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