Monday, June 28, 2010
Friday, June 25, 2010
More Suprises: Teachers, Epidemics and a Celebrity Visitor
Something that I learned early on in studying HIV/AIDS is that the epidemic is vastly different in every setting. This lesson is reiterated weekly as I discuss the client population at the Durham SHAC HIV testing site with my co-coordinators who work at the Carrboro SHAC HIV testing site. With such different populations and two different epidemiological pictures of HIV/AIDS in towns as close as Carrboro and Durham, it seems ludicrous that HIV/AIDS in Africa is so often spoken of as one single epidemic.
So often in both popular media and academic discourse we hear of the HIV/AIDS epidemic of Sub-Saharan Africa. How imprecise! It seems that such a concept must have extremely limited utility, if any at all, considering the wide variety of cultures, economic structures, and public health infrastructure the term Sub Saharan Africa encompasses. (In fact, I think the Western World spends far too much time lumping African or Sub-Saharan African countries together as if they are all the same)
Returning to the idea of the diverse picture of HIV/AIDS, one critical aspect of epidemiology is high risk groups. These groups vary greatly with the setting, though surely there are some common high risk groups sex workers, and men who have sex with men, for example. Today I was suprised to learn that in Malawi the number three high risk group (behind sex workers and police men) is teachers!
The salary and societal position of teachers in Malawi affords them power, which some use for transactional sex. Apparently, teacher/student sexual relations are not uncommon in Malawi. Moreover, teachers are often posted in remote areas where they are isolated from other similarly educated people which leads to promiscuity and transactional sex. This causes problems not only for the spreading of HIV, but also because teachers are supposed to be teaching their students about the virus and how to protect themselves. Yet according to the physician I was speaking with this morning, teachers have many misconceptions about HIV/AIDS and by-and-large are not equipped to provide accurate information.
In response to this problem, teachers are being targeted by non-profit risk-reduction agencies. In educating teachers these organizations are thus able to prevent the spread of HIV through a high-risk population and discount misconceptions and myths so that Malawian teachers are better able to inform their students about HIV/AIDS.
This lesson has reinforced to me the danger of making assumptions about populations or individuals and their risk level. It also makes me think that in facing this epidemic collective honesty and compassion are essential to making any headway against the disease. Shame so often keeps people from disclosing their status, or even from asking questions to obtain an understanding of HIV/AIDS- an understanding that could be critical to avoid becoming infected. Yet changing the societal structures that allow the powerful to manipulate others for sex, that put children at risk and that disenfranchise women is equally important. Whether in Durham or Lilongwe HIV/AIDS thrives on inequality and we cannot eradicate one without minimizing the other.
Postscript:
Leaving the clinic today I got a call that Bill Clinton was coming to the hospital! The Clinton Foundation donated a new maternity wing so he was coming for a tour. I got to meet him and had a group photo op. Pictures of weeks 1-3 to be posted this weekend!
So often in both popular media and academic discourse we hear of the HIV/AIDS epidemic of Sub-Saharan Africa. How imprecise! It seems that such a concept must have extremely limited utility, if any at all, considering the wide variety of cultures, economic structures, and public health infrastructure the term Sub Saharan Africa encompasses. (In fact, I think the Western World spends far too much time lumping African or Sub-Saharan African countries together as if they are all the same)
Returning to the idea of the diverse picture of HIV/AIDS, one critical aspect of epidemiology is high risk groups. These groups vary greatly with the setting, though surely there are some common high risk groups sex workers, and men who have sex with men, for example. Today I was suprised to learn that in Malawi the number three high risk group (behind sex workers and police men) is teachers!
The salary and societal position of teachers in Malawi affords them power, which some use for transactional sex. Apparently, teacher/student sexual relations are not uncommon in Malawi. Moreover, teachers are often posted in remote areas where they are isolated from other similarly educated people which leads to promiscuity and transactional sex. This causes problems not only for the spreading of HIV, but also because teachers are supposed to be teaching their students about the virus and how to protect themselves. Yet according to the physician I was speaking with this morning, teachers have many misconceptions about HIV/AIDS and by-and-large are not equipped to provide accurate information.
In response to this problem, teachers are being targeted by non-profit risk-reduction agencies. In educating teachers these organizations are thus able to prevent the spread of HIV through a high-risk population and discount misconceptions and myths so that Malawian teachers are better able to inform their students about HIV/AIDS.
This lesson has reinforced to me the danger of making assumptions about populations or individuals and their risk level. It also makes me think that in facing this epidemic collective honesty and compassion are essential to making any headway against the disease. Shame so often keeps people from disclosing their status, or even from asking questions to obtain an understanding of HIV/AIDS- an understanding that could be critical to avoid becoming infected. Yet changing the societal structures that allow the powerful to manipulate others for sex, that put children at risk and that disenfranchise women is equally important. Whether in Durham or Lilongwe HIV/AIDS thrives on inequality and we cannot eradicate one without minimizing the other.
Postscript:
Leaving the clinic today I got a call that Bill Clinton was coming to the hospital! The Clinton Foundation donated a new maternity wing so he was coming for a tour. I got to meet him and had a group photo op. Pictures of weeks 1-3 to be posted this weekend!
Monday, June 21, 2010
Impressions Part 2: Surprises
Since coming to Malawi many people have asked me some version of the same question: Is it what you thought it would be? Well, thanks to the breakneck pace of medical school I had very little time to consider what I might be getting myself into, and even less time to develop preconceived notions of how I might find Malawi or my project. That being said, I have been surprised, almost daily, by my experiences in Malawi. To alter the tone from my last post, most of the surprises I discuss here have been pleasant and/or interesting surprises and have in some cases bolstered my resolve to continue my work and to continue seeking out new experiences.
In considering two children who are treated in a Malawian hospital, both for pneumonia, one could reasonably guess that if one child was HIV-positive and one was HIV-negative the child without HIV would have the better prognosis. In actuality I can say very little about the prognosis of children admitted to KCH with pneumonia. However, what I have been surprised to find is that of these two hypothetical children, the HIV-positive child is likely to get a much higher quality of care. Moreover, in a hospital like KCH, where children die not just because of their pneumonia (or any other chief complaint), but are daily threatened by medical error, poor hygiene, understaffing and limited resources, the quality and regularity of care are essential variables in determining prognosis.
The reason for this disparity of care is that all HIV-positive children at KCH are referred to the Baylor Pediatric HIV program. This program provides treatment and care to over 2,000 exposed or infected children. If an HIV-positive child (or a breastfeeding child born to an HIV-positive mother) is admitted for care at KCH, Baylor clinicians will round on the child daily and follow up to ensure the child receives proper care. In contrast, children who do not have this high quality of care often die because they are given the wrong treatment, miss life-saving treatments such as oxygen or blood transfusions, or for other reasons not directly related to their diagnosis. Sadly, these misfortunes befall children enrolled in the Baylor program as well, but (I sense) at a much lower rate. While I do not have any scientific data on these care discrepancies, from what I have seen, they can truly make the difference between life and death.
A second surprise (and to be honest, the one that has been personally most surprising) is how much I like pediatrics. Those of you who know me know that since starting medical school I have never considered becoming a pediatrician and have had little interest in treating kids. Yet, I have found that I really like working with the kids here. Perhaps part of it is that the parents we deal with are not the pushy, hyperattentive parents I fear having to work with in the States. Or because the kids I see are so sick that kicking, crying, and being uncooperative are, in this context, welcome signs of life rather than annoyances.
Beyond gaining an appreciation for the patient population in pediatrics, I have found myself fascinated by the field because, as I see it, pediatrics is essentially public health in action. My layman’s understanding of public health is that its primary goal is to keep populations healthy by a.) dealing with groups of people rather than individuals and b.) preventing health problems before they start. In doing so, public health deals with social justice, environmental issues, economic fairness and a host of other societal issues that are important to me.
I have found in pediatrics that in order to treat the child you often have to treat the entire family. This means not only ensuring the health of the mother and siblings (which is also essential) but also working to establish within the family a degree of social justice, a healthy environment and a sustainable economic structure in order to heal your patient. Moreover, by addressing childhood health issues you are by definition practicing preventive medicine; facilitating your patient’s growth into a healthy adult.
Examples from the past weeks abound. One little girl, a 14 year old who physically appeared to be about 8 years old, presented to an outpatient clinic months ago. She was very sick and HIV positive. A Baylor pediatrician treated her and sought out her family in order to test her parents and siblings for HIV. Surprisingly, the other members of the family were all found to be HIV negative. After building trust with the patient and her mother, the physician found out that the little girl had been sent away from the family to work as a maid. She was living with sex workers and had no adult care or supervision. Likely, the patient contract HIV through sexual assault or by becoming a sex worker herself.
Thus the pediatrician took on the work of healing the whole family in order to ensure that the treatment she gave her patient would actually work. This involved planning, with the patient’s mother, a financially feasible way to bring the patient back home. Once the child was back at home, she then taught the parents how to care for their daughter, and encouraged the mother to consider family planning so as to not conceive more children they would have to send away to work. The most recent mission was to instill in this family the value of sending the patient to school.
While this story had a very sad beginning, and admittedly has the possibility of a tragic ending, the entire family has become healthier in this process Moreover, the 14 year old girl I saw, months after her initial diagnosis, had a high CD4 count, a bright smile, and a chance to start school in the upcoming year. Without the pediatrician treating the family holistically, none of this would have been possible.
In considering two children who are treated in a Malawian hospital, both for pneumonia, one could reasonably guess that if one child was HIV-positive and one was HIV-negative the child without HIV would have the better prognosis. In actuality I can say very little about the prognosis of children admitted to KCH with pneumonia. However, what I have been surprised to find is that of these two hypothetical children, the HIV-positive child is likely to get a much higher quality of care. Moreover, in a hospital like KCH, where children die not just because of their pneumonia (or any other chief complaint), but are daily threatened by medical error, poor hygiene, understaffing and limited resources, the quality and regularity of care are essential variables in determining prognosis.
The reason for this disparity of care is that all HIV-positive children at KCH are referred to the Baylor Pediatric HIV program. This program provides treatment and care to over 2,000 exposed or infected children. If an HIV-positive child (or a breastfeeding child born to an HIV-positive mother) is admitted for care at KCH, Baylor clinicians will round on the child daily and follow up to ensure the child receives proper care. In contrast, children who do not have this high quality of care often die because they are given the wrong treatment, miss life-saving treatments such as oxygen or blood transfusions, or for other reasons not directly related to their diagnosis. Sadly, these misfortunes befall children enrolled in the Baylor program as well, but (I sense) at a much lower rate. While I do not have any scientific data on these care discrepancies, from what I have seen, they can truly make the difference between life and death.
A second surprise (and to be honest, the one that has been personally most surprising) is how much I like pediatrics. Those of you who know me know that since starting medical school I have never considered becoming a pediatrician and have had little interest in treating kids. Yet, I have found that I really like working with the kids here. Perhaps part of it is that the parents we deal with are not the pushy, hyperattentive parents I fear having to work with in the States. Or because the kids I see are so sick that kicking, crying, and being uncooperative are, in this context, welcome signs of life rather than annoyances.
Beyond gaining an appreciation for the patient population in pediatrics, I have found myself fascinated by the field because, as I see it, pediatrics is essentially public health in action. My layman’s understanding of public health is that its primary goal is to keep populations healthy by a.) dealing with groups of people rather than individuals and b.) preventing health problems before they start. In doing so, public health deals with social justice, environmental issues, economic fairness and a host of other societal issues that are important to me.
I have found in pediatrics that in order to treat the child you often have to treat the entire family. This means not only ensuring the health of the mother and siblings (which is also essential) but also working to establish within the family a degree of social justice, a healthy environment and a sustainable economic structure in order to heal your patient. Moreover, by addressing childhood health issues you are by definition practicing preventive medicine; facilitating your patient’s growth into a healthy adult.
Examples from the past weeks abound. One little girl, a 14 year old who physically appeared to be about 8 years old, presented to an outpatient clinic months ago. She was very sick and HIV positive. A Baylor pediatrician treated her and sought out her family in order to test her parents and siblings for HIV. Surprisingly, the other members of the family were all found to be HIV negative. After building trust with the patient and her mother, the physician found out that the little girl had been sent away from the family to work as a maid. She was living with sex workers and had no adult care or supervision. Likely, the patient contract HIV through sexual assault or by becoming a sex worker herself.
Thus the pediatrician took on the work of healing the whole family in order to ensure that the treatment she gave her patient would actually work. This involved planning, with the patient’s mother, a financially feasible way to bring the patient back home. Once the child was back at home, she then taught the parents how to care for their daughter, and encouraged the mother to consider family planning so as to not conceive more children they would have to send away to work. The most recent mission was to instill in this family the value of sending the patient to school.
While this story had a very sad beginning, and admittedly has the possibility of a tragic ending, the entire family has become healthier in this process Moreover, the 14 year old girl I saw, months after her initial diagnosis, had a high CD4 count, a bright smile, and a chance to start school in the upcoming year. Without the pediatrician treating the family holistically, none of this would have been possible.
Sunday, June 20, 2010
Impressions Part 1: Challenges
The past week has been a busy and eventful one, which has kept me from posting because there is so much to tell! As part of the Entrepreneurial Public Service (EPS) fellowship I receive a prompt each month to address in my blog. The June prompt offers a great opportunity to catch up on what I’ve been doing and my impressions of things here in Lilongwe. The prompt asks about challenges and surprises.To prevent burnout (yours and mine) I am going to write this first post about challenges, but stick around because a second post addressing surprises is forthcoming, and promises to be less depressing.
This post also marks the end of my two-week introduction to Pediatric HIV Care. As Dr. McCollum, the PI for my project has been in the States for the last two weeks he arranged for me to shadow clinicians in all of the different areas that kids with HIV receive care in Lilongwe: at the Baylor pediatric HIV Clinic, on the pediatric wards at KCH, in the outpatient clinic at KCH, and at area health centers. This has been a great way to see how the whole system works here. So, without further adieu my impressions of the challenges I have faced during these two weeks:
The two primary challenges that I have faced in these first two weeks have been communication and dealing with such a sick population and such limited resource settings. Communication is perhaps the most obvious challenge to my work here. Prior to arriving in Malawi I was under the impression that a large portion of the population speaks English, and that it is the language of commerce and government. This was a misconception. The primary language of all Malawians I work with is Chichewa, and many of the official interactions take place in Chichewa. So, from the outset I felt that I was on the outside, struggling to learn a language that has few cognates to English and sounds vastly foreign to my ear trained to converse in English and Spanish. Though I have mastered a few key phrases (see below entry on muli bwanji, also sanza= vomit, very important in pediatrics) my experience trying to interact in Chichewa has left me feeling like I suffer from both Broca’s and Wernicke’s aphasia (aka I hear and respond in utter nonsense). Thus, when seeing patients I require a translator, which in this setting is a nurse or clinical officer who is perfectly capable of seeing patients on their own. This limits my utility greatly.
Yet, I am not the only one challenged by language in Malawi. One of the interesting things about Malawian healthcare is their system of medical records. While an individual clinic or hospital may have their own system of stored records, each patient has a “Health Passport” in which each visit, including the chief complaint, physical exam, plan and any prescriptions are recorded (see http://giveaday.ca/blog/wp-content/uploads/2009/11/Malawi-3-174.jpg for example). Interestingly, these passports are kept completely in English. Much of the healthcare in Malawi, and especially in Lilongwe, is delivered by foreign doctors. Furthermore, all Malawians learn English in secondary school. Therefore, all Malawian medical professionals, and presumably all foreign doctors, can understand the notes in the passbook (that is, baring unintelligible handwriting, which abounds). Yet the average Malawian does not attend secondary school and therefore, doesn’t understand the information contained in their own medical record.
Medical records are certainly a hot topic in the U.S. right now, and I think the potential pros and cons of the Malawian system are worth consideration. How do you balance the need for efficiency and clarity in medical record keeping to facilitate good patient care, with simplicity to empower the patient to understand the decisions being made about their health? This seems like a particularly relevant conflict when the record isn’t being kept in the clinic or hospital, but is in the patient’s possession. This tension also brings to mind the question of the potential benefits and drawbacks of having the patient in control of their medical record. While I think an educated and empowered patient is ideal, is it beneficial for patients to know every detail of their diagnosis and plan?
On a more practical level, what do you do if a patient loses or alters their medical record? This is certainly a challenge here, as I have dealt with patients who have lost their passports, who have had animals eat part of the pages, who have spilled on them, or who have forgotten to bring them while traveling and ended up sick or injured. Thus I have found one of the greatest benefits to working in a foreign medical system is that it allows me to live the alternatives to the U.S. system which we collectively as a nation are trying to change for the better.
The other outstanding challenge that I have faced in the past two weeks is exposure to unremitting and irremediable misery. It is hard to articulate the horror of some of what I have seen, heard, smelled and felt in the past two weeks. This is a burden I have chosen to take on, so I won’t share too much but witnessing death and desolation in children is something that has become a daily occurrence for me, and which is the primary challenge to my work here. It is a constant challenge to strike a balance between grieving the lost child while maintaining composure to care for the child in the next bed who could still survive, and somehow holding onto a thread of my own mental well being. The frustration of treating hundreds of sick kids without accurate diagnostic tests, proper medications, or reliable electricity, in a hospital that is understaffed, poorly lit, filthy and teeming with children and their guardians (caregivers, usually a parent, who fill the role of nurses by administering medicines, giving food and baths and alerting doctors of changes in status) is almost paralyzing.
I don’t fully understand how I manage to go to work each day, hopeful to learn, and yet afraid of what I will witness. I do know that for now, I am meeting this challenge. I am still able to feel for the children and their parents, take joy in the kids that live to fight another day and still come home to sleep well at night. However with each day the latter becomes more and more difficult, as visions of what I have seen haunt me.
Throughout all of this I work side-by-side with physicians, nurses and clinical officers who have dedicated their lives to working in this setting. I am humbled by their resilience, especially those Malawian nurses, clinical officers, community health workers and HIV counselors whose own children suffer from many of the same maladies as those they treat. It amazes me the compassion that many are able to show on a daily basis despite the constant stimulus of misery. I have only been here two weeks and already feel great emotional wear and tear; I cannot imagine the impact of working in this setting day in and day out.
Yet I have also seen apathy and hardness in some of the nurses and clinical officers. To me this is a totally human reaction to such a situation, and so I try to also show compassion for these clinicians. It can be infuriating, however, when the Emergency Room in the outpatient clinic is packed full of beds, the physician is running around treating all 8 kids in the room and the nurses are sitting, feet up, shoes off, chatting in Chichewa, apparently oblivious to the chaos around them.
I oscillate between feeling determined, useless, depressed, critical, and hopeful each day. I am thankful for the time that I have off to re-group and decompress with the wonderful colleagues I have here at the guesthouse, and am grateful that I too have lived to fight another day; because, as you will see in my next post, each day is stock full of surprises…
This post also marks the end of my two-week introduction to Pediatric HIV Care. As Dr. McCollum, the PI for my project has been in the States for the last two weeks he arranged for me to shadow clinicians in all of the different areas that kids with HIV receive care in Lilongwe: at the Baylor pediatric HIV Clinic, on the pediatric wards at KCH, in the outpatient clinic at KCH, and at area health centers. This has been a great way to see how the whole system works here. So, without further adieu my impressions of the challenges I have faced during these two weeks:
The two primary challenges that I have faced in these first two weeks have been communication and dealing with such a sick population and such limited resource settings. Communication is perhaps the most obvious challenge to my work here. Prior to arriving in Malawi I was under the impression that a large portion of the population speaks English, and that it is the language of commerce and government. This was a misconception. The primary language of all Malawians I work with is Chichewa, and many of the official interactions take place in Chichewa. So, from the outset I felt that I was on the outside, struggling to learn a language that has few cognates to English and sounds vastly foreign to my ear trained to converse in English and Spanish. Though I have mastered a few key phrases (see below entry on muli bwanji, also sanza= vomit, very important in pediatrics) my experience trying to interact in Chichewa has left me feeling like I suffer from both Broca’s and Wernicke’s aphasia (aka I hear and respond in utter nonsense). Thus, when seeing patients I require a translator, which in this setting is a nurse or clinical officer who is perfectly capable of seeing patients on their own. This limits my utility greatly.
Yet, I am not the only one challenged by language in Malawi. One of the interesting things about Malawian healthcare is their system of medical records. While an individual clinic or hospital may have their own system of stored records, each patient has a “Health Passport” in which each visit, including the chief complaint, physical exam, plan and any prescriptions are recorded (see http://giveaday.ca/blog/wp-content/uploads/2009/11/Malawi-3-174.jpg for example). Interestingly, these passports are kept completely in English. Much of the healthcare in Malawi, and especially in Lilongwe, is delivered by foreign doctors. Furthermore, all Malawians learn English in secondary school. Therefore, all Malawian medical professionals, and presumably all foreign doctors, can understand the notes in the passbook (that is, baring unintelligible handwriting, which abounds). Yet the average Malawian does not attend secondary school and therefore, doesn’t understand the information contained in their own medical record.
Medical records are certainly a hot topic in the U.S. right now, and I think the potential pros and cons of the Malawian system are worth consideration. How do you balance the need for efficiency and clarity in medical record keeping to facilitate good patient care, with simplicity to empower the patient to understand the decisions being made about their health? This seems like a particularly relevant conflict when the record isn’t being kept in the clinic or hospital, but is in the patient’s possession. This tension also brings to mind the question of the potential benefits and drawbacks of having the patient in control of their medical record. While I think an educated and empowered patient is ideal, is it beneficial for patients to know every detail of their diagnosis and plan?
On a more practical level, what do you do if a patient loses or alters their medical record? This is certainly a challenge here, as I have dealt with patients who have lost their passports, who have had animals eat part of the pages, who have spilled on them, or who have forgotten to bring them while traveling and ended up sick or injured. Thus I have found one of the greatest benefits to working in a foreign medical system is that it allows me to live the alternatives to the U.S. system which we collectively as a nation are trying to change for the better.
The other outstanding challenge that I have faced in the past two weeks is exposure to unremitting and irremediable misery. It is hard to articulate the horror of some of what I have seen, heard, smelled and felt in the past two weeks. This is a burden I have chosen to take on, so I won’t share too much but witnessing death and desolation in children is something that has become a daily occurrence for me, and which is the primary challenge to my work here. It is a constant challenge to strike a balance between grieving the lost child while maintaining composure to care for the child in the next bed who could still survive, and somehow holding onto a thread of my own mental well being. The frustration of treating hundreds of sick kids without accurate diagnostic tests, proper medications, or reliable electricity, in a hospital that is understaffed, poorly lit, filthy and teeming with children and their guardians (caregivers, usually a parent, who fill the role of nurses by administering medicines, giving food and baths and alerting doctors of changes in status) is almost paralyzing.
I don’t fully understand how I manage to go to work each day, hopeful to learn, and yet afraid of what I will witness. I do know that for now, I am meeting this challenge. I am still able to feel for the children and their parents, take joy in the kids that live to fight another day and still come home to sleep well at night. However with each day the latter becomes more and more difficult, as visions of what I have seen haunt me.
Throughout all of this I work side-by-side with physicians, nurses and clinical officers who have dedicated their lives to working in this setting. I am humbled by their resilience, especially those Malawian nurses, clinical officers, community health workers and HIV counselors whose own children suffer from many of the same maladies as those they treat. It amazes me the compassion that many are able to show on a daily basis despite the constant stimulus of misery. I have only been here two weeks and already feel great emotional wear and tear; I cannot imagine the impact of working in this setting day in and day out.
Yet I have also seen apathy and hardness in some of the nurses and clinical officers. To me this is a totally human reaction to such a situation, and so I try to also show compassion for these clinicians. It can be infuriating, however, when the Emergency Room in the outpatient clinic is packed full of beds, the physician is running around treating all 8 kids in the room and the nurses are sitting, feet up, shoes off, chatting in Chichewa, apparently oblivious to the chaos around them.
I oscillate between feeling determined, useless, depressed, critical, and hopeful each day. I am thankful for the time that I have off to re-group and decompress with the wonderful colleagues I have here at the guesthouse, and am grateful that I too have lived to fight another day; because, as you will see in my next post, each day is stock full of surprises…
Tuesday, June 8, 2010
Familiar Job, Novel Setting
Going into today I felt simultaneously that I had a fair amount of experience to bank on, and that I was totally unprepared for spending a day with HIV counselors who would test and counsel mothers and their young children. As a SHAC HIV counselor I have never tested or counseled children or their parents, and I have been lucky enough to have never had a positive. Going into today I knew the former was a definite and suspected the latter would occur before the day was out.
I started my day in the inpatient wards. The team of counselors, Gift, Effie, Lonely, and Gertrude who I worked with (more explanation of Malawian names later) are charged with testing pediatric inpatients who are referred by clinicians, whose mother’s have been identified as HIV+ at intake, or who meet certain clinical criteria. Before the day started Gift introduced me to the other counselors and then helped me practice some of my Chichewa. I learned (and then promptly forgot) how to say “I am going home.” I’m not sure what it means that this was the phrase I was taught at the beginning of the day, but things preceded better than they might have given that start.
In testing children for HIV there are several unique considerations: the first is determining the mother’s HIV status. Of the fifteen (or so) women who we counseled this morning, about three were known to be HIV positive. For these mothers there is a risk (I believe around 10-15%) that they transmitted the virus to their child during delivery, and a continued risk of transmitting the virus through breastfeeding. Interestingly, while there is an increased risk of transmitting HIV during breastfeeding, even over delivery itself, breastfeeding is still recommended for the first year of life.
The reason for this recommendation is that malnutrition in the first six months is a much greater threat to children than HIV transmitted from mother to child, especially if the mother is on antiretroviral therapy. Previous guidelines said to wean children from breast feeding at six months, yet it was found that children weaned at this interval had a high death rate due to malnutrition, and yet still had a high risk of mother-to-child transmission (MTCT) because the solid foods were causing micro tears in the infant’s stomach that, when breast milk was given, allowed the virus to enter their circulation. The recommendation has thus been amended to delay weaning to one year which has been shown to reduce risk of both malnourishment and MTCT. This example is illustrative of the complexities of practicing medicine in such a limited-resource setting. The best intentions can be completely confounded by the overwhelming disease burden of the population.
In addition to learning the ins and out of pediatric testing and counseling, it was interesting to see some of the organizational differences between SHAC HIV testing and testing at KCH. KCH employs a group pre-test counseling session with individual post-test counseling sessions. This allows counselors to test a higher volume of patients, and may have the added benefit of normalizing testing without revealing too much personal information, though as other counselors, hospital personnel and other patients often barged in on pre- and post-test counseling confidentiality was certain lacking in both the inpatient and outpatient wards.
I asked one of the counselors whether people had upset reactions to positive test. She told me no, people just accept it. When I’m counseling a patient in Durham who tells me about high risk behaviors, and I being to suspect they are infected I feel a panic start to rise. Of course, it is my job as a counselor to push the panic down and help the patient deal with the test results. Yet, I found that when HIV+ mothers came in with their newly delivered infants that panic didn’t rise. It was as if I too had somehow come to just accept it. I’m not sure what this means. We didn’t deliver a single positive result today; I suspect doing so would have provoked a much more emotional response on my behalf. But I am still left wondering what it means about me that I didn’t have ‘the panic.’ Am I becoming hardened? Or did I simply adapt?
I started my day in the inpatient wards. The team of counselors, Gift, Effie, Lonely, and Gertrude who I worked with (more explanation of Malawian names later) are charged with testing pediatric inpatients who are referred by clinicians, whose mother’s have been identified as HIV+ at intake, or who meet certain clinical criteria. Before the day started Gift introduced me to the other counselors and then helped me practice some of my Chichewa. I learned (and then promptly forgot) how to say “I am going home.” I’m not sure what it means that this was the phrase I was taught at the beginning of the day, but things preceded better than they might have given that start.
In testing children for HIV there are several unique considerations: the first is determining the mother’s HIV status. Of the fifteen (or so) women who we counseled this morning, about three were known to be HIV positive. For these mothers there is a risk (I believe around 10-15%) that they transmitted the virus to their child during delivery, and a continued risk of transmitting the virus through breastfeeding. Interestingly, while there is an increased risk of transmitting HIV during breastfeeding, even over delivery itself, breastfeeding is still recommended for the first year of life.
The reason for this recommendation is that malnutrition in the first six months is a much greater threat to children than HIV transmitted from mother to child, especially if the mother is on antiretroviral therapy. Previous guidelines said to wean children from breast feeding at six months, yet it was found that children weaned at this interval had a high death rate due to malnutrition, and yet still had a high risk of mother-to-child transmission (MTCT) because the solid foods were causing micro tears in the infant’s stomach that, when breast milk was given, allowed the virus to enter their circulation. The recommendation has thus been amended to delay weaning to one year which has been shown to reduce risk of both malnourishment and MTCT. This example is illustrative of the complexities of practicing medicine in such a limited-resource setting. The best intentions can be completely confounded by the overwhelming disease burden of the population.
In addition to learning the ins and out of pediatric testing and counseling, it was interesting to see some of the organizational differences between SHAC HIV testing and testing at KCH. KCH employs a group pre-test counseling session with individual post-test counseling sessions. This allows counselors to test a higher volume of patients, and may have the added benefit of normalizing testing without revealing too much personal information, though as other counselors, hospital personnel and other patients often barged in on pre- and post-test counseling confidentiality was certain lacking in both the inpatient and outpatient wards.
I asked one of the counselors whether people had upset reactions to positive test. She told me no, people just accept it. When I’m counseling a patient in Durham who tells me about high risk behaviors, and I being to suspect they are infected I feel a panic start to rise. Of course, it is my job as a counselor to push the panic down and help the patient deal with the test results. Yet, I found that when HIV+ mothers came in with their newly delivered infants that panic didn’t rise. It was as if I too had somehow come to just accept it. I’m not sure what this means. We didn’t deliver a single positive result today; I suspect doing so would have provoked a much more emotional response on my behalf. But I am still left wondering what it means about me that I didn’t have ‘the panic.’ Am I becoming hardened? Or did I simply adapt?
Saturday, June 5, 2010
24 Hours in Lilongwe
Well, I have arrived! After an uneventful but l-o-n-g series of plane rides we got to Lilongwe around 1 pm Malawi time (6 hours ahead of EST) yesterday. Friday was a busy day! Upon our arrival, Mariah, Timica (the two other UNC med students) and I came to the UNC guesthouse. The guesthouse is where visiting UNC researchers, physicians and students stay. I’ve never stayed in such modern facilities in the ‘developing world’ and I find myself feeling both pleased and awkward/guilty. Much of the culture shock that I have experienced on previous trips abroad has been due to adjusting to cold showers, toilets that don’t flush and co-inhabiting rodents. Here at the guesthouse there is wi-fi, cable and plenty of hot water to go around. I think all of these amenities will help make the transition easier, and will enable me to be more productive on the actual work. It does, however, make me feel uncomfortable to be living such an American lifestyle when Malawi, as a country, is so poor. Knowing all of the good work the UNC Project does helps assuage some of these feelings, but they persist none the less. I’m sure this is just a drop in the bucket in terms of the moral and ethical quandaries that this trip will bring up so I will leave that for now to report on the rest of the day.
One great thing about the UNC guesthouse is that it practically shares a campus with Kamuzu Central Hospital (KCH) and the Baylor Lighthouse facility (for pediatric HIV/AIDS treatment) so after dropping our bags we walked over to KCH to meet our future colleagues and supervisors. During my meeting, I found out that my two supervisors (one from UNC, one from Baylor) will both be gone for the first few weeks of my stay. Thankfully, they have worked out a schedule for me to do rotations on the pediatric wards of KCH, Lighthouse and some outpatient clinics so that by the time my research work begins I will have a good idea of what goes on in all of the facilities where we will be working.
In speaking with other people working at KCH, I heard of the familiar ups and downs of research in the ‘developing world.’ A common frustration was difficulty getting IRB approval on the Malawian side (as I understand it, all projects must be approved by the researcher’s home institution and by a Malawian IRB). I also heard of problems I became familiar with while working in Nicaragua: scheduling meetings that no one attends, problems with staff and patient participation etc. My research in Nicaragua taught me that, as much as possible, the most productive way to deal with these issues is not fight them but try to work with them (eg. incentivize attendance and participation) or when all else fails, just go with the flow. While it may not be official data collection, you can often learn as much from talking to the people around you as you can in administering a survey. Hopefully once I get actual assignments and deadlines I can keep this laid-back attitude.
After our meetings at KCH, Mariah and I went for a short jog to work out some of the kinks we acquired on the plane. The weather here is perfect for outdoor exercise, mid 70s in the day and mid 40s at night. When we started our run we heard the call to prayer from a mosque in Old Town, Lilongwe; Malawi has a significant Muslim population. It’s the first time I’ve ever lived somewhere with this custom, and I find hearing the call five times a day quite beautiful.
Last night we had Indian food for dinner; there is also a sizable Indian population in Malawi (keep your eyes out for an upcoming “About Malawi” page that will have more exhaustive information on the people and culture of Malawi.) Then we headed off to a farewell party for one of the Infectious Disease Fellows who has been working here for the past two years.
This was my first introduction to the large and active ex-pat community in Malawi. This is a phenomenon that I haven’t encountered before with such force. Like living in the guesthouse, there are certain benefits to having a social circle of people who enjoy activities such as running, yoga, and cooking Westernized dinners, that Malawians may be more hesitant to engage in. It is also nice to know there are people who approach this experience with similar perspectives. However, it seems counterintuitive for me to travel all the way to Malawi and work on a project that directly relates to the behavioral habits and well-being of Malawian people only to then spend my time hanging out exclusively with Europeans, Americans and Aussies. For me, it brings up many questions of socioeconomics and race that are difficult to enumerate and even more difficult to resolve. For fear of this becoming a never-ending post I won’t elaborate on those now, but expect to dedicate at least full posts to some of these issues down the road.
Post-party I slept for 12.5 hours and awoke feeling refreshed and ready to take on my first full day in Malawi. One of my major goals for my first two weeks here is getting the traditional Malawian greeting down. While many people here speak English, Chichewa is the native language. In Chichewa you never just say “hi” the exchange (in Chichewa) is as follows:
Muli bwanji? How are you?
Ndili bwino, kaya inu? I am fine. How are you?
Ndlili bwino, zicomo. I am fine thanks.
Zikomo kwamberia. Thank you very much.
There are different variations on this depending on time of day, and infinite ways you can alter it depending on the person you are addressing. For now, I’m just trying to learn the most generic version. So far I can get the first line out if I am the one initiating the conversation. If I don’t initiate, I get completely thrown off and reply in some incomprehensible mumble-jumble. This is why I am also focusing on ‘zikomo’ which means thank you and ‘pepani’ which means sorry/excuse me. I find these phrases are almost always considered polite.
I have also found that running is an excellent time to practice. I call out “Muli bwanjni” as I pass and by the time that it is my turn to respond I am long gone. On second thought, this may not be the best practice but it boosts my morale as I run along calling out a greeting in Chichewa and then motivates me to run quickly before the ‘conversation’ comes to the part where I should respond “ndili bwino, zikomo” -which I find very difficult to pronounce.
After an afternoon of shopping for vegetables and chitengas (spelling approximated), the traditional fabrics Malawian women use as wraps and to carry their babies, I’m back at the guesthouse trying to learn Chichewa and rest up for another full day. So for now I’ll say tsalani bwino! (Stay well)
Tuesday, June 1, 2010
T-Minus Two Days
Hello (soon-to-be) loyal readers!
Now that the whirl-wind that was the first year of medical school is done, I have time and energy to focus my energies on my next adventure: a summer of research in Malawi! This new-found time and energy is just in the nick of time, too, because I take off in exactly 48 hours and 30 minutes!
In Malawi I will be working with the UNC Project, a partnership between the Univeristy of North Carolina and the Malawian Ministry of Health. As such, I will be working with investigators from Baylor University and University of North Carolina to test a new method of diagnosing HIV in neonates.
Traditional HIV tests, which look for antibodies to the virus, cannot be used in children under 18 months because maternal antibodies which are acquired during gestation and delivery are still presesnt in the newborn (potentially giving false positives). This presents a problem because it has been found that if parents of potentially HIV-positive newborns take their children home, they may not have the ability, resources, or desire to return for testing 18 months later.
Thus to effectively initiate antiretroviral therapy (ART) in HIV+ newborns researchers and clinicians need to overcome a public health problem and a diagnositc problem. Clinicians need a diagnostic tool that doesn't look for antibodies and they need a tool that can be used at point-of-care (POC) so that the families don't have to return to the hopsital. The test that we will be evaluating this summer has already been shown to be diagnostically useful, it is called the p24 assay and it looks for a viral protein, which will only be present in children who are themselves HIV+, regardless of the maternal antibodies they carry. The study will also evaluate various manners of administering the test, in terms of which hospital personell are responsible, how the lab work is divided amongst responsible parties etc. The ultimate goal will be to find the most efficient way to identify HIV-positive newborns in order to initiate ART.
Contrary to what was believed in the early days of the HIV epidemic, it is now generally accepted that early initiation of ART therapy is critical to the patient's prognosis and can help sustain CD4 counts and prolong life expectancy. Thus this is an issue of critical importance to the estimated 91,000 Malawian children living with HIV.
While I have a background in HIV-related research in the 'developing world' and currently serve as an HIV testing counselor through the UNC student clinic, SHAC, I anticipate that this summer will be full of new lessons and new challenges. I am looking forward to learning about Malawian people and culture, putting the skills I learned this year into use, and contributing to an important project that has the potential to vastly improve the prognosis for children born with HIV in Malawi.
I'm thrilled and honored to be working with some of the best, brightest and most dedicated in this field, and alongside two of my classmates who are as committed and excited as I am. I'm glad that you all will be joining me on my adventures, some of you actively and some of you vicariously. As the summer progresses and I learn more about blogging I hope to improve the look of the blog and provide pictures, info on Malawi and more about the project. I look forward to your questions and comments and sharing what I'm sure is going to be a great experience with you!
Now that the whirl-wind that was the first year of medical school is done, I have time and energy to focus my energies on my next adventure: a summer of research in Malawi! This new-found time and energy is just in the nick of time, too, because I take off in exactly 48 hours and 30 minutes!
In Malawi I will be working with the UNC Project, a partnership between the Univeristy of North Carolina and the Malawian Ministry of Health. As such, I will be working with investigators from Baylor University and University of North Carolina to test a new method of diagnosing HIV in neonates.
Traditional HIV tests, which look for antibodies to the virus, cannot be used in children under 18 months because maternal antibodies which are acquired during gestation and delivery are still presesnt in the newborn (potentially giving false positives). This presents a problem because it has been found that if parents of potentially HIV-positive newborns take their children home, they may not have the ability, resources, or desire to return for testing 18 months later.
Thus to effectively initiate antiretroviral therapy (ART) in HIV+ newborns researchers and clinicians need to overcome a public health problem and a diagnositc problem. Clinicians need a diagnostic tool that doesn't look for antibodies and they need a tool that can be used at point-of-care (POC) so that the families don't have to return to the hopsital. The test that we will be evaluating this summer has already been shown to be diagnostically useful, it is called the p24 assay and it looks for a viral protein, which will only be present in children who are themselves HIV+, regardless of the maternal antibodies they carry. The study will also evaluate various manners of administering the test, in terms of which hospital personell are responsible, how the lab work is divided amongst responsible parties etc. The ultimate goal will be to find the most efficient way to identify HIV-positive newborns in order to initiate ART.
Contrary to what was believed in the early days of the HIV epidemic, it is now generally accepted that early initiation of ART therapy is critical to the patient's prognosis and can help sustain CD4 counts and prolong life expectancy. Thus this is an issue of critical importance to the estimated 91,000 Malawian children living with HIV.
While I have a background in HIV-related research in the 'developing world' and currently serve as an HIV testing counselor through the UNC student clinic, SHAC, I anticipate that this summer will be full of new lessons and new challenges. I am looking forward to learning about Malawian people and culture, putting the skills I learned this year into use, and contributing to an important project that has the potential to vastly improve the prognosis for children born with HIV in Malawi.
I'm thrilled and honored to be working with some of the best, brightest and most dedicated in this field, and alongside two of my classmates who are as committed and excited as I am. I'm glad that you all will be joining me on my adventures, some of you actively and some of you vicariously. As the summer progresses and I learn more about blogging I hope to improve the look of the blog and provide pictures, info on Malawi and more about the project. I look forward to your questions and comments and sharing what I'm sure is going to be a great experience with you!
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