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.

And Finally...

The Last Blog Entry

I’ve been working on this final blog entry for two and a half months. I started writing this entry from Swanage, England, as I made my way back from Lesotho to the US. I worked a little bit on it while staying with my family in Denton, Texas, and opened it up again while at a Mediterranean style restaurant in San Antonio. Now I’m in Santa Rosa, California, determined to finish what I started. My experience in Lesotho already seems so far removed from my current life. Possibly this is due to the travels I’ve had since returning - having made a road trip across the Southwestern US and working along the Honduras/El Salvador border. But maybe I’ve had trouble finishing this blog for more subtle, difficult to describe reasons. Part of me feels like this last blog entry should be a well thought out, all encompassing synopsis of my experience of living in the Kingdom of the Sky for the last year – wrapping up the advancements made, the joys shared, the loss and pain held inside, mostly out of reach. But I understand there are so many nuances of my experience there I’ll only begin to understand over the next several years of my life, if ever, I suppose. So, instead of waiting for it all to come into focus for myself, I plan only to recount my story, briefly and in simple sentences – and let the rest come as it may. Thanks for sticking with the blog for this long. Knowing that you cared enough to read made writing it so much more fun.

Cheers!
Jeff

I’ve now finished my year long stint in Lesotho. It’s seems so long ago that I began my time in Africa. Thirteen months have passed. I’ve learned much in this year, and I thank those of you who supported me during the hard times and that laughed with me during the fun times. What follows is a brief summary of the events of the last few months.

Anu’s and Kara’s departures
I missed Anu’s leaving, since I was still in the States on vacation. It was weird coming back to Lesotho without him being there. We learned a lot about ourselves and each other, and I am eternally thankful to him for his patience with me as a friend and roommate, as well as thankful for the time shared and love received from his family while traveling through India. When I got back from the States, not only was Anu gone, but Kara had moved out of the house! She was either tired of the bedbugs, or tired of me, but she did mention something about not wanting to leave Seema alone in her house, or something to that effect. In reality, Kara was in the country for a few more weeks. We had a fun time winding down, and it was great getting to meet her parents – who are as crazy and fun as she is. Lesotho will certainly miss the efforts put forth by Kara and Anu.

Leaving Mokhotlong
My last trip to the mountains went well. I kept to the same day to day routine that Tony and I had made for ourselves over the last several months. Some mornings were spent rounding with the local doctor on the children’s ward, but most of the time was dedicated to heading out to the rural health clinics to help the overworked nurses see the HIV positive patients while teaching them some new things along the way. It was nice to look back and see how much has been done over the year. More children and adults have been tested, put on treatment, and kept healthy. This has added up to us seeing many patients when we come, but we welcome the work since it means more people will be living longer, more productive lives. The nurses are in many ways more comfortable with caring for people with HIV, and Tony and I can see that as they become more independent, our presence in some ways will become less necessary. Even though I was ready

for a rest after long hours in the highlands, it was sad saying goodbye to a good group of people. The nurses and doctors welcomed me warmly a year ago, and I have grown to care for them and the future of Mokhotlong greatly. One of the biggest losses I felt leaving Mokhotlong was departing from the working relationship with Tony Garcia-Prats. More than anyone else, he was my mentor during my time in Africa. I wish him and Heather many continued blessings in their work in Africa.

Wrapping up at the COE
I spent the last month in Lesotho in Maseru, working at the COE, packing up, tying up loose ends (well, most of them), and reflecting on my year here. I was lucky enough to get to train a bit with Megan as she prepared herself for the Soweto marathon that she’ll be running in November. While I was still wearing my ski gear at night, the days were warming up considerably, making the weekend long runs wonderful – clear skies, temperature in the 70s, with a cool breeze helping us through the last stretches.

Good-bye events
As is tradition with the departing PAC docs, I said a short speech on my last day at the COE. It was nice to have a chance to thank all those that helped and shared during this year, as well as get to share my feelings on an amazing, difficult, and inspiring year in Lesotho. The next day we had a final party at the house at Happy Villa 4C – bean burritos, caipirinhas, cerveza Sol, good music and good friends. It was in a way the end of an era, now with Anu, Kara, and myself all gone from the house that took care of us for the year. Isaac, our guard and friend was there to say good-bye and also welcome in Tony and Heather, who will be living in 4C now.

Visiting London
I made the drive from Maseru to Johannesburg perhaps for the last time, seeing the rolling hills, wide open fields and sparse trees with a different pair of eyes. The overnight flight from Joburg to London was uneventful. I took a bus south west towards Southampton to spend a few days with Susie and Pete (of Kick For Life), and Susie’s family in the English countryside. We had a great time, from watching the Morrismen dance in the sea, tasting hand pulled British cask ales, climbing trees, exploring a castle, trying “chips” and “mushy peas”, and staying at the delightful B&B that Susie’s family runs. I spent the last day and night in London, going for a great run along the Thames – seeing London Bridge, the Parliament Building and Big Ben, and at night watching England route Croatia, Scotland beat Iceland, and N.Ireland tie with Czech Republic - all at the same sports pub on the same night.

Texas
After 2 weeks relaxing with the family in Denton, seeing Dave play good Cuban music and eating great home cooked food, I’ve started my next small adventure. I’m sitting in a café in San Antonio, and have been hanging out with my old friends from college and med school. They’re all grown up. Chuy has joined a private family medicine practice and is talking about getting engaged, Xav is working toward finishing his radiology residency and just got engaged, and Tony is a successful ER doc and living the good life with his lovely family. Tomorrow I head West, planning stops in Las Cruces, Phoenix, LA, San Jose, Santa Rosa, Honduras and El Salvador, and a few other places before I return to Denton for Thanksgiving, Lord willing. It’s been a good year. And if these few weeks back are any indication, I think another good one is just starting.

April, May, and June

It’s been a long time since posting to the blog, but I’m still here. I've been in Lesotho for about 9 1/2 months, and I have 2 1/2 more months to go before returning to the States. As I haven't written for a while, most of the events I'm writing about in this blog entry are now foggy in my memory (I'm getting old; see below for details). So I’ll just do a short recap (which will also appease the “I haven’t read your blog since your entries are so long” group). You’ll notice few pictures this time around as my camera wasn’t working, but it’s doing better now.

Jeff’s 30th Birthday Party (Saturday April 26th)

I entered a new decade on April 28th. To continue the very short trend of themed birthday parties (last year was the “uniparty” – no details to be disclosed on this website), we chose a Shoprite theme. Guests could wear anything they wanted as long as it was purchased at the local supermarket (picture Safeway or H.E.B, not Super Walmart). There were some very innovative and even attractive outfits – from gift wrapping paper, suitcases, shower curtains, to blankets, plastic bags, toilet paper and cling wrap – to name a few. I’m not sure if I should post any pictures from this night, but I wanted to give a shot-out to my man Jerry, seen here with the bag warrior princess, Kara DuBray.

10th trip to Mokhotlong (April 28th through May 2nd)

As Monday was my birthday, Baylor and the Kingdom of Lesotho decided to celebrate by holding a ground-breaking ceremony for the new satellite clinics to be built around the country. It was a grand affair, with the Right Honorable Prime Minister Mosisili as well as Mark Kline and a lot of the BIPAI team from Houston attending the ceremony. I drove up to Mokhotlong in time to do no work, but I was at least able to share a few cold ones with the local docs – a few from Zimbabwe and a few from Cuba, as well as my good friends Dan the Dual Citizen and Dutch Elise of UNICEF. Overall, it was more of the same business in the mountains. I was a little worried that it would be bitterly cold as we were in Fall and getting close to Winter, but the weather was great the whole week. There had been a large snow storm the week before – the day after it hit the taxis were taking 7 hours to travel what normally takes 2 hours.

Maseru (May 3rd through May 25th)

I worked at the clinic most days, seeing patients, training nurses, and grinding my teeth over patients that weren’t taking their HIV meds correctly. It is so hard to take any medicine in the best of circumstances. But when you don’t have money to get to the clinic, your husband throws away your and your child’s meds because he doesn’t believe in them, or a flooded river has kept you from getting your refills it gets a lot harder. The amount of viral resistance brewing out there due to inadequate adherence is daunting.

11th Trip to Mokhotlong (May 26th through May 30th)

I went up with visiting 3rd year UCSF peds resident and budding pedi ER fellow Kajal Khanna. About an hour into the trip we saw that the distant peaks we were to drive through were oddly white. We got to the first mountain pass and met first ice then snow blanketing the road and surrounding mountains. The drive was slow going, but we didn’t have to turn back – even though a few minutes of minimal visibility and 6 inches of snow on the road made me think about it a few times. The trip was good overall, working in the rural clinics as usual, but this time with a resident who could

carry things for me (just kidding, Kajal; mostly). Thursday in the dark we managed to find the Sani Top Chalet, a nice B & B further east of Mokhotlong town and overlooking the border town at Kwazulu Natal, South Africa. Most importantly, it has the highest pub in Africa – allowing me to obtain the much coveted award for both climbing to the highest point in Africa (Kilimanjaro) and drinking a beer at the highest pub in Africa. Autograph signing to be held at a later date. Friday night we made it back to Maseru to join Anu for our last happy hour together at the Lesotho Sun. I took off the next day on vacation, and he would be gone before I returned. Anu, dude, we miss you here already. Safe travels and rock on with your bad self in your pedi heme-onc fellowship. I'll see you in the Bay Area. [The picture featured above was taken by Anu in Thaba Tseka, which gives you an idea of what Mokhotlong looked like].

Vacation to The Good Old United States of America (May 31st through June 15th)

Along with my brother and sister-in-law, I surprised my mom by showing up to the house unannounced. Thankfully they hadn’t changed the locks (or adopted another child). With 4 nights in Corpus and about 8 in Santa Rosa, I enjoyed all the things I had been missing. We shared good microbrews (Belgian ales in particular), ate good pizza, watched movies, enjoyed great hot weather, ran and biked by the beach (a particularly nice run in Corpus after dawn with the dolphins surfacing in the Bay), ran and biked in some of my favorite California state parks, visited some wineries [saw Wilson winery out in Dry Creek (Sonoma County) for the first time where my friend Dawn is working - what nice zins they have], listened to outdoor music, and slept in my old room. By far the best times were spent just hanging out with my family and friends, especially the group from residency. Traveling in India, Dubai, South Africa, Swaziland, Mozambique, and Tanzania was great, but it was good to be reminded about the true blessings of home, family and friends. To my graduating friends from Santa Rosa, congratulations on finishing 3 years of grueling work (well, not counting Thursdays - except Team Meetings). I love you very much and will see you soon.

Flying Around with Mission Avian Fellowship and Bristol-Myers Squibb

I had the pleasure of hanging out with Tim Vennell from MAF. Tim, his wife and his kids (one boy and 4 girls at last count) have been in Lesotho for about 5 years. He and his fellow pilots fly docs, patients, and supplies around Lesotho in Cessna planes, providing an invaluable service to the Basotho. We traveled with Elliott Sigal, MD, PhD (Executive Vice President, Chief Scientific Officer, President of Research and Development at BMS), John Damonti (president of the BMS Foundation) and Charlotte (a BMS photographer) on a quick tour of the Mokhotlong hospital and one of the rural health centers (Tlanyaku). I was floored when we made the trip that takes me over 4 hours by car in 45 minutes. The health center we visited is 2 to3 hours from the hospital by car, but it took us a mere 8 minutes by plane. Besides being just a little deaf and nauseated (4 flights in 3 hours), I had a good time.

Thats it for now. I'll try to update the blog every 2 to 4 weeks until leaving in September. Hope you are all well,

Jeff

Cape Town and 9th Trip to Mokhotlong

Cape Town and Stellenbosch

We flew out to Cape Town for a long Easter weekend. The trip was great. We stayed in South African wine country, enjoying good wine, cheese, chocolate, and breath taking panoramas. It was so similar to being back in Sonoma County. Similarly Cape Town proper was very reminiscent of San Francisco in so many ways. Located on the ocean, surrounded by fog laden hills, with a vibrant gay population and happening night life, this trip made me feel like I was back in the Bay Area.

Interim Week in Maseru

That was a routine week at the COE. We’re still seeing lots of patients a day, trying hard to finish before dusk some days. Not too much to report.

Back to Mokhotlong

Another week of outreach in the mountains of Mokhotlong. I drove 900 km, much over unpaved roads, and visited 5 rural health centers this week. Mornings are still consisting of rounding with the docs in the children’s ward. The patients on the ward mostly are fighting pulmonary infections and malnutrition. Additionally, an adolescent with meningitis not responding to antibiotic treatment was being transferred to Queen Elizabeth 2 hospital, and another young boy was in traction for a displaced femoral shaft fracture. Most days I returned with a patient for admission: a man with wasting and likely TB, a woman with likely TB whose child recently passed from TB meningitis, and another man with wasting and intractable hiccups for the last 3 months. I had to read about this condition, which has over 100 causes, from central nervous system syphilis to toxic-metabolic causes to phrenic nerve irritation. The drive back was gorgeous. Fall is here, and the hills are starting to dry up a little bit, bringing red grass to contrast the green shrubs on the hillside. More beautiful yet are the pink, violet and white wild flowers that dominate much of the midlands and some of the highlands. The weekend was spent in celebration of Susie’s (Kick For Life) and Kameko’s (Clinton Foundation) birthdays. Anu is getting ready to celebrate his birthday alone in Thaba Tseka on outreach this week L as am I in 3 weeks when I go back to Mokhotlong for my 10th trip. More stories to come!

Take care,

Jeff

March Madness

A Few Interesting Points From The CIA World Fact Book

https://www.cia.gov/library/publications/the-world-factbook/geos/lt.html

Average life expectancy at birth
US: 78 years
Lesotho: 39.9 years

Lifetime risk of maternal death
Sierra Leone: 1/6
NW Europe: 1/30,000

Countries with the highest HIV prevalence (% of the population living with HIV)
Swaziland 38.8% (1st)
Botswana 37.3% (2nd)
Lesotho 29.8% (3rd)
USA 0.6% (71st)

Equatorial Guinea
Only African country with Spanish as one of its official languages
12th highest GDP per capita in the world (Luxemburg is 1st, US is 9th)
But most of the people live on less than a dollar a day, since all of the money (oil) is in the hands of the politicians

A Hard Week At The Baylor Center of Excellence (COE)

The COE is getting busy. We are seeing over a hundred patients every day, with several newly diagnosed kids and adults per day. The new kids are always our sickest ones, as I’ve mentioned in prior blog entries. Several of them have been losing weight, and suffering from fevers, cough, diarrhea and malnutrition for months before they are brought in – frequently by their grandmothers, as the mother has recently passed away. They often come in with skin stretched on bone, with so little muscle and fat. They are basically on Death’s door. We work hard, giving them strong antibiotics and oral rehydration solutions specially formulated for severely malnourished children. We battle over starting and restarting IVs for the administration of the medicines and for emergency fluid replacement when they go into shock. Anu admitted 4 of these very sick children on Monday, and I admitted 3 children on Tuesday, most of which sadly have passed away. Later in the week a woman came in and spontaneously went into labor in the blood drawing room, delivering a stillborn fetus that had probably stopped living a week before. The next day I found myself on a panel that is in charge of writing Lesotho’s national prevention of mother to child transmission of HIV guidelines. It is an unfair world where a recent residency graduate plays a big part in making these kinds of decisions for an entire country. During the week we saw some kids that were incompletely or inappropriately managed at outside hospitals dumped off at our clinic, hoping for better care and more resources. I saw my first case of ophthalmia neonatorum, an experience I won’t forget. Seema was seeing this newborn in the exam room next to mine. The child was born at home and started having eye discharge during the first week of life. After about a week of eye goop, the mother finally brings the baby to our clinic. She has a rag that she’s been using about once a minute to wipe pus off of the closed eyes. I went to better examine the eyes, and while trying to open the lids a thimble full of pus came out from under the lids. The lids were so swollen I couldn’t open them. I was amazed, others were shocked, the mom wasn’t impressed. No one fainted. Those of us that see kids in the office have met a hundred new moms who come saying that their baby has “eye discharge”. The med student or resident in training needs to know how to differentiate harmless eye discharge from true ophthalmia neonatorum. There is no confusing what I saw that day for harmless eye discharge. If all of the new moms of the world could see what I saw, none of them would ask if the scant eye boogers that they have to wipe off in the morning once in awhile were dangerous eye discharge. Seema treated the child with ceftriaxone and erythromycin, treated the Mom, and asked for the dad to come in. That’s because the pus coming out of the baby’s eyes was likely caused by infection from gonorrhea (and probably also chlamydia) – transmitted to the child while traveling down the birth canal. Yes. Gonorrhea of the eyes. I’ve never seen this in the States, due mostly to the fact that most newborns get preventative eye medicine at birth (and partly due to a lower rate of gonorrhea in the US). While reading up on eye medicine for the newborn, I found a study in Kenya showing that iodine eye drops not only are cheaper than the meds we use in most of the world, they worked better and were less irritating. This study was done 13 years ago! My best guess why we haven’t changed to iodine drops is that Big Pharma (the pharmaceutical industry) can’t market cheap iodine and prefers us to use their expensive meds. Gotta love Big Pharma.

A Louse In The House?

Kara (fellow PAC doc and one of my two roommates) found a very small bug on her back when she was changing her shirt. She squashed it, and realized that it was full of her blood. We all took a close look, and voted that she most likely had body lice picked up from a patient at clinic. We also by a non-unanimous decision voted her off the island. I kept the squashed bug in a piece of clear tape and looked at it under the microscope at work the next day. Upon closer look under the scope, we saw a creature of uncertain identity but one that did not resemble a body (or other) louse. That night I woke up because I felt something crawling on my foot. I’m a vegetarian and don’t like to kill things, but I occasionally make exceptions for evil creatures I find in my bed. I caught the thing and squashed it. In the morning I opened UpToDate (a medical resource on the computer) and on a hunch opened the article on bed bugs. Yep. I was right. The thing I found crawling on my foot was a dead ringer for the bed bug featured in the article. What in the world? I’m not a particularly dirty guy. The sheets get washed, I bathe fairly frequently, I don’t wear clothes I find in alleys. We have a really clean, modern house. There are no thatched roofs or mud floors here. Going into crime scene investigator mode, I found another 2 that night, losing one on the floor in the living room (much to my roommates’ dismay). I quickly learned a lot about bed bugs. Bed bugs are a little gross. They suck your blood. They can live for a year. They are found in dirty homes but also well-kept abodes. They have a sweetish smell when squashed (like a South Texas stink bug). They come out of cracks and crevices at night, attracted by your body heat and carbon dioxide, and they feed on you while you sleep. They are associated with areas where birds and bats roost, and they can live for a loooong time without a blood meal. I bombed my room with FumaTab, something I bought at the store that has more health warnings on the label than a nuclear bomb and behaves like a ninja smoke bomb when lit. I quarantined myself to the couch (again to Anu’s and Kara’s dismay). I slept there for 7 days as the smell of the Fumatab’s carcinogens slowly cleared. One day I came back from a run, and Anu said to me, quite seriously, “You’re going to have to stop sleeping on the couch. Because Kara is going to start sleeping on the couch”. She showed me her bed, which was totally infested. Of course that meant that it wasn’t a louse on her the week before - it was a baby bed bug, a nymph, if you will. So now, about 3 FumaTabs and a can of Doom insect spray later, we seem to be bed bug free. We’re both back in our own beds, and Anu’s room, somehow, still seems to be bed bug naive. Apparently they prefer Mexican food and California cuisine to Indian food. Hopefully they aren’t in our couch. Hopefully they aren’t looking over my shoulder while I write this about them. They might get upset. Unfortunately, the chance is moderately high that they’ll surface again. Then we’ll call the exterminator. If that doesn’t work, we’ll get new beds. If that doesn’t work, I might come back to the US. Or better yet, Antarctica. They don’t do particularly well on icebergs. See attached NYT article.

http://www.nytimes.com/2006/10/15/realestate/15cov.html?pagewanted=1&_r=2

8th Trip to Mokhotlong

It was good trip. I came in on Sunday night, having made the beautiful 4 hour drive without incident and arrived at the Touching Tiny Lives orphanage in Mokhotlong proper where I’ve been staying. This has been a cool place to stay. I get to hang out with Dan and Mo, two North Americans who have been working here for several months. They are fun to hang out with, and coincidentally happen to be good cooks. The orphanage is well funded from the US, so they have hot running water, electricity and dial-up internet.

I spent the week in the typical fashion: rounding with the local docs on some of the inpatients, driving to rural health clinics in the mountains, mentoring nurses on the care of HIV positive and negative patients. The weather has been great; it’s starting to rain less but isn’t terribly cold at night. It’ll start snowing here in May or June.

I saw a variety of patients during the week: HIV positive adults with lung cavitations caused by tuberculosis, sick and healthy HIV positive kids and pregnant women, a term pregnant woman with 5 days of a big swollen tender leg, likely caused by a blood clot that could break off and float to her lungs - possibly killing her (there’s no access to PTT monitoring at that hospital, and at times nowhere in the country. We started her on subcutaneous unfractionated heparin and flew her to the capital). There was a young boy with a Colles’ fracture, an impressive case of pruritc papular eruption, a 12 fingered baby, severe nipple eczema, hydranencephaly with hydrocephalus, and a 2nd case of ophthalmia neonatorum. This one had been “treated” by a nurse assistant a few days earlier with chloramphenicol eye drops and trimethoprim/sulfamethoxazole. We started the right drugs and think the baby will be fine (the infection, when left untreated, can cause blindness).


Back At The COE

Work in Africa has brought a mixture of strong emotions. You’ll find a family slowly wasting away due to lack of money, education, and power. The man of the house just won’t let them test for HIV until it’s too late. Then you’ll see a new mom who did everything right from the beginning – like the woman who I met in the first trimester when I had just arrived in Lesotho – and the newborn baby’s test shows that he is HIV free. Both instances affect your soul.


Lesotho’s First 80s Party of 2008

So the 80s was an interesting time. I was reminded of this decade of my life as I found myself “pegging” (aka, “tight rolling”) my jeans, putting on clothes that didn’t match, and creating my mohawk for the 80’s party on Saturday night. A


mid the sounds of Toto, Bon Jovi and Journey, we enjoyed a bit of caipirinhas, drinking games, and dancing. There isn’t much more I can say about the party. Is there really much more to say about 80s parties? Let the pictures do the talking.

News From The Farm

By brother David and his wife Jessica just celebrated their 6th anniversary together. Dave, I owe you a twenty. Just kidding. I’m very excited to think about spending some time together with you guys when I get back home, and maybe we’ll even get a chance to meet up off the continent before then. I love you.

I’m excited to say that my mom is enjoying her first weeks of retirement. She put in a ton of years at Del Mar College in Corpus Christi, Texas, and they are missing her already. I can’t remember life before coming to see Mom at the office, hearing her laughter from down the hall, and selling Christmas wrapping paper and chocolates to the nice ladies and gents in the office. I want to send a big hello to all at the Registrar’s Office that read the blog – your support has kept mom sane (relatively) and helps me all the way out here as well. Thank you.

Happy Moshoeshoe’s Day,









Jeff