Kilimanjaro today from the hotel

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.

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

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)

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."

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

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.

Quote for the day

"Doctors use statistics like a drunk uses a lamp-post. For support, rather than illumination."

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.

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.

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.

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.

A tro-tro / dodgy taxi down memory lane

http://farhadcooper.livejournal.com/

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.