Pediatrics Ward

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"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

Day 4 & 5 - Congres Medicale

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

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

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

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

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

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

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

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

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

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

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

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

Hospital tours

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

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

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

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

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

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

New country, new adventures!

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

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

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

I'm excited for the hospital visit tomorrow.

More later!
Laura