day 10

Sadly my last day. We still don't have any data back from the labs - not surprising since having to process 72 samples can't be easy.

Ward round was fab as it was led by Dr Marcano who is a brilliant "internista" and took great histories and did some great teaching as he went on to illustrate the point that the history generally gives away the diagnosis. Which is probably the most useful thing I can think of, that a student should be taught, if nothing else. It doesn't take a genius to take a good history.

There weren't any new patients today, but I did spend the rest of the day doing about 10 semi-structured interviews, which was both tiring and interesting. Its mad how you can get by with spanish as basic as mine!

day 9

Yesterday was Fab - long long ward round - about 5 hours long, then a bit of clinic.
And lots of great cases. 

A case of Myiasis, and probable neurocysticercosis, and lots of toxoplasmosis as usual. Oh and a girl with an oculogyric crisis. Still don't know exactly what the precipitant for hers was. 

Day 8 - dyspepsia

Sadly I started day 7 feeling nauseous after breakfast and throwing up just after getting out of Douglas' car. Not a nice feeling.

It took me a while to put dos and dos together; day 8 I felt like crap and like my skin and throat were on fire - yes it was the deaded doxycycline. My trusty, budget, friend that has kept me malaria free for all these years at a bargain basement price no longer agrees with me, and gave me oesophagitis and skin hypersensitivity.

I spent the day in bed and have tried omeprazole (freely available over the counter here along with most prescription meds) which is doing the trick so far. No more voms and far less heartburn

Day 7 - back to the wards and clinic

Day 6 - the sabbath

Day 5 - more puerto la cruz

Day 4 - conference, puerto la cruz

Day 3 - second day in the delta

Day 2 - first day in the Amacuro Delta

Day 1 - hospital Manuel tovar Nunez

I had the good fortune of getting just 4 hours sleep before my first day which was also my birthday. Well worth it though -

Ward rounds start at 7am which makes sense given how hot it gets here.

The hospital was much like a district hospital in the UK, with excellent availability of drugs including most antiretrovirals which are all free.

My ward round had a heavy Toxoplasmosis theme to it - very common out here and usually treated with septrin as it's hard to get hold of sulfadiazine and pyrimethamine.

CMV is also something far commoner here and readily treated if suspected.

It's amazing how with more and more patients on HAART we are seeing very little CNS related admissions in the UK compared with when I started as an FY2.

It's 1am. Just arrived at my amazing hotel, paid for by my hospital's in house charity, the St Stephen's Aids Trust. Thank you. Dr Arias, his wife and daughter came to pick me up and told me first that Venezuela is a relaxed country unlike Spain (mm hmm) and I need to loosen up, and instead of saying thank you to Mrs Arias for the lift, they just say it with "un besito". Great I thought, I love relaxed.

Then the bombshell. "Pues, Farhad, yo vendre a cogerte las 6.30 ...". Relaxed, and 6.30am ward rounds... don't quite go together. Happy birthday Farhad ;-) better get to bed.

Farhad

The hidden curriculum goes to the Orinoco delta

I am sat in the departures lounge of Maiqetia Domestic Airport in Caracas, awaiting a flight to a town on the edge of the Orinoco Delta called Maturin. 

My brief was to go "have fun". Seriously. 

My boss, Dr Mark Nelson, met one of my colleagues here, a while back at a conference on Margarita Island, and then in Peru, where they were were awed by his presentation. A doctor called Dr Arias approached him and mentioned that a local tribe called the Warao, who live in the delta, had an abnormally high prevalence of HIV, Hep B and Hep C triple infection. 

I just met Mara, one of my contacts here in Caracas, who has been instrumental in putting together this "SpR exchange" and apart from equipping me with the knowledge required to be safe and get by in Venezuela (this is no Magalluf), has also insisted that if I like drinking cervezas, I will have a great time. 

So why exactly am I here?

Well, since my days as a medical student, I've always wondered why clever doctors don't talk to clever anthropologists much. I met one of the cleverest, in my opinion, on elective and decided that culture and health are pretty much inseparable and that trying to improve health outcomes without an appreciation for the culture is simply futile in most cases. 

Many people know about Venezuela's recent past - Chavez's fiercely socialist stance and fiery relationship with their big neighbour the USA. It's oil wealth. Some know that Chavez's policies towards social inclusion and the health and welfare of minorities have been commendable, in my opinion. Fewer (myself included) know that this country has a national health service that is committed to providing free health care and at present can and does provide care for HIV, Hepatitis, Oncological illnesses and much more, that many other nations struggle with.

So the big questions is, when a country has the motivation and the resources to tackle some of this planet's most perplexing problems, why then are we not reaching those who need us? And more to the point, why are the better known more simple killers such as diarrhoeal illness and malaria, still killing scores of people here? 

I recently read a book called the 10 day MBA, which took me back to a presentation I gave when I was 18, talking about why certain religious/ethnic communities are in decline whilst others are flourishing. I remember I started my trying to define the problem and the question. Little did I know then that that was exactly what most MBAs teach when employing problem solving strategies. This is actually a very useful tool to use, when faced with any problem. 

So I asked myself, what is the question I am here to answer. The truth is, I don't quite know as yet. All I know is that on a google and medline search, there is very little data regarding the health of the Warao people. 

I have potentially only a few days in the field, its best to ask the people, or "stakeholders" what they think. Drawing on the health needs assessment my group performed as a part of our diploma in tropical medicine last year in Pangani, Tanzania, I've decided to conduct some semi-structured interviews asking the following: 

1) what do you perceive to be the main health problems here?
2) What do you perceive to be the solutions you need to these problems?
3) what do you perceive to be the barriers that exist at present to achieving solutions to these problems?

I think a cross-section of stakeholders including health providers and users would be ideal, as would various community leaders. 

I would then like to liaise with supervisor Dr Arias, here, in Maturin, and ask what the actual main health problems, solutions and barriers are, using data from his practice. 

I am sure this plan with evolve, but I think one thing to bear in mind is that whilst it may be very convenient to try and focus in on a perceived area such as "cultural barriers to health seeking behaviour" this may in fact be a distraction from the real issue, which may be that the tribe's ethnicity and culture may in fact have little impact on their risk factors for acquiring blood borne viruses such as HIV and Hepatitis B and C. 

***

So lets go back to the problem solving methodology. I originally learnt it years ago as follows: 

1) What actually is the problem / question? 

- Is it really a problem?
- Can it be broken down? 

- Can we analyse the problem further? 

2) What are the possible solutions? 

3) Implement a solution 

4) Evaluate the solution - did it work? what have we learned from it 

5) is the problem still what we thought it was? 

***

So as I sit here in Caracas awaiting my flight to Maturin, I would like to hypothesise that the problem statement is simply: 

"Individuals in the Warao tribe have been noted to have triple infection with HIV, Hep B and Hep C."

I would then like to analyse it further

- what is the background rate of each infection in the country/region/ethnic group?

- does the ethnic group span national boundaries ?

- what do we estimate to be the uptake of testing and what is the undiagnosed burden?

- how are we investigating and are our tests appropriate?
- who are we reaching / not reaching eg due to linguistic and physical barriers (50% of Warao don't speak any Spanish) 

- is the distribution equal in all sexes / age groups / occupations / social groups 

and then to the interesting bits: 

If this phenomenon is real and significant, what are the potential causes: 

- cultural?

- behavioural?

- linked to economic / social / political factors (ie is it structural)?

[interesting point - read Paul Farmer's definition of "structural violence"]

My flight is about to depart, I shall return to this soon!

F

the move

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...

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".

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.

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.