Tuesday, October 16, 2007

Southern African Adventure

Back From Abroad

Hello. I hope all are doing well. I’ve been traveling a lot over the last 2 -3 weeks, so here is some catch up blogging. The first entry speaks of some of the variety we've been seeing in the clinic, followed by a description of my first trip to my rural assignment, the mountain city of Mokhotlong. Lastly I write about our trip to Swaziland for a conference with a little vacation on either side of it, magnificent Kruger National Park and the suave and vibrant Mozambique!

Tuesday Variety Show

I saw a great variety of patients on one Tuesday at the COE. I’m so happy that I’m starting to get some continuity (patients that I've seen on more than one visit). Started off with a pregnant woman I’ve seen a few times now. She sticks out because she voices her opinion and asks a lot of questions. She’s on HAART due to having a low CD4 count and is about halfway through her pregnancy. We started addressing some of the tougher issues: scheduled cesarean section versus vaginal delivery, for one. That one I can say pretty strongly that a routine vaginal delivery is the preferred route, as her HAART will give her child around a 98% likelihood of delivering an HIV negative infant. Formula feeding versus breast feeding is a much harder issue. Yes, she can probably afford the formula, but that still puts the child at a risk for higher mortality due to other infections, particularly diarrhea and upper respiratory tract infections. No easy decisions there.

Next saw another woman I’d seen before, this time no longer pregnant but a beaming new mom with her one week old baby. She delivered after being on the PMTCT regimen of Lesotho, which is based on the WHO guidelines for resource poor settings. She took AZT from 28 weeks, took her Combivir and sdNVP properly during labor, dosed the newborn with a squirt of NVP followed by AZT syrup BD. So tough to then see that she’s breastfeeding this child, increasing the chance that it becomes infected with HIV, but decreasing the chance that it’s going to die from other causes in the neonatal period.

Later I saw a middle aged woman with possible Ramsay-Hunt syndrome (herpes zoster oticus). She had a few days of fever, L sided ear pain, L sided hearing loss, decreased sensation on the L side of her face, and L sided tongue tingling and taste changes. She had no facial droop or lesions in or around her ear. Seems like either HSV or VZV can cause this. I started her on acyclovir and hope that it helps.

Another mom, this one had weaned the baby off of breast milk, and was now giving only soft porridge for the last 2 weeks. Couldn’t afford formula, couldn’t afford trips to the clinic, couldn’t afford insecticide to kill the fleas that were biting the child (though maybe those were from scabies, since I’ve been itching all night).

Lastly I saw the first presentation of both a mom and child that were both so sick they both got admitted to the hospital together straight from the clinic. The woman had a long hx of cough, fever, and TB exposure (but who doesn’t in Lesotho?) was febrile, was breathing almost 40 a minute, O2 sat around 95%, with L sided decreased breath sounds, dullness to percussion and egophony – most likely pulmonary TB with pleural effusion. The child was admitted for severe malnutrition, dehydration, and sepsis.

First trip to Mokhotlong

Tony Garcia-Prats and I made the 5 hour road trip to Mokhotlong, high up in the mountains of eastern Lesotho. We drove through some pretty amazing scenery. Once outside of Maseru, we were greeted by vast expanses of tan, brown and golden fields highlighted by solitary deciduous trees and small thickets of evergreens along the side of occasional rock outcroppings. The peach trees are still providing their pleasant contrast of spring pink flowers in this rather mute background. The real beauty began once we entered the mountains. Overcast skies with pregnant clouds lay low over the peaks of some very impressive mountains. The road was winding but well paved, and the drive was peaceful and quiet, interspersed with yells from smiling kids running along the road when they saw the pale faces. The steep slopes were dotted with small sheep herds and their herders – young men wrapped in traditional blankets and carrying walking sticks. As we drove higher, the air became cleaner and crisp. When we reached the summit, the sky opened up – releasing pea sized hail in droves. We pulled off to the side of the road to enjoy the storm. As the bolts of lightning became more impressive, we decided that being at the highest point of the mountain was not a great idea and began our descent. We passed the one and only Lesotho ski resort (a single slope with a rope pull that was currently devoid of snow), and besides a lot of rain, we had an uneventful remainder of the trip.

The Mokhotlong District Hospital

Maseru is divided into 10 districts, each with its own district hospital and associated health centers. We found the hospital and grounds to be in very good condition. I was pleasantly surprised to see that the hospital was in a much better state than the run-down central government referral hospital in the capital (the Queen Elizabeth 2 Hospital that I’d mentioned prior). The hospital grounds incorporate adult women’s and men’s wards, a TB ward, maternity ward, maternal child health clinic, the Lerato HIV clinic, a pharmacy, and an outpatient department. Though there have been times that the district has been without skilled doctors, currently the area is fortunate to have 5. There are two Zimbabwean doctors, Dr. Nyamutukwa and Dr. Munzararikwa, two Cuban docs assigned for a 2 year contract, Alberto and Francisco, and Dr. Karumba, a physician from the Democratic Republic of Congo. The African physicians cover the hospital and the Lerato HIV clinic, take a week of call at a time, and do necessary procedures. The Cuban doctors see only the outpatients and do not take call, in part due to their lack of Sesotho language skills and limited English. Some procedures that were being provided the days I were there included chest tube placement for empyema, cyst excision, cesarean sections, orchiectomy for testicular torsion, and closed reduction of fractures. The c-sections are most often done under conscious sedation with ketamine administered by a nurse (scary, if you’ve ever seen someone start to come out of ketamine sedation during a painful procedure). At least one of the providers can do spinal anesthesia, but they avoid it since there are no working laryngoscopes or endotracheal tubes for intubation in case of a complication such as a “high spinal”. The lab is rather well set up. It can run CBCs, LFTs, urea, creatinine, CD 4 (a new and potentially very important machine to check the strength of a patient’s immune system, but no reagents yet and can only do about 15 tests a day). The microbiology capability includes gram stain and culture of infected secretions, urinalysis and microscopic evaluation, smear for acid fast bacilli, CSF gram stain and India ink evaluation. There are no blood or CSF cultures, no electrolyte machine, and no other “fancy tests”. Diagnosis of HIV in children less than 18 months of age needs a special machine that doesn’t exist in the area (nor in the entire country). We send dried spots of blood on a special paper card by DHL mail to South Africa, receiving the results in 4 -6 weeks.

Lerato Clinic

The one clinic on the hospital grounds that sees HIV positive patients is also the smallest clinic on the campus. It has no electricity, no water, 3 rooms (waiting room/vitals, nurses’ room/counseling room, doctors’ exam room/blood draw room). Besides the small waiting room, there is no place to get out of the rain (they built a covered waiting area but it caught fire the day after it was finished). I saw a woman at the end of the day who had missed her period, had new onset lower abdominal pain and a new vaginal discharge – but no pelvic exam (I was seeing her in the nurses’ room which had no bed or table, and it was twilight and we had no electricity), no urine pregnancy test available at that time of the day (to help evaluate for possible ectopic pregnancy). Luckily she lives so far away from the clinic that she had to find shelter in town. At least she should be able to make her way to the hospital if it is an ectopic that gets suddenly worse tonight. The last patient of the day was a woman that “had no problems, just here for medicine refill” according to the nurse. A quick glance by the almost non-existent light of dusk showed that her CD4 count had been steadily decreasing while on anti-retrovirals. This suggests that she “has a problem” and shouldn’t just be getting a medicine refill. Luckily she also wasn’t able to get back to her mountain village and will be seen tomorrow in the daylight.

“Rural” Health Clinic

While Mokhotlong is far removed from the capital of Maseru, it is still a sizeable city. We jumped in the UNICEF Land Cruiser and visited the health center in the small town of Libibing (pronounced: Dibibing). Here, there is a small health clinic staffed by a nurse, a nursing assistant, and a social worker – much more support than most clinics of its size. Besides a room to see patients, they have a basic pharmacy, including recently accrued antiretroviral meds, a few beds, a delivery room, and two waiting areas that can also be used for patient education. Just when I thought this was the end of the line, it seems like patients still have to walk long distances to be seen here – even up to 3 to 4 hours. I asked a woman how long it took her to walk to the clinic and she answered poignantly – it depends if I am health or sick. We went on two days, saw patients with the social worker and the nurse assistant (the nurse was out of town at a training) and encouraged the patients and their families to be tested for HIV. There are another 6 rural towns in the Mokhotlong district with health clinics, and unfortunately we didn’t visit any of them on this trip. The next sojourn up to Mokhotlong will be in mid November, and we plan on addressing many issues, including: PMTCT (what is being done in the rural clinics as well as the district hospital), visit the remainder of the rural clinics, plot out where and how we will be building the new BIPAI funded family HIV clinic on the district hospital campus, attempt more testing to diagnose HIV positive children and their family members in the rural periphery, and continue to train the local doctors, nurses, nurse assistants, social workers, and community health workers/expert patients. I liked the feel of the area, and I think we’ll be spending more time up there – maybe a few weeks at a time.

Happy Hour In Maseru: Jowling Update

Still lots of work to do with the Lesotho Jowling team.

Kruger National Park

We took off Thursday morning, October 4th, to Kruger National Park in north east South Africa. The group was made up of myself and Anu, along with the 3 current Lesotho visiting scholars - Megha Patel and Amit Singh, two visiting med students from Baylor, and Djin-ye Oh, a visiting resident from Germany. Thursday was Independence Day in Lesotho, so the line was long, even at 8 AM, at the border crossing. In line we met a small group of Peace Corps volunteers, getting away for a little much needed R and R themselves. The drive from Maseru, Lesotho, to Hazyview, the little town outside the southern portion of Kruger Park was a little long but filled with some beautiful vistas. The early portion was the same road we took to Clarens a few weeks earlier – magnificent buttes jutting out of a rolling, light green and tan landscape. There was a stretch south east of Joburg that reminded Anu and I of West Texas – pretty brown, pretty flat, and not too exciting to drive through. But just within an hour of that we got into a valley that started out like Sonoma County – complete with “golden” hills, then with eucalyptus and then evergreen trees. The main differences from northern California were the street signs - like “hippopotamus crossing” and “Crockadile River”, etc.
We stopped for a great dinner at “The Fez at Bagdad”, a great fusion restaurant in a fancy little area of White River, the town outside of Hazyview. After 7 hours of driving, we feasted on bruchetta with soft goat cheese, great 12 dollar bottles of wine, a warm pumpkin/feta/lime-infused red onion and pine nut salad and chocolate polenta cake.
We rolled into “Hazyhaven”, a pleasant little bed and breakfast in Hazyview, run by Dawie and Shirley Malan. We definitely feel like we lucked out – all of the places we were calling the night before our trip were either closed, full, or too pricey. Hazyhaven turned out to be clean and cozy, with a pool, and breakfast provided, all for about $35 a night.

Big Animals

We spent both Friday and Saturday driving around Kruger Park. Instead of being in a big safari 4x4 driven by a local with a blunderbuss, Kruger allows you to drive yourself in and do a self-guided tour. It’s hard to describe the feeling of seeing animals outside your car window that you’ve only seen in zoos or on the television. Day 1 brought my first sights of big African animals. These animals really are big. The experience was amazing. Within the first few minutes of entering the park we came across a group of baboons. We pulled to a stop and watched them play in the trees and amble across the street. Just a few minutes down the road came the first views of the deer-like impala (but with horns instead of antlers), followed by the impressive kudus (almost the size of elk, with spiraling horns). Our first sighting of an adult giraffe blew me away. He walked across the road right in front of our car, ate some leaves off of a tree, and then continued on his way. We were lucky enough to also get really close views of an adult male elephant and a pair of white rhino (all of which at one point seemed on the verge of getting too close to our little Volvo). We also captured our first views of zebra, vervet monkeys, hornbills, storks, crocodile, and hippos. The second day, we were joined in the park by our new friend Ursula Jessee, a hip chick living in Joberg who is currently doing research on evicted people there. Under a grey-blue overcast sky and occasional showers, we had a sighting of a beautiful leopard, hippos out of the water, and a family of hyenas (the mom, big and more than a bit scary, approached Ursula’s very little rental car as she smelled the kudu jerky that had been ripening in the car for the last day). After an amazing day of seeing these peaceful animals enjoying existence with their families in their natural habitat, what a better way to wrap up the day than order up some mama kudu for dinner, medium rare. Well, that’s what the carnivores in the group did – I found the shiraz much more appealing.

Jerry Goes to Kruger

As we were on our way to a Baylor International Pediatric AIDS Initiative meeting in Swaziland, we were transporting a mannequin – a roughly 12 year old boy CPR mannequin that we named Jerry, to be exact. After a few hours of fruitless searching for the elusive cheetahs and lions of Kruger, Jerry came out of the trunk for his first views of big African game. He was a little unnerved at first, but much less so than the people in other cars who got a glimpse of our shannanagans (I just realized that I have no idea how to spell shinnanegans). I’d say he had a really good time (see attached photos). The highlight was when we passed him through the window between our cars (it’s illegal to get out of your car at Kruger, for obvious reasons). We think it was also the highlight for the woman in the car behind us.

Baylor International Pediatric AIDS Initiative Network Meeting

Anu, Ursula and I said good-bye to the visiting scholars as they headed back to Maseru, and we headed over to Swaziland. Like Lesotho, Swazi is one of the few remaining kingdoms in Africa, and similarly is in a state of crisis due to the HIV epidemic. With a population of nearly 1 million people, it has the world’s highest percentage of people living with HIV – around 40% in pregnant women and even higher in some age groups (I believe 1 out of 2 people aged 24-29 are HIV positive). As more people get sick with HIV, health care needs increase, but health care capacity is simultaneously falling – there are fewer doctors and nurses alive to take care of all the sick people. The life expectancy just five years ago was 60 years (the US is around 67 yrs). Currently the life expectancy is only 31 yrs of age. Around 70% of the population lives below the poverty line – this is living on less than a dollar a day. There are about 76,000 orphans (about 1 out of every 4 children). This would be like the US having 18 million orphans. Swazi is also known for its laid back pace, natural beauty, and the tradition of polygamy. To make the dire health care situation in Swazi even worse, many of the government officials, including health care leaders, are appointed by the king, seemingly irregardless of their skills and lack of training. Anu and I came to Swazi since we were traveling to attend the Children’s Clinical Centers of Excellence network meeting in the capital and second largest city of Swaziland, Mbabane. We checked into our rooms at the Ezulwini Sun Hotel, a somewhat less ostentatious hotel in the swanky international Sun Hotel chain. The conference was attended by doctors from the 9 countries within the BIPAI system (Swaziland, Lesotho, Botswana, Malawi, Burkina Faso, Uganda, Tanzania, Libya and Romania). Much was shared between groups and hopefully the care of HIV positive children and their families will be improved because of the effort.

Mozambique: Nao e tudo bem!

Ahh, Mozambique. What can I say? Moz was more than I had expected. It is one of I think only two Portuguese speaking countries in Africa, the other being Angola. Immediately upon crossing from Swaziland into Moz, you could feel a difference. The energy of the country – its people, culture, and food to name a few points, was a level above. Moz, as some of the gringos call it, is definitely the most Latin American feeling place I’ve been to in Africa. The Holiday Inn, where the people with foresight stayed, was a beautiful beach front hotel unlike any Holiday Inn I’ve ever stayed, complete with a pool overlooking the Indian Ocean. I definitely recommend it as a great place to chill with a local brew, perhaps a Laurentina Clara or a 2M beer. A fellow PAC doctor working in Lilongwe, Malawi, Chris Buck joined Anu, Ursula, Anouk and me at the Hoyo Hoyo hotel, which was Spartan, to say the least – closer to solitary confinement to be more descriptive. We had a lot of fun speaking Portuguese mixed with Spanish and English, enough to maneuver around the city and get moderately ripped off by the merchants. The dining experience was great for the carnivores but left a lot to be desired for those of us who don’t like hurting the little fishies. Regardless, the fish market was an impressive place, with row after row of fish, large and small, shrimp, octopus, lobster, crab, prawns and mussels. You could walk through the market, pick your kill, and they’d take it back to the kitchen, douse it with butter, lemon, salt and other spices, and bring it back to you on a platter, fresher than anything you’ve seen at Red Lobster. A number of the group almost registered as permanent Mozambican citizens just so they could eat there a few times a week. We went to a night club looking for glimpses of the famous dancing skills of the mozambicanos, but were disappointed as three separate djs on separate dance floors played their own mixes of bad and worse electronica and hip hop. For their credit, the locals could dance well, just not to the music I was hoping to see them dance to.

On Saturday, while bargaining with over-zealous artists in the local craft market, I got a text saying that part of our group was relieved of their cameras by some of the local miscreants (who were possibly rugby enthusiasts). Luckily our folk were relatively unscathed, though it seems that when you finally find the police station to report the incident, the officials aren’t particularly likely to rise to the occasion (a huge surprise to the readers out there who have traveled in developing countries, I’m sure).

My respect for the law was not strengthened when we were stopped later that night for making a “mildly” illegal U-turn. The three cops were on foot and only had one AK 47, for the record, so we could have likely gotten away, but instead we decided to talk a little while with the nice gentlemen. To his credit, Buck did a decent job with the bargaining game. He was able to negotiate the cop down from a 150,000 US dollar fine, a trip to the station, plus having his passport revoked – all the way down to a whopping 12 US dollar fine. I wish I had negotiated that well at the crafts market.

On the way back, we enjoyed a glimpse of a zebra at the outskirt of a park, wishing us good bye from northeastern South Africa. It was a good 10 days away from Lesotho. To travel is nice, but it will also be good to start seeing patients again. There is so much to be done, and I often feel the pull to get back to it while away from the clinic. I also feel very fortunate to have the ability to travel. Such a small percentage of the people living on this continent can do so. So much beauty abounds here, from sunsets on a Mozambican beach, to baby giraffes grazing with their mothers, to mountain scapes stretching across the land of the Basotho. In 10 days I’ve been able to see all of these things, with relatively little hassle, and for little money out of my pocket. The disparity is brought home more emphatically as we drove past the shanty towns outside of Joberg. It’s not fair. Not at all.

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