Procrastination and my list of things to do

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

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

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

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

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

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

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

another week done

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

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

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

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

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

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

Happy birthday small, blonde & sisterish!

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

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


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

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

Siesta

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

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

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

How civilized!

the Nightlife of Bobo Dioulasso: "Farafina Love"

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

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

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

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

made it through

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

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

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

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

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

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

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

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

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

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

whirlwind

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

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

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

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

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

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

Mother’s Day for a motherless daughter

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

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

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

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

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

A tough day

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

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

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

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

Have a safe, fun and relaxing weekend

On my own

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

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

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

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

inspirational colleagues

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

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

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

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

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

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

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

Granola, "More with Less" and Fair Trade

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

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

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

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

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

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

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

Un peu de repos

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

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

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

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

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

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

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

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

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

Vitamin A victory!

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

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

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

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

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

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

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!