fdn meeting but the big outcome was that CMLS needs to follow the formal channels to engage people in this UNITAID donation (a huge donation of 1st & 2nd line ARVs, lab testing supplies and nutritional supplements for 2000 kids), otherwise they will block it. That's just the reality of life here; very formal, very hierarchical. Even trying to organize a donation; there are lots of examples of donations being sent back / thrown out / put in a cupboard never to see the light of day not because they weren't needed, or useful, etc, but because the director (or whichever person at the top of the pecking order) wasn't officially informed.

The workshop was cancelled - on the morning it was supposed to start. I am SO annoyed that I went all the way to Ouaga for that! Then i organized some things for today, but they too got cancelled so I hopped on a bus and came home. I'm in my own dining room now, glad to be here.

I did have some really useful informal meetings with Clinton Fdn & UNICEF, so it was actually worth the trip, I think. Still aggravating though.

Ouaga has a new Indian restaurant, so I had chana masala & naan & chai & gulab jamun for lunch today - expensive but really tasty. What a treat!

quiet but relaxing weekend

2007-02-12T20:36:00.000Z

It was a nice, though quiet weekend. We had a meeting at a nearby restaurant - its a lovely spot, under a thatched roof with a swimming pool and lots of tropical plants. And pretty good pizza. I did some knitting, finished another novel (a fun mystery novel called "Charm City" set in Baltimore... the descriptions of Baltimore and its places are great), had naps. I didn't get as much work done as hoped.

As a resident, when there are endless patients to be seen, and your pager is going off, and you're running from one thing to the next you manage to keep going (though it often stalls when you sit down)... here, if I'm really tired, I find it suprisingly hard to force myself to work. Today I had a particularly long day (started at 0730, and its 8:30pm now) and I'm still supposed to be working.... but am really struggling to force myself to do it. even though the sooner I get to it, the sooner I can go to sleep.

I was pleasantly suprised to meet the pharmacists - they are really friendly and seem like they will be supportive to our efforts. I'm preparing for my Ouaga meetings - forecasted patient loads, medication and lab needs. Plus I have a bunch of questions to address with respect to the national norms and protocols. However, I think I'm not going to work any later than 9:30... enough is enough.

Its crazy, the Ministry of Health people swear up and down that there is enough cotrimoxazole for all who need it - HIV exposed infants and HIV infected kids. The pharmacists and Dr. Nacro say that the gvmt doesn't even provide enough cotrim for the HIV infected kids who need it... somehow between the two is an immense gap that I don't begin to understand. However, I'm getting better at asking everyone I can think of about the problem, and its starting to become very slightly less murky... at least the pharmacists are game to work together!

Have a good week. I'll write again when I return from Ouaga again.
Laura

learning patience

2007-02-10T21:09:00.000Z

I have a weekend home in between Ouaga trips.... have to go back on Tuesday again for more meetings and a workshop on national pediatric treatment guidelines.

Our goal is to treat kids with HIV but actualizing it is harder than you would think. We were led to believe that we'd arrive in country and start seeing patients. And even though from early on I knew that wouldn't be the case, I keep hoping we can get to that part.

But, in fact, what we're doing is really important. In a setting where there is a lot of hostility and distrust towards foreign NGOs and workers, we are working very hard to build good working relationships with our colleagues. Making sure they know that we realize that they are the local experts - we're the spare hands, trying to push things along. Making sure its clear that we respect their knowledge and expertise (even if we sometimes disagree... though that can be challenging). We are trying to set up our clinic from the outset so that it will be sustainable, with solid partnerships.

Another challenge is that we are here as "experts" in HIV care of children - but I have only very limited experience for the kids we have in Toronto are all stable and well on their ARVs, for the most part... and I have significantly more experience than my colleagues! So despite having studied and read a great deal, there is knowledge that comes along with experience that, well, we don't have yet.

The meetings this last week in Ouaga were productive. I met with people about malnutrition care in Burkina, and learned that there IS a national plan to try to address some of the challenges currently being faced. Within the next few months (inshallah), UNICEF and the Ministry of Health will be rolling out training programs and then providing the supplies needed, like therapeutic formulas, vitamins and supplies.

I also found out that there IS vitamin A out there if you know who to ask... so starting Monday I will see if I can get our hospital staff to ask for it. As a foreigners, we can't ask for it - the request must come from the hospital - but according to my sources, there is enough Vit A donated by the Micronutrient Initiative - a Canadian group - to provide it to ALL kids who need it.

And it looks like the big UNITAID / Clinton Foundation donation will be available within the next couple months, which will provide us with anti-HIV drugs, cotrimoxazole (to prevent infections in infected kids) and testing supplies. And, I found out that there is a supply of other medicines available for HIV positive kids for free.

While I was doing that, my colleagues were meeting with the peripheral centers around Bobo and the surrounding areas to discuss HIV care and let people know that they can start refering patients ASAP. (We don't have any "motivation" so we're depending on people's good will to actually refer patients... hopefully that will work).

So, all in all I think that was some good progress. We keep revising our target dates further and further back because of various delays. Now we're hoping for our day hospital renovation to be finished at the end of April / early May (the initial estimates were for end of Feb, but has it hasn't started yet, I don't think that will happen).... every time I start to have a little optimism, something happens to dash it. Either a colleague points out the obvious, or something happens to push things farther back. But I keep hoping that my year here won't be in vain. That in the end we will make some small difference for at least a few kids. Because really, that's why I came. For the kids who deserve to have a chance at life. For those 20% of Burkinabe kids who die before age 5.

life outside medicine

2007-02-04T17:03:00.000Z

I've added 2 more Groundbreaking ceremony photos, taken by my friend Allison (Dana's husband). The first is the 4 of us, plus four of our 'bosses' from BIPAI; Nancy Calles (in the pink shirt), and in the back row, Mark Kline, Mike Mizwa and Gordon Schutze. The second photo is us 4 pediatric AIDS Corps doctors at the future COE site.

Over the last little while, I've been trying to do more social things outside of work. Its easy to do nothing on weekends and evenings except play on the computer, watch DVDs, etc. This weekend, I've been doing lots of knitting which I am finding really relaxing and its nice to be producing something. I listen to CBC podcasts of Dispatches and As It Happens.

Also this week, Suzanne & I went to the Fete de l'Eau - the water festival, which is a sort of new years festival. We went to one of the "quartier populaires" called Balamakote, and wandered the streets a little (there are rarely tubabous who venture into that area, so we attracted quite a crowd of kids at times). The young girls (before they've had a baby) were dressed up for the dancing - they have a tall headdress, sometimes 2 feet high that is covered in shiny, sparkly garlands, and a bra (no kidding), and a very very short skirt, barely covering the underwear (in a place where skirts showing the knees are incredibly risque!). In fact, we didn't stay for the dancing, because there isn't a set time... it can happen any time between 9pm and 2am and happens at the whim of the Griots - a caste (that is present in most West African cultures) of performers. Half the fun was just watching the kids chase each other around, and see what night life looks like in les quartiers populaires. There are few women out, other than the girls who are dancing. Mostly, its the men who are cruising around.

Saturday night we went to a movie screening at the house of a friend. A French couple is staying there for a week who were here for 8 months last year, and the woman, Sophie, worked with HIV prevention projects including one group that has a big screen and DVD projector who hosts HIV prevention films in a number of villages. We watched a French animated film called "Kirikou" that is set in Africa, and features a very smart, tiny kid who saves his village. Its a cute movie. There were probably 75 people there, many of our HIV-association contacts, a few of the doctors from the hospital, etc. There was a big meal of rice and sauce, with meat. It was lots of fun.

Today was another big day - got a haircut! (don't worry, just a little trim). There is a woman who knows how to cut toubab hair who comes to Bobo once every few months, so Suzanne, Leah, & I all went to Nanette's where we each had our hair cut (as did Nanette and her kids) and had tea and visited. It was nice (and I'm glad to be able to get a comb through my hair again).

Take care & please keep in touch - I can't tell you how much I treasure the emails from friends & family.

Love

Laura

Ups and downs

2007-01-29T20:28:00.000Z

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

2007-01-24T18:29:00.000Z

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!

2007-01-16T17:47:00.000Z

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

2007-01-14T07:13:00.000Z

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'

2007-01-10T18:42:00.000Z

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

2007-01-08T05:59:00.000Z

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.

Lost at sea

2006-12-11T09:56:00.000Z

This post has nothing to do with Africa but with another life I once had, that of an offshore sailor - so long ago I sometimes wonder if it really happened.

I'm not sure if you've seen the news, but a 25 year old Canadian woman (named Laura, who'd lost her mom to cancer when she was younger) went overboard off a tall ship on Friday night. They can't find her.

Its amazing how much this single person - who I've never met, had never heard of before Friday - has brought back my experience of falling overboard, in the middle of the South Pacific Ocea, over 1500nm from anywhere (back when I was about 25). Last night I laid awake thinking about how I could have been just like her, disappeared without a trace.

The Picton Castle was in 7m swells, and it was night time (9:30pm) when a wave washed over the boat and swept Laura into the water. The crew threw life rings & life jackets into the water to mark the spot & give her something to hang on to, they sent out a mayday and the search started. That was more than 48 hours ago, and they haven't found her despite the ongoing search by a tanker, the Picton Castle and US Search & Rescue.

When I went overboard, it was day time. That was the biggest thing that saved my life that day. I also managed to grab the side of the boat and then onto the fishing line and hold on for a little while - long enough to know they'd seen me go. Even then, the stuff that they threw was a ways away from me. When I was at the top of the swells (they were around 5-6m), I could see the man overboard pole (which is about 8ft high, with a bright yellow flag to mark the person in the water), and the white ring and was able to swim to them. By the time the boat came to a stop and a dory launched, they were a long way away from me; only the pole marked my position. The open ocean is so featureless, so changing, and the boat is floating on the top, turning with the wind and waves... its nearly impossible to find an object that isn't well marked.

When I was in the water, I knew the Swift would find me. I knew they'd seen me go, and I was hanging out next to the pole; I wasn't even frightened at the time (just felt really foolish). I can't get out of my mind what it would have been like for that other Laura, in the pitch black. Maybe able to see the boat but knowing that they wouldn't find her.

My thoughts and prayers are with that woman and her family.

Ouagadougou and back again

2006-12-10T18:18:00.000Z

With the slow progress and the fact things seem are more mundane, there doesn't seem to be as much to write about lately. We spent last week at the First Annual Mother-Infant Congress in Ouagadougou - basically, a joint meeting of the Burkinabe Pediatrics & Gynecological societies. It was good to be there, and make some more connections. I've never seen so many retrospective chart reviews in my life (without understanding of their limitations)! There were some useful studies though.

We visited the main hospital in Ouaga and were impressed by their malnutrition service; they have dedicated nurses, WHO-based protocols and the hospital provides the ingredients for the therapeutic milk. Each meeting and site visit gives us more of an understanding of how things work (or not) here. I think we are slowly convincing people that we are interested in integrating into the existing system. All 4 of us are anxious to start doing more HIV related clinical work. The 3 pediatricians will continue to look after the Over 3 Ward in 2 week blocks. After Christmas in addition to taking my turn on the ward, I will spend a couple weeks at the TB clinic that currently sees the few identified HIV/TB infected kids - will work on developing those partnerships.

Our major focus over the next while will be to work on getting kids tested for HIV. There are around 1500 "Orphans and Vulnerable Children" (that is, children of parents with HIV)registered with the various agencies and only about 20% have been tested. Plus, few of the kids in hospital are tested even though in our hospital about 10% of the inpatients are HIV+. And we are also working on linking with programs that work to prevent mother to child transmission of HIV - those kids are nearly all lost to follow up.

For a variety of complex reasons, I have decided to go home for Christmas - will be swinging through Baltimore, Calgary and Victoria. I am worried about the cold, and the culture shock. So many things took some getting used to all seems quite normal to me...
... most consumer goods are sold from roadside stands, from the clothes from bales of used clothes sent from North America, to hardware (hammers & nails), to artisanat, to fruit from the roadside table that I pass each afternoon on my way home...
... everytime I am in town men wave cell phone recharge cards in my face (OK, I still don't like that)...
... people (away from the sellars of artisanat and the market vendors) are so polite, and kind even to strangers...
... most school age kids I pass stare and call "toubabou, toubabou" and smile their beautiful smiles...
... the roads are all unpaved, rutted red dirt roads that require one to pick their route carefully through on any kind of vehicle...
... kids in the hospital arrive far to late because their parents have no money, and even then sometimes can't buy the medicines they need....
... the taxis are dilapitated vehicles that you would wonder that they are still on the road, no mirrors, door handles usually broken off...
... in the mornings people are people are dressed in toques and heavy coats to ward off the cold - and its rarely colder than 18C (and worse yet, I need to wear a coat to ward off the cold)...

It should be interesting, at any rate. I am really looking forward to spending some time with my friends & family and putting some perspective on these last few months.
Take care!
Laura

winter time

2006-11-29T18:05:00.000Z

Well, its officially winter now. When Bertand, our taxi driver, picked us up for a meeting this morning he was dressed in toque (thats a woolen cap for the Americans) and down jacket. My guards are similarly dressed, bundling to keep the cold away. The daily high temp is 34C (or 92F)! I can't imagine how people tolerate being bundled up like that. Though it is cold at night right now... well, cold is relative.... its getting down to 15C.

This week we have been visiting the various "associations" - local non-profit groups that work for people living with HIV / AIDS. I have been really impressed by their motivation and hard work. There are many of these groups in Bobo, and they have a variety of activites, including voluntary counselling and testing (mostly of adults), treatment (of adults - the kids are refered to Dr. Nacro, with whom we work at the hospital), nutritional support (through donations from the World Food Programme), and various psychosocial activities. They provide much of the psychosocial and drug adherence support as well.

I'm also spending some time in the microbiology lab at the hospital, and one interesting lesson is that the way things are perceived on the wards is not necessarily the way things really are - thats very true in Canadian hospitals too by the way. I was struck though by the disconnect between what the lab director says is available, and how long things take, from what we were told on the pediatrics ward. It will be important for us to build this relationship I think. And work on the systems problems within the ward that are keeping us from getting the tests we do think are important.

Take care - and be careful in the slippery roads & real winter weather that I know many of you are facing.
Love
Laura

Happy American Thanksgiving!

2006-11-27T17:27:00.000Z

I haven't been writing that often lately as there isn’t much exciting that’s been going on. For American Thanksgiving on Thursday we were invited a fellow American’s house for dinner, which was really lovely.

I had a lovely but quiet weekend – mostly took it easy and worked on our day hospital proposal. After traveling for so many weeks, I was really glad to stay at home, putter in the garden, and start reading my stack of new novels – I bought some in Kenya, and Claire sent me some. I started my Christmas shopping at Adama’s little artisanat stand; Adama helped me get me telephone hooked up (he’s a friend of the house owner’s nephew who manages the house). Despite being in the artisanat business, he is like a typical Burkinabé person; really friendly & open (and chased away an annoying batique seller who came running up when he saw a toubabu at an artisanat stand); we sat and drank tea, and he taught me anwali, which is an African board game (I think there are versions in most countries). I’m glad to buy things from people who are honest salesmen like that!

Work has mostly been focused on writing our proposal for our clinic; once we have completed it, we hope that BIPAI will help us identify and find the resources we need to provide the level of care we want to provide. We’ve divided up the tasks (both of the proposal and our other work) and one thing I’ve been working on is forecasting numbers of patients & necessary medications and supplies…. I just wish I knew what I was doing! Its interesting trying to put on paper what we’ve learned about the health care system and HIV care here.

The Clinton Foundation has arranged a large donation of all 1st and 2nd line antiretrovirals, cotrimoxazole prophylaxis (to prevent infections in HIV exposed children), testing reagents to provide free HIV testing for kids and a nutritional supplement. That should arrive in January and will be a huge help to our work here. The more challenging problem will be finding funding for some of the other medications for treating opportunistic infections (not to mention the regular problems of childhood) and supplies for treating children with severe malnutrition. We are trying to sneak malnutrition into our HIV clinic because, well…. how to put it diplomatically… that is the biggest weakness we’ve recognized in the general pediatrics care of children here.

By the way, the American issue of Time that has just come out (see http://www.time.com/time/magazine/current) will have two articles about BIPAI and the pediatric AIDS corps. Nothing about Burkina of course, but it does talk about the program in general.

Ouagadougou again

2006-11-21T21:53:00.000Z

I had brief weekend at home to check out the garden and eat very many cucumbers... the photo is my gardener, Moussa - who has provided all the labour for this gardening project - in between the cucumbers and the basil. Against the wall are the tomatoes, and in the foreground the zucchini. I'm really pleased and I think Moussa and I get along well. I'm looking forward to being at home for a while after this current trip!

Then, it was back to Ouaga... I tried to fly but the flight was cancelled (another mechanical problem) so ended up taking the bus. Its not as fun to be in Ouaga on my own, though I've still had a few really good meals and I've enjoyed the internet access. I head back to Bobo Wednesday.

I've had productive meetings with UNICEF, and some Ministry of Health people about training sessions. We are hoping to fairly rapidly train the physicians who do primary care at regional hospitals to look after kids on ARVs. Right now, they're pretty uncomfortable starting kids on treatment so no kids get started.

At home, my colleagues have been working hard on putting together a proposal for our transitional clinic; BIPAI will help us find the resources we need to get things going. We've divided the tasks to try to be more efficient.

The weather seems cooler now, especially the early mornings - though part of that is just that it is much less humid. And our perspective on what is "hot" is changing... getting off the plane in Bobo the other day, it seemed refreshingly cool... so it was a surprise to hear the pilot say that it was 26C. The rainy season has ended, so we won't expect any more rain until June.

Take care, Laura.

If its not a good time, its a good story... part II

2006-11-16T00:24:00.000Z

Well, we made it back to Ouaga but our 3 day journey home has turned into nearly a week. We spent Sunday going from Lusaka to Nairobi (normally a 2 hour flight, but from hotel room to hotel room it took us 16 hours...)... then we had a day in Nairobi, Kenya, where I did some shopping and got things that aren't available in Bobo and had a wonderful afternoon with my friend from fellowship, Maryanne. Nairobi has nearly everything a person could want... the grocery store was overwhelming it was so enormous. We spent Tuesday flying from Nairobi-Bamako, Mali-Burkina. Were we ever glad to get off the plane and into the familiar streets of Ouaga.

Now we're in the middle of a couple days of meetings etc here in Ouaga before we head back to Bobo on Friday. We met with the American embassador today; strange to go in through all those layers of security... even stranger that the American embassador really wanted to meet us! But besides the work, we heard all about what things go on in the American community here.

We are all really looking forward to getting home to Bobo - despite the lack of material goods, and fancy malls and restaurants, its got a certain charm... and its home for now.

A plane with a flat tire !?!

2006-11-12T16:37:00.000Z

Our week in Malawi has drawn to a close. Its been very interesting to spend some time in an existing center, and see what is possible. We spent a fair amount of time meeting with various staff and learning about their perspectives and advice on starting a new program.

The Malawi clinic is much like a clinic in North America; clean, new exam rooms with sinks, computers, examining tables and otoscopes. They even have tongue depressors. The cleaning staff wash the floors about three times a day (though ironically, it is a little hard to get the soap dispensers filled). Upstairs is a room of 4 desks & computers for the 13 PAC docs to share. They have a reasonably fast internet connection, which we definitely took advantage of.

We spent some time sitting with the PAC docs while they saw patients; it was neat to see some actual HIV patients. They have clinical officer students (they are the first line caregivers in Malawi; they have 4 years post high school training) who help with translation, and in return they get some teaching. The clinical director is a world expert in malaria, but also has an enormous font of HIV knowledge and experience, as does the other Malawian staff physician.

I actually had quite mixed feelings about being there, because is sure highlights everything that we don’t have…. materials & supplies. free medications for the kids. administrative staff. clinical support. help to figure out how to navigate the HIV treatment world of Burkina and get what we need. What we do have (which the other PAC docs don’t) is the freedom – to hopefully set things up the way we think they should be, to set our own priorities, to set our own hours (which end up being longer than that of the folks in Malawi – but we choose which hours they are). I wish we could have some level of support but still be able to play a crucial role in the design and running of this clinic. As always, David is the most helpful of anyone, and clearly knows how to get things done, where to get resources. His long experience makes him an invaluable resource.

For us, Malawi seems so Westernized… there are so many NGOs, so many foreigners – hundreds of project vehicles. Its interesting, because with this has come a huge industry of Western-style coffee shops, restaurants and stores that to us seems incredible. Although, as in Burkina, many Western luxury items are really expensive for dubious quality.

I’m actually writing this from the departure lounge in Lusaka, Zambia – when we landed on our stopover, the runway was so hot that it blew out 2 of the tires. So, we’re waiting while they try to replace the tires & repair the mechanism – or failing that, send a new plane from Kenya (a 3 hour flight from here). I am dreaming of the dinner I am supposed to have with my friends Maryanne & Doug, a home cooked dinner that I have been looking forward to for weeks…. that sadly, may not happen. Ah well, the perils of international travel.

…. An update ….

So, my lovely dinner with Maryanne is on hold indefinitely as the flight was cancelled. We’re holed up in the Intercontinental. As always when flights are cancelled, a chaotic scene at the airport, with uptight passengers, a lack of information and general chaos. Those who know me well may be surprised (or doubtful to hear) that traveling along I don’t get too uptight… but in a group of 4, I do absorb some of the anxiety of my traveling partners, despite myself.

Malawi - the BIPAI Network Meeting

2006-11-05T19:46:00.000Z

Well, we've had a productive several days in Malawi at the network meetings. Great to see all the PAC docs and BIPAI staff from all over. The people in the other countries are doing some really neat projects and some great work in all sorts of areas of HIV care of children. We're all learning lots, and the staff of BIPAI are very creative at finding solutions to lots of different problems regarding the care of kids with HIV.

Unfortunately, we didn't get to present as we weren't informed of the potential to do so until after the schedule was full.

The downside of seeing everyone is that we realize how much support etc the others have. Though its a trade off; with support also comes less freedom. We are thankful for the freedom we have, and to be starting a program from scratch is an amazing opportunity - just the kind of thing I want to know how to do. We just often wish we got some feedback / support to know if we're on the right track, or to let us know if there are avenues we should be exploring etc. So, we're going to try harder to ask more for things that we need / want, and for feedback etc. And we're sticking around here next week to see more about how they do things in Malawi.

One person suggested we should bail and let someone more experienced do this; and I have to say that I don't like that idea one bit. I really, really want to develop this program. I would just like a little advice now and then to help guide us, or even encourage us.

A real highlight was our visit today to Chiwere, David Jones' village - well, not exactly his, but his adopted village. On a hiking trip he met some motivated villagers and then helped them create a community-based orphan / vulnerable children (OVCs) support program. Now the 277 AIDS orphans in the village have been tested, those that need are on therapy, and they have food and other support through a variety of activities. They have a singing and drama group as well. We had a wonderfully warm welcome from the children and the NGO volunteers, with singing, dancing, poetry and a drama. It is just so neat to see how pround they are of their activities. David has said (and I think he's got a good point) that the real battle against HIV in much of Africa won't be fought in the fancy COEs in the capital cities... it will be these small scale, grassroots responses that will be the key to surviving this pandemic.

I don't know how much I've mentioned David; he's one of the Vice Presidents of BIPAI, and I have a world of respect for him. At first glance, you might think him an average administrator, but he is anything but. As far as I'm concerned, he is the key to the success of the AIDS Corps, though he doesn't get much credit. He works quietly in the background, but after 5 years of living in Malawi, and being really touched by Malawi and its people, he really understands things here, and how to get things done. And he keeps us sane, especially us in Burkina Faso who have no other administrative support from BIPAI.

PHOTOS: The first photo is David, and the orphans & vulnerable children. The second one is two orphans, and the final one is 5 of the orphans singing us a welcome song, with the other kids in the background. I can't begin to describe how touching the whole day was.

A weekend off: Lake Malawi

2006-11-05T19:37:00.000Z

We’ve just returned from a really, really wonderful weekend away at Mumbo Island, on Lake Malawi. “We” is Dana, Allison, Leah and myself. It was a 4 hour drive down to the resort at Cape MacLear on the southern end of the long, thin lake. The water was incredibly blue, with lots of jacaranda in bloom and bougainvilleas everywhere, bright with red, orange and pink flowers. Despite being the hottest time of year here in Malawi, its cooler than at home in Burkina, so we are enjoying the relatively temperate weather (30C during the day).

The 10-km boat ride took about an hour, and as we approached, we could scarcely believe our eyes, a small islet with 5 permanent tents (tents with a thatched roof over top for shade and rain protection, and on the main island hiking trails and a white sand beach with kayaks, snorkel gear, and the main lodge.

We spent the last few days languidly moving from snorkeling to kayak trips around the island, to sunset cruises (well, cruise may be an exaggeration – 10 people in a 15 foot wooden boat with an outboard motor). The snorkeling was better than I expected for a freshwater lake – lots of brightly coloured chiclids (a type of freshwater fish), and the chance to watch cormorants swimming underwater. Leah and I kayaked around the island in about 45 minutes. The meals were lovely.

All in all, it was a wonderful break – good to get some space from the annoyances of work, to help work on keeping some perspective. I feel totally rejuvenated (though I got a terrible cold yesterday). Made me remember how important it is to keep some fun in my life. Since moving to Burkina Faso, I have done very few fun things, besides a little reading, knitting, a concert and designing my garden. Not enough activities that totally separate me from the work. I will work on doing that more!

Anyhow, please do keep in touch – the emails / comments from folks really are important to me, they encourage and sustain me during the lonely times, of which there are quite a few.

Take care
With love
Laura

Dakar – its all about the work

2006-11-02T20:19:00.000Z

Its been hard to find time to write lately. We spent 3 days in Dakar; hardly left the hotel so I’m not in any position to comment on Dakar, other than to say it is MUCH more cosmopolitan than anything in Burkina – high rise buildings, traffic jams, smog – the whole 9 yards. The food was really good, and women dress very well. The hotel had a beautiful, large pool overlooking the ocean.

But, as geeky as it is… the highlight of the time in Dakar was the work. We made lots of great contacts with people working on various HIV projects across West Africa; some really innovative, others very much needed. The participants were all passionate about decreasing the burden of HIV on the population, whether their role was community mobilization or scientific studies. We made lots of great contacts. Really inspiring people working amazingly hard to lessen the effects of the disease on their community.

In the interest of disclosure… the meeting was a Bristol Myers Squibb sponsored one, and we spent much of the time with the president of the BMS foundation – a guy with control of more money than I will be able to even imagine (the Secure the Future grants, just one small part of his money to give away, was $115 million). Its weird, and not always completely comfortable to think about that my salary and much of my budget comes from “big pharma” (it goes against my social justice bent)… but, to be honest, I am really grateful for how strongly they feel about AIDS in Africa, and how much they believe in us and our program.

A highlight was Île Gorée, which was one of the slave trading outposts… a world of contrasts, of physical beauty with palm trees and white sand beaches with the terrible history of people’s inordinate cruelty against one another. The poverty of the islanders with the tourists who walk through every day.

Garden update

2006-10-26T00:48:00.000Z

I forgot to add... My garden (after 6 weeks) is coming along nicely – there are lots of baby tomatoes, all still very small & green, and cucumber & zucchini flowers. I’ve been eating basil, spinach, green onions and lettuce too. There are 3 huge and one smaller basil plant, two of which were from seeds; enough for a very large supply of pesto. It will be interesting to see the change after 3 weeks of traveling! I am hoping the veggies hold off until my return. Here is the back garden again (in the photo, the front garden doesn’t look much different although it has filled in quite a bit).

heading out

2006-10-26T00:37:00.000Z

Well, last weekend was the end of Ramadan, the biggest holiday of the year in this primarily Muslim country. I had a mostly quiet weekend, with some fun things thrown in. Good distractions from work, like a concert, a swim at my friends Dana & Allison’s house, and an Eid luncheon, where we ate a lovely meal and had some music – the kids just LOVED the digital camera, and laughed and laughed at their photos. (The musician hasn't been to Toronto - our host of the event brought the t-shirt back from the AIDS Conference in August).

Tuesday we headed to Ouaga where we’ve discovered a few more good places to eat – very exciting! And also had some productive meetings. Tomorrow I head to Dakar, Senegal – which is supposed to be fascinating, but very dangerous – for a couple days, then on to Malawi. In Malawi we will be having the BIPAI Network meeting, and it will be great to hear what the other sites are doing. Hard not to feel frustrated about our slow progress, but we are making progress nonetheless.

Anyhow, have a lovely week.
Laura

Thoughts on a stressful week

2006-10-22T11:19:00.000Z

As an ID fellow, we tend to have a lot of time for each patient; we carefully think through each potential diagnosis, how to test for it, the possible treatments. That pace actually suits me quite well; I really like having the time to think carefully through a decision or a patient. I like having as much information as possible. I'm not one for snap decisions...

The style of medicine here is anything but that. Instead, its rushing through the patients, rapid fire. Trying to get through them all before I’m abandoned by nurse and/or intern because I’m taking too long (we round from 8:30 – 12:00; any later and the nurse & intern become mutinous). Struggling with the medical jargon in French, and unable to speak with most of the parents directly. Knowing what the recommendations are, but unable to do them because of “lack of resources” – or lack of will on the part of the hospital. Not knowing the system well enough to get things done. If investigations are done at all – and often the orders are just ignored – they happen the next day.

Some of the kids, so sick when they come in, get better quickly and go home. Actually, that’s most of the kids – its malaria season, so there are at least 10 admissions / night of various forms of severe malaria. Most of them get better quickly with IV quinine. That is so nice to see! But then other kids don’t have malaria… its hard to get other investigations done to sort out what they have. Those kids, I would love to have the time to work through carefully; but there is so little time and so many kids. And sometimes the parents have no money to buy the needed medicines (usually antibiotics).

I know that I will get used to it, and the language get easier, and I will get to know the hospital. Its hard to be patient for those things to happen though! There was nothing else this week besides work, Jula lessons and sleep. No energy for anything else!

However, we did go to a concert at the French Cultural Center Friday night, which was fun – it was really good to get out and do something social.

This weekend is a long weekend here, the end of Ramadan. And then, on Tuesday we head to Ouaga – by plane this time!! Hopefully no misadventures like our last trip. And then on to Dakar for a couple days and Malawi for 2 weeks. We’ll have a long weekend in the middle to do some exploring in Malawi. By the time we come back, my garden will be full of tomatoes, cucumbers, and zucchini as they are all flowering now.

the Pediatrics Ward

2006-10-18T16:45:00.000Z

OK, so now I am really working. I'm exhausted, and very stressed. (warning... much jargon ahead... I apologize for the medical entry... )

The peds department is organized into 4 wards - Urgences (emergency / "intensive care"), over 3, under 3 and neonates. The doctor who is supposed to be on Over 3 is on Mat leave - so there is no doctor (that's where we come in). And the intern is sick - though yesterday & the day before I shanghaiied another intern into working with me. Today I was on my own. I have never seen so many patients in one day in my life... and in a foreign language (as it turns out, there are VERY many french medical words that I don't know... words that are part of my every day vocab in English....), and the parents rarely speak French, and the nurse doesn't seem to like being a translator.... I think I saw about 45 inpatients.

It is a frusterating ordeal mostly... hard to get the tests done that I think are absolultely essential ... things like malaria smears, blood counts, etc. So, I'm making decisions based on a partial history, physical exam (but no otoscope) and usually no investigations. Sometimes you prescribe antibiotics and the parents don't buy them - so the kid goes without. Other times, they buy them but for unclear reasons, they aren't administered - or they're administered but not recorded. Sometimes the pharmacy dispenses a different medication than is ordered. It is so exhausting that I have more sympathy for the MDs that never work on changing anything.

Some of the things that I want to do - based on WHO recommendations - are not whats done here, so the nurse doesn't like them. Things like, giving de-worming meds to anemic kids and giving a second drug with the artemesinin compounds. Some recommendations that are proven to improve child survival are not available - like zinc tablets for kids with diarrhea. (And I haven't even seen any kids with severe malnutrition on the over 3 ward, so haven't tackled that yet).

The doctor who works in "Urgences" said to Dana & Suzanne - thank God the kids mostly look after themselves, because we sure can't look after them. Its sadly true. There is such a shortage of personel, tests, drugs, and willingness to get things done. Its really hard.

Anyhow, its sure to get easier with time.