Garden update

I forgot to add... My garden (after 6 weeks) is coming along nicely – there are lots of baby tomatoes, all still very small & green, and cucumber & zucchini flowers. I’ve been eating basil, spinach, green onions and lettuce too. There are 3 huge and one smaller basil plant, two of which were from seeds; enough for a very large supply of pesto. It will be interesting to see the change after 3 weeks of traveling! I am hoping the veggies hold off until my return. Here is the back garden again (in the photo, the front garden doesn’t look much different although it has filled in quite a bit).

heading out

Well, last weekend was the end of Ramadan, the biggest holiday of the year in this primarily Muslim country. I had a mostly quiet weekend, with some fun things thrown in. Good distractions from work, like a concert, a swim at my friends Dana & Allison’s house, and an Eid luncheon, where we ate a lovely meal and had some music – the kids just LOVED the digital camera, and laughed and laughed at their photos. (The musician hasn't been to Toronto - our host of the event brought the t-shirt back from the AIDS Conference in August).

Tuesday we headed to Ouaga where we’ve discovered a few more good places to eat – very exciting! And also had some productive meetings. Tomorrow I head to Dakar, Senegal – which is supposed to be fascinating, but very dangerous – for a couple days, then on to Malawi. In Malawi we will be having the BIPAI Network meeting, and it will be great to hear what the other sites are doing. Hard not to feel frustrated about our slow progress, but we are making progress nonetheless.

Anyhow, have a lovely week.
Laura

Thoughts on a stressful week

As an ID fellow, we tend to have a lot of time for each patient; we carefully think through each potential diagnosis, how to test for it, the possible treatments. That pace actually suits me quite well; I really like having the time to think carefully through a decision or a patient. I like having as much information as possible. I'm not one for snap decisions...

The style of medicine here is anything but that. Instead, its rushing through the patients, rapid fire. Trying to get through them all before I’m abandoned by nurse and/or intern because I’m taking too long (we round from 8:30 – 12:00; any later and the nurse & intern become mutinous). Struggling with the medical jargon in French, and unable to speak with most of the parents directly. Knowing what the recommendations are, but unable to do them because of “lack of resources” – or lack of will on the part of the hospital. Not knowing the system well enough to get things done. If investigations are done at all – and often the orders are just ignored – they happen the next day.

Some of the kids, so sick when they come in, get better quickly and go home. Actually, that’s most of the kids – its malaria season, so there are at least 10 admissions / night of various forms of severe malaria. Most of them get better quickly with IV quinine. That is so nice to see! But then other kids don’t have malaria… its hard to get other investigations done to sort out what they have. Those kids, I would love to have the time to work through carefully; but there is so little time and so many kids. And sometimes the parents have no money to buy the needed medicines (usually antibiotics).

I know that I will get used to it, and the language get easier, and I will get to know the hospital. Its hard to be patient for those things to happen though! There was nothing else this week besides work, Jula lessons and sleep. No energy for anything else!

However, we did go to a concert at the French Cultural Center Friday night, which was fun – it was really good to get out and do something social.

This weekend is a long weekend here, the end of Ramadan. And then, on Tuesday we head to Ouaga – by plane this time!! Hopefully no misadventures like our last trip. And then on to Dakar for a couple days and Malawi for 2 weeks. We’ll have a long weekend in the middle to do some exploring in Malawi. By the time we come back, my garden will be full of tomatoes, cucumbers, and zucchini as they are all flowering now.

the Pediatrics Ward

OK, so now I am really working. I'm exhausted, and very stressed. (warning... much jargon ahead... I apologize for the medical entry... )

The peds department is organized into 4 wards - Urgences (emergency / "intensive care"), over 3, under 3 and neonates. The doctor who is supposed to be on Over 3 is on Mat leave - so there is no doctor (that's where we come in). And the intern is sick - though yesterday & the day before I shanghaiied another intern into working with me. Today I was on my own. I have never seen so many patients in one day in my life... and in a foreign language (as it turns out, there are VERY many french medical words that I don't know... words that are part of my every day vocab in English....), and the parents rarely speak French, and the nurse doesn't seem to like being a translator.... I think I saw about 45 inpatients.

It is a frusterating ordeal mostly... hard to get the tests done that I think are absolultely essential ... things like malaria smears, blood counts, etc. So, I'm making decisions based on a partial history, physical exam (but no otoscope) and usually no investigations. Sometimes you prescribe antibiotics and the parents don't buy them - so the kid goes without. Other times, they buy them but for unclear reasons, they aren't administered - or they're administered but not recorded. Sometimes the pharmacy dispenses a different medication than is ordered. It is so exhausting that I have more sympathy for the MDs that never work on changing anything.

Some of the things that I want to do - based on WHO recommendations - are not whats done here, so the nurse doesn't like them. Things like, giving de-worming meds to anemic kids and giving a second drug with the artemesinin compounds. Some recommendations that are proven to improve child survival are not available - like zinc tablets for kids with diarrhea. (And I haven't even seen any kids with severe malnutrition on the over 3 ward, so haven't tackled that yet).

The doctor who works in "Urgences" said to Dana & Suzanne - thank God the kids mostly look after themselves, because we sure can't look after them. Its sadly true. There is such a shortage of personel, tests, drugs, and willingness to get things done. Its really hard.

Anyhow, its sure to get easier with time.

Week 2 in the periphery

This week was another informative week. I spent the first 3 days at CSPS Farakan, a clinic where women are actually offered prenatal HIV testing – and if they are positive, they are referred into a study that provides free treatment, including all medications necessary, and if wanted, formula to help prevent mother-to-child transmission of HIV. (Its such a good deal that the consent process is almost coercive – no woman could turn down free care for herself & her baby, plus free ARVs, plus maybe free formula!)

Testing of people over the age of 18 months costs 500-1000CFA though it is supposed to be offered free to pregnant women as part of the free prenatal care. PCR testing (the test you do on children under 18 months) costs 10,000CFA – not affordable to anyone here (remember than most people live on less than 500CFA / day). So in effect, they only diagnose HIV in kids over 18 months.

I watched a “sensibilisation” session – the assembled pregnant women sat on a bench and looked at their toes uncomfortably, while the midwife appeared to be haranguing them… it was in Jula, so all I could understand was the word “SIDA” which appeared in almost every sentence. I wondered what she was saying – although no one filled me in.

The moto riding is going pretty well – though still a bit frightening. I rode to work every day this week, a 20-minute drive through parts of town that were new to me. It was neat – although sometimes I was so interested in what was going on around me it was hard to focus on the road.

I stopped one afternoon to buy a pottery plant pot. Everyone tells me that people here are reluctant to get their photos taken and so I’ve really taken very few photos. But on a whim, I asked the pot seller if I could take a photo of her - much discussion ensued and the end result was that I could take a photo of her – if I also took a photo of another woman too and then brought back a copy of the photo. Then, there was a long discussion of where I should take these two photos… and then they announced that I should come back another day and take photos of them making the pottery. It was a funny experience. But the photo you see here is pretty typical of the roadside vendors, with the wares on the ground beside the road, and more stalls in the background – most of the shops are of the plywood stall-type.

Have a safe week.
Laura

Thanksgiving.

You may have noticed a gap in entries. In a way its been because I’ve been busy – but also because its been hard to know what to write as well.

Its funny, I have so much training and so many degrees & diplomas now… but even though I can easily talk theoretically about many of these problems that we are seeing – for example, the various causes and contributors to child malnutrition, how it should be managed in theory, etc – I feel somewhat overwhelmed when thinking about what to do practically to help ameliorate this system that often just doesn’t work. Part of why I have so much education is that I always think I don’t know enough to actually start… yet, here we are. So, where do you start? What can you do that is going to have a lasting impact? How do you make changes & suggestions without sounding imperialistic? Where do you find sustainable funds to pay for necessary medicines and treatments? These are the questions I’ve been wrestling with, how to take all this theory I now know so well and transfer it to action.

We are starting with an 8 week orientation of sorts. A series of rotations through the peripheral clinics, the pediatric service and the adult (maternity & internal medicine) services so that we can get a handle on the way the health system functions. Or doesn’t.

I’ve been in the peripheral clinics and Thursday and Friday I spent visiting the CSPS Accart-Ville, where I got to see nutrition interventions – the monthly weighing of well kids (with checks of their vaccine records) and the CREN (Centre de Rehabilitation et Education Nutritionnel) where they provide food supplements and education to mothers of kids who are malnourished. Severely malnourished kids are referred to the main hospital, but mild-moderate ones are treated locally. The kids receive vitamin A on admission to the program, and their mothers come every day and are taught how to make a number of different “bouilles” or gruels, with rice or milk or eggs. The mothers are responsible for cooking the bouille, with supervision of the nurse / nutritionist. In the process, they learn about different public health interventions, like hand washing & hygiene, vaccinations, home management of diarrhea, signs of severe malnutrition and other topics chosen by the mothers. At this CREN, it costs the families 25 CFA / day; nearly everyone can scrape together that much and it would cost more to buy the nutritious food that is provided. The kids are weighed once weekly, and referred to see the nurse if they aren’t gaining weight appropriately.

Friday I did consultations with two of the nurses – there are not enough doctors, so nurses provide the primary care. At first they seemed displeased that I was there, but over the course of the morning they warmed to me, and I did a few teaching things. (Like, recommended that they use Tylenol instead of aspirin for kids who may have viral infections because of the risk of Reye’s syndrome, which they’d never heard of). Most of the kids had fever, and they were all given a diagnosis of malaria and prescribed oral quinine. No smears are done at the CSPS level (or in the hospital for that matter but that’s for another day). It was interesting to see how things work. I asked about their PMTCT (Prevention of Mother to Child Transmission of HIV) program – the person who was trained in that left, so they don’t do it any more. They do recommend HIV testing and if the mothers accept testing, and are positive, they are referred on to a center that can follow them.

This coming week, I’ll be spending time at another CSPS that does lots of maternity and even PMTCT. It will be interesting to learn more about the barriers to care, and the strengths too of the decentralized system.

The other big news was my moto. I’ve been thinking about purchasing it since shortly after arrival and the only reason it took this long was procrastination. Bobo has more motorcycles / mopeds / scooters per capita than any other city I’ve ever seen. Even the hospital parking lot is mostly for motos. There are relatively few cars on the road here (1 car for every 5-10 motos!) and many of the streets are wide although rutted & potholed. However, until a few weeks ago, I had never driven any two wheeled motorized vehicle… so its still a little terrifying. But I have to say that it is SO much nicer to have my own transport and not have to depend on finding a taxi willing to take me to my house. All 4 of us now have motos – Dana bought hers yesterday, the last to go. Sunday, I was able to go visit Dana for a while, a feat nearly impossible without wheels as no taxis go from my house to hers.

Anyhow, I hope everyone at home had a lovely Thanksgiving. (OK, well, all those Canadians for whom it was Thanksgiving this weekend). Its odd to think of you at home, the leaves turning, the weather cold, tucked inside and having turkey feasts… while I am sitting here sweating in a tank top & shorts, and struggling to think of where we’re going to find refeeding formula to give to the malnourished kids in the hospital.

What is it like there?

I was thinking about that question as I took a taxi home from our meeting this afternoon. Let me try to describe a typical taxi ride.

At the corner of the market, next to the lady where I often buy my fruit (right now, papayas, grapefruit, avocado, pineapple) I can often find a taxi. The corner has lots of people around, and across the street is a moto parkade – more motos than I’d ever seen in one place, neatly placed one against the next. It costs 50CFA (10 cents) to park your moto in the lots. Also in front of the market is one of very many plastic bucket sellers. I’m not sure why, but many corners have a woman with a large array of brightly coloured plastic buckets, and occasionally other things like jugs, baskets and garbage cans. The taxis are all painted green, and almost all are in dreadful condition… often, you can either open the door from the outside or the inside – but rarely both. And the inside handle is often a twisted piece of wire. The windows are stuck where they are (so if it rains, you get wet). The upholstery has a general red tinge from the dust. The car often sounds and looks as if its on its last legs (they all do). I pile in, with a number of other people and head off. Sometimes, there’s two people in the front bucket seat, and up to 4 in the back. (These are small cars!)

The main roads downtown are paved, but on the edges the pavement breaks. There’s no sidewalks, just red dust. Even downtown the smaller roads are unpaved. As we head for the first rond-point (traffic circle), we pass many men with sticks displaying cell phone recharge cards, 2 or 3 on every block. We may pass the pillow salesman, walking down the road with a stack of 4 pillows on his head, and two hanging from each arm. Or the bag salesmen, with 10 different backpacks or sports bags hanging from them. Or one of the dozens of women with a large tin bowl or platter balanced on her head, containing bananas or papayas or something else. We also will pass the beggars, there’s a family on each of several corners; the kids dressed in fancy dresses (that surely came from the clothing donations that are packaged and sent to Africa in 1-ton cubes) with small plastic bowls and sad eyes. We will also see a number of 10-12 year old boys with boxes balanced on their heads, containing travel-sized packages of Kleenex, or toothbrushes, or some other random thing. We will pass several “telecentres” which are Burkina’s answer to public phones – they’re private businesses that let you make a phone call for a fee. There are always a group of 6 or 7 men hanging around the foosball table that’s on one corner.

Past the rond-point, we’ve now left the “urban” area and get to the “suburbs”. Now we pass more women carrying loads of fruit or wood, or other packages on their head. At least 2/3 of them have a baby strapped to their back, almost always sleeping or quietly looking around (never crying or fussing). We will pass on each corner a woman sitting on a stool in front of a little charcoal burner that has ears of corn being roasted, or sometimes plantains. There is a plethora of plywood stalls, sometimes just a bench with a sunshade, sometimes a small building; they sell fruit or eggs or sometimes drinks.

The taxi turns to the right, off the paved road and into the “quartier populaire,” either Balomakote or Sarfalo – the first time this happened, I just about had a heart attack. Now I know that 80% of the taxi’s I take will swing through one of the neighbourhoods bordering my own. The pavement ends, 5 meters from the main road, and the road becomes a rutted obstacle course, with huge grooves carved by the rainfall, and goats (many goats), and occasionally donkeys, cows and rarely pigs. There are small children everywhere, often wearing a t-shirt & underwear and nothing else. The houses are all made of red mud brick and some look quite tidy but many appear as if they are about to fall down. There are markets out there too, but rather than the stalls of the Grand Marché, there are plywood benches with a roof, each with a scanty pile of tomatoes, or peanuts, or peppers. We pass people collecting water from a communal tap, some with oil drums on wheels (I think those are small businesses that then deliver water to homes & businesses), some by girls and sometimes boys with buckets or large bowls that then get hoisted onto the head and gingerly walked home. On several corners we pass what are effectively garbage dumps, in the middle of the road; there is often someone picking through to find any recyclable, and often an animal or two rooting around in there as well. Sometimes we’ll pass some bigger girls carrying firewood on their heads, and a smaller sibling walks behind with one small thing, learning to balance it on his or her head. The kids stare at me peering out of the taxi and yell “toubabu, toubabu” and I smile & wave and they get a huge kick out of that. Eventually, we drop off the other passengers and continue back on the paved road towards my house.

At my corner, we turn to the left, down a street that almost never sees taxis (people who live on this street own cars, except me!)… despite the fact that its one of the fancier neighbourhoods, the roads are just as rutted but there’s little garbage around. And instead of mud brick houses, the streets are lined with the walls of the homes, each with a metal gate and a driveway for the car. There are trees & shrubs along the sides, and it is green, much greener than the neighborhood we’ve just left. And in comparison, there is hardly anyone about, just a guard sitting board in front of each door, and a couple kids running around. And then, I walk into my house (which is as big as 6 houses in Sarfalo), with the refrigerator running, and turn on my fan and lights, pull out my computer or my books, and look at my garden. My home existence is so very privileged. Even though I have few “toys”, no TV, or stereo, and only a few books, and my house is sparsely furnished, its hot running water, fridge, stove and air conditioners are still unimaginable luxury compared to how the vast majority of Burkinabé live.