The last two days here in Tanzania were spent finishing my exit report and signing out. On Friday I went to see a Christmas Pageant. The daughter of the country director was in the school's annual play. Actually just about everyone was which I thought was wonderful. Later we went back to the Lebanese restaurant for a farewell late lunch as they were traveling that evening back to the US of A for Christmas. Saturday was spent wandering about a relatively fancy shopping area called Slipway just on the Indian Ocean where I managed to get rid of all the Tanzanian schillings that I had left and actually a bit more. That night off to the airport and my Bird home. The flight left and arrived on time and the trip was not bad though long and cramped as usual. I had just a bit more than an hour between connections and was apprehensive but my arrival gate was E2 and my departure gate was E3. So a leisurely stroll over, a bit of standing in the check-in line and onto the next flight. As we left the pilot announced that the snow had begun in Boston. "How wonderful," I thought, "New England is so happy to see me that it is giving a nor'easter in my honor". Then for the next 6 hours nothing further. The movies were so bad that even I, who will watch the lousiest movie on a flight, skipped this one. Finally about an hour before arrival we got the news, not unexpected, that Boston had closed for snow removal. Onto JFK where we refueled and then back in the air to Boston. We got in about 3 hours late but it was a lot better than circling about Boston endlessly. By good fortune the Concord buses were running and I managed to get the 1530 bus up here. It was slow going as the light rain that was then falling in Boston had changed to freezing rain in New Hampshire and then into snow in Maine. Our driver had to stop around Saco to clean the ice from his windshield and while we were sitting there, some poor soul in an SUV slid into us. I felt nothing but heard a noise that I thought was the driver changing gears to start up. A good advertisement for buying the largest vehicle one can instead of these compact cars that I do. Though with gas at three dollars plus, you can't go very far these days. We sat there for an hour until the police came by and then did get into Portland about 2030.
By then the roads were so bad that I spent the night in Portland at the "Clarion" hotel. Used to be the "Doubletree" but now a bit more upscale. Actually it was quite comfortable. The restaurant was surprisingly good and it was not that expensive.
Monday beamed bright and sunny with that beautiful white purity that only a fresh snow can impart. Gerda got plowed out, got down to Portland and took me home where I was able to give a cheery hello to my good friend Jack Daniels who had been patiently waiting such a long time for my return.
Strange feeling now three days later on Thursday morning as I write this. It is almost as if I had never left but I do know that I did and did return. More than "deja vue". Perhaps a new syndrome and we can call it "ne deja vue pas".
And, as the caption at the end of the Loony Tunes and Merry Melodies always said, "That's all, folks".
Stephen
Thursday, December 20, 2007
Thursday, December 13, 2007
The Long Road Home, Part 1
It was a dark and stormy night. The wind whistled ominously and the trees branches beat on the window as if they were trying to break in. Now this has absolutely nothing to do with my day yesterday but I did think that it might just get you interested to read a bit more.
Actually the day started out without problem. It had only rained a slight bit on Tuesday so that I thought that the road would not be a real problem. Wednesday morning just as I wandered over to have a bit of breakfast at 0630, a few drops of rain began to fall. Over the next 30 minutes as I finished packing and loading my bags in the car, the rain began to pick up and the low hanging clouds began to cover our hillside. Starting out was no problem even though the rain began to pour down. We had to stop at Nduta to pick up some specimens from the respiratory surveillance program to bring to Dar. I had not been in the camp for almost a week and I was eager to see it again. But what I found was a village under water. There were large puddles of water everywhere and what was not under water was just that cement-like mud that clung and refused to bescaped off. The ditches that channeled the water were torrents of brown water rushing by. People were peering out of their huts watching dejectedly. Occasionally thunder would roar as if a beast had been struck by the lightening that had just proceeded it.
From Nduta we traveled on to Kisulu as we had mail to deliver there. Swaying from side to side, our car tried to avoid the larger puddles and ruts that dominated the road but, though slow, we made it to Kisulu without a real problem. we had two young boys, one of about 5, the other about 7 with us as they were traveling to Kigoma to spend the holidays with their grandmother. The younger, a bit unexpectedly for a child of a staff member, was frightened of me, refused to sit too close and kept staring at me as, if like Michelangelo's Moses, I might grow horns. I didn't. He did relax a bit as we went on because we pick up two more staff at Nduta to take along. So he was forced to crowd close to me and he survived.
At Kisulu, we were greeted by the coordinator, a lovely Kenyan lady that I had medically helped before. We stayed for about an hour for tea and lunch. Ominously she told us that it had been raining very hard for more than 12 hours.It still was coming down heavily and still the clouds were lower. We left Kisulu, about 1230 and drove out of that small dilapidated town through streets that were flooded and drainage ditches that were overflowing with garbage and muddy water. Like the road from Kibondo to Kisulu, it was all packed dirt but, unlike that road, this one was only mud and water. Where the large trucks had passed, it was churned-up mud and ruts. We had enough time to drive even slower and still make it to the plane that was scheduled to leave at 1630. We were assuming that it would not be canceled because of the weather. This was a bit optimistic as we had earlier learned that Dr. Vachagan's flight on Sunday had been canceled for "technical reasons" and, although he made it out the next day, he had missed his connections to get back home to Yerevan. I was a bit more careful as I gave myself a couple of buffer days just for that contingency.
We traveled slowly along dodging back and forth between small lakes, ruts, the ditches, the few people on foot or bicycle. Suddenly ahead of us, as we topped a small hill, was a truck stuck in the road and jackknifed. There was, fortunately, a bit of space near the not to deep side ditch that we were just able to inch by. Shortly after that the road became more hard packed and the mud less slippery. On we went, a bit of calm overcoming my nervousness. Again we climbed a small hill and there in front were a few stopped cars but in front of them about halfway up the hill coming toward us was a huge truck stuck and behind that was a line of about 20 more vehicles of all sizes. People were gathered and chatting as if at a grand fete. There were folks trying to brace the truck. It was a double load with a trailer attached and it really had that resigned look that so clearly said, "I am not going anywhere". Off to one side in the ditch blocking that way was another truck so mired down that it would never more during this rainy season unless "all the king's men and all the king's horses" came along. There was even less room on the other side. I looked at my watch, 1330. I had visions of a long very uncomfortable night. We were out of Codan (radio) range and also mobile telephone service range. One little bright spot, the rain slowly stopped as we got out to walk a bit and watch the proceedings. The truck had started up the hill but because of the weight it was dragging and the slippery mud it was traversing it could not get traction. It had begun to slip backward and in doing so the link between the 2 portions had twisted so that it could not be further backed down. As we watched and silently cursed a bit, actually more than a bit, men were filling in the ditch on the side of the road. After an apprehensive 30 minutes during with I was growing more resigned though not any less annoyed, a Toyota land cruiser from the opposite way managed to get through, a UNHCR car no less. Right after that we too got in place and and went through very very slowly. We were the third car through and that was also fortunate as the ditch was getting chewed up. As we inched along through the ditch very close to the truck looking more and more like a beached whale in my imagination, the car began to tilt ominously until we were at a 30 degree angle and I felt sure that we would tip on our side. Luckily at that point there was a small hillock that blocked further tilting and we scraped along it. As we passed the beached truck we were able to get back to the middle of the road and could easily get by the line of cars and trucks stranded there.
The weather continued to improve and and the road got harder and less muddy as it had not rained so much. So as we got closer to Kigoma it became hard packed again and once we got into the town there was, believe it or not, there was tarmac. We turned off the tarmac road onto a small, almost a path, road to the airport. Bouncing along through the deep ruts, we did without further mishap make it to the dirt strip airport that fortunately the UN also used so that it had been upgraded. We got there at about 1530, stood in the passenger line to squeeze through the narrow door, to have the luggage hand searched and finally check in. The plane had not been canceled though it was an hour late. I was comforted as I saw a Catholic priest among the passengers, thinking God will now definitely not let anything happen to us. Carmen DelRosario who was traveling with me to go back to her family for the holidays, a Catholic, told me that she had had the very same thought. The flight back to Dar was without problem. I was further reassured when I went to the loo and saw that the instruction signs were in English and German indicating that the plane was made in Germany. The only real disappointment was that I missed having enough time to make a pilgramage out to the spot where Stanley met Livingston on the shores of Lake Albert (Tanganika) at Ujiji so tantalizing close by.
A short ride to the hotel, the Markham, the same one I was in when I first got here, a small supper at the new Lebanese restaurant across the way and then to bed after an exhausting day and, like Ishmael, I lived to tell the tale.
Stephen
Actually the day started out without problem. It had only rained a slight bit on Tuesday so that I thought that the road would not be a real problem. Wednesday morning just as I wandered over to have a bit of breakfast at 0630, a few drops of rain began to fall. Over the next 30 minutes as I finished packing and loading my bags in the car, the rain began to pick up and the low hanging clouds began to cover our hillside. Starting out was no problem even though the rain began to pour down. We had to stop at Nduta to pick up some specimens from the respiratory surveillance program to bring to Dar. I had not been in the camp for almost a week and I was eager to see it again. But what I found was a village under water. There were large puddles of water everywhere and what was not under water was just that cement-like mud that clung and refused to bescaped off. The ditches that channeled the water were torrents of brown water rushing by. People were peering out of their huts watching dejectedly. Occasionally thunder would roar as if a beast had been struck by the lightening that had just proceeded it.
From Nduta we traveled on to Kisulu as we had mail to deliver there. Swaying from side to side, our car tried to avoid the larger puddles and ruts that dominated the road but, though slow, we made it to Kisulu without a real problem. we had two young boys, one of about 5, the other about 7 with us as they were traveling to Kigoma to spend the holidays with their grandmother. The younger, a bit unexpectedly for a child of a staff member, was frightened of me, refused to sit too close and kept staring at me as, if like Michelangelo's Moses, I might grow horns. I didn't. He did relax a bit as we went on because we pick up two more staff at Nduta to take along. So he was forced to crowd close to me and he survived.
At Kisulu, we were greeted by the coordinator, a lovely Kenyan lady that I had medically helped before. We stayed for about an hour for tea and lunch. Ominously she told us that it had been raining very hard for more than 12 hours.It still was coming down heavily and still the clouds were lower. We left Kisulu, about 1230 and drove out of that small dilapidated town through streets that were flooded and drainage ditches that were overflowing with garbage and muddy water. Like the road from Kibondo to Kisulu, it was all packed dirt but, unlike that road, this one was only mud and water. Where the large trucks had passed, it was churned-up mud and ruts. We had enough time to drive even slower and still make it to the plane that was scheduled to leave at 1630. We were assuming that it would not be canceled because of the weather. This was a bit optimistic as we had earlier learned that Dr. Vachagan's flight on Sunday had been canceled for "technical reasons" and, although he made it out the next day, he had missed his connections to get back home to Yerevan. I was a bit more careful as I gave myself a couple of buffer days just for that contingency.
We traveled slowly along dodging back and forth between small lakes, ruts, the ditches, the few people on foot or bicycle. Suddenly ahead of us, as we topped a small hill, was a truck stuck in the road and jackknifed. There was, fortunately, a bit of space near the not to deep side ditch that we were just able to inch by. Shortly after that the road became more hard packed and the mud less slippery. On we went, a bit of calm overcoming my nervousness. Again we climbed a small hill and there in front were a few stopped cars but in front of them about halfway up the hill coming toward us was a huge truck stuck and behind that was a line of about 20 more vehicles of all sizes. People were gathered and chatting as if at a grand fete. There were folks trying to brace the truck. It was a double load with a trailer attached and it really had that resigned look that so clearly said, "I am not going anywhere". Off to one side in the ditch blocking that way was another truck so mired down that it would never more during this rainy season unless "all the king's men and all the king's horses" came along. There was even less room on the other side. I looked at my watch, 1330. I had visions of a long very uncomfortable night. We were out of Codan (radio) range and also mobile telephone service range. One little bright spot, the rain slowly stopped as we got out to walk a bit and watch the proceedings. The truck had started up the hill but because of the weight it was dragging and the slippery mud it was traversing it could not get traction. It had begun to slip backward and in doing so the link between the 2 portions had twisted so that it could not be further backed down. As we watched and silently cursed a bit, actually more than a bit, men were filling in the ditch on the side of the road. After an apprehensive 30 minutes during with I was growing more resigned though not any less annoyed, a Toyota land cruiser from the opposite way managed to get through, a UNHCR car no less. Right after that we too got in place and and went through very very slowly. We were the third car through and that was also fortunate as the ditch was getting chewed up. As we inched along through the ditch very close to the truck looking more and more like a beached whale in my imagination, the car began to tilt ominously until we were at a 30 degree angle and I felt sure that we would tip on our side. Luckily at that point there was a small hillock that blocked further tilting and we scraped along it. As we passed the beached truck we were able to get back to the middle of the road and could easily get by the line of cars and trucks stranded there.
The weather continued to improve and and the road got harder and less muddy as it had not rained so much. So as we got closer to Kigoma it became hard packed again and once we got into the town there was, believe it or not, there was tarmac. We turned off the tarmac road onto a small, almost a path, road to the airport. Bouncing along through the deep ruts, we did without further mishap make it to the dirt strip airport that fortunately the UN also used so that it had been upgraded. We got there at about 1530, stood in the passenger line to squeeze through the narrow door, to have the luggage hand searched and finally check in. The plane had not been canceled though it was an hour late. I was comforted as I saw a Catholic priest among the passengers, thinking God will now definitely not let anything happen to us. Carmen DelRosario who was traveling with me to go back to her family for the holidays, a Catholic, told me that she had had the very same thought. The flight back to Dar was without problem. I was further reassured when I went to the loo and saw that the instruction signs were in English and German indicating that the plane was made in Germany. The only real disappointment was that I missed having enough time to make a pilgramage out to the spot where Stanley met Livingston on the shores of Lake Albert (Tanganika) at Ujiji so tantalizing close by.
A short ride to the hotel, the Markham, the same one I was in when I first got here, a small supper at the new Lebanese restaurant across the way and then to bed after an exhausting day and, like Ishmael, I lived to tell the tale.
Stephen
Friday, December 7, 2007
Last Post from Nduta/Kibondo
On December 1st, the world, at least some parts of it, noted "World Aids Day" with ceremonies in many places. There was one at our camp, Nduta. Although the mood looks very cheerful, there was, indeed, a very serious message about safety and commitment. Whether the men and it is the men who hold the key to curtailing this scourge paid any attention is up in the air right now. Statistics would suggest that they do not. Statistics from America also suggest that this absolutely fatal incurable disease is now regarded as an annoyance that can be controlled much as hypertension and diabetes are. Incidence rates are rising and this is tragic news.
I had my last day at the camp on Wednesday and have spent the past few days here at the base tidying up the end of mission details that are always there. The major one is the "End of Mission" or Exit Report". It is basically a summery of what I found, what I did and what I think needs further work. On Wednesday, the 12th, I will, early in the morning with another ex-pat from Boston, no less, make the 6 hour drive to Kigoma to catch the flight to Dar es Salaam. Six hours if it is not raining and the roads still are functional. So far the rains have not been that bad and the roads have remained quite reasonable for out here this time of year. I remember when my time to leave Sierra Leone during the height of the rains in August drew close, I would get up every day and check the sky. The road out from Kailahoun to Kenema was 60 kilometers of rut and mud but we did, albeit quite slowly, make it.
That's the latest and the last from out here where
the days are cloudy
the roads muddy
and I am giddy.
Stephen
Saturday, December 1, 2007
Short-Timer
Officially I became a "Short-Timer" this morning as I will leave here (Kibondo) on the 12th to Dar es Salaam and from there on the 15th back to "our fair city". As usual the red-eye special. At least this time it is at midnight rather than the 4 a.m. ones from Khartoum.
Little of note happened this week. Our new technical advisor for this area of the world arrived for a visit. A very nice knowledgeable physician lady from Belgium who has a vast experience working in this part of the world. We took her on a tour of the clinic/hospital facility on Thursday. She agreed with our concerns and, hopefully, we can get some money to improve things out here. That won't happen during my tenure but, at least, there is a chance of it happening.
Now,as I have nothing else to write about, here is a bit about our weather and Thanksgiving.
Yesterday was a return, albeit briefly, to hotter weather. I did enjoy the change but today it is again cloudy and cool. Last night was glorious as a storm slowly came tramping in from the East and slowly spread over the sky. As the sun moved further West and the clouds gave chase, the colors changed dramatically. Streaks of red and bright pink began tickling the bellies of those dark grey-black storm clouds and here and there at the vanguard the clouds piled up as if climbing on each other, just a bit reluctant to pursue the assault against so powerful a foe. As that happened, a bright light illuminated them and they just glistened going from dark black to intense white. Further back bolts of lightening occasionally burst forth and thunder rumbled as if to encourage or perhaps threaten the front line troops to press forward.
We did have our Thanksgiving dinner and it was the same as we had back in Darfur, mainly as we had the same ingredients, tough chicken, potatoes, some stuffing, biscuits and corn muffins. The enjoyable part was that we were really all together for a meal instead of a few drifting in and out which is the usual pattern. The rest of the day I read a bit, put another note on the Blog and answered a few letters. Today I will make up a small protocol on the use of a nebulizer which we found in the storeroom. I am have been waiting for the solution to arrive. Not here yet but, hopefully, this week.
And that's the news from here where
I have become a "short-timer"
And you know you're in trouble
when you can't wait for airplane food.
Stephen
Little of note happened this week. Our new technical advisor for this area of the world arrived for a visit. A very nice knowledgeable physician lady from Belgium who has a vast experience working in this part of the world. We took her on a tour of the clinic/hospital facility on Thursday. She agreed with our concerns and, hopefully, we can get some money to improve things out here. That won't happen during my tenure but, at least, there is a chance of it happening.
Now,as I have nothing else to write about, here is a bit about our weather and Thanksgiving.
Yesterday was a return, albeit briefly, to hotter weather. I did enjoy the change but today it is again cloudy and cool. Last night was glorious as a storm slowly came tramping in from the East and slowly spread over the sky. As the sun moved further West and the clouds gave chase, the colors changed dramatically. Streaks of red and bright pink began tickling the bellies of those dark grey-black storm clouds and here and there at the vanguard the clouds piled up as if climbing on each other, just a bit reluctant to pursue the assault against so powerful a foe. As that happened, a bright light illuminated them and they just glistened going from dark black to intense white. Further back bolts of lightening occasionally burst forth and thunder rumbled as if to encourage or perhaps threaten the front line troops to press forward.
We did have our Thanksgiving dinner and it was the same as we had back in Darfur, mainly as we had the same ingredients, tough chicken, potatoes, some stuffing, biscuits and corn muffins. The enjoyable part was that we were really all together for a meal instead of a few drifting in and out which is the usual pattern. The rest of the day I read a bit, put another note on the Blog and answered a few letters. Today I will make up a small protocol on the use of a nebulizer which we found in the storeroom. I am have been waiting for the solution to arrive. Not here yet but, hopefully, this week.
And that's the news from here where
I have become a "short-timer"
And you know you're in trouble
when you can't wait for airplane food.
Stephen
Thursday, November 22, 2007
The UN Comes A'Callin!
Wednesday, November 21stThe UN and all the major donors to them and therefore to us came on a visit that they termed euphemistically the JAM, Joint Assessement Mission. We presented, all the various programs, what was happening in them and then took them about to highlight the myriad problems that we have, what we were trying to do to strengthen the program and why we need additional funds. They did listen but whether this will translate into any supplemental grants is totally unknown. Do not hold your breath. We did also learn that BPRM, an American agency with the full name of Bureau of Population Resettlement and Migration, cut their grant for next year in half by $500,000. And where we are to find replacements for that alone is totally unknown. After that I went to the OPD again until we discovered that there was no one checking on the pediatric ward. So I spent the rest of the day there. I have a CO who is the most faithful and we have spent the most time together. He has changed his habits and I do think that he will continue to do so even when I leave. About the others, I have no such illusions. For example, I gave another training session as I do every Wednesday and he was the only CO there. The rest were all Community Health Workers and nurses. I am grateful that they were there.
That's all there is to report today from here where
The UN and donors came and went
A jam they called it
But who knows if it was heaven sent.
7:57 AM 11/22/2007
A small bit of minutia:
One bit of interest from about a week ago. The ants had disappeared for some time. At least they were not in view and not serepticiously biting. One morning last weekend on the way to breakfast, there was a long column of them, about 10 meters, marching through the drainage ditch of my house. Now they were tramping along two by two in a very long line. Generally they were quite orderly and well mannered. Every so often one here and there would break off and scout about. They were, I am sure, a food finding expedition. As they reached the end of my house, there were still more tramping out from their nest in the walkway. They had evidently dug a tunnel at the side of the walkway and no longer were coming out on top where we galoofed by. Nevertheless I was apprehensive as to their motives and, as I could not speak Antese, I decided that this was an act of blatant aggression. I raced into my house for my "weapon of mass destruction", the can of SUPER DOOM and attacked. A rout and shortly thereafter came a heavy rain and washed the bodies away. So I do believe back at ant headquarters they could only report, "lost, whereabouts unknown".
Sunday, November 18th.
Today I do have to prepare some additional teaching guides for the clinicians so that they might think of ear infection without waiting to see pus draining out from an ear. We have been over this several times before but it just does not seem to percolate through to them.The favorite sequence here, as I have written about, for diagnoses is first and always, Malaria and throw in an antibiotic for a respiratory infection though they have done nothing to prove either. If that does not work, gears are switched and the next diagnosis up is Enteric Fever. Now that is difficult to diagnose but it does have a pattern that tends to be more characteristic. A serological test called the "Widal", named after the good doctor who first described it more than a century ago, is ordered. This test has been abandoned in developed countries as useless as it has little sensitivity nor specificity. You might as well flip a coin. We back in developed countries rely on blood, stool and bone marrow cultures. But the news has yet to reach Africa and no amount of discussion can shake this belief, just like dialogue with fundamentalists. Then chloramphenicol is added and that drug, while cheap and useful out here, has a lot of bad side effects. So part of my next session will be on just that disease. I really do not expect any paradigm shift but I have to try.
And that's the news from out here in Tanzania where
the clinicians can diagnose without examining patients
malaria abounds even with negative tests
and the UN keeps trucking them in.
Stephen
Saturday, November 17, 2007
The Weeks Keep On Rolling!
Today is the 14th of the lovely month of November and one bright spot, as I was walking over to the car to go back to base late in the afternoon, there appeared on a tree peeping at me a gecko with a bright blue face. But, like some of the children here, when he saw me he just scurried up his tree. Not that the children scurry up a tree but they find me so strange with my pale white skin that they hide themselves in their mother's body and periodically peer out and cry in terror. Tonight the black rain clouds are rolling from the north with some thunder and lightening. The clouds spread across the sky like tentacles and leave patches of dusky blue in between with a few stars twinkling through as if to reassure me. So far no rain though.
November 16th.
It rained a lot last night for about 2 hours but this morning was delightfully bright and cool. As usual down at Nduta it was hot but it never gets as bad as in Sudan or in Kakuma. I am working with a new C.O. and he is good. I am still on the adult wards. Now comes a longer tale with an interesting twist at the end. I have for the past two weeks been giving presentations on malaria and yesterday the health coordinator came out to present a survey that he did on our use of anti-malarial drugs. He found, and this was not unexpected from my observations, that 2/3s of the people treated for malaria did not need it according to the tests that were done. I have been trying to tell the clinicians, ad absurdum, that, if the tests are negative, you have to look for other causes of the fever, which they just do not do. They simply diagnose "suspected malaria", put the patient on anti-malarials and throw in an antibiotic just to cover everything possible but are really too lazy to try to make a proper diagnosis. This afternoon, as I was leaving, the Tanzanian doctor said that the COs wanted me to show them how to do a better examination. Instead of saying something sarcastic such as, "What the hell do you think that I have been trying to do for the past 2+ months.", I replied that I would be delighted to. So Monday I will head back to the pediatric outpatient department and try again. I can deal with this as I have but 3 more weeks to go out here and, who knows, something just might stick. I will not get too excited. I had found myself over the past few days getting too exasperated and that just interferes with my ability to make good decisions. It has been building for some time. I keep getting too personally involved. It really did almost come to an explosion yesterday during the training when several of the people there came out with their personal anecdotes of tests being wrong. None of the examples that were cited had anything to do with malaria. Finally I decided to just laugh and said, " OK, lets just get rid of the tests, treat everyone with fever for malaria and buy beer with the money we save." I do think that the message I was trying to give got heard. Sadly, by today's admissions to the adult wards, not everyone was paying attention.
The camp consolidation process goes on and, fortunately, the weather has not been too bad with rain so that people are constructing their shelters. And so far, despite the very harsh conditions, no outbreaks of diarrhea or other problems. And that's the latest from Nduta where
Two camps merge into one
The UN thinks that this is fun
And, mercifully, no one has the runs.
Stephen
November 16th.
It rained a lot last night for about 2 hours but this morning was delightfully bright and cool. As usual down at Nduta it was hot but it never gets as bad as in Sudan or in Kakuma. I am working with a new C.O. and he is good. I am still on the adult wards. Now comes a longer tale with an interesting twist at the end. I have for the past two weeks been giving presentations on malaria and yesterday the health coordinator came out to present a survey that he did on our use of anti-malarial drugs. He found, and this was not unexpected from my observations, that 2/3s of the people treated for malaria did not need it according to the tests that were done. I have been trying to tell the clinicians, ad absurdum, that, if the tests are negative, you have to look for other causes of the fever, which they just do not do. They simply diagnose "suspected malaria", put the patient on anti-malarials and throw in an antibiotic just to cover everything possible but are really too lazy to try to make a proper diagnosis. This afternoon, as I was leaving, the Tanzanian doctor said that the COs wanted me to show them how to do a better examination. Instead of saying something sarcastic such as, "What the hell do you think that I have been trying to do for the past 2+ months.", I replied that I would be delighted to. So Monday I will head back to the pediatric outpatient department and try again. I can deal with this as I have but 3 more weeks to go out here and, who knows, something just might stick. I will not get too excited. I had found myself over the past few days getting too exasperated and that just interferes with my ability to make good decisions. It has been building for some time. I keep getting too personally involved. It really did almost come to an explosion yesterday during the training when several of the people there came out with their personal anecdotes of tests being wrong. None of the examples that were cited had anything to do with malaria. Finally I decided to just laugh and said, " OK, lets just get rid of the tests, treat everyone with fever for malaria and buy beer with the money we save." I do think that the message I was trying to give got heard. Sadly, by today's admissions to the adult wards, not everyone was paying attention.
The camp consolidation process goes on and, fortunately, the weather has not been too bad with rain so that people are constructing their shelters. And so far, despite the very harsh conditions, no outbreaks of diarrhea or other problems. And that's the latest from Nduta where
Two camps merge into one
The UN thinks that this is fun
And, mercifully, no one has the runs.
Stephen
Sunday, November 11, 2007
Camp Consolidation
Today the camp consolidation, as it is euphemistically by the UN, started. They are closing Kenembwa as I have written about and the folks are being all moved to Nduta, those that do not want, as yet, to repatriate. I had wanted to go there earlier in the day when the first convoy arrived but there was no vehicle available until late in the day so I went there before heading for Kibondo. You know that I have been questioning my sanity and the purpose of my being here. I guess God, Buddha, The Great Spirit, whatever you would like to call the force that somehow guides this universe of ours got tired of my quengelig mutterings and gave me a very clear answer. I was so overwhelmed by what was taking place that it brought me to tears. I will try to give you an idea of the pictures that I saw. I did have my camera but did not have the ability to use it. I spoke with both the field and health coordinators this evening upon my return and we will go back in the morning to see if there has been any improvement. I arrived there at the "reception center" at about 1630 and it was utter chaos. The center is rather small, perhaps 400 meters square and that is a guesstimate. There were lorries including a container vehicle unloading these poor folks' possessions, mainly wooden objects as doors, window frames and furniture into a large pile in the center. It looked like a pyre that would soon be set on fire to propitiate the Gods. People were scrambling about trying to find what was theirs and cart it off to the shelters. Others were carrying large bags full of clothes, rags and other possessions into the shelters that were only wood frame rectangles covered with plastic sheets with a brick floor. The majority of the bricks were loose and jumbled about.There were no assigned places just the words"men", "women" scrawled on the plastic and people were trying to find spots to sleep. Wandering about were small flocks of chickens and ducks. Outside the wire fence, men were herding about 20 cows and more goats to keep them from wandering off or being stolen. The Nduta inhabitants were all crowded up against the fence trying to see relatives and contact them or just watching the entertainment.There was an NGO, Tanzanian Christian Relief Services (TCRS) that had about 10 people there that were not of any help. A few were at the gate with sticks pushing people back. The rest were just sitting and watching the turmoil, chatting amongst themselves, not trying to assist or control the confusion. Off to one side there was a shelter of about 5 x 10 meters where people were cooking. As they had not taken down the plastic siding, the wood smoke was swirling about in there and it looked like a sauna but the fumes were deadly. No firewood was supplied and they were forbidden to bring any with them so they had to scrounge about and there was precious little. Right in front of these was a large deep pit with a skimpy rail fence around it. the was a garbage pit. The children were playing near and, surely, one will fall in. The water points were adequate but the kids, having little else to do, were playing with them and rivulets were forming and the mud was accumulating. There were only seven toilets for what was reported to be at least 500 and possible up to 800 people. At least that was all that I could find. There were some outside the fence but I was told that the people could not go out there. Now, as I was wandering about asking questions, more trucks kept coming in as the second convoy of the day was arriving. And indeed on the way home here to Kibondo, more trucks went by us. So more goods on top of those already piled up. It would become dark soon about 1900 and there is no electricity to assist unloading. Over the next few days, they will build mud/wattling houses on the plots in the camp that have been assigned to them. The will be given some sisal rope, plastic sheeting, framing posts and a handshake. It rained this weekend. Today was overcast most of the day and there was only a bit of sun late to dry the ground. If it does not clear for the mud to dry then it will just melt right off in the first heavy rain that comes. The next group is slated for Friday and the whole move is supposed to be done by mid-December. So back again tomorrow and, if there has been no significant improvement, we will try to stop the process and get it better organized.I will let you know in Wednesday's letter.
This part was written on Friday, the fifth day of the consolidation process. Refugees keep coming in daily from Kenembwa which is certainly not the way the UNHCR described the move. I went this evening over to the "reception center" which is crammed with people and very unsafe from a health perspective. I won't comment on the social aspects. Construction materials were to be given out on Monday and then there would be three days that were allowed for the men to build their homes and then the next group would be moved in. However convoys arrive daily. For the first time today framing posts were supplied and in very limited quantity but so far no rope and no plastic sheeting. And today is the 5th day that the Monday arrivals have been living in even worse squalor than usual. I went over there again this evening to see so that I could report to our FC (field coordinator) & HC (health coordinator). I can not tell for sure how many are now crowded in there and the UN will not supply us with a list but they claimed earlier in the week that they could safely get up to 1200 refugees in. It certainly looks like that number but it sure ain't safe. Debris still is strewn about. The barnyard animals wander in and out. The shelters are over packed and stuffed with their possessions, enough so that quite a number have to sleep outside. There are not enough blankets, thievery abounds as you might expect in such an unstable condition. And to add those further twists of the screw, there are now two more gathering places with a fourth being constructed. The second is at part of a school and that one is not bad as there are many fewer people, there is more space and the buildings are solid. The newest one opened evidently last evening and consists of four huge WFP (World Food Program) storage tents that are generally used to store food supplies.Now they are supposed to house 100 people each. I have been in each and they will be crowded with 50 as most of the space is taken up by bundles of the refugees' possessions, leaving precious little living space. Some women were cooking inside with charcoal and rather noxious fumes were drifting about. There was only one water point. A second one had not yet been connected and a group of women were digging latrines while the men watched with a casual interest. I was told that even last night, the first night, some had to sleep outside and still daily new refugees keep arriving from Kenembwa. Once again as I was leaving the buses and trucks were rolling in with frustrating regularity. Our FC did write an excellent letter protesting and has been in touch with our country director. The next bit of good news from the UN was that they would give us no additional money to upgrade our hospital/clinic/ outpost complex and we have but a fraction of what we really need to make those critical changes that I have already outlined. That has also draw a strong protest. Whether anything comes of this is totally unknown but I will, of course, let you know.
Stephen
Mirabili Dictu!
At last I have convinced at least one clinical officer that the use of an inhaler with a spacer is the best way to quickly treat and stabilize an acute asthmatic attack instead of their previous dangerous relatively ineffective use of intravenous aminophyllin. Also please note that he is counting respirations on the child. Yippie!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Saturday, November 3, 2007
My Week at Nduta
Here are some of my good friends at Nduta that usually wait for me as I make daily rounds on the pediatric.ward and a view of the compound on weekly wash day.Monday, the start of my week.I should have known what kind of a day it was going to be when it was inaugurated by that ant attack that I wrote about earlier today. At the pediatric ward the chief CO decided to attend and he was a bit better than some but not by much and he was very full of his importance. Rounds started well but then I began picking up the mistakes from the weekend, the undetected pneumonia because some still do not count respirations nor listen to the lungs. so what was on Friday a mild pneumonia by today was very severe and possibly life threatening. I went to the pharmacy to look for some medications and, how unusual, they were out. I asked if they had ordered them.
"Oh yes", came the reply.
"Well were are they?"
"Oh they will come in with the monthly order in 3 days."
"But you are out now!"
Then comes that rather silly smile that I do so hate and that I see all too often. What to do. I must keep remembering that this is a long term task. It really ain't going to change during my tenure. What I can do has been put into place. Pointing out the deficiencies, suggesting ways of correction and starting a reasonable reliable training program. I have also found a fine physician to replace me.
The heat has returned here over the past 2 - 3 days. The sky starts clear in the cool morning but then the puffy fluffy clouds come slowly drifting in as the day heats up. We see the same type of cloud in Maine but they are just so much more energetic. By then I am down in the valley at Nduta where I do recognize that I am very very close to the Equator. But back up here on the hill it does cool off at night and that makes it easier to sleep. We are in what would be the Fall as many leaves are drifting down but they have none of that vivacity of the colors that we are blessed with. They turn a paler shade of green and give up the ghost with a sigh as the rains are too late to save them. They cover the ground to the delight of the goats that wander through the compound, depositing their small pebbles as a thank you. They have begun to make a habit of lying about in the shade outside the pediatric ward where I daily work so that I see them from the window gazing at me when I go over to the hand washing bucket. Today two young males were butting heads to see who could attract the ladies who were not very interested.
TuesdayI did get another CO so that, certainly at this point, the system does seem to be running. Today's was good and he quickly got the idea that counting respirations is a good idea as is the washing of hands. And to my delight the aides and nurses on the ward are beginning to do the same.
We did lose our first baby today that I am aware of since I came. A newborn who after about 30 minutes started having trouble breathing. It was a good sized baby of 3.3 kilo. Looked normal but had a big liver. It was not cyanotic, had no heart murmur and both lungs were receiving air. We suctioned him and gave antibiotics which really was all that we could do. I ask the doctor involved about transferring him to the KIbondo hospital but he felt that they would do nothing which is generally the way they do things there.
Well now another bit of the ongoing ANT WAR. Last night 2 of the lady ex-pats were attacked as I had been earlier in the day. No serious injuries only lost dignity as clothes had to be removed and brushed out and the vicious little creatures removed, rather pulled off. Fortunately there is more than one room in the staff lounge/dining area. So they were able to discreetly run in the other room to do this. And I do mean run. Those guys really hurt. I had found out where they had built their nest, actually there were two colonies. There were two nests side by side, one with big guys and the second with the smaller fire ants, so called as their bites burn. I had decided that if they behaved, I would not bother them. But they broke the truce this morning. As I walked very carefully by I got bitten again. So after breakfast, I took my can of Super Doom and attacked. Right and left I sprayed. Up and down the canister of deadly poison flared. Meanwhile two of the guards appeared to see what was going on as thousands of ants milled about trying to form ranks and counter-attack. I handed over the canister to them, pointing out the entrance to the nests and left them to mop up the battlefield. Tonight I am pleased to report, no ants and the dead have been buried with proper respect.
On the ward today, well I have noticed it over the past week or so. There must have been a sale on jerseys from the Valencia Fussball Klub as there are at least 6 women wearing the same one that says Rinaldinho on the back. It does confuse me as I tend to recognize some of the mothers from their garments. Around noon today, as the kids were getting medication and, at least, a dozen were crying, I was reminded of the word BEDLAM and its origin from the English insane asylum of the same name.
Wednesday was very sad. We did have another death night before last. A one month old that had been discharged 4 days earlier after an episode of what I was convinced was neonatal sepsis. He was treated appropriately and got better, only to suddenly at home have difficulty breathing and high fever. The CO did put him on antibiotics, not the best ones that we have and the child, a few hours later, grew dramatically worse and died. As we have so little to evaluate anyone and as the records are so scanty, it is difficult to put this together. We also have another child that came in forming large blisters on his skin and actually sloughed about 15% on his upper chest and face. I started him on antibiotics believing it was a staphylococcal infection but he did not improve. I then added cortisone on the possibility that it might be pemphigus, usually a disease of older people thought I have seen it in 30 year olds. Anyway it has also been described in children and the child did start getting better. Now sadly I think that he has a bowel infection caused by the antibiotics called Clostridia difficle colitis. Basically the antibiotics kill off the normal flora and this allows the germ to grow as there is now space. This germ secretes toxins that severely damage the colon's wall. There is a good test for the disease but, obviously, it ain't here. So, like I have to do so often, you go with your instincts. What makes it even more difficult is that I have been trying for almost a week to get a good antibacterial cream for him as I consider him as an extensive second degree burn and I finally today got what I wanted. So we shall see but I do not think that he will survive.
Thursday started cloudy but then gradually cleared and about 1300 we got a strong wind and the fine red dust that I so dearly love coated me and everything. I left the camp early as I had to go to a camp consolidation meeting at the UN. I wrote earlier that they were closing Kenembwa and moving the people to Nduta. Well it will start next week when they move the first group. They will go to temporary housing at something called "the reception center", which has always housed new arrivals. Each family will be given building supplies consisting of poles, plastic sheeting and two rolls of sisal rope. They will have but three days to build a shelter and then they will be moved out to make room for the next group. They want to get this done over a month's time. By their estimate that will be about 9000 people. They were given a choice of the move or repatriation back to Burundi and only about 1000 chose to go back. Meanwhile we have only gotten preliminary plans and cost estimates for the renovations that are so necessary. well I do like living with a bit of chaos as you so well know. I have been talking with folks again about my replacement and they appear to now be convinced. I am just waiting for final approval from the country director. Now no ants have been sighted today and no threatening notes have been slide under my door and no bites have been reported by anyone.
Nothing very dramatic today, Friday, as that child that I described yesterday is a bit better. I think I was right about the diarrhea as it is improving today and there are no more new skin lesions. Mother now tells us that another child in the same family had the same illness last year. As there are no reliable records and the story keeps changing, I really do not know what to believe.
Another child we saw with a mild congenital heart problem that is being followed in the regional hospital. The child also has seizures that are not being treated but mother is so focused on the heart that all she can talk about is to go to a Western country to get it fixed. Well I was able to start the child on anti-seizure medication but I so far have not been able to convince mother that the heart has nothing to do with the seizures as she was told that at the regional hospital. She says that she knows some one with the exact same problem who went to Norway and now everything is fixed. Well you know how difficult it to shake something like that. So I will see her again next week.
Well we might be back in the rains. I am not quite sure but today, Friday, at Nduta about 1530 we had a really torrential rain that lasted a good 30 minutes. The kind that causes the drainage ditches to fill like small torrential rivers. The children love it as they then have a new place to play as they go wading through the reddish waters swirling by while mothers look on a bit anxiously lest one of their charges gets washed down stream. The shelters that they live in get rather wet and uncomfortable but they are still so much more stable than the ones back in Darfur. What I find fascinating is the rather narrow swath that these storms seem to take at least at this point. Back at Kibondo there was only a light shower and nothing else. The road is still quite dry and travelable. There are drainage ditches on each side and, every 50 meters or so, there are deep ditches leading from the road to the adjacent fields. So we have not been mired in the mud as yet.
And that has been my week here in Kibondo.
Stephen
Sunday, October 28, 2007
That was the week that was
Well another week has past out here in Kibondo/Nduta. I have decided to focus all my efforts at Nduta for several reasons. The most important is that, with the exception of one clinical officer, there was essentially no interest in learning or changing poor practice habits and I have gotten a bit too old to keep beating my skull against the trees even though it does feel so good each time I stop. Hated to give that up. Also there will be a move shortly ( always up in the air out here) over to Nduta. And there I can assign other duties to those recalcitrant souls as janitorial until they see that obstreperousness, like crime, does not pay.
Last week at Nduta, there was a definite change in attitude. I had written that I had gotten 3 very interested clinical officers. Now they are all coming. I had a different one each day and all were eager to learn. Four of them were a delight to be with. The fifth on Friday was very difficult. She was extremely slow and had a weak fund of skills. Nevertheless she tried and that is really all that I do require. But I was very happy when the long day finished and, unlike some, I needed more than one day to rest. I can only hope that this effort will continue in the six weeks that are left for me here. There were many good teaching problems. The most important one that I have reiterated ad nauseum is that NOT ALL FEVERS ARE MALARIA. Now that does not seem to be too difficult a concept to incorporate but it is. We are in a holoendemic area with stable year round transmission and that, certainly, has to be always in the foreground of one's thoughts but,when all the tests are negative, it just ain't sensible to diagnose "suspected malaria" and leave it at that. You must do a very diligent search for other causes such as pneumonia which is also so very common here. The most sensitive tool we have is counting the respiratory rate as we have no x-ray. Now that is a concept that, like washing hands after every patient, is finally beginning to take root. YIPPEE!!
The case though that I started to write about was a two year old that was sent into the pediatric ward where I spend my teaching days as they are the most vulnerable. She came in with that all too ubiquitous diagnosis of "suspected malaria" and had the negative tests to prove it. Turns out on a more through examination that what she really had was a large foot abscess with a cellulitis half way up her leg. What she needed was not the quinine that had been prescribed but good old cloxacillin and gentamycin and drainage.
We are seeing more malnutrition now. Not in the refugee population as they have a stable food supply from World Food Program but in the Tanzanians. We care also for any of the local host population that comes into our clinic. We are just at the beginnings of the rains though they, after that first few days two weeks ago, essentially stopped again. The fields are being prepared for planting with that so efficient, time-honored, slash and burn method. Periodically from the veranda of my bungalow, I can see plumes of smoke and hear the crackling of the fires and, as we travel back and forth to the camp, we pass through the acrid stench. But planting has not really started and food is getting more expensive here. This is a very poor area and is neglected by the government as it is the home of different clans and the opposition party. We have now several children with marasmus and kwasiorkor and they are very sick.
So my friends that is the way it looks from out here. I have past the half way mark and I have found an excellent physician that I worked with in Thailand to replace me. Now all that has to happen is that they hire her. In my followup note to them after she wrote that she had, as yet, heard nothing, I wrote, "if you let her get away, you definitely need psychiatric assistance".
Stephen
Last week at Nduta, there was a definite change in attitude. I had written that I had gotten 3 very interested clinical officers. Now they are all coming. I had a different one each day and all were eager to learn. Four of them were a delight to be with. The fifth on Friday was very difficult. She was extremely slow and had a weak fund of skills. Nevertheless she tried and that is really all that I do require. But I was very happy when the long day finished and, unlike some, I needed more than one day to rest. I can only hope that this effort will continue in the six weeks that are left for me here. There were many good teaching problems. The most important one that I have reiterated ad nauseum is that NOT ALL FEVERS ARE MALARIA. Now that does not seem to be too difficult a concept to incorporate but it is. We are in a holoendemic area with stable year round transmission and that, certainly, has to be always in the foreground of one's thoughts but,when all the tests are negative, it just ain't sensible to diagnose "suspected malaria" and leave it at that. You must do a very diligent search for other causes such as pneumonia which is also so very common here. The most sensitive tool we have is counting the respiratory rate as we have no x-ray. Now that is a concept that, like washing hands after every patient, is finally beginning to take root. YIPPEE!!
The case though that I started to write about was a two year old that was sent into the pediatric ward where I spend my teaching days as they are the most vulnerable. She came in with that all too ubiquitous diagnosis of "suspected malaria" and had the negative tests to prove it. Turns out on a more through examination that what she really had was a large foot abscess with a cellulitis half way up her leg. What she needed was not the quinine that had been prescribed but good old cloxacillin and gentamycin and drainage.
We are seeing more malnutrition now. Not in the refugee population as they have a stable food supply from World Food Program but in the Tanzanians. We care also for any of the local host population that comes into our clinic. We are just at the beginnings of the rains though they, after that first few days two weeks ago, essentially stopped again. The fields are being prepared for planting with that so efficient, time-honored, slash and burn method. Periodically from the veranda of my bungalow, I can see plumes of smoke and hear the crackling of the fires and, as we travel back and forth to the camp, we pass through the acrid stench. But planting has not really started and food is getting more expensive here. This is a very poor area and is neglected by the government as it is the home of different clans and the opposition party. We have now several children with marasmus and kwasiorkor and they are very sick.
So my friends that is the way it looks from out here. I have past the half way mark and I have found an excellent physician that I worked with in Thailand to replace me. Now all that has to happen is that they hire her. In my followup note to them after she wrote that she had, as yet, heard nothing, I wrote, "if you let her get away, you definitely need psychiatric assistance".
Stephen
Saturday, October 20, 2007
The Operating Theater and Delivery/Gynecology Room
The operating room, an excellent facility for this part of the world, at Kibondo camp. This camp is slated for closure over the next two months and we are debating whether to move the theater to Nduta. against the move is lack of money to construct the facility there and the small number of procedures done, predominantly Cesareans. For the move is the fact that refugees and poor Tanzanians are extremely badly treated at Kibondo government hospital and there have been maternal/infant deaths because of mismanagement as these patients have no money to pay. This despite the fact that they are supposed to be cared for free. facts all too commonly seen out here.
Our delivery/gynecology area is also desperately in need of repair and suffers all the same problems as the rest of the hospital.
Our Hospital
A view of the exterior and interiors of the wards here at Nduta. I have previously described them as decrepit, filthy crumbling, dark. whatever epithet you can think of is appropriate. It is difficult to believe that this could happen even in this setting. Yesterday we went with our logistician and listed what needs to be done. Unfortunately there is not enough money now available so we will do the most critical first and that's a hard decision as everything is so important.
Our Clinic
Views of the OPD and the vaccination area on a typical early morning. The congestion and chaos are startling and have gone on since time immemorial. We are working on ways as I have previously described to improve this situation
The Camp at Nduta
These pictures are from the camp and are typical of the shelters that have been erected here. They are somewhat similar to the structures that the refugees build back at home but are very decrepit, dark and poorly kept up. They have been here for years as this camp is now more than 12 years old. There is little encouragement or incentive to repair and refurbish them as there is always talk of return or movement to other places.
Saturday, October 13, 2007
Rainy season has begun though, fortunately, at this point it is not too intense. Generally there is a brief shower that, at times, becomes intense and sometimes it will last up to 30 minutes. Yesterday though we had no rain and today, so far, is lovely with a bright sun and a cool breeze on our hilltop. It is Saturday and so I am at the base and not down in the camps where it is much hotter. On Wednesday, I had started my training session at Nduta when it began to rain, a few drops at first, pinging on the metal roof of the shelter we were at. Then it turned into a downpour. The noise of the water hitting that roof seemed as if a thousand skeletons were doing a fandango on the roof. I couldn't even hear myself speak so we waited for a bit. As soon as it quieted down, I would begin again and shortly the skeletons picked up the beat and off they went again.
We got word this week that there would be another camp consolidation starting in the next week or two. We have two camps here where we are responsible for the health care, Nduta with about 45,000 and Kenembwa with about 13,000. By the end of the year (2007), Kenembwa will be closed with all the people moved to Nduta. There still is repatriation occurring but that is a slow process at this point with only about 100 - 200 a week returning. So many have no place to go back to and those that try find little infrastructure to support themselves. They are given food for three months and medication, if needed, for the same period and about $100 in cash but most still do not want to leave the security of the camps at this time. Fortuitously I had asked just the day before that we all (ex-pats) get together and think out the changes that needed to be made in the clinics not only to make them more efficient but, more importantly, to deliver better care. we had that meeting yesterday afternoon and did come up with a preliminary plan. The major problems leaving aside clinical care are the congestion and intolerable delay at the registration area as well as at the pharmacy. I have started some changes already in those spots. We are now identifying sick children (adults also) that need to be seen quickly. They are given paracetamol (an antipyretic) and fluids and then brought into a clinician. More needs to be done to expedite this, a work in progress as I all too often have to say. At the pharmacy, I have ordered two compartmentalized containers that will hold prepacked medications the dozen or so that we use frequently. This, hopefully, will eliminate the long delay and crowding there while the pharmacy assistants labouriously count out the pills for each prescription. My next project is to establish a better system for educating patients and their caregivers, instructing them on proper use of the prescribed drugs, possible side effects and a bit about the disease they are afflicted with. Meanwhile I will continue with daily mentoring in the hope of changing some of the rather interesting practice habits that some clinicians have developed. Another of my pet projects is hand washing which is minuscule at best now. I have found only one clinician that does it routinely. Of course, first we have to make sure that the wash buckets have water and that there are soap and towels available.
So that is the way it looks from here at this moment where
the clinic is full and chaotic
the soap missing, the buckets empty
and the clinicians diagnose everyone with malaria.
Stephen
We got word this week that there would be another camp consolidation starting in the next week or two. We have two camps here where we are responsible for the health care, Nduta with about 45,000 and Kenembwa with about 13,000. By the end of the year (2007), Kenembwa will be closed with all the people moved to Nduta. There still is repatriation occurring but that is a slow process at this point with only about 100 - 200 a week returning. So many have no place to go back to and those that try find little infrastructure to support themselves. They are given food for three months and medication, if needed, for the same period and about $100 in cash but most still do not want to leave the security of the camps at this time. Fortuitously I had asked just the day before that we all (ex-pats) get together and think out the changes that needed to be made in the clinics not only to make them more efficient but, more importantly, to deliver better care. we had that meeting yesterday afternoon and did come up with a preliminary plan. The major problems leaving aside clinical care are the congestion and intolerable delay at the registration area as well as at the pharmacy. I have started some changes already in those spots. We are now identifying sick children (adults also) that need to be seen quickly. They are given paracetamol (an antipyretic) and fluids and then brought into a clinician. More needs to be done to expedite this, a work in progress as I all too often have to say. At the pharmacy, I have ordered two compartmentalized containers that will hold prepacked medications the dozen or so that we use frequently. This, hopefully, will eliminate the long delay and crowding there while the pharmacy assistants labouriously count out the pills for each prescription. My next project is to establish a better system for educating patients and their caregivers, instructing them on proper use of the prescribed drugs, possible side effects and a bit about the disease they are afflicted with. Meanwhile I will continue with daily mentoring in the hope of changing some of the rather interesting practice habits that some clinicians have developed. Another of my pet projects is hand washing which is minuscule at best now. I have found only one clinician that does it routinely. Of course, first we have to make sure that the wash buckets have water and that there are soap and towels available.
So that is the way it looks from here at this moment where
the clinic is full and chaotic
the soap missing, the buckets empty
and the clinicians diagnose everyone with malaria.
Stephen
Friday, October 12, 2007
Getting to know you, getting to know all about you.
Out on the trail for a walk, you are greeted by myriads of children, all wanting to touch you. They greet by clenching a fist and touching yours while calling, "tanu, tanu". I startled them initially by clicking my tongue, eliciting bursts of giggling especially among the girls. Now though there is a cultural shift as they have started doing the very same. The real test is how long it will last.
Stephen
Saturday, October 6, 2007
Here we go again!
Well my first complete week at the clinics has passed. I guess I really have a very short attention span or I am just a bit dumb as I seem to quickly forget just how difficult it is to change habits. Evidently there has been little, if any, clinical supervision by an expat physician for a very long time. No one can give me any definition of "a very long time". In my last post I mentioned some of the problems that I came across in my first two days. Working in the pediatric OPD at Nduta, I watch a clinical officer diagnose and prescribe without once examining a patient. A florid case of scabies was diagnosed as a reaction to worms and prescribed the appropriate treatment for helminths but, alas, it won't do much for scabies. When I said that that was the diagnosis, I got an incredulous look and little else.
I did find one clinical officer, retired military, that was eager to learn and became very excited about starting a triage system to identify the very sick children and get them treated quickly with fluids and paracetamol and into a clinician. We actually did set the system up and on Monday, I will return to Nyduta to see if it is working.
At Kenembwa, very little success, in fact the attitude was frankly depressing. Enough so, that I was very happy when my ride back to base showed up in the late afternoon. I will go back and see what their attitude will be next week.
There is a project starting to monitor respiratory illness, part of a surveillance for Avian Influenza. I was asked by the coordinator for this project about the state of infection control awareness at our facilities. Sadly it was a very easy answer, none. Just the idea of hand washing, something so basic, is rarely practiced. I have written about that before. Well if I can get the triage system working and some hands washed, why then, I will have done something.
The high point of the week was a visit to the International Organization for Migration (IOM). What one can accomplish when there is an abundance of money available. Their task is to screen and treat those refugees that are going for resettlement in other, usually Western, countries as America, Australia, Canada, Scandinavia. I had "the tour". A wonderful laboratory, an x-ray unit for chest x-rays but it could take abdominal and bone films. A fully stocked pharmacy that made me drool. The refugees are screened by expat doctors. There are no clinical officers there. We can utilize occasionally their facilities, essentially the x-ray unit and that is helpful as they are close at hand just outside of Kenembwa.
Sunday is now winding down. we did get some thunder and lightening last night and a brief sprinkle this afternoon. Not enough to dampen down the incessant clouds of fine red dust that coat everything but just a taste of what is brewing. We will have a few good dust free days and then mud season begins. Those of us in Maine are familiar with that as it is our Spring.
And that's the way it looks from here in Kibondo where
the dust abounds
the rains threaten
and I hope to get people to wash their hands.
Stephen
I did find one clinical officer, retired military, that was eager to learn and became very excited about starting a triage system to identify the very sick children and get them treated quickly with fluids and paracetamol and into a clinician. We actually did set the system up and on Monday, I will return to Nyduta to see if it is working.
At Kenembwa, very little success, in fact the attitude was frankly depressing. Enough so, that I was very happy when my ride back to base showed up in the late afternoon. I will go back and see what their attitude will be next week.
There is a project starting to monitor respiratory illness, part of a surveillance for Avian Influenza. I was asked by the coordinator for this project about the state of infection control awareness at our facilities. Sadly it was a very easy answer, none. Just the idea of hand washing, something so basic, is rarely practiced. I have written about that before. Well if I can get the triage system working and some hands washed, why then, I will have done something.
The high point of the week was a visit to the International Organization for Migration (IOM). What one can accomplish when there is an abundance of money available. Their task is to screen and treat those refugees that are going for resettlement in other, usually Western, countries as America, Australia, Canada, Scandinavia. I had "the tour". A wonderful laboratory, an x-ray unit for chest x-rays but it could take abdominal and bone films. A fully stocked pharmacy that made me drool. The refugees are screened by expat doctors. There are no clinical officers there. We can utilize occasionally their facilities, essentially the x-ray unit and that is helpful as they are close at hand just outside of Kenembwa.
Sunday is now winding down. we did get some thunder and lightening last night and a brief sprinkle this afternoon. Not enough to dampen down the incessant clouds of fine red dust that coat everything but just a taste of what is brewing. We will have a few good dust free days and then mud season begins. Those of us in Maine are familiar with that as it is our Spring.
And that's the way it looks from here in Kibondo where
the dust abounds
the rains threaten
and I hope to get people to wash their hands.
Stephen
Saturday, September 29, 2007
The Clinics
Once again a Saturday and a bit of time to write about the past week though it has been frustrating to try to do this. The Internet is being very temperamental as our services have been cut down by our country director in Dar es Salaam because of supposed excessive use and that curtails everything from the Blog to contacting colleagues, and creating appropriate treatment guidelines. Yet it still works albeit very very slowly. I suppose that I should not really complain though I will. In Darfur, the government would shut us down for days on a whim though usually it was when they were planning to do something stupid. So we always had a pretty good idea of when an attack was coming. Anyhoo our field coordinator hopes to have this resolved next week as he,too, can not get his work done.
I spent Monday and Tuesday, getting my work permit/pass authenticated and then signed in each camp. I was given "The Grand Tour" and introduced to many people so that, hopefully, when I did reappear I would be recognized. I spent 2 days in Nduta which is the busiest and most chaotic with about 40,000 refugees and Friday at Kanembwa, which has only about 13,500 at present. Repatriation is ongoing but the number has dwindled down dramamtically as the earlier returnees pass back messages of no services, lost lands and general instability. There have also been some fighting. It is considered minor but, for me, the appearance of armed people is major whether or not shots are fired.
I got more than I expected on my first few days. At Nduta, we were so busy that I had to do rounds on the pediatric ward and I could not observe anyone. There was sadly the usual crowding with 2 children/bed but, by the end of Thursday, there were enough discharges that we did get down to only one/bed with even a few open spots. At Kenembwa, I made rounds with the physician and then spent a bit of time in the OPD with one of the clinical officers, sort of a P.A. by our definition. The task of trying to change things will be Herculean as there just is so much amiss here from basic handwashing between patients to misuse of antibiotics to a general lack of knowledge of pathophysiology and even appropriate diagnosis. The doctor never washed her hands except at the end of ward rounds even after examining a woman with open Herpetic lesions. AT least she did wear gloves when doing a proceedure though one of the midwives was about to start an IV without them when I intervened. I suppose the most comical really saddest sights was the clinical officer trying to get a blood pressure on an adult patient with a pediatric cuff. It kept popping off as it was just too small. I asked him if he had a bigger size. He replied, "yes" and continued on.
I tried to start a teaching program with a session at each camp. They were used to having one on Wednesday at Nduta and on Friday at Kanembwa. I just could not get them together at either camp as they said they had not been given advanced notice. Well I gave it to them for next week and we will see what happens. Unlike Pip, I do not have "Great Expectations".
I spent Monday and Tuesday, getting my work permit/pass authenticated and then signed in each camp. I was given "The Grand Tour" and introduced to many people so that, hopefully, when I did reappear I would be recognized. I spent 2 days in Nduta which is the busiest and most chaotic with about 40,000 refugees and Friday at Kanembwa, which has only about 13,500 at present. Repatriation is ongoing but the number has dwindled down dramamtically as the earlier returnees pass back messages of no services, lost lands and general instability. There have also been some fighting. It is considered minor but, for me, the appearance of armed people is major whether or not shots are fired.
I got more than I expected on my first few days. At Nduta, we were so busy that I had to do rounds on the pediatric ward and I could not observe anyone. There was sadly the usual crowding with 2 children/bed but, by the end of Thursday, there were enough discharges that we did get down to only one/bed with even a few open spots. At Kenembwa, I made rounds with the physician and then spent a bit of time in the OPD with one of the clinical officers, sort of a P.A. by our definition. The task of trying to change things will be Herculean as there just is so much amiss here from basic handwashing between patients to misuse of antibiotics to a general lack of knowledge of pathophysiology and even appropriate diagnosis. The doctor never washed her hands except at the end of ward rounds even after examining a woman with open Herpetic lesions. AT least she did wear gloves when doing a proceedure though one of the midwives was about to start an IV without them when I intervened. I suppose the most comical really saddest sights was the clinical officer trying to get a blood pressure on an adult patient with a pediatric cuff. It kept popping off as it was just too small. I asked him if he had a bigger size. He replied, "yes" and continued on.
I tried to start a teaching program with a session at each camp. They were used to having one on Wednesday at Nduta and on Friday at Kanembwa. I just could not get them together at either camp as they said they had not been given advanced notice. Well I gave it to them for next week and we will see what happens. Unlike Pip, I do not have "Great Expectations".
Sunday, September 23, 2007
Wednesday, September 19, 2007
That was the week that was.
Once again, a Saturday and the weekend.
Last weekend, my first out here, we went to the UN compound Saturday night to partake of their bar and disco.
My, they do live well here and indeed in all the UN living sites I have been very impressed at the way that they care for themselves. Enough so that I did once inquire about a position. But, as they are mainly administrative, I let that drop.
Sunday we took a long walk to a small mountain called the Mump. Exactly what that denotes, I have to find out. Found out later in the week that it is just a nickname that it got as someone thought that it, sticking up out there, looked like a child with unilateral mumps. Along the way we encountered the usual gaggle of children running out from the little clusters of homes to greet and walk with us as we were the only entertainment about. The children have a unique greeting that I had not seen before. They approach calling "tene, tene" with their fist extended and then touch your fist gently. I startled them by either clicking my tongue when touching or by singing "ding-dong". Soon they were doing it and on the way back they were still doing it. I'll find out this weekend whether I have shifted the culture here.
The rest of the week, I have spent rewriting the outdated treatment protocols. So far diarrhea and respiratory illness have been done and I am now in the midst of malaria. Those are the major causes of morbidity and mortality in all the places that I have been and this is no exception. After that I will start on the less common diseases but I need to get to the clinics to see exactly what is occuring now.
Now another Saturday morning and I did finally get the precious document that will allow me to get my camp pass on Monday after I visit the various offices and officials that abound in every bureaucratic system. With a bit of luck, I might even get into a camp in the afternoon, though I suspect that Tuesday is more likely. As usual I had to threaten to resign to stir things a bit and get this. I had almost gotten in the mindset of knocking on the door at home and surprising Gerda. Not such a good idea at our ages.
I did finish the malaria protocol and now will begin on some others to pass the weekend. Last weekend, I did learn how to use the digital camera that our son, Jan, gave me and to get the pictures onto Snapfish. Now I will try to get them onto this Blog.
That's the way it looks from here.
Stephen
Last weekend, my first out here, we went to the UN compound Saturday night to partake of their bar and disco.
My, they do live well here and indeed in all the UN living sites I have been very impressed at the way that they care for themselves. Enough so that I did once inquire about a position. But, as they are mainly administrative, I let that drop.
Sunday we took a long walk to a small mountain called the Mump. Exactly what that denotes, I have to find out. Found out later in the week that it is just a nickname that it got as someone thought that it, sticking up out there, looked like a child with unilateral mumps. Along the way we encountered the usual gaggle of children running out from the little clusters of homes to greet and walk with us as we were the only entertainment about. The children have a unique greeting that I had not seen before. They approach calling "tene, tene" with their fist extended and then touch your fist gently. I startled them by either clicking my tongue when touching or by singing "ding-dong". Soon they were doing it and on the way back they were still doing it. I'll find out this weekend whether I have shifted the culture here.
The rest of the week, I have spent rewriting the outdated treatment protocols. So far diarrhea and respiratory illness have been done and I am now in the midst of malaria. Those are the major causes of morbidity and mortality in all the places that I have been and this is no exception. After that I will start on the less common diseases but I need to get to the clinics to see exactly what is occuring now.
Now another Saturday morning and I did finally get the precious document that will allow me to get my camp pass on Monday after I visit the various offices and officials that abound in every bureaucratic system. With a bit of luck, I might even get into a camp in the afternoon, though I suspect that Tuesday is more likely. As usual I had to threaten to resign to stir things a bit and get this. I had almost gotten in the mindset of knocking on the door at home and surprising Gerda. Not such a good idea at our ages.
I did finish the malaria protocol and now will begin on some others to pass the weekend. Last weekend, I did learn how to use the digital camera that our son, Jan, gave me and to get the pictures onto Snapfish. Now I will try to get them onto this Blog.
That's the way it looks from here.
Stephen
Sunday, September 16, 2007
Pictures
I have posted some pictures on Snapfish. If you have any interest in them, send me an e-mail and I will forward them to you.
Stephen
Stephen
Wednesday, September 12, 2007
In The Bush
I am finally here in Kibondo. We left Dar es Salaam early in the morning on the 12th. First a commercial flight to Mwanza, a city on the southwestern shore of Lake Victoria. From there we took a UNHCR plane, a Caravan, the bush plane. Room enough for 10 and a bit of lugagge. Fortunately there were two no-shows so that we were able to get a bit extra on board. We were supposed to take only 10 kilos each but I had 22 and still left some back in Dar. Getting on that plane rekindelled my excitement about being here in Africa again, especially as we flew over that familiar landscape. This included a good portion of the Lake which is always breathtaking. We landed in Kibondo and then a 20 minute drive to the compound, again through the landscape that I am so fond of.
The compound here is very large and situated on a hill. I have a bungaloo which faces south. The Burundian border is northwest of us, about 10 kilometers distant. A private shower with hot water twice a day. We arrived shortly before lunch which was excellant and we get 3 meals a day every day. So there goes my African diet plan. This is a bit more like Club Med. and a nice change from other places that I have been.
So far my camp pass that allows me into the refugee camps has not arrived. Hopefully that will not be long as I have been granted (so I am told) my medical license and my exemption which allows me to stay in the country for a year. Those two documents are needed and then the camp pass is automatic. Meanwhile I will review the "essential drug" list and be sure it is accurate. Then, evidently, the treatment guidelines are very out of date and need updating and standardizing so that I should have enough to do for the next few days.
Now it is Saturday, the 15th. and so far I have designed forms for the in- and outpatient departments as well as developed a diarrhea protocol. Actually WHO did that and I creatively borrowed much of it. What remains to do are prot9ocls for malaria and respiratory tract infections. There will be more but these are the most important causes of morbidity and mortality in this setting. What is difficult for me to comprehend is that we (IRC) have been here delivering health care for at least 10 years and this has not been kept up to date.
We went into the "big city" of Kibondo today and it is the same as so many rural African cities. This, being dry season, there was a swirl of red dust every time a vehicle past. You learn to gauge the direction of the wind very quickly. We went into the central market where everything is sold and went to the "supermarket". One room but, evidently, the proprietor just got a shipment of goods, the first in three months. All my favorites were there and I did get a few packages of tea biscuits. The ubiquitous cheese, "la vache qui rie". was there. It exists, like coke. in the most remote places. I even saw a small bottle of my buddy, Jack Daniels.
The weather is wonderful. Cool at night and in the morning until about 1100 then it warms up but not that fierce heat that I have experienced in other places. I have taken pictures of the area and our compound and will try to post them. Hopefully I will get my camp pass in the next few days and be able to be more helpful to all.
And that's the way it looks from here.
Stephen
The compound here is very large and situated on a hill. I have a bungaloo which faces south. The Burundian border is northwest of us, about 10 kilometers distant. A private shower with hot water twice a day. We arrived shortly before lunch which was excellant and we get 3 meals a day every day. So there goes my African diet plan. This is a bit more like Club Med. and a nice change from other places that I have been.
So far my camp pass that allows me into the refugee camps has not arrived. Hopefully that will not be long as I have been granted (so I am told) my medical license and my exemption which allows me to stay in the country for a year. Those two documents are needed and then the camp pass is automatic. Meanwhile I will review the "essential drug" list and be sure it is accurate. Then, evidently, the treatment guidelines are very out of date and need updating and standardizing so that I should have enough to do for the next few days.
Now it is Saturday, the 15th. and so far I have designed forms for the in- and outpatient departments as well as developed a diarrhea protocol. Actually WHO did that and I creatively borrowed much of it. What remains to do are prot9ocls for malaria and respiratory tract infections. There will be more but these are the most important causes of morbidity and mortality in this setting. What is difficult for me to comprehend is that we (IRC) have been here delivering health care for at least 10 years and this has not been kept up to date.
We went into the "big city" of Kibondo today and it is the same as so many rural African cities. This, being dry season, there was a swirl of red dust every time a vehicle past. You learn to gauge the direction of the wind very quickly. We went into the central market where everything is sold and went to the "supermarket". One room but, evidently, the proprietor just got a shipment of goods, the first in three months. All my favorites were there and I did get a few packages of tea biscuits. The ubiquitous cheese, "la vache qui rie". was there. It exists, like coke. in the most remote places. I even saw a small bottle of my buddy, Jack Daniels.
The weather is wonderful. Cool at night and in the morning until about 1100 then it warms up but not that fierce heat that I have experienced in other places. I have taken pictures of the area and our compound and will try to post them. Hopefully I will get my camp pass in the next few days and be able to be more helpful to all.
And that's the way it looks from here.
Stephen
Saturday, September 8, 2007
Still Here
After many perhaps and possibilities, I could not get a flight out to Kibondo as yet. It seems that there is only one airline and one daily plane that holds only 30 people. So I remain ensconced in a rather luxurious hotel. On Friday two more expats came in so I do have company. They will go out to Kibondo with me whenever we can get on the flight.
Saturday we spent droodling about Dar es Salaam (which means, "House of Peace" in Arabic"). We got a tour of the city past the elegant parts where the rich and diplomats live, by the harbor which is lovely, by the fish market though we knew that place about a kilometer away as we were down wind of it and finally through a few of the upscale shopping plazas. We did get to the National Museum which is sad compared to the one in Nairobi. The most interesting parts were the actual skull of Zinjanthropus (Australopithecus Boisei) 1.6 million years old found by Louis Leaky in Olduvai in 1959. Then there were the actual earliest footprints of hominids, 3.6 million years old, found by Mary Leaky at Laetoli. Other bits were a review of Tanzania history from the Neolithic through Independence with the usual panegyrics to the first president, Julius Nyerere. He was a committed socialist who tried to establish collectives though he called them, Cooperatives. That ruined the economy for decades. The idea was excellent but the implementation disastrous. There was also an exhibit of the Duong, a sea mammal somewhat akin to the Manatee that is endangered here. It has the shape of a Manatee but a face more like a pig's. It is evidently the creature that gave rise to the myth of the mermaid not only because of its looks but also as its call is similar to a woman crying.
Our next stop was at the Botanical Garden which was in sad disrepair. The best feature was the myriad peacocks and peahens that were wandering about looking very insouciant. There a bus full of children also visiting and we were more exotic to them than the birds. They were polite and curious except for the one wag, always a bit older and male who would mouth his few words of English, ask for money and then say something in Kiswahili to make the others laugh nervously.
Back at the room at night, I wandered through the 60 or so channels on the TV. Except for ESPN, BBC and would you believe Hallmark Playhouse from decades ago, there were only Bollywood movies, Arabic news and Indian rappers. By happenstance, there was a feature on Stanley's discovery of Livingstone.
Today we will visit something called the Village Museum which has a multitude of traditional living huts as well as music and dancing.
And so the weekend will go and hopefully we can move on tomorrow and start work, the reason I decided to come out here.
Stephen
Saturday we spent droodling about Dar es Salaam (which means, "House of Peace" in Arabic"). We got a tour of the city past the elegant parts where the rich and diplomats live, by the harbor which is lovely, by the fish market though we knew that place about a kilometer away as we were down wind of it and finally through a few of the upscale shopping plazas. We did get to the National Museum which is sad compared to the one in Nairobi. The most interesting parts were the actual skull of Zinjanthropus (Australopithecus Boisei) 1.6 million years old found by Louis Leaky in Olduvai in 1959. Then there were the actual earliest footprints of hominids, 3.6 million years old, found by Mary Leaky at Laetoli. Other bits were a review of Tanzania history from the Neolithic through Independence with the usual panegyrics to the first president, Julius Nyerere. He was a committed socialist who tried to establish collectives though he called them, Cooperatives. That ruined the economy for decades. The idea was excellent but the implementation disastrous. There was also an exhibit of the Duong, a sea mammal somewhat akin to the Manatee that is endangered here. It has the shape of a Manatee but a face more like a pig's. It is evidently the creature that gave rise to the myth of the mermaid not only because of its looks but also as its call is similar to a woman crying.
Our next stop was at the Botanical Garden which was in sad disrepair. The best feature was the myriad peacocks and peahens that were wandering about looking very insouciant. There a bus full of children also visiting and we were more exotic to them than the birds. They were polite and curious except for the one wag, always a bit older and male who would mouth his few words of English, ask for money and then say something in Kiswahili to make the others laugh nervously.
Back at the room at night, I wandered through the 60 or so channels on the TV. Except for ESPN, BBC and would you believe Hallmark Playhouse from decades ago, there were only Bollywood movies, Arabic news and Indian rappers. By happenstance, there was a feature on Stanley's discovery of Livingstone.
Today we will visit something called the Village Museum which has a multitude of traditional living huts as well as music and dancing.
And so the weekend will go and hopefully we can move on tomorrow and start work, the reason I decided to come out here.
Stephen
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