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!
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