Ups and downs

Today was definitely a bipolar sort of day...

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

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

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

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

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

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

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

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

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

La Guingette

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

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

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


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

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

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

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

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

Anyhow, all the best - enjoy your week.
Laura

Long awaited groundbreaking ceremony!

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

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

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

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

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

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

window onto Burkina life

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

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

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

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

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

Urgences - the 'intensive care unit'

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

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

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

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

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

Back to Burkina Faso

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

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

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

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

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

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

Lost at sea

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

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

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!

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

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

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 !?!

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

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

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

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

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

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

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

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.