Experiences of a med student with an incurable travel bug.

Archive for the ‘Global Health’ Category

The Editors

For anyone who hasn’t heard, I found out who we have to thank for the Pope’s recent condom condonation:

Great work, guys! Keep it up, you’ve certainly got your work cut out for you!

Condoms are OK!

…at least to stop the spread of AIDS, according to the Pope. In any other situation they’re still prohibited.

*sigh*

Well, it’s a start. This a huge improvement from last year when he declared that “condom use did not help prevent the spread of AIDS, only abstinence and fidelity did” — a scientifically disproven fact, by the way. Condom use can, in fact, significantly reduce the spread of HIV infection, which can develop into AIDS, in both men and women. (“A critical look on condoms,” Kigbu and Nyango, Niger J Med 2009, Oct-Dec; 18(4):354-9)

Cholera Sucks

Today’s lectures explored the variety of nasty little bacteria that are infamous for their ability to ravage the intestinal tract. Diarrhea, dysentery, typhoid fever, plain old food poisoning, and my personal favorite — cholera.

My avid fans (all two of you) may remember that I got really sick in Laos while traveling this summer. Looking back on that post I realize how much I downplayed my illness, mostly to prevent panic of those back home. Now that everyone knows I made it home safe and healthy, I’ll divulge the dirty details from that experience in a bit. (Those of you not morbidly amused by disgusting things may want to skip the descriptions.)

Anyway, as we watched and listened to the “bug parade”, as our prof called it, of all the little nasties that make you sick to your stomach, I was trying to guess which one made me sick in Laos. The standard traveler’s diarrhea caused by E. coli is statistically most likely, but it didn’t adequately fit my symptoms. Nor did dysentery or typhoid fever.

You know what did fit? Exactly? The same disease that’s currently wreaking havoc in Haiti — CHOLERA. (For those who, for some reason, don’t trust wiki, feel free to peruse the WHO or the CDC websites.) Contaminated food or water? Check. Infection resistant to antibiotics? Check. Expelling liters upon liters of clear fluid from both ends for days? Check.

Told you it was gross.

I’m really lucky that I didn’t land in the hospital needing IV hydration, though for a while it seemed like an inevitable eventuality. I tried to force and keep bottled water down, but that was a major fail. Instead, I forced soda and powdered Tang (which I initially mocked my travel buddy for buying two countries earlier because it looked disgusting, but the electrolytes saved my butt) down my throat to get some hydration, glucose, and electrolytes back in me, and fortunately that got me through.

It started to clear up after about three days, whether on its own or in part due to the cocktail of ciprofloxacin, azithromycin, pepto bismol, and immodium and tums I’d been ingesting* I’ll never know. I’m just glad — and lucky — that my immune system kicked it before the cholera kicked me.

*Don’t try this at home.

Let’s get it started in here (again)!

You may have noticed that I’ve been on hiatus for a few months. Unfortunately it wasn’t for any fun, exciting travels or adventures — it was for trying to acclimate to the second year of medical school. I’ve finally come to terms with the fact that I’m always going to be swamped and feel like I have no free time, so rather than waiting around I’m going to go ahead and start blogging again anyway.

I can’t promise regular posts or coherent themes but I can promise random updates and musings about medicine, school, news, global health and events, and random interesting tidbits as determined by yours truly.

Stay tuned, and start checking back more often — there should be new posts here soon!

Losing the battle against AIDS

Uganda, which was once a leader in the fight against AIDS, is now struggling to continue the battle. Insufficient funds (“According to the Uganda AIDS Commission, the lifetime bill for treating one Ugandan AIDS patient, counting drugs, tests, and medical salaries, is $11,500.”), insufficient education, insufficient medical personnel, insuffient…everything. Despite cheaper, generic antiretrovirals becoming available earlier this decade, there are still not enough. “‘Family members…will often share one set of pills, an act of love that leads to disaster. Incomplete treatment means both will probably die, but may first develop drug-resistant AIDS and pass it on.'” Furthermore, the medications and treatment strategies are still considered too expensive; donors and world leaders have begun to shift their focus from AIDS to other diseases, such as malaria and diarrhea, that have much cheaper remedies, like mosquito nets and water filters. Read more from the NY Times.

These other diseases certainly deserve attention and need to be addressed, but this needs to happen IN ADDITION to combating AIDS, not instead of. Encourage your government representatives to support the Global HEALTH Act of 2010, which will assist developing countries in recruiting, training, and keeping qualified health care workers. (Check out the bill here.) Give to your favorite organization and make a direct; a friend of mine recommended this fantastic organization as one that is both reputable and brings real, tangible results. Talk to others and educate about this devastating disease and how much more needs to be done globally.

Do something.

Go. Treat. Heal.

Go. Seek out adventure. Travel. Don’t wait for life and solutions to its problems to come to you; go where you’re needed, meet challenges head on and….

Treat. Address the issues you encounter. Whether it be a lack of clean water in Uganda or inadequate health care access in your community, do something in an effort to…

Heal. Remedy the situation. Whether it’s a physical disease or societal problem, whether you are the one being healed or doing the healing, mend and recover to the best of your ability.

Refugees, concerts, and bobotie

On Saturday I went downtown with my roommate Amanda to meet Muhammed Ali, a Darfur refugee she met the other day. He’s really amazing; he was a doctor in Darfur, and he was imprisoned by the rebels when he continued to practice and to help all injured people/anyone who needed to help. While in prison, he was tortured and God only knows all of his experiences. He was fortunate enough to escape, at which point he literally ran through the jungles to seek refuge in South Africa, sneaking across the border as he didn’t have passport or anything of the sort. SA has a policy that permits all Darfur refugees to remain here, so he is allowed to remain here as he tries to rebuild his life. Currently he is selling his and others’ art downtown to help pay for necessities while he is earning his Masters in Public Health. Though he is no longer a “practicing” doctor per se, he continues to help all sorts of street and poor people in the area that can’t afford health care when they fall ill.

On Sunday we went to Kirstenbosch Botanical Gardens for the sunset concerts that they have there all summer. We got there early so we could wander around the vast, beautiful gardens at the base of Table Mountain before picnicking at the concert. The Rudimentals were playing that night, a ska band that’s pretty big here. It was a very fun time, will definitely be doing it again.

Today, Monday, was the first official day of classes. It went pretty well, and my courses should be relatively interesting. Tonight Graham and Claire had a big party at their house since Graham’s sisters, Sandy and Sharon, were both in town from India and California, respectively. It was a blast; their whole family was there, plus all their friends, so it was a huge party. I obviously didn’t know hardly anyone, but it was very fun, and it was kinda cool to be on the opposite side of things for once – it was interesting to see what people experience when they come to my family holidays! Graham and the family were warning me initially about how there’d be so many people and they’d all be curious about me so I’d be kinda in the spotlight, but then they’d say that actually it shouldn’t be too bad, that it probably wouldn’t be anything compared to my family’s gatherings and that I’d be used to it! Lol, I guess I do come from a bit of a sizeable, rambunctious family, don’t I…

Claire made bobotie for the party, a traditional Cape Malay dish that was positively amazing. It was kind of like meat loaf, but better. She also made ice cream. When I left they insisted on sending home leftovers with me – clearly the concept of the poor, hungry college student is universal, and I was glad to have them!

Adjustment

Adjusting to life in Cape Town has been particularly interesting, mostly because I came here with a totally different frame of reference from everyone else. All of my friends are comparing this to home, and there seems to be a consensus around all the ways Cape Town is deficient in comparison: the internet is so slow, the mini busses are so sketchy, there isn’t this or that, such and such doesn’t work like at home, the power goes out all the time, and “South African” time is such a pain.

Well.

Having come here directly from Uganda, a very, very “third world,” developing country, I have a bit of a different outlook on things.

For one thing, this is a first world city, and it’s pretty strange to have access to things like malls, varieties of fast food, and nice roads again. Any thing you might want is attainable, which is great to know.

I’m just so excited to have internet at all, and it’s actually pretty darn fast, even compared to home it seems. Even though it is pretty expensive, at least it’s available.

As it turns out, mini busses are SA’s version of matatus, only they are much classier; I have yet to be in one with a shattered wind shield, all of the doors tend to open, and I’ve never had more than 20 people in one here. They are also a very cheap, effective way to get around the city, even if they’re not always the quickest or most direct. Unfortunately you really can’t take them at night as they’re just too dangerous after dark (which is true of the city as a whole).

I still marvel at the presence of hot water. I mean, it’s there every time I want to shower! It’s pretty exciting to have regular hot showers.

Food. I can drink milk again without worrying about whether it was boiled. Milk from the stores, shakes in cafes…and really, pretty much anything that I’d want is just a few blocks away at the grocery store. It’s not exactly what I’d get at home, but there’s a huge selection compared to three weeks of starch starch starch (and the same starch each time).

And the best thing? WE CAN DRINK TAP WATER!!! I hate having to buy water. Everyone should have access to clean water, thank goodness we do again. Shameless plug: check out Village Health Project if you’re interested in how our organization is working so that more people can have clean water sources.

It’s a little tough because coming from Uganda, things are expensive here! In reality, everything’s still cheap in comparison to home, but after being able to eat for an entire day for less than $2 it does take some adjusting. Now if I want to eat on campus or cheap take away each meal is under $2, so it really adds up! 🙂 It’s hard to adjust the perspective. Going out to eat at the nicest places in town can run you about $20, more if you’re drinking, but you can go to pretty nice places for about $12-15. Plus they deliver anything you can imagine – sushi, thai, ostrich, shakes, and pretty much all of it’s under $10.

As for the power outages, it’s all a lot of hype. There is supposed to be load shedding here at the moment, which means that different electricity grids in the city are supposed to have planned power outages for 2-3 hours every couple of days to cut down on usage. This is all because a few years back SA realized that it would need new power sources soon, and then failed to do anything about it. Now they’re facing a huge energy crisis and it’ll take another decade or so to build more power plants. This typical example of the planning, organization, and foresight here means that we should be regularly losing power; however, this hasn’t been happening at all. There was a huge, unplanned blackout the first Friday I was here, but nothing since then, so we’ve been really lucky. Knock on wood. We didn’t have power a lot of the time, especially nights, that we were in Uganda, so this is pretty nice.

And really, people need to stop whining about South African time. Yeah, someone will tell you 7:00 and show up half an hour late….One night in Uganda JB told us he would be over at 6. He texted to say he’d be late, so we figured about 1-1.5 hours late. Nope. 3.5 hours later he strolls in, totally casual and completely unaware that he may have irritated us. I threw a shoe at him to demonstrate otherwise. His response? “Don’t worry about it! I’m here!” ai yi yi. I was hoping that people would walk faster here as one would think they’d have things to do, places to be, but no such luck. Any time you get behind a group of South Africans you might as well be moving backwards for all the progress you’re going to make. I really have no idea how people make it to class or anywhere else on time, ever.

I’ve been trying not to be too obnoxious about my excitement over all the little things. I try to restrain myself from commenting on it every few seconds and irritating my roommates, so mostly Molly and I just marvel to each other about our hot, drinkable water, and try to ignore other people’s complaints over their unrealistic expectations.

Kampala, Uganda

During our last few days in Kampala, I shadowed doctors at Mulago hospital for three days, one day each in Endocrinology, the Labor Ward, and Pediatrics.

Monday: Everyone in Endocrinology had Type II diabetes, often with other afflictions and always with the diabetic foot; several patients had gangrene. We went to some of the local craft markets on Buganda Road and at the National Theatre to have a look around and then met Annette for dinner (liver, rice and chips). Annette was the other doctor who showed us around last year with JB, and she’s incredible. Quite the life story, but she’s one of the only Ugandans I know who likes schedules and organization — it’s a nice change!

Tuesday: The Labor Ward was positively overflowing, with women on the floors and in the hallways nearly ready to give birth. I even saw a live birth, it was amazing! Now I’ve held the youngest baby in my life; the baby came out, it’s cord was cut, it was wiped off a bit and put into a blanket, and then the sisters let me pick him up! Less than three minutes old and he was holding my finger and trying to suckle the air — it’s amazing! That night we went to Krua Thai with Regina, another woman we met last year. She runs the CHAIN program that a few of us visited and that I looked closely at for my research project last January. She took us to her house afterwards for drinks and to show us the promotional video they’ve made for CHAIN.

Wednesday: In pediatrics the doctor would see each child for maybe 10 minutes before the next one came in, and he was still hardly able to make any progress through the huge line of people waiting. Nearly every child we saw had a herniated umbilicus (I believe that’s what he called it), and of course there were TB and other illnesses. Their pediatric operating room wasn’t able to be used for a month already when I was there as sewer was backing up into it, and they figured it would be at least another month before it would be open again. This lead to many cases that should have been operated on being postponed indefinitely, with only the most emergent being refered. Just the previous day they had someone come in with a severely broken foot, with one of the bones cutting through the skin. The doctors had want to properly set the break through surgery, but as they were unable to they just filed down the protruding bone, set the foot and sent the child on his way. Unfortunately it seems as though this is going to continue for some time. That night we met up with Miriam, a girl who came to the UW for a month last year and Molly got to know, for tea and sandwiches at her home. She’s married and pregnant now, so that was exciting!

That night we finished up our packing and got ready to leave at 5am to catch our flight to South Africa.

The morning of our flights was sufficiently chaotic. At 6am we were checking in for our flight to Johannesburg, at which point the woman behind the counter informed us that my luggage was about 20 kilograms overweight. uhhh, what?!? Having checked all the luggage restrictions before leaving, I knew that I should have been allowed two bags at 23 kilos each since my origin point for the trip was the US; however, since we were checking back in at Entebbe/Uganda, they decided we should only be allowed 23 kilos total, the limit for flights within the continent. After attempting to sort it all out with the one South African Airways person working at that hour, I redistributed weight as best I could and ended up paying ~$200 to get everything here, as did Molly. Positively ridiculous, but I’m working with SAA to try to get it refunded.

The layover in Joburg was relatively painless apart from the impressively pushy employees. Porters insisted on pulling our luggage, literally wrestling it out of our hands, even after we told them several times that we had zero money. When we got to our point to check back in as we had to go through customs, they lingered and insisted we tip them for the 50 foot journey. Nope, we told them we didn’t have anything and we weren’t lying, we hadn’t been able to exchange or withdraw any cash yet. In our line to check back in we were surrounded by two big groups of bikers, likely heading to Cape Town to train for the upcoming race. A uniformed employee ushered us through to the counter since we’d be quick and the bicyclists were going to take a looong time. Of course, after we checked our stuff he follows us half way to our gate, demanding a tip. As we still didn’t have money, and he really didn’t do anything, there was no tip for him either. After all of this and Joburg’s reputation for losing the most luggage of any airport on the planet, we were convinced that our luggage would never make it to Cape Town. After the two hour flight, we waited for quite a while for our luggage to come off the plane, and miraculously it all made it!! We couldn’t believe it, so many other people I’ve met here lost luggage coming through Joburg.

There was someone from UCT waiting for us at the airport, and after a few more students arrived a big van took us to all our different houses, dropping each of us off on the curb with our luggage and driving off. Apparently they had called ahead to all of our landlords, so there was someone to let us in.

So, after three weeks of constant travel, I arrived in Cape Town! I’m living a beautiful old historic Victorian row home, just two houses down from the first house my Aunt Mona lived in when she moved to Cape Town!! Small world. My room is on the second floor at the top of the stairs, overlooking the back garden. It’s painted green and has old wooden furniture; it’s very nice. The living room is painted a deep red with white covers on the couches, and the kitchen is in good condition. This place is so much nicer than any student housing at Madison, and cheaper! I even have my own room, and it’s almost twice the size of the room I’m going to have next year!

Lyantonde, Uganda

So we’re finally back in Kampala after two weeks in rural Uganda. You already heard about our time in Kabale, so I’ll pick up at the end of our stay there…

We left Kabale on Monday morning, taking a matatu to Lyantonde. It was pure chaos getting one; a lot of buses and matatus turn around in Kabale, so there are a lot there and every driver is competing for the business. Dozens of people were shouting prices and destinations at us, fighting with each other when we’d start to go to someone else. With the help of Elias, we finally escaped into a matatu for a reasonable rate. What’s a matatu, you ask? Only the worst form of public transportation known to mankind. It’s a van, not quite full size but not really mini either, with four rows of bench seats and fold-out seats crammed behind the driver’s row. Three people can comfortably sit next to each other on each row, which means there are always at least five people jammed into each row, more if you’re lucky. What’s really great about long journeys, like the five hour trip from Kabale to Lyantonde, is that everyone has baggage too, which is all piled on your lap. Then, if you’re really lucky, you happen to end up in one that distributes newspapers, so in addition to screeching to a halt every few kilometers to pick up more people you get to stop even more frequently to pick up and distribute huge bundles of papers. The matatu’s seem to have the same motto as Irish families – there’s always room for one more. After we had 20 people plus bags and newspapers loaded in, I was certain we had to be full. Nope. We got at least another four people in there, maybe more but it’s hard to count when you can’t see everyone that’s being sat on. Really, it’s awesome, you should try it.

After arriving in Lyantonde, we went to our friend Lillian’s house, a contact of ours through Village Health Project, and spent some time with her and Anna, another Wisconsin student who’s staying there for a month. Anna will be helping Lillian conduct interviews with the Family Care Workers of the Community Based Integrated Nutrition (COBIN) group that we also work with. We found out that since they were busy with the interviews, there wasn’t really much we could do with the water projects or COBIN at the time. Instead, we would be able to shadow doctors at the Lyantonde District Hospital, which we had hoped to do as well.

Working at the hospital was very interesting. Each day we got to work in a different area, though primarily with the same doctor.


Day 1: HIV Clinic. Molly helped distribute meds with Hiral, the closest person they have to a pharmacist. I sat in on appointments with the doctor. One of the patients was a six year old girl who looked about three as the HIV had stunted her growth so much. None of the adults that we saw weighed more than ~95 lbs, most of them were significantly less than even that.


Day 2: Antenatal (aka Prenatal in the US). We spent the day with the nurses/midwives in the antenatal clinic. We sat in on an education session, of which we understood nothing as it was in Lugandan, but we got the Women’s Health Passport that they give to the women, so we just went through that for the info. It’s a booklet issued to each patient that has info on everything from their own health records (each pregnancy is documented in the book) to what they need to bring with them to the hospital to give birth (sheets, food, gauze, etc as the hospital has virtually nothing). The patient keeps this booklet and brings it with them to each visit. We then went to the exam room and watched the check-ups. General health is checked, and each woman is tested for HIV if her status is unknown. We were able to check the blood pressure and listen for the fetal heartbeat in some patients, and to feel the abdomen and locate the fetus’s head in others. Listening for the fetal heartbeat was very difficult; they just use this small black cone pressed against the abdomen as they seldom do ultrasounds (this hospital may not even have the equipment).


Day 3: SURGERIES! Probably the most interesting day of the week. We were right in the OR with the surgeon, so we had to scrub up. You wouldn’t think that putting on scrubs would be all that difficult, but when the top is roughly the size of a circus tent and each pant leg could comfortably house a family of four, it suddenly becomes quite the project. I was lucky enough to have a drawstring in my pants that, after considerable wrenching, pulling, shifting and shuffling I was eventually able to utilize. Molly, however, only had what must have once been an elastic waist and was now a limp opening the size of a hula hoop, which she ended up tucking into her underwear in order to keep them up. Once we put on the white rainboots, we felt, and undoubtedly looked, distinctly like Oompa Loompas. I assure you, it was the pinnacle of style. We also got scrub caps and masks, completing the outfits. In the morning we watched a Cesarean section. It was very bloody and the doctor said the surgery usually wasn’t so messy, but the fetus was in distress so they had to work quickly. The baby seemed huge when he pulled it out, we’re guessing around 10 lbs, and it was blue from lack of oxygen. It took a while, but they were able to resuscitate her. She was then wrapped in a blanket and left wailing on a bed in another room while they finished working on the mother. Molly and I got to hold her, easily the youngest baby I’ve ever held at less than an hour old!


That afternoon we watched a hysterectomy, which was a much cleaner surgery. The only anesthetic they have at the hospital is (frequently expired) ketamine, so the patient’s aren’t totally out during the operation. Both women would move their arms or legs on occasion, and their gut was never calm. During the hysterectomy the woman’s eyes were open for nearly the whole thing, and clearly not all of the pain was blocked, but they usually don’t remember it after waking up. There’s virtually no equipment or staffing available to do anything remotely high-tech, so there’s no suction, no monitoring equipment, and the patients have to breathe entirely on their own. It was crazy; we had more equipment and drugs when I worked with monkeys than they have here for people.


All in all, it was a really great day. I didn’t have any trouble watching the surgeries; I wondered how it would go but I didn’t have to sit down or take a break or anything. Still, as awesome as it was to watch, I’m not sure that it’s something I would want to do all the time; parts of the procedures can get pretty physical, which I wouldn’t enjoy. Very interesting to observe though! I’ll save the blood and guts details, though.


Day 4: Pediatrics. We did ward rounds in pediatrics where nearly every kid had malaria plus pneumonia, anemia, or malnutrition. There were two families on every bed, some families with multiple ill children, plus extra mattresses on the floor – overflowing, to say the least. We also went through the women’s ward to check up on the patients from the surgeries; it was here that we saw someone with a terrible case of Herpes, a common opportunistic infection for those with HIV. This woman looked like she had been horribly burned and skinned; the skin was gone across her right shoulder, the top of her chest and back, and up her neck. I’m sure you can find similar pictures on google if you want a visual, but it was awful, I can’t imagine the pain.


That afternoon we both helped Hiral distribute meds again. We’d just count out pills in lids or on the counter with our bare hands, put them in plastic baggies, give them to the patient, sign the chart, and then start counting the next batch. All of this would be highly illegal and against health code in the US, but they were just happy to have people who could count to 30 and were willing to help since we made it go faster. After finishing Hiral took us to see the Muslim clinic his mother runs, which was run with a great deal more organization than the district hospital, though I’m sure that’s easier with a smaller clientele.


Each night that week we went over to Lillian’s to hang out with Anna. If the power was on, which was fairly unpredictable, we’d watch movies. Here you can get one DVD with 6-8 different movies on it, usually with a related theme. We were lucky enough to have a J.Lo one, so we had quite the J.Lo marathon. I had no idea she had so many movies and most of them I’d never normally watch, but it was nice to have a little piece of home like that. If there’s power and a tv, the only thing that’s ever on is futbol or terrible Nigerian movies, so it was nice to have something familiar.

Saturday morning we headed back to Kampala after a delicious breakfast; we bought fresh chapatti and a pineapple from the street vendors, all for about $0.80. mmmm. Then we tackled getting a bus. It was a bit less chaotic, but this time we were all on our own. We finally made it onto a bus (we weren’t doing a matatu again!), but only after getting past the matatu drivers who were physically blockading us from getting on. After we got on they decided to change a tire, which took a solid hour but at least we had a bus. Then the tire blew about 30 km outside Kampala; luckily they didn’t stop to fix it, otherwise we would have been delayed even longer. Though it was a far superior journey to the matatu escapade, it was a relief to arrive and go back to Kampala City View, where we’ll be staying until Thursday when we leave for Cape Town!