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

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.

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

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

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