In the end, College Inn (the hotel on top of the nightclub) became a bit of a barrier to study and sleep, and so we decided to leave, in search of greener pastures. And boy, didn't we do well.
361 Golf Course Apartments is my new address for now, everyone...
Sunday, 20 November 2011
Kampala, HIV and TB
First and foremost, I love Kampala. And I love Mulago hospital.
We have had two weeks of teaching on HIV and TB and I couldn't have wished for a more up to date, cutting edge set of talks, from world leaders.
Some highlights for me were:
- Hearing Barre-Sinoussi herself, give the opening address to the HIV symposium at Makere University
- Seeing patients on the wards and having to think how differently we need to act in resource poor settings compared to at Chelsea and Westminster
- Going to Africa's only Persian Restaurant in Kampala
- Meeting one of Kampala's six female taxi drivers
- Having quite interesting talks about what has caused HIV to spread in Africa like nowhere else (and yes, the issue of sexual networks / polygamy / beliefs about the acceptability of sex outside a relationship)
- Going to see Kampala's free circumcision program
- Arguing with colleagues about the appropriateness of research and trials in Africa, and the ethical considerations
I really should have written this bit contemporaneously, as its not easy to do it justice this way. Needless to say it has been amazing, especially as someone who wants to pursue a career in HIV and Infectious Diseases.
What, if any are my take home points?
1) women, once again have a raw deal, and will continue to do so unless more investment goes into prevention of HIV that they can be in control of (eg PrEP and microbicide gels)
2) behaviour is hard to change, but if we are going to try, it shouldn't just be a medical model, but a complete sociological one that looks at self-esteem, stigma, disclosure, and an overall sense of being well with HIV
3) as a UK trained physician, i've really only seen a fraction of what this epidemic means to the world
4) TB will hopefully, be picked up more readily with the help of technology such as GeneXpert, but we need ideally a version that is less reliant on electrical power and cheaper, before it can be a true point-of-care, rapid diagnostic test
5) Africa needs a plan for the future in terms of getting more people on treatment - currently there is a massive deficit in terms of those who need treatment and those who are getting it. The problems aren't just financial or supply related. Ideally, we need to follow in the footsteps of Kenya, who has just had one of its local drug companies approved by WHO to produce ARV's, which will account for a significant cost saving compared to having to source external products.
Once again, I quote Paul Farmer, who stated that we do not just need an equal option, but "a preferential option for the poor".
We have had two weeks of teaching on HIV and TB and I couldn't have wished for a more up to date, cutting edge set of talks, from world leaders.
Some highlights for me were:
- Hearing Barre-Sinoussi herself, give the opening address to the HIV symposium at Makere University
- Seeing patients on the wards and having to think how differently we need to act in resource poor settings compared to at Chelsea and Westminster
- Going to Africa's only Persian Restaurant in Kampala
- Meeting one of Kampala's six female taxi drivers
- Having quite interesting talks about what has caused HIV to spread in Africa like nowhere else (and yes, the issue of sexual networks / polygamy / beliefs about the acceptability of sex outside a relationship)
- Going to see Kampala's free circumcision program
- Arguing with colleagues about the appropriateness of research and trials in Africa, and the ethical considerations
I really should have written this bit contemporaneously, as its not easy to do it justice this way. Needless to say it has been amazing, especially as someone who wants to pursue a career in HIV and Infectious Diseases.
What, if any are my take home points?
1) women, once again have a raw deal, and will continue to do so unless more investment goes into prevention of HIV that they can be in control of (eg PrEP and microbicide gels)
2) behaviour is hard to change, but if we are going to try, it shouldn't just be a medical model, but a complete sociological one that looks at self-esteem, stigma, disclosure, and an overall sense of being well with HIV
3) as a UK trained physician, i've really only seen a fraction of what this epidemic means to the world
4) TB will hopefully, be picked up more readily with the help of technology such as GeneXpert, but we need ideally a version that is less reliant on electrical power and cheaper, before it can be a true point-of-care, rapid diagnostic test
5) Africa needs a plan for the future in terms of getting more people on treatment - currently there is a massive deficit in terms of those who need treatment and those who are getting it. The problems aren't just financial or supply related. Ideally, we need to follow in the footsteps of Kenya, who has just had one of its local drug companies approved by WHO to produce ARV's, which will account for a significant cost saving compared to having to source external products.
Once again, I quote Paul Farmer, who stated that we do not just need an equal option, but "a preferential option for the poor".
Uganda
The journey from Nairobi to Kampala was a painful 16 hours in a bus, with minimal breaks. We all felt rather beaten up, especially as we had to be in lectures from 8am the following morning.
The scenery is stunning and the border crossing was a unique experience, under the cover of almost complete darkness! My only memory is of how we queued in the rain and the dark, and the free condom dispensers (yes) next to each counter. Still haven't quite worked that one out.
Sadly we arrived at our hotel which was on top of a nightclub, and at 1am, it wasn't the best combination.
The scenery is stunning and the border crossing was a unique experience, under the cover of almost complete darkness! My only memory is of how we queued in the rain and the dark, and the free condom dispensers (yes) next to each counter. Still haven't quite worked that one out.
Sadly we arrived at our hotel which was on top of a nightclub, and at 1am, it wasn't the best combination.
Nairobi
Nairobi, not that I saw much of it in between work, was a very different place to Tanzania. Much more of a big city, like any other, with malls and highways. We had a fairly low-profile week given that Kenya was officially at war with Somalia that week. We were hosted by Kenyata hospital, where we took the ETAT+ (Paediatric life support) course, which was super. I also had the chance to meet up with mum and dad, who did the Masai Mara and were staying with their friends.
Most notably though, I camped for the first time and loved every minute! Definitely up for doing it lots in the future!
Zanzibar
So, I spent my week off in Zanzibar, which was a really welcome break from the mainline. Zanzibar has an interesting history, and the slave trade played a large part in it. As an outsider, it felt like another world. Its winding streets make you feel like time has stood still.
Mum and dad joined me in Zanzibar, and we spent the first few days in a charming converted mansion in the centre of town, which had the best view of Stonetown I'd ever seen. We then went to the loveliest resort, which was out of this world.
One of the highlights for me was meeting the last Zoroastrian family to remain in Zanzibar - Bomi and Diana Darukhanawala. Another example of the dynamic nature of communities. The Tembo hotel was actually the office of Cawasji Dinshaw and Brothers, and still bare's their name over the entrance.
One of the highlights for me was meeting the last Zoroastrian family to remain in Zanzibar - Bomi and Diana Darukhanawala. Another example of the dynamic nature of communities. The Tembo hotel was actually the office of Cawasji Dinshaw and Brothers, and still bare's their name over the entrance.
No excuses...
So it's been an extremely long time since I last wrote for a number of reasons. I've had my parents over and then we went to Nairobi and finally arrived in Uganda. I'm going to try and blog somewhat chronologically, if that helps. It has been an amazing time and there may well be some areas that are glossed over.
Friday, 28 October 2011
The sense of an ending
So I read this in three nights because it was also so addictive. Some poignant quotes below that I liked. 
A thousand splendid suns
The first book I read on a "kindle app" here. An excellent sequel to the kite runner.
Very hard to put down but so sad.
I hope the reality of life for women in Afghanistan - both urban and rural, has changed for the better
Very hard to put down but so sad.
I hope the reality of life for women in Afghanistan - both urban and rural, has changed for the better
The Zoroastrians of Zanzibar
What an interesting day yesterday was. After dad did a bit of detective work, and a few phone calls, we realised that Zanzibar's Zoroastrian temple, was still standing.
Established by Cowasjee Dinshaw and brothers in the Nineteenth Century, the community numbered no more than 150 people at it's height.
The temple was closed in the 1970's and currently only two Zoroastrians remain, and I was privileged to meet them today.
There was also a Zoroastrian cemetery which is sadly in a poor state of repair.
The Tembo House Hotel still bears the names of Cawasji Dinshaw, the building's one time owners, over it's entrance, along with portraits in the lounge.
Established by Cowasjee Dinshaw and brothers in the Nineteenth Century, the community numbered no more than 150 people at it's height.
The temple was closed in the 1970's and currently only two Zoroastrians remain, and I was privileged to meet them today.
There was also a Zoroastrian cemetery which is sadly in a poor state of repair.
The Tembo House Hotel still bears the names of Cawasji Dinshaw, the building's one time owners, over it's entrance, along with portraits in the lounge.
Wednesday, 26 October 2011
Parasitology...
Is hard when you only have about 9 hours of teaching before your diploma exam! Help!
The end of an era
So we are at the end of our time in moshi.
Last week was pretty heavy - lots of hard parasitology followed by the dreaded exam on Friday. Thankfully the stress of the week was relieved by the best weekend ever, in Tarangire national park and then the spectacular Ngorongoro crater. What a sight.
And now - off to Zanzibar for a week of R and R.
As for Nairobi, it's a bit of an open book at the moment, whether we go or not. If al-shabab continue their terrorist attacks then we may well not.
Will keep you all posted.
Last week was pretty heavy - lots of hard parasitology followed by the dreaded exam on Friday. Thankfully the stress of the week was relieved by the best weekend ever, in Tarangire national park and then the spectacular Ngorongoro crater. What a sight.
And now - off to Zanzibar for a week of R and R.
As for Nairobi, it's a bit of an open book at the moment, whether we go or not. If al-shabab continue their terrorist attacks then we may well not.
Will keep you all posted.
Tuesday, 18 October 2011
Kate's a mum!
I am so proud to say that my dear dear dear friend, Lady Katherine Malhotra (nee Medlow) of West Chelsea (Parson's Green), who got me though medical school and continues to tolerate me, gave birth to a love little healthy girl this morning x
So yes, it
has been ages since I last wrote. Partly due to exhaustion after our week away.
We arrived back in Moshi on Sunday night, sadly other groups got stuck in the
mud and had to be shipped out by boat and then local bus. Proving how hard
access to anything is, when you don’t have surfaced roads.
On return,
half of our week was spent preparing our verbal presentation and finalising the
written report, a picture of which i’ve put online (all 116 pages of it).
The rest of
the week was spent on malaria teaching, and it was pretty shocking. This one
illness doesn’t kill for the obvious reasons, and it doesn’t target the obvious
groups. The take home message from Dr Baz Nadjm and Dr Tom Doherty, was that it
kills children, mainly under twos. And if you make it past that age, whilst you
may well get severe malaria later, you are less likely to die from it. The
other sad fact was that the reason most people die is that they just do not get
to healthcare facilities in time. There is a lot of malaria that is never seen
because people die in the community. We estimate approximately 2000 lives a
day, yes, a day, are lost to it.
Finally,
our other take home message was that we are massively overdiagnosing malaria
without testing people first – and missing other important killers as a result.
In my study group at Pangani, we found that four out of five people who were
treated for malaria we not even tested, and may well have had other problems.
And of those who were lucky enough to be tested, in whom malaria was suspected,
half of them didn’t have it either.
Lots of
food for thought there – if you want to know more, you can read our report!
As for the
weekend, well a rather lively night at the “Glacier”, sprinkled with generous
amounts of Konyagi, led to a ceilidh on the roof of our hotel, and sore heads
the day after.
Sunday
however was incredible. I saw giraffes. Wow.
Wednesday, 12 October 2011
Tropical medicine in a nutshell
Why does this person
Who has come from this place
Develop these symptoms
At this particular time?
---
Prof Eldryd Parry
Who has come from this place
Develop these symptoms
At this particular time?
---
Prof Eldryd Parry
Tuesday, 11 October 2011
Rural visit to dispensary
So today we visited a village 66km away from Pangani, which itself is in the back and beyond. No running water. No power. No latrines.
Why?
Two cases of measles sent to us in the last 2 days.
All children should be vaccinated but uptake is scanty.
We performed, after our 2 hour 4x4 journey involving a boat across a river, and house to house search for other possible cases.
1 definite (with koplik spots - only the second time I've seen them) and several suspected.
The advice - to keep cases here for management to contact the infection.
We also visited the dispensary itself - which was actually fairly well stocked and not busy at present. One problem - poor communication with the district hospital at Pangani. No phones or faxes - the staff just use their own mobiles at their own expense - which is a deterrent given the cost of calls here.
I am exceedingly hot and tired after just three hours in sun.
Ps did you notice the mosquito net placed next to a fishing net? Sadly the district medical officer (the only doctor at Pangani hospital) also reiterated that out of all the nets he'd distributed, for free, not a single one was in use (at least, for the purpose for which it was intended). He also explained how local beliefs prevailed and that people thought that both vaccination programs and impregnated mosquito nets were a ploy by the government to render the population impotent and infertile.
Why?
Two cases of measles sent to us in the last 2 days.
All children should be vaccinated but uptake is scanty.
We performed, after our 2 hour 4x4 journey involving a boat across a river, and house to house search for other possible cases.
1 definite (with koplik spots - only the second time I've seen them) and several suspected.
The advice - to keep cases here for management to contact the infection.
We also visited the dispensary itself - which was actually fairly well stocked and not busy at present. One problem - poor communication with the district hospital at Pangani. No phones or faxes - the staff just use their own mobiles at their own expense - which is a deterrent given the cost of calls here.
I am exceedingly hot and tired after just three hours in sun.
Ps did you notice the mosquito net placed next to a fishing net? Sadly the district medical officer (the only doctor at Pangani hospital) also reiterated that out of all the nets he'd distributed, for free, not a single one was in use (at least, for the purpose for which it was intended). He also explained how local beliefs prevailed and that people thought that both vaccination programs and impregnated mosquito nets were a ploy by the government to render the population impotent and infertile.
Rural visit to dispensary
So today we visited a village 66km away from Pangani, which itself is in the back and beyond. No running water. No power. No latrines.
Why?
Two cases of measles sent to us in the last 2 days.
All children should be vaccinated but uptake is scanty.
We performed, after our 2 hour 4x4 journey involving a boat across a river, and house to house search for other possible cases.
1 definite (with koplik spots - only the second time I've seen them) and several suspected.
The advice - to keep cases here for management to contact the infection.
We also visited the dispensary itself - which was actually fairly well stocked and not busy at present. One problem - poor communication with the district hospital at Pangani. No phones or faxes - the staff just use their own mobiles at their own expense - which is a deterrent given the cost of calls here.
I am exceedingly hot and tired after just three hours in sun.
Ps did you notice the mosquito net placed next to a fishing net? Sadly the district medical officer (the only doctor at Pangani hospital) also reiterated that out of all the nets he'd distributed, for free, not a single one was in use (at least, for the purpose for which it was intended). He also explained how local beliefs prevailed and that people thought that both vaccination programs and impregnated mosquito nets were a ploy by the government to render the population impotent and infertile.
Why?
Two cases of measles sent to us in the last 2 days.
All children should be vaccinated but uptake is scanty.
We performed, after our 2 hour 4x4 journey involving a boat across a river, and house to house search for other possible cases.
1 definite (with koplik spots - only the second time I've seen them) and several suspected.
The advice - to keep cases here for management to contact the infection.
We also visited the dispensary itself - which was actually fairly well stocked and not busy at present. One problem - poor communication with the district hospital at Pangani. No phones or faxes - the staff just use their own mobiles at their own expense - which is a deterrent given the cost of calls here.
I am exceedingly hot and tired after just three hours in sun.
Ps did you notice the mosquito net placed next to a fishing net? Sadly the district medical officer (the only doctor at Pangani hospital) also reiterated that out of all the nets he'd distributed, for free, not a single one was in use (at least, for the purpose for which it was intended). He also explained how local beliefs prevailed and that people thought that both vaccination programs and impregnated mosquito nets were a ploy by the government to render the population impotent and infertile.
Sunday, 9 October 2011
The hospital with no supplies
It's depressing.
Our rural project. Pangani district hospital. Everyone says the same thing.
If you've got HIV you're one of the lucky ones cos at least you're getting some drugs thanks to the international community.
But if you've got a simple chest infection - the pharmacy is all but
Empty. And oxygen? You must be joking.
My remit is to perform a health needs assessment and then write a business case for external funding for the hospital.
The problem is that we only have 4.5 days and most of the issues people have highlighted are slightly beyond us.
"we have no supplies- no drugs - no petrol for our vehicles"
"all our staff leave - and 80% of our posts are vacant"
Our rural project. Pangani district hospital. Everyone says the same thing.
If you've got HIV you're one of the lucky ones cos at least you're getting some drugs thanks to the international community.
But if you've got a simple chest infection - the pharmacy is all but
Empty. And oxygen? You must be joking.
My remit is to perform a health needs assessment and then write a business case for external funding for the hospital.
The problem is that we only have 4.5 days and most of the issues people have highlighted are slightly beyond us.
"we have no supplies- no drugs - no petrol for our vehicles"
"all our staff leave - and 80% of our posts are vacant"
Plus ca change
On our way back we are told that there is a 36/40 pregnant woman who needs to be transferred over. We pick her up at another dispensary then take her to the health centre, who carry on to Pangani.
I'm struggling at present though with the task I've been given. Writing a needs assessment is easier when you have queues of patients and full wards. But here at the health centre only one bed out of ten is occupied. There is little activity after midday. It was similar at the first dispensary. And they all have the same complaint - people present too late because of distrust of western medicine and a preference for traditional healers.
I speak to my Tanzanian colleague about this.
He tells me it is a difficult situation because most of the public don't trust the hospital
I'm struggling at present though with the task I've been given. Writing a needs assessment is easier when you have queues of patients and full wards. But here at the health centre only one bed out of ten is occupied. There is little activity after midday. It was similar at the first dispensary. And they all have the same complaint - people present too late because of distrust of western medicine and a preference for traditional healers.
I speak to my Tanzanian colleague about this.
He tells me it is a difficult situation because most of the public don't trust the hospital
Sisal
The export crop that is tanzania's main export. It is hated by many because whilst it creates jobs for unskilled labourers, it feeds no one. Similar to coffee.
We see it everywhere here but at the same time we have people living on less than 30p a day, unable to give a decent meal to their families.
We see it everywhere here but at the same time we have people living on less than 30p a day, unable to give a decent meal to their families.
Pangani
How to summarise yesterday and today ...
1) a very long a bumpy journey
2) getting stuck in mud and having to push the bus out
3) a lovely house by the sea
4) a visit to the tanga yacht club
1) a very long a bumpy journey
2) getting stuck in mud and having to push the bus out
3) a lovely house by the sea
4) a visit to the tanga yacht club
Shake it like a Polaroid picture
Has become the anthem of our bus given how we all lose a filling / prosthetic hip joint every time we get in, due to the vibrations!
Useful fact for the day
1) an LMA ( laryngeal mask ) can easily double as an effective "She-wee". I'm told.
Thursday, 29 September 2011
Preparing to move on...
So today was our last day in moshi before our rural field trip. I'm off to a sleepy seaside town called Pangani at 6am tomorrow.
Today was a mixture of fever, ethics and neurology. Interesting point - we diagnose malaria far too often, when on average less than half of those we treat for it actually have it. We also miss the other causes of a fever, most importantly bacterial sepsis.
Take home message - in a low prevalence setting, believe your negative malaria rapid test and treat with broad spectrum antibiotics if sick.
We also had a very interesting session on the ethics of medical placements abroad - i've ranted for a few years about the issue of not really benefitting the host country when we are abroad.
http://www.ajtmh.org/content/83/6/1178.abstract
John Crump summarises issues that occur commonly when we are sent abroad eg on elective, but interestingly enough the field of ethics in this domain is a rather new one.
Finally we spent the afternoon back on the wards with Dr Howlett (one of Tanzania's two neurologists) seeing cases ranging from a space occupying lesion causing several neurological sequelae, to a haemhorragic CVA with subarachnoid transformation in a 20 year old. Sadly, haemhorragic strokes account for approximately 40% of CVAs here.
We asked our fellow African students why Tanzania has so few neurologists. The answer was not surprising, "it makes you no money. You cannot do much for most of your patients".
In reality, Dr Howlett highlighted that whilst we were in in Faith-based hospital Africa, little more than a full blood count was free of charge, and CT scans too exorbitantly priced (at $100) for most of our patients. He also reminded us that whilst certain conditions (eg TB) have been prioritised by the international community to make treatment available for free, we forget that high blood pressure is being ignored. With urbanisation and lifestyle changes, we are missing this growing problem.
Yet it impacts more than half of over 50s in Tanzania and we know how important a risk factor it is for several serious conditions.
So another take home message could be:
Just because we're in the tropics doesn't mean that people aren't frying strokes, heart attacks and COPD.
Today was a mixture of fever, ethics and neurology. Interesting point - we diagnose malaria far too often, when on average less than half of those we treat for it actually have it. We also miss the other causes of a fever, most importantly bacterial sepsis.
Take home message - in a low prevalence setting, believe your negative malaria rapid test and treat with broad spectrum antibiotics if sick.
We also had a very interesting session on the ethics of medical placements abroad - i've ranted for a few years about the issue of not really benefitting the host country when we are abroad.
http://www.ajtmh.org/content/83/6/1178.abstract
John Crump summarises issues that occur commonly when we are sent abroad eg on elective, but interestingly enough the field of ethics in this domain is a rather new one.
Finally we spent the afternoon back on the wards with Dr Howlett (one of Tanzania's two neurologists) seeing cases ranging from a space occupying lesion causing several neurological sequelae, to a haemhorragic CVA with subarachnoid transformation in a 20 year old. Sadly, haemhorragic strokes account for approximately 40% of CVAs here.
We asked our fellow African students why Tanzania has so few neurologists. The answer was not surprising, "it makes you no money. You cannot do much for most of your patients".
In reality, Dr Howlett highlighted that whilst we were in in Faith-based hospital Africa, little more than a full blood count was free of charge, and CT scans too exorbitantly priced (at $100) for most of our patients. He also reminded us that whilst certain conditions (eg TB) have been prioritised by the international community to make treatment available for free, we forget that high blood pressure is being ignored. With urbanisation and lifestyle changes, we are missing this growing problem.
Yet it impacts more than half of over 50s in Tanzania and we know how important a risk factor it is for several serious conditions.
So another take home message could be:
Just because we're in the tropics doesn't mean that people aren't frying strokes, heart attacks and COPD.
Neurology day
Time for more stats
1) no of people living in Tanzania
- approx 40 million
2) no of neurologists in Tanzania
- two.
3) average wage of a doctor qualified for five years - £200/month
4) last time my fellow doctor was actually paid by the government
- over three years ago, and still chasing his salary
1) no of people living in Tanzania
- approx 40 million
2) no of neurologists in Tanzania
- two.
3) average wage of a doctor qualified for five years - £200/month
4) last time my fellow doctor was actually paid by the government
- over three years ago, and still chasing his salary
Tuesday, 27 September 2011
Tuesday
So today started with another very productive lesson in Swahili, where we sang the equivalent of "heads, shoulders, knees and toes" which was great fun.
I then had probably the best lecture I've ever had about STIs in Africa, from professor David Mabey. Lots of interesting points, a few of which were a shock - that 80% of adults here have HSV-2 infection, which of course increases your chances of transmitting and acquiring HIV. A shocking number of mothers - 1 in a 100, have a stillborn child due to Syphilis infection. A point of care test exists but like most STI campaigns it's not simple to implement programmed here.
We've long known that other STIs, especially HSV can increase genital tract viral loads of HIV and therefore increase infectiousness. Yet in a country with an 80% prevalence, where access to healthcare is difficult at best, it's hard to envisage an effective solution on the horizon.
Our afternoon was an interesting mix of ocular pathology which i'd never see in the Uk. I'm always amazed at how cooperative our patients are given how bad our Swahili is.
Cases I saw today:
1) lady with keratitis
2) a Masai child with a shockingly large 5cm ocular neoplasm - who will almost certainly lose it and need chemotherapy and radiotherapy. Whether she gets it is another issue.
3) a lady with bilateral cataracts
4) a child with unilateral proptpsis and a divergent squint. We once again, fear the results of her cranial imaging.
5) a lady with pingeculae and glaucoma
6) a 12 year old girl who successfully received a corneal graft for keratoconus (specially flown in from the USA as there is no tissue bank here)
I then had probably the best lecture I've ever had about STIs in Africa, from professor David Mabey. Lots of interesting points, a few of which were a shock - that 80% of adults here have HSV-2 infection, which of course increases your chances of transmitting and acquiring HIV. A shocking number of mothers - 1 in a 100, have a stillborn child due to Syphilis infection. A point of care test exists but like most STI campaigns it's not simple to implement programmed here.
We've long known that other STIs, especially HSV can increase genital tract viral loads of HIV and therefore increase infectiousness. Yet in a country with an 80% prevalence, where access to healthcare is difficult at best, it's hard to envisage an effective solution on the horizon.
Our afternoon was an interesting mix of ocular pathology which i'd never see in the Uk. I'm always amazed at how cooperative our patients are given how bad our Swahili is.
Cases I saw today:
1) lady with keratitis
2) a Masai child with a shockingly large 5cm ocular neoplasm - who will almost certainly lose it and need chemotherapy and radiotherapy. Whether she gets it is another issue.
3) a lady with bilateral cataracts
4) a child with unilateral proptpsis and a divergent squint. We once again, fear the results of her cranial imaging.
5) a lady with pingeculae and glaucoma
6) a 12 year old girl who successfully received a corneal graft for keratoconus (specially flown in from the USA as there is no tissue bank here)
RIP inominate goldfish
It is with great regret that I inform you that, one of our goldfish (the bigger of the two) passed away, peacefully today, at 35 Collingham Place, at the age of three and a half years.
Our thoughts are with his fellow goldfish, who said, "call me Bubbles" and of course, Smog and Dolly. When seen earlier, Dolly was, "this is borrrring". Smog said, "oh
my god i can't believe you just said that but shut up I didn't do nuffink and anyway he was always tryin to lez me
up."
Our thoughts are with his fellow goldfish, who said, "call me Bubbles" and of course, Smog and Dolly. When seen earlier, Dolly was, "this is borrrring". Smog said, "oh
my god i can't believe you just said that but shut up I didn't do nuffink and anyway he was always tryin to lez me
up."
Monday, 26 September 2011
How to summarise a
week in East Africa. Well, one thing that was certain, I didn’t want to do
anything but relax this weekend. Whilst most of the group went trekking on
Saturday I decided to take it easy and visited a lovely local swimming pool,
and then did the same again on Saturday.
I’d forgotten how
tiring Africa can be and in particular, Moshi. Sadly, Moshi isn’t the safest
place –you get hassled all the time and there have been a few attemps, some of
which occurred in broad daylight, to grab bags / money etc from us. Hence the
opportunity to escape for a day without hassle was inviting enough.
On reflection, the
first week was amazing and way beyond my expectations. What has struck me is
the structure of the hospital and how well it is run. If you take away the
obvious i.e. that we are in one of the poorest countries in the world, you
still have a hospital with a library, lecture theatre, grand rounds, housemen
and registrars, and even the same politics.
What I do take away
with me however is the cases I see here on the wards every day. Today was a day
dedicated to ophthalmology which took me back to my days in Budumburam – the
refugee camp I worked at in 2004, in Ghana. Day in and day out, we tested and
treated people who had poor eyesight, and distributed the hundreds of pairs of
glasses we had collected prior to our trip. I still recall the look on
patients’ faces when we were able to correct something as simple as
short-sightedness, so easily.
Sight is something we
all take for granted (to quote my colleague Dan today, when he tested my acuity
– “Farhad, do you realise you are blind according to the WHO” which was true
since i barely scored 1/60. BUT. The big difference is that I have had the
opportunity to do something about my eyesight, and I suffer no deficit as I can
afford to get tested and get glasses.
The single largest
cause of blindness in Africa is not trachoma, or river blindness, though this
is what makes the news. It is refractive error (short and long sighted-ness)
and cataract. Both are treatable, and essentially a “non-issue” in the
developed world.
My afternoon on the
wards was once again an eye opener and a reminder of why i got into medicine. I
ask my colleagues from East Africa – “don’t you get depressed, seeing child
after child with preventable conditions, and many of whom die in your care”. I
mean, several of them have to pay for treatment which they can’t afford, and in
the end – they die. The answer was, “of course we get depressed, we cry.”
What can you do? One
third of the UK’s drug budget is consumed on Antiretrovirals for HIV / AIDS
treatment, and the majority of the epidemic is driven by, non-heterosexual and
non-vertical transmission. And yet here, day after day, I am seeing case after
case, especially in children, who have contracted the disease from their
mothers, who are often orphaned, and who often have such severe complications
by the time we see them that there is little hope. If only they had access to
the incredible resources we have in the UK.
This afternoon we saw
a 21 year old boy with 5cm tumour of the left nostril. He was HIV positive and
this was probably Kaposi’s. Who back home would let things get to this stage
before presenting? Sadly his parents were both dead, and the boy will get
little more than a full blood count paid for by the hospital. Chemotherapy and
antiretrovirals are what he needs however.
Similarly, a lady in
her twenties with classical Kaposi’s sarcoma affecting the nose and palate. We
line up to see these patients who obediently agree to our requests in poor
Swahili to examine them. How frustrating must it be to know however that you’re
only hope for a bit more time and some quality of life is a relative with some
money coming out of the woodwork, who may pay your treatment fees.
Other cases seen
today – Suppurative lymph nodes secondary to probable TB (for once, HIV
negative), Massive Splenomegaly (possibly due to Chonic Malaria or
myeloproliferative disease), Hepatomegaly and ascites (possibly due to
Vertically Transmitted Hep B) and a man who had had massive haematemesis (?
Schistosomiasis).
Each afternoon we
turn up on the ward, which is usually lined with beds either side, and then
down the middle, and then trolleys in the corridor. There is little room for
anything, especially not us. Families perform most tasks such as feeding and
bathing. Often they share the patients’ beds. There is little privacy and it is
very difficult to maintain patients’ confidentiality and dignity, in the same
way that we try to usually.
What is strange is
that I have been here before, in the sense that I have worked in India, Ghana
and Azerbaijan, and in conditions worse than this. I did not however, in those
settings, ever appreciate what a toll HIV had had on ordinary peoples’ lives.
Here, 7% of
Tanzanians are affected. I.e. 1 in about 14 people in the whole country are
infected. In parts of South Africa, this figure is more like 50%.
So virtually everyone
who comes into hospital here gets an HIV test, and a large number of them end
up being positive. Sadly, many slip through the net, and they go on, getting
ill outside hospital, and never getting tested. They pass the condition onto
their husbands and wives, and then onto their children. Often by the time that
their children are born, their parents are often dying, or dead.
This is no
exaggeration of what is affecting this continent today, a land where a taxi
driver / nurse / teacher will earn little more than £100 / month, and yet a loaf of bread costs what it does back in
the UK. Yet there is no safety net – there is no social security, or national
health service.
HIV medicine was once the realm of specialists, but it is the bread and butter of physicians in Africa, who come face to face with it daily, with almost every other patient who ends up in hospital.
What am I saying –
well, in summary, we have two very different epidemics here. Let us not try and
simplify things.
We have what is
happening in the “West” and then a very different, more sinister epidemic,
which I am witnessing today.
What does it need ? –
in my opinion, universal testing for EVERYBODY, and treatment. And we need to
perform “outreach” measures to get to everybody and not just rely on people to
attend only when they are sick, and it is often too late. People are most
infectious when they are infected but unaware, and not on treatment.
We must abandon this
outdated view of at risk groups, and to quote one of the most outstanding
people I’ve worked with, Dr Rob Davidson, “There are only two risk factors for
being HIV positive – one is being male, and the other is being female”.
How we get there is
sadly not going to depend on physicians or the millions of healthcare workers
and volunteers who work tireless in these disease stricken areas, but on the
politicians and policy makers who hold the purse-strings.
We can do our bit,
but we cannot do it alone. Perhaps one day, we will look back, just as we have
done on so many issues, with the benefit of hindsight, and wonder why mankind
stood so still in the midst of an epidemic that is taking so many lives?
Thought for the day:
“Be the change you want to see in the world”. Mahatma Gandhi
Friday, 23 September 2011
End of a week
So everyone. I have finished a week of my diploma. This is an experimental first run of a course which has been truly remarkable.
Yesterday after our Swahili and epidemiology classes I came face to face with the side of my speciality which I don't deal with- children.
There are few conditions that affect me as much as children with AIDS. My 12 year old patient was admitted with TB, but was also thoroughly emaciated. 80% of people with TB in Africa are also HIV positive. A sobering statistic. Sadly for this young boy, on top of all his problems, he had some subtle signs in his mouth which we almost missed and rarely ever see these days in the UK - Kaposi's sarcoma.
His parents are both positive and on treatment. He has two siblings who his parents don't want to test just as yet. And for my patient, TB treatment and having to start ARVs wasn't enough. He will now probably also start chemotherapy.
Today, we learned how to model an epidemic and hopefully, how to best control one spreading.
At present i am just a bit overwhelmed and tired but will write more soon.
Yesterday after our Swahili and epidemiology classes I came face to face with the side of my speciality which I don't deal with- children.
There are few conditions that affect me as much as children with AIDS. My 12 year old patient was admitted with TB, but was also thoroughly emaciated. 80% of people with TB in Africa are also HIV positive. A sobering statistic. Sadly for this young boy, on top of all his problems, he had some subtle signs in his mouth which we almost missed and rarely ever see these days in the UK - Kaposi's sarcoma.
His parents are both positive and on treatment. He has two siblings who his parents don't want to test just as yet. And for my patient, TB treatment and having to start ARVs wasn't enough. He will now probably also start chemotherapy.
Today, we learned how to model an epidemic and hopefully, how to best control one spreading.
At present i am just a bit overwhelmed and tired but will write more soon.
Thursday, 22 September 2011
Quote for the day
"Doctors use statistics like a drunk uses a lamp-post. For support, rather than illumination."
Wednesday, 21 September 2011
Wednesday
Today started with a grand round: the role of isoniazid prophylaxis for TB in south African gold miners.
We then had a session of Swahili. I now know how to say I am 20 years old (am not rushing to learn numbers over thirty yet).
Epidemiology continued and we have been struggling with our paper to review which I cannot believe actually got into an international PR journal.
After lunch was the low point for me - having to talk about myself to the class. I think I said something about hating that, and that my sense of humour is deemed by some as offensive but that wasn't intentional so sorry in advance.
We then had a session of Swahili. I now know how to say I am 20 years old (am not rushing to learn numbers over thirty yet).
Epidemiology continued and we have been struggling with our paper to review which I cannot believe actually got into an international PR journal.
After lunch was the low point for me - having to talk about myself to the class. I think I said something about hating that, and that my sense of humour is deemed by some as offensive but that wasn't intentional so sorry in advance.
Tuesday, 20 September 2011
East African Diploma in Tropical Medicine and Hygiene
So I'm here. All settled in and the course has started.
Describe it in a word so far - wow.
Moshi is small, and has incredible views of the snow covered Kilimanjaro.
We are based at the Kilimanjaro Christian Medical Centre at present but have lots travel and rural projects.
Today - epidemiology based on real outbreaks. Case study - bloody diarrhoea from six different refugee camps.
Followed by ward bedside teaching and then discussion.
Case 1 - HIV positive, obtunded patient with no other history given.
Just think about how you'd manage her when she has focal neurology but the family can't afford a CT scan, which the hospital can't pay for.
Sadly you just treat for everything (TB, Toxo and Crypto) and just hope it's not Lymphoma. And don't give steroids in case it is Crypto.
Case 2 - Hansen's disease (leprosy).
Not every day we see it anywhere at home, and even less so these days in Tanzania.
Tonight's homework:
Appraise a paper on calcium and TB, and prepare my case presentation from my time on the ID unit at Northwick Park.
Describe it in a word so far - wow.
Moshi is small, and has incredible views of the snow covered Kilimanjaro.
We are based at the Kilimanjaro Christian Medical Centre at present but have lots travel and rural projects.
Today - epidemiology based on real outbreaks. Case study - bloody diarrhoea from six different refugee camps.
Followed by ward bedside teaching and then discussion.
Case 1 - HIV positive, obtunded patient with no other history given.
Just think about how you'd manage her when she has focal neurology but the family can't afford a CT scan, which the hospital can't pay for.
Sadly you just treat for everything (TB, Toxo and Crypto) and just hope it's not Lymphoma. And don't give steroids in case it is Crypto.
Case 2 - Hansen's disease (leprosy).
Not every day we see it anywhere at home, and even less so these days in Tanzania.
Tonight's homework:
Appraise a paper on calcium and TB, and prepare my case presentation from my time on the ID unit at Northwick Park.
Friday, 16 September 2011
Addis Ababa
So I've landed in Addis Ababa again. And feel like a proper entry in this blog.
Sadly i can't leave the airport on this occasion but my fondness for this place remains.
The weather is beautiful today and as always, the smell of beautiful ethiopian coffee awaits me in the airport.
Perhaps I'm tuning into this smell and not the smell of cigarette smoke (banning smoking in public is probably one of the other major public health interventions we have undertaken in several countries).
Most people know very little about Ethiopia and how ancient their civilisation is. My exposure came from my grandmother telling me about her trip to visit her sister who was posted in Diredawa and Asmara which is now in an independent Eritrea (in the 1940s/50s).
During my last trip, the piety of the people, the majority of whom I came across in Addis were Coptic Chistians, was most striking. Most people associate Christianity with Europe and the holy land, but few acknowledge that it was in Ethiopia and Armenia who were two of the first nations to adopt it as there own religion, long before Europe did.
As a result, Christianity appears to be practiced in unique orthodox way here, and is steeped in symbolism. I remember walking into a church filled with Ethiopians, praying, in the middle of the working day, in Addis. This would be a rare sight in the UK.
Whether religion is a force for good or evil is a subject for debate by many. The world would certainly not be what it is without it, but I doubt very much it would be wholly better.
A recent radio 4 program spoke about physicians embracing the placebo effect as an intended therapy for chronic conditions. Ethical - probably not. Effective - probably much more than many "chemo-active" drugs.
My point - hope and belief enhance quality of lives, and if faith provides this, or equally a pill containing nothing more than a placebo, it is of value.
If I tell a patient when I first meet them, "we see that patients symptoms improve with certain treatments which are unorthodox and rely on the placebo effect, would you be happy to try them whilst you are a patient here if you need them, and tell us if they work" - I wonder how many of them, when they return with say a chronic pain syndrome, would not be grateful, if I took their longstanding symptoms away.
Is it wrong that doctors may effectively heal by "giving hope" - I think not. As long as the patients consent (most helpful ahead of time), and they know that the objective is to make them better, I think. How and why though does it work, and have a role in the NHS?
It is probably the mutual discussion, time to listen, follow up, and hope given by several "non-traditional" therapies, including placebos, that makes chronic symptoms better.
So next time we just hand a prescription to a nurse to hand out, think twice about the time we are in fact wasting in the long term.
Sadly i can't leave the airport on this occasion but my fondness for this place remains.
The weather is beautiful today and as always, the smell of beautiful ethiopian coffee awaits me in the airport.
Perhaps I'm tuning into this smell and not the smell of cigarette smoke (banning smoking in public is probably one of the other major public health interventions we have undertaken in several countries).
Most people know very little about Ethiopia and how ancient their civilisation is. My exposure came from my grandmother telling me about her trip to visit her sister who was posted in Diredawa and Asmara which is now in an independent Eritrea (in the 1940s/50s).
During my last trip, the piety of the people, the majority of whom I came across in Addis were Coptic Chistians, was most striking. Most people associate Christianity with Europe and the holy land, but few acknowledge that it was in Ethiopia and Armenia who were two of the first nations to adopt it as there own religion, long before Europe did.
As a result, Christianity appears to be practiced in unique orthodox way here, and is steeped in symbolism. I remember walking into a church filled with Ethiopians, praying, in the middle of the working day, in Addis. This would be a rare sight in the UK.
Whether religion is a force for good or evil is a subject for debate by many. The world would certainly not be what it is without it, but I doubt very much it would be wholly better.
A recent radio 4 program spoke about physicians embracing the placebo effect as an intended therapy for chronic conditions. Ethical - probably not. Effective - probably much more than many "chemo-active" drugs.
My point - hope and belief enhance quality of lives, and if faith provides this, or equally a pill containing nothing more than a placebo, it is of value.
If I tell a patient when I first meet them, "we see that patients symptoms improve with certain treatments which are unorthodox and rely on the placebo effect, would you be happy to try them whilst you are a patient here if you need them, and tell us if they work" - I wonder how many of them, when they return with say a chronic pain syndrome, would not be grateful, if I took their longstanding symptoms away.
Is it wrong that doctors may effectively heal by "giving hope" - I think not. As long as the patients consent (most helpful ahead of time), and they know that the objective is to make them better, I think. How and why though does it work, and have a role in the NHS?
It is probably the mutual discussion, time to listen, follow up, and hope given by several "non-traditional" therapies, including placebos, that makes chronic symptoms better.
So next time we just hand a prescription to a nurse to hand out, think twice about the time we are in fact wasting in the long term.
Back to Africa
I'm finally here. Bum in seat. On Tarmac at Heathrow. It is incredibly exciting to think that I have a place on the DTM&H, and one in Africa at that.
At present all I can think of is sleep, hoping I can get some Injera and veggies when I land in Addis, and that I'm not too tired when I finally get to Kilimanjaro tomorrow.
I've spent 5 weeks at 56 Dean Street and Chelsea and Westminster and loved every second.
We have had lively debates at work about PrEP, criminalisation and prevention strategies. PrEP is probably going to be one of the most significant public health interventions of all time for for this planet.
How we have progressed from a time when we feared the virus and there was little one could do, to when in the UK at least, we have several established clinics for the "older person" living with HIV as a manageable chronic condition. Most
of sub-Saharan Africa however has a shockingly high prevalence of HIV and relatively few treatment options.
One thing is for certain - we have got two, very different epidemics in Africa vs the "developed" world, and a "one size fits all" solution just won't work without taking these differences into account.
"Social medicine", or better put, "why certain people get ill from certain things", is going to be vital, and I believe that physicians must take on the role of asking those uncomfortable questions that make us feel awkward, and out of our comfort zones, if we are to truly understand and focus our efforts on succeeding where so many other prevention campaigns have failed.
At present all I can think of is sleep, hoping I can get some Injera and veggies when I land in Addis, and that I'm not too tired when I finally get to Kilimanjaro tomorrow.
I've spent 5 weeks at 56 Dean Street and Chelsea and Westminster and loved every second.
We have had lively debates at work about PrEP, criminalisation and prevention strategies. PrEP is probably going to be one of the most significant public health interventions of all time for for this planet.
How we have progressed from a time when we feared the virus and there was little one could do, to when in the UK at least, we have several established clinics for the "older person" living with HIV as a manageable chronic condition. Most
of sub-Saharan Africa however has a shockingly high prevalence of HIV and relatively few treatment options.
One thing is for certain - we have got two, very different epidemics in Africa vs the "developed" world, and a "one size fits all" solution just won't work without taking these differences into account.
"Social medicine", or better put, "why certain people get ill from certain things", is going to be vital, and I believe that physicians must take on the role of asking those uncomfortable questions that make us feel awkward, and out of our comfort zones, if we are to truly understand and focus our efforts on succeeding where so many other prevention campaigns have failed.
Thursday, 15 September 2011
Packing
Trying to prepare for 3 months away was never such a hassle before. Obviously I'm getting old.
Passport - check. Cash - check. Haemhorroid ointment - oh crap.
Passport - check. Cash - check. Haemhorroid ointment - oh crap.
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