26 October 2014

A World of Difference





“You should try the cheese and chocolate,” she said. “Cheese and chocolate?!” A confused facial expression accompanied my response. The local Stone Town woman smiled warmly under her ornate hijab and instilled confidence in this Zanzibar pizza chef – she was a regular. I couldn’t decide between the savory tomato, meat, and cheese or the sweet nutella, chocolate, and banana. She’d made my decision for me. “Don’t worry,” she said as she walked off with her pizza in hand, “you’ll try it anyway - this one’s on me.”

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The first few times I traveled in sub-Saharan Africa, it was only natural to be confronted with how different this was from my world. There were people living in conditions like I’d never seen, receiving healthcare in clinics and hospitals considered substandard in Texas, and those with cultural practices and beliefs that seemed so odd. I was confronted with these differences each day, smelling the air, hearing the sounds, feeling the heat, stomaching the tastes. But following a more prolonged stay, becoming more comfortable with the setting, and after wading past the differences, I’ve started to appreciate all of the similarities. Why is the focus so frequently on our differences?

In American politics, we focus on what distinguishes one candidate from another, bringing us to the polarized place in which we find ourselves. In religion, one hears the call to prayer and sees the dress and thinks about the divergence of Muslims from Christians. In healthcare, physicians are trained to observe or judge patients based on differences in culture, gender, generation, or sexual preferences. And in current events, the media highlights the many challenges our dissimilarities have brought us. Perhaps if our global village started to focus on our similarities, our mutual reliance on a healthy economy and environment, and our collective desire for basic necessities, we would avoid much of the needless conflict we see ourselves in today.

When Ebola first set foot in the U.S., we were already 8 months and about 4,000 cases into the current epidemic. It was already 10 times larger than any prior Ebola outbreak. And then the West took notice. We were different from Liberians, until we were in the same boat. Ebola was a world away, until prevalent international travel put us on the same globe. Then we started a furious search for a drug or a vaccine. Lower resource countries don’t have the market power to create the demand to inspire solutions to many tropical diseases. Instead we wait for vocal advocates such as Bill Gates, Bill Clinton, or Margaret Chan to push donors into these arenas to find an answer.

The silver lining of this experience with Ebola ought to be a resurgence of civil debate on how we spend our abundant resources, with renewed focus on the societal good.

The last two weeks I spent learning predominantly about Palliative Care and HIV/AIDS care in Uganda. Our week at Hospice Africa Uganda involved learning about the expansion of oral liquid morphine access for pain control in terminally ill patients, followed by home visits to those receiving home hospice services. Our home visits involved two women dying of cervical cancer, dealing with pelvic pain and urinary incontinence. They simply wanted pain relief and urinary care to die with dignity and in peace. Much like patients in the U.S. 




These patients many times get confused by difficult drug regimens, despite only having ibuprofen and morphine for pain control. Primary care doctors, nurses, and clinical officers at times are not trained to refer to Palliative Care at the appropriate time. There is also a shortage in these providers to competently prescribe this powerful drug, which lowers the amount of patients who can benefit from it. And Hospice Africa Uganda is on the brink of a severe funding shortage, with 70% of their funding coming from external donors, much of that being cut in the near future, leaving inadequate funding from the government to keep the service up and running as it is now. They are the only producer of oral liquid morphine for all of Uganda. All of this – poor funding, health worker shortages, patient education challenges – we deal with in the U.S.

The HIV/AIDS epidemic is showing signs of improvement. The number of new cases each year is dipping, but due to a lack of functioning health facilities and a severe shortage of health workers, many are still diagnosed late, dying of largely preventable causes. Mulago Hospital, the national referral hospital for Uganda is overcrowded and under-staffed, but still the best place to handle complex cases. There, we rounded on patients with advanced lymphoma, visceral leishmaniasis, advanced lung cancer, and toxoplasmosis. The chemotherapy or proper treatment is largely unavailable or too expensive, and thus these patients rely on family to take them home and care for them, without the help of the public health system. Despite seeing this for a couple months now, it doesn’t make it easier. In the U.S., we too still have many without basic health insurance and poor access to primary care services, thus they present late in their disease, which can lead to worse morbidity or even mortality, and is more costly on society.





When I return home from traveling and studying this time, I’m sure I’ll be asked about the differences. But in addition to telling of these, I plan to speak of the many similarities, and how we are in this together. Whether we plan to bring the current Ebola outbreak to an end, or to control tropical ailments with basic public health efforts, or plan to alleviate poverty in any setting, it may just be in our interest to focus on how similar we are, rather than taking the easier route of considering us all so different.

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My cheese and chocolate pizza was ready around the time my friends caught up to me circulating the nighttime food market on the water’s edge. We each tried a bite and she was right - it was a hit. So we ordered three more to finish off our dinner.

09 October 2014

Morning

Morning view for coffee and Al Jazeera, WSJ, and Health Affairs reading.


16 September 2014

Pemba!

The aroma of Zanzibar spices and fresh vegetables is filling our dining area as May prepares our curry meal for dinner. She’s one of my classmates from Australia who has, through her offer to cook dinner, become even more popular this evening – each of us has peeked into the kitchen one-by-one to half-sincerely offer to help, but more so to check in to ensure our spot at her dinner table. Tonight is the first night we have had a long rain, providing a calm evening for our hostel to dine together and catch up.

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Malaria was the major theme of the second week. Our main professor practiced as an Infectious Disease physician and studied Malaria for over four decades. He retired just three weeks prior to joining us for his week of lectures. Most fascinating, he was part of studying the malaria vaccine. It was particularly eye opening to hear him, the academic, the expert, point first to the importance of access to basic healthcare, existing medicines, and public health infrastructure, before more advanced studies on new treatments or vaccines that are either too expensive to be rolled out any time soon or not even very effective.

The middle of the week, instead of exploring three cases in-depth, we rounded rapid fire on about 8 cases within 2 hours.  Case 1: Tuberculosis. Poorly treated the first time, and concern for a multi-drug resistant case, perhaps with an overlying cancer. Case 2: Lymphoma, but we could not investigate further due to lack of pathologist. And even then, there is no access to even basic chemotherapy here at this regional referral hospital. Or an Oncologist. Case 3: Acute onset lower extremity neuropathic symptoms. No MRI machine. No X-rays completed yet due to cost.

You get the idea. It can be gut-wrenching and it’s simply not fair.

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Today was a full day of presentations, hearing about each small group’s one-week (week 3) rural placement. One group studied palliative care and end-of-life beliefs amongst Maasai villagers, another studied malaria rapid diagnostic test use amongst physicians and traditional healers, and another focused on battling malnutrition.

My group traveled to Pemba, the northern of the two major islands that make up Zanzibar. We spent the opening weekend at the apparently infamous “Biederman’s Farm.” The farm excursion was a 2.5-hour bumpy dirt ride from Tanga, and came with fresh cold milk and cheese that we think was properly pasteurized. Mr. Biederman has lived there for 50 years, following an initial placement on the Tanzanian coast by his engineering firm. His property is dotted with barrels of mosquito larva-eating fish that Dr. Albert Schweitzer reportedly introduced to him (?) and swore by as protection from malaria. We spent hours swimming in the incredible warm water of the Indian Ocean, where the stressors of real life back home finally washed away. Some take a few days to really relax on vacation; I took about 12 days to be fully on board here.





The following day we flew to Pemba on a 14-seat plane. A couple cold beers at the airport treated the pre-flight anxiety. The safety demonstration was two sentences. The 20-minute flight ended safely and we were eventually delivered to our destination – the Public Health Laboratory (PHL) guesthouse. Zanzibar is largely Islamic as evidenced by the more conservatively dressed women and the 0445 calls to prayer.









The PHL was originally started by an Italian NGO but is now well integrated into the Zanzibar Ministry of Health (MOH) and its public health campaigns. Zanzibar is actually its own “country,” depending on who you speak to, and is part of the United Republic of Tanzania, but its Ministry of Health functions autonomously.

Health spending in Zanzibar reaches $13 per person per year, versus $3600 and $8600 in the UK and US respectively. Stop and think about that. I didn’t accidentally add or omit zeros.

Our hosts provided lectures on schistosomiasis, water quality, the Zanzibar health system structure, and sanitation, and then we set out on field trips to see some water quality measurements and latrine construction in action. In the evening, we ate our home-cooked meal, played Mafia, and watched the British TV favorites of The Inbetweeners and Fawlty Towers. I had forgotten about Mafia, played when I was younger, but when 11 physicians from different countries are put in a dry guesthouse with little else nearby to do, Mafia proves quite entertaining.








Thursday evening ended with a lavish thank you dinner for our hosts at a nice hotel. We mixed with another group of consultants and funders in town from the UK and US here to assess the Millennium Village on Pemba. Our hosts were actually key leaders in the implementation of the village, selected as one of the poorest in the world. Some of our hosts sat at the consultant table for political purposes while others chose to sit with us to avoid the formal chat. 2015 will be the final year of the Millennium Villages Project and it is when the Millennium Development Goals will essentially “expire.” The Pemba village appears to be on track and the funders seemed pleased with the results in this penultimate year.

And then came Friday night. Friday we flew another short flight across to Unguja (the main island of Zanzibar) to join forces with two of the other small groups. After completing our write up of our project on shistosomiasis, and traveling hours longer than expected, we arrived after dark at the guesthouses on the beach of northeast Unguja. We threw down our bags and walked 10 minutes down the beach to join the others at happy hour – and you would have thought we were heroes returned from battle! Clapping, hugs, kisses, high-fives! I think we surprised ourselves by how happy we all were to be reunited.

It has always struck me how quickly people can become close and build relationships. During times of stress, people seem to need each other. And when the group starts off with baseline commonalities, they start from an advanced position due to an existing high level of trust. Fraternity pledgeship. Residency training. Summer camp. Whatever the experience, it’s a powerful pull that is difficult to put into words and it’s exhilarating to be in the middle of it.




We spent the final night on the beach taking in the clear view of the stars and rising moon celebrating our classmate’s birthday. After blowing out her candles on the dry chocolate birthday cake, she wondered aloud: “I wondered today if this might be the best birthday I’ve ever had. And I think it is.”

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Dinner is ready. Thankfully, I’ve contributed some wine and a chocolate bar for dessert.

31 August 2014

From the base of Kilimanjaro



Energized by the 2.5-hour church service at the Anglican Church here in Moshi this morning, I figured it was time to check in. I arrived in Moshi (Tanzania) last weekend, but my delayed checked bag stayed behind a few nights in Nairobi at the international airport. Following some local advocacy by our course administrator, a handful of patient phone calls to London, Nairobi, and Dar es Salaam, and a few clean shirt changes thanks to our course director, my bag arrived at Kilimanjaro International Airport for pick-up Tuesday evening.

We are now one week into the East African Diploma inTropical Medicine and Hygiene put on by the London School of Hygiene andTropical Medicine (LSHTM). 58 physicians are attending the three-month course. Roughly one-third are from the UK, 8 are from Australia, and the rest represent places such as Ireland, Botswana, Scotland, Austria, Denmark, Canada, Portugal, Uganda, Tanzania, with yours truly being the sole American representative.

Our course began Monday morning with brief introductions, registration, the passing out of our heavy textbook, Principles of Medicine in Africa, distribution of some bicycle helmets (in case we decide to hop on the back of a motorcycle as transportation instead of a taxi), and safety warnings. The first week focused on Epidemiology, where we reviewed the basics of epidemiological study design, had a review of biostatistics, and went in depth into the original outbreak of Ebola in the DRC. A timely topic, we thought... Our lecturer was a well-known epidemiologist and Infectious Disease (ID) specialist from LSHTM. She made a potentially dry topic interesting, and is (like many of our lecturers), an author of chapters in our reference textbook.



The mornings were spent in lecture, and the afternoons were spent in group Swahili lessons and clinical rounds. I rounded at Kilimanjaro Christian Medical Center (KCMC, our home-base in Moshi), with our small group of seven. Our Attending was an ID specialist from Cape Town who conducted bedside rounds. First, we saw a case of an HIV-positive woman with a Co-trimoxazole (Bactrim) induced dermatologic drug reaction. Unfortunately this could have been avoided as at the time she started the medication for PCP prophylaxis, it was not yet indicated. Our second patient was battling chronic schistosomiasis with resulting splenomegaly and esophageal varices. These patients end up severely anemic from GI bleeds and have a fairly poor prognosis. Lastly, we saw a patient with a history of TB, currently struggling with an exacerbation of chronic interstitial lung disease from his years of work in the tanzanite mines. My second day of rounds, we went off site to a smaller district hospital, where we saw four pediatric patients with viral gastroenteritis, rickets, tonsillitis and severe malaria respectively. Our Attending this day, was a local Moshi-based physician who claims he has an allergic reaction any time he travels too far out of the Moshi area.



In these settings, there is very limited access to laboratory tests or imaging, so most of our diagnosis was based on clinical examination and physical signs. Even though this is a tertiary referral hospital, there is no pathologist on site most of the year to read biopsies. There is a CT scanner, but it has been broken for three years. The machine to do a complete blood count is broken – and there is no back-up. These local Attendings are unbelievably impressive with what they can deduce from just a physical exam, whereas in the States we have come to rely on more costly measures to nail down a diagnosis in nearly every case.

Socially, or what our course director affectionately calls the “Hidden Curriculum,” things are ticking along quite nicely. Most of my classmates are in the middle of their specialty training and many have a wide variety of experience. A common thread however, is that they have almost all had an “elective” experience working in a developing area, and are currently taking, or have already taken, a year off in the middle of their post-graduate training to travel and learn more about healthcare in different settings. That’s in stark contrast to American docs who are in such a hurry to complete residency training for a variety of reasons. More on that later. I have enjoyed getting to know my classmates and lecturers, slowly adding in one or two at a time, hearing about their travels, their training, and their feelings on the system within which they work.

Our lodging is decent, and Thursday night we had a meal cooked at our hostel (our group is staying in one of four places around town) for $5 per person. A few from the other hostels came by, and half the group hung around on my hostel’s terrace ("Terrace Thursdays" we've dubbed it) for a few Kilimanjaros (beer) and some Konyagi (the local spirit). 





Most of the group went on safari or to stay a night at the Ngorongoro crater this weekend, but Micah, my new Irish friend, and I went out to Honey Badger Lodge for some relaxation poolside. An Epidemiology professor associated with the LSHTM based here in Moshi owns the Lodge.



We are now preparing our reading for next week’s topic – Malaria. The end of next week we will travel in six small groups to our one-week rural placements to learn about different community-level health services or projects. I’ll be headed out to Pemba, the northern island of the Zanzibar region, and most of us are eagerly anticipating the week away.


The first week was busy, but it is about to end with our hostel’s cook serving a homemade meal. What a blessing to be here – when your Sunday evening sunset looks like this, it’s easy to be reassured you are exactly where you should be.


22 August 2014