Getting settled

Tuesday, February 28

We arrived on Sunday afternoon and were met by WAM's outstanding program manager, Laura. She took Amy and me to our backpacker hotel, Mufasa Lodge, and arranged for us to meet with the dynamic Dutch duo Rob and Renske. They have been helping Kabudula community and the surrounding area for a number of years by supporting some of their schools. Currently, they are helping to fund the building of school benches, so that the students don't have to sit on the ground during class. After a nice dinner at Don Briones of avocado vinaigrette (they are huge and in season!) and garlic cheese bread (not exactly the plato tipico of Malawi, I admit, but very tasty), I put my head down and slept for 15 hours. Monday was all about recuperating, changing money, and buying groceries. Tuesday morning we met at the Baylor pediatric AIDS clinic in order to head out to Kabudula. The team subjected to an hour long and mostly bumpy road trip was made up of Baylor clinicians and outreach workers, Renske and Rob, and Amy and myself. The Baylor group has been mentoring for the last 4 months at the antiretroviral clinic, and the outreach workers have been organizing home based care of HIV positive patients. Their HIV clinic (run by nurses and midlevel providers) has around 1,500 patients, and today being the pediatric clinic held on Tuesdays, the patients were spilling out of the small and crowded clinic into the yard. As a comparison, our HIV clinic in Santa Rosa has three doctors and about 400 patients, none of which are kids. About 13% of the Malawian adult population has HIV, as compared to 0.6% in the US.

Like the HIV clinic, the hospital itself was really busy. On Tuesdays, clinical officers from the capital come to run the specialty clinics of orthopedics, ophthalmology, and dermatology. Aubrey, the 25 year old Malawian clinical officer that is the head of hospital, met us and debriefed us.

Debriefing: Per the latest count, there are about 110 beds, not counting the nutritional rehabilitation unit (or NRU) for malnourished kids). A team of around 15 nurses, 6 of which are full RNs, are divided to cover the day and night shifts. There are two data clerks to track all of the data for the hospital, including how many admissions, discharges, deaths, causes of death, etc. Both are new and are getting their training on the job. They don't have a computer, so they use the hospital's one computer that lives in Aubrey's office. There is still not a pharmacy technician assigned to the hospital, so in addition to rounding on patients, taking women to the operating room for cesarean sections, fulfilling his administrative duties and seeing consultations, he is also the pharmacist for the hospital. There are about three newborn bassinets, and one non-functional newborn warmer. The lab currently has no way to check blood glucose, hemoglobin, screen for syphilis or hepatitis B, or test for pregnancy. They do have blood delivered to them from the Lilongwe blood bank, but the refrigerator alarm has been going off for a "long time", which makes me wonder if the appropriate temperature is maintained. Four medical assistants (2 years of training out of high school) see the approximately 200 outpatient visits per day.

Tour: Aubrey led us on a tour of the hospital grounds. We were excited to see a completed antenatal ward, that is still awaiting beds, so unfortunately is locked. It was built to house up to about fifty pregnant women who come from outside Kabudula town when they are close to delivery. Currently, these women still sleep outside on concrete, exposed to malaria carrying mosquitos, bats, and the like. We saw a motorcycle with a side-car set up as an ambulance that will be stationed at one of the outlying clinics. The radiology suite was in full swing, being ortho day, and Augustin, the technician, was very excited about getting an ultrasound with our shipment. My hope is that we can train the technician and clinical officers ultrasound skills, as well as send them perhaps to the referral hospital for additional training. We stepped into the malaria screening room to learn that there had been 62 cases of malaria diagnosed that day. And it was 11:00AM. They were using One Step malaria rapid tests that screen for the HRP 2 antigen to Plasmodium falciparum instead of the old school blood smears.

NRU: the nutritional rehab unit was the ward most in need of help. Or a wrecking ball (or a medium-strong wind, really). Separate from the rest of the wards, it is a water-stained, dark inferno without electrical plugs and with one working light. Therefore there are no electric kettles to boil water, and the mothers must start a fire (photo) throughout the night to boil water for formula. That
is, when there is formula available. The one thermos is broken beyond repair, there are no graduated measuring cups, nasal gastric tubes, beds, pots for cooking demonstrations, clock to help with the required three hour feeds, vitamin A, or toys. I take that back, there were two toys. Two. Two toys to stimulate the already starved brains of malnourished children. There are no sinks or soap in the NRU, and there isn't even a plasma screen TV. Shocking. There were about four patients today, one of which had the total body swelling associated with protein malnutrition, known as kwashiorkor (photo).

Staff housing: The best news of the day came when we visited the new house that WAM helped build. It is a duplex, with two rooms each, and it is almost finished! The roof is up, and there is actually running water (photo). Some internal work needs to be done, and the electricity still needs to be put in, but it's close, and people are really happy. There are nurses that are ready to be placed in it, even without working electricity. Progress. Slow, but definitely progress.

Flight to Africa

Saturday, February 26, 2012

Sitting thirty four thousand feet above the horizon makes for a nice sunset. Peeking outside my little window on the South African Airlines plane, I was surprised to notice the moon, accompanied tonight by a planet (Venus? Endor?), tucked into the corner of the view. I'm sitting next to a middle-aged Zimbabwean man with massive hands who is listening to headphones and quietly singing along in a rumbly baritone as he reads a textbook on finance. Somehow, after napping, eating a hot lunch, and napping again, we're still only about 5 hours into this 14+ hour direct flight from New York to Johannesburg. But I'm not really complaining. I've got plenty of leg room, lots to read, and mostly I'm excited to catch up on sleep. In Joburg, if all goes well, I'll meet up with Amy Gail Williams and Chris Buck, two pediatricians in the relatively small group of people on this planet that have been to the remote mountain region of Mokhotlong, in Lesotho where I spent some time in 2007/2008. We were all part of the Pediatric AIDS Corps, a program started in Houston to reach the many thousands of children living with HIV in Africa. Chris was stationed in Malawi for an amazing three years, and Amy spent a year in the Kingdom of Lesotho, working between the capital of Maseru and the mountainous moonscape of Mokhotlong. She will be joining me as we evaluate how a little NGO, World Altering Medicine (or WAM as it's affectionately called), started by two friends of mine in residency, is doing in helping the impoverished Malawian rural town of Kabudula.

Located a mere 1-2 hours by car from the capital city of Lilongwe (depending on what the rain has done to the unpaved road), Kabudula Rural Hospital has about 100 beds, serves a catchment area of 350,000 people, sees more than 200 outpatients most days, and has no doctors. Aubrey Nsunza, a midlevel practitioner (termed Clinical Officer in Malawi) and lead clinician at the hospital is, needless to say, busy. He sees the sickest patients, treating and operating on those he can and referring many others to the central hospital in the capital. For a few years now, WAM has been involved with the Ministry of Health in efforts to support Kab. Though still in its infancy, our projects up to now have been varied and are going pretty well. We have been helping to purchase medications when they run out. There have been months when there is no treatment for malaria (the biggest killer of children in the area, and a complete course of medication costs less than 2 dollars) or no medication to stop a child from seizing. We have brought oxygen concentrators to the hospital (oxygen via tanks is too expensive for most places in Malawi, so they use portable devices that concentrate oxygen out of room air. These amazing devices are typically used in the home by people with emphysema in affluent counties like the US). We helped bring limited Internet connectivity to Aubrey, and we pushed for Aubrey to get another Clinical Officer to share the huge burden of work (Ms. Fyness Sibande). Construction on a duplex house for clinicians that WAM funded is finishing (even though the hospital has half or fewer of the expected staff for its size, there is not enough housing to support more). We are working with the US Peace Corps to bring a health volunteer for the first time to Kab. Currently there is a shipment worth hundreds of thousands of dollars of used medical equipment en route to Kab, including basic necessary items such as beds, all the way up to an EKG and ultrasound machines. Through efforts by WAM star Sarah Greenberg, we've started working with the local primary and secondary schools, who have a teacher student ratio of about 1 to 100. We're helping with books and school supplies, scholarships for orphans, youth support groups, field days, and have hopes to build the school's (and community's) first library. Amazingly, this has all been feasible through private donations from friends and family (learn more at www.worldalteringmedicine.org), though we are looking for grants as well.

After three weeks in Malawi, I'll head out to South Sudan for a few months where I'll join the team that is teaching South Sudanese medical students clinical medicine. Afterwards, I hope to meet up with Anu Agrawal, long time friend and now pediatric hematologist-oncologist working in Botswana, for some serious R&R on the Okavango Delta.

It's morning now as we finish the long transatlantic flight into South Africa. The sun brings hope, warmth, and a closer look at the duct tape apparently holding the wing together.

Pierce In Haiti

Sunday February 19th

I'm sitting on the Sonoma County Airport Express as it slowly works its way up beautiful Park Presidio road along the Golden Gate park in San Francisco. The sun is shining on the park's verdant cypress and eucalyptus, ivy hugs the wall leading up to the MacArthur tunnel, and it's a cool 51 degrees. Days like this remind me that San Francisco is one of the world's great cities. I'm returning home after a week of celebration and relaxation in Puerto Rico and the British Virgin Islands, followed by a week of hard work in Port-Au-Prince, Haiti. Few times in my life have I spent more dissimilar weeks. In Puerto Rico we witnessed the joy and love of Andy and Janira joining in matrimony. Surfing, playing music, and sipping piña coladas filled the hours. And in the BVIs we set out with wind in our sails, rainbows at our stern, searching for pirate coves...and mostly trying not to crash. And then, there was a week of work in Haiti, which contrasted sharply with my sleeping-'til-late-morning island lifestyle.

Now I do realize that blogging about Haiti on a "Pierce In Africa" blog is taking a little artistic liberty. But not so much, really. I'm far from an expert on Haiti, but it felt more similar to my experiences in Africa than any other place I've worked. It was without a doubt a tough week. Leaving the small and very congested airport, a brief ride passed by tents still erected, I'm assuming, since shortly after the earthquake in January 2010. Hopital Bernard Mevs is amazingly easy to get to, about 10 minutes from the airport right along the main avenue. And that was all I saw of Port-Au-Prince, as we were basically under lockdown once we got to the hospital. Before the earthquake PAP was not the safest place to take a Sunday evening stroll, and this wasn't improved after the prison-break on the day of the quake.

Due to my recent island escapes of the week before, I arrived a day later than the rest of the team. Expecting to work in the trauma ER, I was a bit surprised when the first question posed to me by the head physician was, "Do you see kids?". Apparently there was no volunteer pediatrician scheduled this week, and the other family doc hadn't taken care of kids in a long time. I let them know that I was no pediatrician, but that I was happy to help and would do my best. My introductory rounds with local Port-Au-Prince physician, Dr. Renee Alce was a bit intimidating. The small ward had a capacity of about 13 kids (thankfully not more than that), and most of the cases weren't simple. There were premature infants trying to grow (I knew I should have paid more attention in NICU rounds), another infant septic on the strong IV medicine called dopamine to support blood pressure, an adolescent with an infected wound from a surgery that relieved the pressure of a swollen leg due to a football injury, multiple post-op infants with hydrocephalus (many cases of which can be attributed to previous meningitis), a few small children with vomiting and diarrhea, a kid with hemophilia who had bled into his knee and was receiving treatment for hemophilia and physical therapy for his now stiff and contracted knee. One adorable infant had fallen into a cooking pot of boiling water while being watched by her older sister, weeks later she finally received care, which included surgery to remove the thick, black eschars that had contracted the 3rd degree burn wounds. She was now getting twice a day painful dressing changes and was febrile, in need of another surgery to debride dead tissue. I knew I was over my head. But was there any other option? Thankfully there was a Haitian pediatrician, Dr. Bienamie, working from noon until 8pm, and Dr. Alce, the Haitian generalist interested in pediatrics, was very good and was present a lot of the time as well. I also was in phone contact with the American head internist/pediatrician who was in Miami that week. I ended up working from about 8 pm until after midday the following day, and even though I worked more than 100 hrs that week, it felt good, better than most 40 hr work weeks in the States. Sure we were working hard, but we were helping those that wouldn't otherwise have access to care. And there were no dull moments.

A few days into the week, a one month old previously term infant came in weighing about 3 pounds. The child had needed removal of part of her small intestine due to infarcted bowel in the first weeks of life, and now she wasn't able to absorb what she ate. She had severe dehydration and malnutrition, and looked shrunken, old and in agony. Her condition, know as short bowel syndrome, is difficult to treat in the US, at times needing a special concoction of nutrition through the vein, and even sometimes small bowel transplant. Here in Haiti, her chances of surviving are slim. One night she stopped breathing effectively and her heart rate fell. The team assembled and we did our best to breathe for her and use medications to help her heart pump stronger, also starting antibiotics for fear that a systemic bacterial infection might be the culprit of her new distress. From the look of things, I thought we'd be lucky if she made it long enough for the arrival of her mom the next morning. She surprised us by hanging in overnight and was still alive, though tenuously so, when our team left days later.

On Saturday, weary and in need of a good shower, I found it hard to believe that a week had already passed, and that our crew had only known each other for such a short time. Intense situations have a way of speeding the formation of relationships. I'm thankful for having met them and look forward to working with them again.

And the big question, which should be asked of every similar endeavor - did this help Haiti? This is usually a hard question for me to answer. I certainly benefited from the experience. I learned a lot about managing sick kids, and I got to do what I love. And I think some of the patients and Haitian medical students benefitted from my being there. But clearly we had a finger in the dyke, and it's up to someone else (like Haiti itself and groups like Partners In Health) to fix the chronic ailments of Haiti's health system. I'm grateful for the chance to have participated.