Three children

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

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

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

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

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

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

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

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

lack of resources or lack of effort?

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

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

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

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

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

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

In fact, its not automatically provided to the hospitals.

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

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

not much to report

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

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

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

Anyhow, take care & keep in touch
Laura

Back to the grind

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

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

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

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

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

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

Association des Veuves et Orphelins de Burkina Faso (AVOB)

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

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

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

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

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

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

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

Exploring Southwestern Burkina Faso

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

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

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

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

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

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

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

FESPACO

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

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

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

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

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

Distributed zoo

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

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

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

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

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

Take care!

Laura

Our first 4 patients!!!!!!!

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

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

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

workshop cancelled - AGAIN

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

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

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

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

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

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

quiet but relaxing weekend

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

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

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

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

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

learning patience

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

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

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

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

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

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

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

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

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

life outside medicine

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

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

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

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

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

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

Love

Laura

Ups and downs

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.