This week has been our busiest yet. In fact, with one more day to go in April, the month has been record breaking for us. We now have 115 patients registered (about half are Nacro's) and had 143 patient encounters (that is, seperate visits). After our days in clinic, I spent the afternoons and evenings getting ready for a regional pediatric HIV care planning meeting that Suzanne is going to. We were only invited to the meeting 1 week ahead of time, and I suddenly had to sign over everything that I've been doing to Suzanne in such a way that she could represent us as well as possible, and seek the answers to a number of issues. In having to compile everything I've done in the last 6 months, I realized I've actually done a lot of work. Sometimes it feels I have little to show for it. But I do think we've made important progress.
Even though I know that Suzanne will do a good job, it was really hard to let that stuff go; I'm really invested in it and wanted to follow it through to the end.
Over 40% of our kids are moderately to severely malnourished (that is, less than 2 SD below the mean weight for age) and a third are stunted (less than 2 SD below the mean height for age) and a third are wasted (less than 2 SD below the mean weight for height). Some of them, its their illness(es). But for some, its that the family doesn't have enough to eat. In either case, we have nothing to give them but advice. All the ARVs in the world won't solve that problem. But what to do? We are waiting for the Clinton Foundation donation which was promised to be bringing nutritional supplements... but it seems to be totally stalled.
One of the things I struggle with the most is the feeling of guilt. Every day we are face to face with how much privilege we have, and how little people here have. On my salary (which is 1/4 - 1/3 of what I would be making at home), I am incredibly wealthy here. Several of our patients are trying to feed multiple children, pay school fees, buy medicines and pay for doctors visits all on less than $1 / day. If the adults are to get treatment, it costs $10 / month plus the lab testing. Thankfully pediatric HIV care is provided for free.
But what about the little boy I saw yesterday who has some sort of congenital heart defect (not HIV)? How do I tell his family that the only way he'll get better is with surgery that, even if it were available, wouldn't be affordable?
What about all the families who spend the last of their money on the hospital fee for a hospitalization and then have no money for medicine? (everything must be paid for up front).
And what about the one legged elderly gentleman that asks me for money every time I go to the post office. And the young paraplegic man in a wheelchair who also lurks by the post office, and alternately asks me for money and to buy his postcards. And the two mothers with toddler twins who beg outside the grocery store. And the two mentally ill people who live under the tree on the corner near the hospital with their hair matted, often having battles with their voices.
I don't have an answer; those faces haunt me.
But when the economy is so weak, and there is corruption, and lack of motivation amongst most health care workers (at every level) and lack of productivity due to malaria and HIV etc, and an inhospitable climate that has marginal food growing conditions, and the country is landlocked.... its hard not to despair sometimes.
Other times I think, I am working on it. We are making a difference, even if its only to a few children. Me and my colleagues (including Pr Nacro) are doing the best that we can, working long hours and trying to give high quality care to the HIV infected & exposed kids. Sometimes we can even visibly help them; this week I treated a girl for really severe thrush and cold sores and it was wonderful to see her back in followup feeling better. It is a sort of instant gratification that helps make the job easier.
Saturday, April 28, 2007
Tuesday, April 24, 2007
Vitamin A victory!
Well, its been a number of months since I realized that the most cost-effective child survival tool wasn't being used at CHU-SS.
The administration of Vitamin A (which costs a few cents / dose, and is given for free by the Canadian government) is one of the cheapest interventions there is. It can make a huge difference in the survival of kids with severe malnutrition, and measles.
When we first arrived, no hospitalized child was getting vitamin A for any reason; I was told "its not available to hospitals"... after months of digging around, interviewing people and trying to understand the system, it seemed that Vitamin A is in fact available to the hospital. But only if they ask for it. And no one has asked recently (if ever). It took dozens of phone calls, meetings in Ouaga and Bobo and today a near sit-in in the office that distributes it. But today I was the pround recipient of 1503 hard-earned but free vitamin A capsules. Hopefully enough to last us until our order theoretically arrives with the next order in June.
The other part of the battle has been with the hospital staff. They too believe that vitamin A is only for vitamin A distribution campaigns. But with Pr Nacro supporting me, I've been trying to encourage the physicians and interns to realize that it is a key part of the treatment of severe malnutrition. I have Dr. Sessouma, the pediatrician in charge of the Urgences ward on my side too, which helps.
It may seem small, but as a Johns Hopkins alumnus, it is an important accomplishment for me!! (For those of you to whom that doesn't make sense... it was Hopkins researchers who played a huge role in establishing vitamin A as a child survival tool, and anyone who studies public health there learns very much about vitamin A over the course of an MPH).
The administration of Vitamin A (which costs a few cents / dose, and is given for free by the Canadian government) is one of the cheapest interventions there is. It can make a huge difference in the survival of kids with severe malnutrition, and measles.
When we first arrived, no hospitalized child was getting vitamin A for any reason; I was told "its not available to hospitals"... after months of digging around, interviewing people and trying to understand the system, it seemed that Vitamin A is in fact available to the hospital. But only if they ask for it. And no one has asked recently (if ever). It took dozens of phone calls, meetings in Ouaga and Bobo and today a near sit-in in the office that distributes it. But today I was the pround recipient of 1503 hard-earned but free vitamin A capsules. Hopefully enough to last us until our order theoretically arrives with the next order in June.
The other part of the battle has been with the hospital staff. They too believe that vitamin A is only for vitamin A distribution campaigns. But with Pr Nacro supporting me, I've been trying to encourage the physicians and interns to realize that it is a key part of the treatment of severe malnutrition. I have Dr. Sessouma, the pediatrician in charge of the Urgences ward on my side too, which helps.
It may seem small, but as a Johns Hopkins alumnus, it is an important accomplishment for me!! (For those of you to whom that doesn't make sense... it was Hopkins researchers who played a huge role in establishing vitamin A as a child survival tool, and anyone who studies public health there learns very much about vitamin A over the course of an MPH).
Attack of the termites
For a moment this evening I thought I was back in Noumea. I looked around my dining room and there were dozens of termites flying around, knocking off their wings and falling to the ground wiggling. ugh. (In my extremely termite infested apartment in Noumea, they would fly up into the hanging paper lampshades, knock their wings off and then fall onto my kitchen table). They're small, only about 1-1.5cm long, and a mm or so wide. But they make up for their small size by the volume. I guess its with the mango rains that they're coming out. At night now, outside you can see thousands hovering around any light source. I don't know how they get it, given my place is totally screened. Its just one of those things about living in a hot climate.
I'm in one of those frustrating cycles... i can't sleep at a reasonable hour because I'm worried about how much work I have to do... and then am exhausted in the day when I am trying to work. So its 12:40am and I'm still wide awake, and I know that the 6am alarm and the hectic clinic, followed by meetings, and a number of administrative tasks will make tomorrow a long, long day. And that just makes the insomnia worse!
I'm glad we're busy in clinic though. And over the next little while I think I will be passing a number of my jobs onto other people which should make things a little easier. Although I'm loathe to do so, being really interested in most of what I've taken on as responsibilities.
I'm in one of those frustrating cycles... i can't sleep at a reasonable hour because I'm worried about how much work I have to do... and then am exhausted in the day when I am trying to work. So its 12:40am and I'm still wide awake, and I know that the 6am alarm and the hectic clinic, followed by meetings, and a number of administrative tasks will make tomorrow a long, long day. And that just makes the insomnia worse!
I'm glad we're busy in clinic though. And over the next little while I think I will be passing a number of my jobs onto other people which should make things a little easier. Although I'm loathe to do so, being really interested in most of what I've taken on as responsibilities.
Sunday, April 22, 2007
Mango rains
Its the hot season here - and as someone who generally likes warm weather (you'll not hear me complain about a 30C day at home), even I am hiding in my air conditioned room in the hot part of the day, often exceeding 40C. But this is also the time of year of the mango rains, or little rains - little rainstorms that are much less frequent than in the wet season, that often just dampen the ground and quell the dust a little. But we've had a few wonderful, glorious rainstorms - its just pouring rain right now, and the beauty is that everything will be wonderfully cooled off afterwards, and the garden loves the rain. People say that the mango rains make the mangos sweeter. The other day I had to ride my motorbike home in a similar rainstorm and was actually cold - it was wonderful!!!
Its a quiet weekend for me - catching up on paperwork, knitting, reading, emailing and talking with folks at home on Skype. After the very long days and stresses of the week, its great to have some down time.
Take care.
Its a quiet weekend for me - catching up on paperwork, knitting, reading, emailing and talking with folks at home on Skype. After the very long days and stresses of the week, its great to have some down time.
Take care.
Friday, April 20, 2007
an ethical dilemma
Well, this week has been our busiest yet with Pr Nacro away. We are seeing about 10-12 patients / day that are new to us (followed by Pr Nacro); each one takes a while because we can't just prescribe ARVs without knowing anything about the child. Plus, our followups. We're up to about 15 or so patients / day, sometimes more. We're seriously limited by space in our 1 room clinic. Each morning we seek out a free consultation room because we can get through many more kids with 2 rooms.
From about 8am - 10 or 11am each day one of the pediatricians does consultations. So patients come and line up (and its a shared waiting space with our patients for now). Between when the morning doctor finishes and when the on call intern starts (which can be 4 hours or more), there are no physicians to see acutely ill patients. Sometimes the nurses see the most critically ill patients, but even things like stiff neck & fever (in the middle of meninigitis season) waits for the intern. So, often we get patients at our door wanting us to see them and generally, we refuse. On one hand, they're sick and they need to be seen. On the other, there is a system in place (of sorts) that we don't want to disrupt; also, our mandate is to care for the HIV infected and exposed kids, and to help on the wards. If we start seeing those patients, we may have negative systemic consequences. On the other hand, we feel terrible about making them sit and wait for the intern.
My last patient of the day was a child who accidentally got into our "line" - neither HIV infected or exposed; however the patient was so sick that I decided to see him anyhow. It was a 3 month old refered for poor feeding. The child weighs 2.8 kg; which is what he weighed at birth. So, I did the history and physical, wrote my first admission orders in 3 years (it was so routine in residency!). Then comes the dilemma of how to execute the orders. The mother of course had no money for the medicines and infant formula (mom has minimal breast milk). We scrounged up most of what we needed from hospital supplies. And I went out and bought 2 cans of infant formula and brought them back. 3 hours after leaving the supplies etc with the nurses, I checked back and nothing had been done since I left; the baby hadn't been fed, no oral rehydration solution had been given, nothing. I stood in the ward until we got things going.
The thing is... there were 10 other kids in the Urgences ward, as sick. Some can't afford their medicines either and just go without. The wards are full of kids who's parents can't pay for their medicines.
So ethically its tough. On the one hand, I want to do good to my patient (who I shouldn't have even been seeing). I can't sit and watch him die because his mom can't afford the $4 can of formula.
On the other hand, what I am doing is unjust. I am not paying for all of the kids, and some are going without medicines and food because their parents can't afford it. Also, foreigners stepping in to buy some kids drugs is not sustainable and potentially weakens the health care system.
And what is really unjust is that some of these children are dying for lack of $2-3 worth of medicine. That the system (imposed by the World Bank and the IMF) demands that the poorest people in the 3rd poorest country in the world pay for their own health care costs - something that Canadians, with all their privilege and all their disposable income for SUVs and TVs etc etc etc, don't have to do. The economic theory is that health services will be more valued and health care usage will go up and quality will improve with a pay as you go system. In fact, several studies here in Burkina suggested that the exact opposite happened when Burkina instituted those changes.
These sorts of things tear me up.
From about 8am - 10 or 11am each day one of the pediatricians does consultations. So patients come and line up (and its a shared waiting space with our patients for now). Between when the morning doctor finishes and when the on call intern starts (which can be 4 hours or more), there are no physicians to see acutely ill patients. Sometimes the nurses see the most critically ill patients, but even things like stiff neck & fever (in the middle of meninigitis season) waits for the intern. So, often we get patients at our door wanting us to see them and generally, we refuse. On one hand, they're sick and they need to be seen. On the other, there is a system in place (of sorts) that we don't want to disrupt; also, our mandate is to care for the HIV infected and exposed kids, and to help on the wards. If we start seeing those patients, we may have negative systemic consequences. On the other hand, we feel terrible about making them sit and wait for the intern.
My last patient of the day was a child who accidentally got into our "line" - neither HIV infected or exposed; however the patient was so sick that I decided to see him anyhow. It was a 3 month old refered for poor feeding. The child weighs 2.8 kg; which is what he weighed at birth. So, I did the history and physical, wrote my first admission orders in 3 years (it was so routine in residency!). Then comes the dilemma of how to execute the orders. The mother of course had no money for the medicines and infant formula (mom has minimal breast milk). We scrounged up most of what we needed from hospital supplies. And I went out and bought 2 cans of infant formula and brought them back. 3 hours after leaving the supplies etc with the nurses, I checked back and nothing had been done since I left; the baby hadn't been fed, no oral rehydration solution had been given, nothing. I stood in the ward until we got things going.
The thing is... there were 10 other kids in the Urgences ward, as sick. Some can't afford their medicines either and just go without. The wards are full of kids who's parents can't pay for their medicines.
So ethically its tough. On the one hand, I want to do good to my patient (who I shouldn't have even been seeing). I can't sit and watch him die because his mom can't afford the $4 can of formula.
On the other hand, what I am doing is unjust. I am not paying for all of the kids, and some are going without medicines and food because their parents can't afford it. Also, foreigners stepping in to buy some kids drugs is not sustainable and potentially weakens the health care system.
And what is really unjust is that some of these children are dying for lack of $2-3 worth of medicine. That the system (imposed by the World Bank and the IMF) demands that the poorest people in the 3rd poorest country in the world pay for their own health care costs - something that Canadians, with all their privilege and all their disposable income for SUVs and TVs etc etc etc, don't have to do. The economic theory is that health services will be more valued and health care usage will go up and quality will improve with a pay as you go system. In fact, several studies here in Burkina suggested that the exact opposite happened when Burkina instituted those changes.
These sorts of things tear me up.
Wednesday, April 18, 2007
Designing systems
Another busy week for us (yay!); we’ve run out of health records folders, having bought out the store’s whole stock. Our 1-room clinic is starting to be too small, as despite the fact that there are 2 or 3 MDs in clinic each morning, we only have 1 room and the few times we have more than 1 patient in there, it just doesn’t work.
While Pr Nacro has done an amazing job at caring for 300 kids with few resources, things aren’t very systematic. I think if you asked him, he’d say he’s too busy to be organized. The HIV counselors keep track of the patients by date of visit in notebooks they have, and he has a pile of the last 6 months of CD4 results in random order. And the rest is in his memory. One of the neat things is that the HIV counselors have decided they like our index card system and are adopting that, so with time we’ll have all of the kids recorded at least on an index card with name, date of birth and whether they’re on ARVs. That’s a start!
So, we’re trying to systematize things to create better flow of information between the various doctors and health care workers caring for these kids – in a health care system which doesn’t have a culture of keeping chronic health care records. The challenge is, we’re trying to do it without any real experience in a resource-poor setting or guidance. So, while I know what’s in the literature, what’s taught at public health school and have some idea from that, I am – we all are – learning lots of things from our mistakes…. Creating patient care forms that are comprehensive but as short as possible… figuring out our own adherence plan and disclosure strategies that are culturally appropriate… figuring out how to get things done in a system that seems to be designed to be as difficult as possible.
On top of that, there are lots of clinical lessons… how to manage things with few tests and fewer drugs. And most importantly, not very much experience. (Our PAC colleagues in the other countries have had 8 months of clinical work to get a handle on that issue but we’re getting there now too). But the experience will come with time, and each day we are in clinic I am thankful that we have gotten this far.
While Pr Nacro has done an amazing job at caring for 300 kids with few resources, things aren’t very systematic. I think if you asked him, he’d say he’s too busy to be organized. The HIV counselors keep track of the patients by date of visit in notebooks they have, and he has a pile of the last 6 months of CD4 results in random order. And the rest is in his memory. One of the neat things is that the HIV counselors have decided they like our index card system and are adopting that, so with time we’ll have all of the kids recorded at least on an index card with name, date of birth and whether they’re on ARVs. That’s a start!
So, we’re trying to systematize things to create better flow of information between the various doctors and health care workers caring for these kids – in a health care system which doesn’t have a culture of keeping chronic health care records. The challenge is, we’re trying to do it without any real experience in a resource-poor setting or guidance. So, while I know what’s in the literature, what’s taught at public health school and have some idea from that, I am – we all are – learning lots of things from our mistakes…. Creating patient care forms that are comprehensive but as short as possible… figuring out our own adherence plan and disclosure strategies that are culturally appropriate… figuring out how to get things done in a system that seems to be designed to be as difficult as possible.
On top of that, there are lots of clinical lessons… how to manage things with few tests and fewer drugs. And most importantly, not very much experience. (Our PAC colleagues in the other countries have had 8 months of clinical work to get a handle on that issue but we’re getting there now too). But the experience will come with time, and each day we are in clinic I am thankful that we have gotten this far.
Friday, April 06, 2007
Good Friday
Well, for us it certainly was a Good Friday - not a holiday here in Burkina Faso (the Easter Holiday is Monday) but it was our busiest clinic day so far. While the busyness is a little stressful, it is a good kind of stress - I am really glad to have lots of patients, and to be getting into the swing of things. We have some routine patients, some challenging ones - and every day we learn a lot.
Our first patient, Omar, came in for a follow up today. He was our very first patient, Dana & Leah looked after him over the Christmas holidays on the ward, with TB & HIV, very malnourished. He is 13 but weighs only 24kg... he is WAY shorter than me (which is very stunted for a 13 year old boy!) Since we've been caring for him, he started on TB drugs, improved a little, started on HIV drugs, improved a little more. Today in follow up we started him on iron (for anemia) and for the first time, he asked "what is this medicine for?". I was glad he was asking the question... here too often, people don't ask those questions.
Our new administrator, Julien, seems really good - it is GREAT to have him. He has lots of good ideas, and is MUCH more skilled at many of the admin stuff than we are. And he's enthusiastic, and dedicated to the cause. He's worked for HIV organizations in the past, and has experience as an HIV counsellor.
Its SO wonderful to feel like we're making progress. A lot of the initial work was necessary but not so obviously helpful... now, we're actually caring for kids. And its great - even if I worry about the kids, I am SO happy to be at the point where we can care for our own patients, institute our own organization, start systematic adherence counselling, and followup up etc.
Have a safe & blessed Easter weekend.
Laura
Our first patient, Omar, came in for a follow up today. He was our very first patient, Dana & Leah looked after him over the Christmas holidays on the ward, with TB & HIV, very malnourished. He is 13 but weighs only 24kg... he is WAY shorter than me (which is very stunted for a 13 year old boy!) Since we've been caring for him, he started on TB drugs, improved a little, started on HIV drugs, improved a little more. Today in follow up we started him on iron (for anemia) and for the first time, he asked "what is this medicine for?". I was glad he was asking the question... here too often, people don't ask those questions.
Our new administrator, Julien, seems really good - it is GREAT to have him. He has lots of good ideas, and is MUCH more skilled at many of the admin stuff than we are. And he's enthusiastic, and dedicated to the cause. He's worked for HIV organizations in the past, and has experience as an HIV counsellor.
Its SO wonderful to feel like we're making progress. A lot of the initial work was necessary but not so obviously helpful... now, we're actually caring for kids. And its great - even if I worry about the kids, I am SO happy to be at the point where we can care for our own patients, institute our own organization, start systematic adherence counselling, and followup up etc.
Have a safe & blessed Easter weekend.
Laura
Monday, April 02, 2007
Raining mangos
Its a long weekend here - one of the lunar Muslim holidays that everyone thought would be Friday, but on Thursday it was declared that the holiday would be Monday throwing scheduling into chaos. So, i've had a nice quiet weekend, doing stuff around the house, knitting, reading, writing letters, etc.
The weather is odd today - its down right cool (the BBC website says 30C). OK, maybe not - but I can sit outside at 9am without sweating! The sky is cloudy and the wind is blowing clouds of dust around. And in my garden its raining mangos - many of the early mangos that are getting ripe are getting blown out of the tree. (All of the ones in easy picking height are still hard as rocks).
One of my colleagues, Suzanne has just headed back to the US for her holiday; perfect time to get away from the heat. And Dana is coming back after 2 months of working in the other COEs. I am looking forward to hearing about her experiences in the COEs that are up and running. And our other very exciting news is that our administrator is starting Tuesday; he seems like he will be great. And act as an important liaison between BIPAI and the Ministry of Health, helping negociate the cultural landmines that we keep finding.
Little by little the bird builds its nest!
The weather is odd today - its down right cool (the BBC website says 30C). OK, maybe not - but I can sit outside at 9am without sweating! The sky is cloudy and the wind is blowing clouds of dust around. And in my garden its raining mangos - many of the early mangos that are getting ripe are getting blown out of the tree. (All of the ones in easy picking height are still hard as rocks).
One of my colleagues, Suzanne has just headed back to the US for her holiday; perfect time to get away from the heat. And Dana is coming back after 2 months of working in the other COEs. I am looking forward to hearing about her experiences in the COEs that are up and running. And our other very exciting news is that our administrator is starting Tuesday; he seems like he will be great. And act as an important liaison between BIPAI and the Ministry of Health, helping negociate the cultural landmines that we keep finding.
Little by little the bird builds its nest!
Saturday, March 31, 2007
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.
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.
Wednesday, March 28, 2007
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.
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.
Tuesday, March 27, 2007
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
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
Tuesday, March 20, 2007
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.
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.
Saturday, March 17, 2007
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.
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!!!
Thursday, March 08, 2007
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.
Sunday, March 04, 2007
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
Tuesday, February 20, 2007
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.
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.
Thursday, February 15, 2007
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!
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!
Monday, February 12, 2007
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
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
Saturday, February 10, 2007
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.
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.
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