Malaria Season

Fri, 7 Dec 2007 19:43:08 +0200

Every night before I go to bed I crawl under blue mesh hanging from my ceiling for one reason only...to prevent a mosquito from injecting Plasmodium falciparum, the malaria parasite, into my bloodstream.

Sadly, thousands of children in Malawi don’t yet have a mosquito net and get infected with malaria over and over again. Children lack the gradual immunity adults eventually build.

The rains have started now bringing a beautiful carpet of green to the landscape and hopes of an overflowing harvest. Though with it come countless mosquitos hatching in the brackish pools of water collecting along the roads and in the fields.

25-40% of hospital admissions this time of year are malaria, if not higher in pediatrics. It is amazing to see one child with fever and pasty anemia after another flow into the ward. Mother and children crowd the boxcar bays of patients, often sitting on floors or 3 children to a bed so that everyone may have a roof over the head from the rains. There are no private rooms, no playroom, no 4:1 nursing that’s for sure! Mothers line up in the morning as nurses shout names in order to make a match and administer the right medication. Many children die of severe anemia before they make it to a hospital where transfusions are available.

Earlier this week I joined the regular ward team in order to help care for this constant flow of anemic toddlers. I volunteered to work in the Treatment Room or “Opisthotonus Room” as I have nicknamed it.

Opisthotonus is a horrible condition where the child’s head and back are arched backward in spasm, in this case due to meningitis or cerebral malaria. The room is full of ‘em. Many moan or froth foam as hopeful mothers fan them cool. I go from one child to the other looking for signs of improvement as we treat their malaria with quinine and their meningitis with antibiotics.

Once the malaria parasite has gotten to the point where it has clogged the blood vessels supplying the child’s brain, you cannot help but wish something was done earlier to prevent this miserable state. In fact a simple piece of mesh would have done.

This holiday season consider adding an insecticide-treated mosquito net to your shopping list. The Canadian Red Cross is active in their disbursement in the region. Click here to donate. Select the “Campaign Against Malaria”.

Dusk in zomba

Thu, 29 Nov 2007 20:54:27 +0200

I LOVE dusk in Zomba! There are a couple of large rocks in my front yard where I’ll sit and simply soak it all in. A perfect decompression for a busy day in the clinic.

One of my favorite sights are the nurses in uniform marching single file through their corn field on their way home. It strikes me as visual poetic commentary, of what I do not know,

Of course the sunsets are always worth catching....

And taking part in the neighborhood soccer romp can’t be missed...

Anyone over 3 feet absolutely schooled me in soccer! I need lessons quick.

A Reunion to remember

Sat, 17 Nov 2007 20:32:22 +0200

My friend and fellow AIDS Corps doctor Janell is a seasoned honorary Malawian. She first came to Malawi as a Peace Corps volunteer in 1993, living in the lakeside village of Pondasi.

I always love hearing Janell talk about her Peace Corps days. Who wouldn’t? Former PC volunteers always have the best stories, usually involving getting stranded somewhere or horrible cultural misunderstandings rooted in crossed translation. She has her share of those, but most touching of all are her memories of Jeffrey. He was her cook and housekeeper for 2 years while she taught English in the village school. He was such a nice guy that he would start her dinner and then wipe away his footprints leading up to her house so that she would be surprised at the gesture. A+ kind of guy for sure.

So when Janell invited me to go to her village and meet Jeffrey I jumped at the opportunity to document this 14 year reunion.

By now Jeffrey would be an old man. We didn’t even know if he would still be alive. But sure enough, after a short walk with the village headwoman, we crossed a sun burnt courtyard to his grass-thatched home. Jeffrey was there! After a shriek of joy from Janell, I was choked up...along with half the village! For Janell is a Pondasi rockstar. She brought them electricity in 1994 for the first time.

Holding hands with the Village Headwoman

Jeffrey and Janell reunite!

The electricity Janell helped bring as a Peace Corps volunteer

Zomba: My new home

Wed, 14 Nov 2007 19:41:38 +0200

This week I moved to my new home in Zomba, located in the south-eastern part of the country at the base of a 7000 ft plateau. Zomba is one of the 3 “remote outreach” sites Baylor supports in addition to Blantyre (also in the South) and Mzuzu in the north. I visited shortly after my arrival to Malawi and was instantly drawn to the beautiful landscape and community-level HIV outreach efforts going on.

Shutterbug driving south to Zomba

Zomba is the former capital of what was colonial Nyasaland back in the days of the Brits. With government subsequently moving out to Lilongwe and Blanytre, the town quieted down though remains home to Chancellor College and the National Archives. The population of Zomba District benefits from the health efforts of Dignitas International, a Canadian NGO and off-shoot of MSF that is dedicated to HIV care delivery. Dignitas is our main partner in Zomba with an impressive community-based care model.

Keep ‘em in mind if your looking for a great organization to support.

I also work with a German pediatrician named Charlotte who is quite possibly the most overworked pediatrician I have ever met! Simply amazing. Earlier this week there were 411 children on the pediatric ward at Zomba Central Hospital, all cared for by a cadre of clinical officers and Charlotte. As now the SECOND pediatrician for a catchment area of 2 million people, (My catchment are for HIV training extends from Zomba north to the Cape McClear peninsula on Lake Malawi.) I try to help her out on the ward when I can, which frankly doesn’t seem like much compared to the immense need.

Most of the time I either work clinically delivering medical care to HIV-positive children at the Antiretroviral Clinic operated by Dignitas or I join them in outreach visits to smaller health centers in order to build the comfort of healthcare workers in caring for children.

You see, delivering HIV medications for adults is relatively straight forward. One pill in the morning, one at night. Watch for X, Y, Z side effects and make sure the patient takes the medication each and every day to avoid resistance. Children get tricky. You have to cut pills, make sure they don’t spit it up, gauge when it’s time to tell them they are HIV-positive and always be on the lookout for subtle signs of side effects. This makes many community-level providers nervous such that they either don’t see children or simply treat them as small adults. That’s where I try to come in and help. There are only 2 lines of defense in treating HIV in Malawi. Added pressure to get it right the first time.

After work it’s a 10-minute walk home. Just across the corn field from the Mental Hospital is my new “nyumba” (home)! What sounds less than appealing is actually a front row seat to the natural beauty of the Zomba Plateau...

Front yard with rain cloud surrounding the plateau

Hiking through the grassland on top of the plateau

View from Chingwe’s Hole towards the Shire River Valley

Safari Break

Mon, 5 Nov 2007 16:02:52 +0200

This past weekend four of us took a long weekend break from medicine to go on safari in South Luangwa National Park, Zambia. I had been there twice before when living in Zambia in 2003/2004 and was itching to return. What used to be a lesser-known park known to Zambians only, has now become a premier safari destination in Southern Africa. It’s only a 5 hour drive from Lilongwe, so we piled into Chris’ truck and headed west.

After a 1.5 hour drive we made it to the Mchinji border crossing. With little economic trade between the two countries by comparison to other nations, the border was very quiet and quick to cross. You then pass into Chipata, Zambia where you turn north and begin a 3 hour trek down a jarring dirt road to South Luangwa. Fortunately the engine held together and despite a small fuel leak we arrived in good style.

The first thing you notice arriving into the Luangwa River Valley is that it is HOT, HOT, HOT. High temperatures this time of year are consistently 100-110 degrees. Though this might not seem ideal on the face of things, the lack of water during the hot season causes the animals to congregate and make for great safari viewing.

While in the valley we stayed at Flatdogs Camp (www.flatdogscamp.com) near the park entrance. The 4 of us stayed in 2 en-suite tents right on the river bed. Taking a nap while looking out at hippos and elephants crossing the river made you feel as if you were in the middle of a National Geographic special.

Twice a day, morning and dusk, we hopped in the Land Cruiser to go on game drives. We were incredibly lucky spotting a juvenile leopard only an hour into our first drive.

From there on out it was a one amazing sight after another:

Everyone’s Favorite Pachyderm

Carmine Bee-Eaters

Lion cub at night

Sunset in the Luangwa Valley

Driving (MIS)Fortune

Thu, 1 Nov 2007 15:51:31 +0200

Driving in Africa always seems to be an adventure. You generally want to avoid driving at night when narrow roads and lack of street lights make it a harrowing ordeal.

Today Janell and I were leaving Blantyre on the road to Lilongwe in her mighty Land Rover, when suddenly we lost acceleration and heard something flapping beneath our seats. We pulled off the road onto the gravel wayside. Crawling beneath the vehicle I noticed nearly the entire network of electrical wires snapped and wrapped tightly around the drive shaft. Problem identified!

With no way to fix it we called our official Problem Solver Extraordinaire, Tassy, at the Lilongwe Clinic for help. She phoned our mechanic friend, Jeremy, who just happened to be headed south only 30 minutes away from where we were stranded. Sure enough, we bought a cold Coca-Cola from the market to pass time and before you knew it, he was there with 2 fellow mechanics. Soon enough, the Rover was purring again and we were off.

Sometimes fortune smiles down on you.

Diagnosing the babies

Tue, 30 Oct 2007 15:35:37 +0200

Part of the challenge of treating children with HIV in Africa is knowing if they are infected in the first place. Rapid tests are most widely available, even in the smallest of health centers, though they cannot be used to reliably tell if a child under 18 months of age is infected. Waiting until an infant becomes clinically severely immunocompromised can flirt with near death.

That is about to change.

A partnership between UNICEF, Clinton Foundation and Ministry of Health is working with Baylor-Malawi to implement specialized HIV testing (PCR) for these little ones.

Today Janell and I headed to Chikwawa, a town south of Blantyre in the hot Shire River Valley. I have never in my life met a more pleasant group of healthcare workers while working in very difficult conditions of high healthcare need among the population. They make every worry I fretted about during residency seem trivial in comparison. Every person, whether it be nurse, HIV counsellor, midwife or clinician, holds about 3 jobs so that a host of individual and public health services can be provided.

They are Medical McGyvers.

Each introduction was started with a smile and “You are most welcome.” Our conversations were punctuated by the sounds of creaking ceiling fans, bleating goats outside the window and the cries of infants wanting to feed. Staff candidly shared their strengths, limitations and how they envisioned improving the care they provide if afforded more resources.

I hope we deliver.

Patient Story: Daniel

Mon, 29 Oct 2007 15:12:04 +0200

Daniel is a 17-year old with AIDS. We’re not sure how he became infected. His mother is negative. Maybe it was a blood transfusion.

Daniel has Kaposi Sarcoma or KS for short. KS is a type of cancer that was well described at the start of the AIDS epidemic in the United States. All the while it had been occurring in Africa as well. Sometimes it can be mild and localized to the skin. Other times, as is the case for Daniel, it can be invasive and involve the internal organs.

But let me not make the ultimate flaw in medicine and define Daniel by his disease. You see, he is a bright and forward-thinking teenager who helps support his family by selling kerosene along the roadside. If his legs cooperated better he would be playing soccer, a favorite hobby. His mother is quiet, reserved and very dedicated to his care though at times overwhelmed by the prospect of paying for a bus ride to see me once a week.

Daniel has had tuberculosis, malaria, shingles and now KS invading his lungs. More than his fare share! Though I cannot offer him a cure, I hope treating his HIV and providing him with what chemotherapy I can, he will be comfortable. Despite all this, he manages a “thumbs up” each time we meet.

When I reflect on the big picture of children living with HIV and AIDS, I see Daniel as the cost of inaction. So much of what he has endured is now wholly preventable. He is an inspiration that if we remain optimistic with our thumbs up, we can hope for a bright and equitable future for African children.

My new mask

Sun, 14 Oct 2007 19:01:08 +0200

Today I travelled back to Mua Mission with co-workers Amy, Carrie and a visiting emergency medicine doc named Sue. You may recall from an earlier post, Mua is an artisan center, specializing in wood carvings. There are tons of amazing works there for sale. With my upcoming move to an empty home in Zomba I figured it was time to shop.

Well, perhaps I wasn’t expecting to find a carved version of Don Rickles but it made me laugh! So, from now on...good ‘ol Don will be gracing my home!

On a separate note...here’s a picture of a cool lizard I found in my front yard at dusk.

I think he’s squinting from the flash.

Malnutrition to Mumps

Thu, 11 Oct 2007 20:20:33 +0200

This past week has been “crunch time” at the Lilongwe clinic. Many of my colleagues are away at a meeting in Swaziland, while myself and several others remain in Malawi to hold down the fort. It has been extremely busy, but a great opportunity to become more comfortable with HIV medicine just the same.

One of the very common ailments we see every day, though I doubt I can ever become very comfortable with, is child malnutrition. Malawi is the 4th poorest country in the world, so it is no surprise children go hungry. An estimated 49% of children under-5 are malnourished. This is dramatically worsened by HIV infection and malnourished children are far more likely to get life-threatening infections.

Today I saw a 3 year old who weighs 6kg, or about 14 lbs.

Yesterday I saw an 18-year old who weighs 20kg or 44lbs.

As malnutrition and hunger worsens, the body begins to slow in order to save precious energy. The mind and heart beat slower, energy to move subsides and a glazed look waves over the eyes while piercing your soul.

In order to help each hospital has an NRU or nutritional rehabilitation unit which provides therapeutic food to slowly and safely regain weight. Better yet, we hope to prevent children from reaching that stage by providing outpatient foods to the at-risk. My colleagues, Anjalee and Maria, have done a lot of great work in getting a program going at the Lilongwe clinic to do just that.

That being said, the problem at the root of it all remains: poverty.

Today I also saw a children with mumps, a condition where the glands around the ear and jaw swell to impressive proportions. It is rare in the States thanks to the MMR vaccine which prevents infection with the mumps virus.

Not nearly as serious as malnutrition, mumps shares the distinction of being totally preventable. We often talk so much about “the next great discovery”. Cure for cancer. New Alzheimers treatment. Gene therapies. These are the concepts which drive the great academic medical centers of North America and Europe. The fact remains we already have discovered and know SO MUCH. We are simply failing to translate this into action.

In the past 2 centuries the world population has increased over 6-fold, now up to 6 billion people. Life expectancies have boomed in the developing world thanks to hygeinic living conditions and simple healthcare measures. Here in Sub-Saharan Africa, however, life expectancies are locked in the mid-30s. So much of this is preventable.

In the U.S., there are somewhere around 60 children born each year with HIV. We have the capability, through medication, to drop a mother’s chance of passing the virus on to her baby from about 30% to 2%. Last year an estimated 30,000 children in Malawi where born with HIV!

Statistics can be impressive but it is the stare of starvation that makes you want to shout WHY?