Forward Thought Blog - Africa

Two Weeks Back (by Anna)

Mark Abramson — Fri, 12 Mar 2010 06:29:12 GMT

The first two weeks back in the U.S. have been filled with awe and novelty, and a sense of deep dissatisfaction.   After enjoying Botswana and safari, we spent two full days of driving and flying to return to our home. The airport was filled with so many people and once we finally stepped outside, my eyes could barely adjust to all of the shiny new cars. How strange to see so many paved roads. How strange we have a paved road all the way to our house.   We have a paved driveway.   A good friend picked us up at the airport and was surprised how intact we were. I felt happy. We live in a nice house with no termite mounds inside or outside. It’s roomy and clean. Our bedroom does not have a mosquito net and our bed is the most comfortable place either one of us has ever slept in a long time.

Past experiences have taught me that I need time to adjust to the western wastefulness, so I had 5 days off before having to return to work, to slowly rediscover stores, abundance, and the comparable self-entitlement of the general population. My first day back at work seemed easy enough. I only had seven patients. After having a ward of 50+, then outpatients and then some additional patients on another ward (either ARV clinic or TB ward), I wondered how hard seeing seven (seven!) patients could possibly be. My first patient was a very elderly lady; she had a significant memory deficit.   I was struck by how fragile she was. The women of Zambia do the majority of the hard labor; their hands are heavily calloused to the wrist almost like leather. Their skin is thick and shiny, even the extremely dilapidated are constantly oiled and cleaned by their sisters and daughters. I was also struck that no family member was tucked under her bed to make sure she was OK. This woman looked like she might disintegrate, covered with huge bruises from one day of transport by EMT and several attempts at placing IVs. We discussed her food preferences for five minutes. I found it difficult to act natural. She called me “nurse” the entire conversation, regardless of my clarification that I am, in fact, a “doctor.”

The next patient is well known to the ward, she comes for admission to the hospital when her home life becomes difficult (under the pretext of “disease exacerbation”). She has loud, public arguments with her husband on speaker phone. As far as we’ve been able to tell, her actual disease process has been stable for years. Her psychiatric state, however, is as predictable as New England weather.   She greeted me at the door of her room with a big open armed hug. I thought about how uncomfortable that usually makes me, but being constantly around people took away the awkwardness. This patient started off by giving me a thick coat of compliments. She then explained that regular IVs fall out of her arms and she would need an invasive 30 centimeter IV to get intravenous pain medication. Considering the dubiousness of her actual admission diagnosis, I refused to order the procedure. She then proceeded to call me a bad and unsympathetic doctor, and yell at me at the top of her lungs while forcing tears out of her eyes about the myriad of her perceived hardships. I called a psychiatry consult for her.

I then called Mark for me.   I asked Mark if I had chosen this work, if I was going to survive seeing another five patients, if I was an OK human being. He was helpful.

Riled up by the experience, I proceeded to a particularly feared room among the staff, where a 20-year-old woman who had willingly injected herself (including a hearty dose of bacteria) was recovering from her infection. She was angry that her visitation privileges were curtailed after she almost died from previously injecting herself – on purpose – while in the hospital. She didn’t feel that she could be in the hospital for six weeks without the support of her “friends.” I understood her well, but couldn’t take the risk of introducing more drugs with her visitors. We talked for a full 30 minutes, arguing in circles. She told me she would leave if she didn’t have visitors. I had to call risk management. A letter was written and after a short e-mail exchange, our security staff took on the responsibility to present behavioral contracts to the patient. More tears shed, more names yelled, more virtual undressing of my character. I watched her worn teeth gnashing at me while I explained the lethality of her condition; she explained that she would rather die than not see her friends for the next few weeks.   I breathed deep through this one.

I moved on to another patient. The family insisted on calling me “Dear” and “Hun” with every sentence and informed me that “no one was running the show” and a big meeting of all the doctors was required immediately to sort things out. I did my best to get in touch with their outpatient specialist. The specialist came in the afternoon, ushered me into an unoccupied room and gave me a private, and personal, verbal beating for the terrible job I have been doing for the past week.   The defense of “I was in Africa” (i.e. not in the country and thus, not taking care of the patient) did nothing to thwart her anger since we have a very important patient on our hands and I really had better get my act together.

The rest of my patients were very old and very confused. Their families didn’t want to take them home because they are a hardship around the house, yet the families demand chemotherapy for highly advanced cancers, request aggressive treatment for infections, and call for resuscitation of their major organs if those failed. These unfortunate and unknowing seniors are facing the precipice of death, and the families don’t know what to do so they demand the works. I felt sad after my day, leaving 11 hours after I came. Instead of one doctor and one nurse for 30 to 50 patients, we have 3 doctors and 5 nurses to 20 patients and many seem completely dissatisfied with their care.

Two weeks passed, I worked every day and for the first time ever, I felt some bitterness of my job. My knowledge and hard work arrive like waves on rocky shores, sometimes unwelcomed and rejected. I turn to my backyard garden and running to clear the bitterness from my soul.   The nurses are surprised to see me riled by the patients; I usually take it all in stride. I try to reset the clock by working in the urgent care clinic. Patients are appreciative and I feel rewarded, happy. Then towards the end of the day a man attempts to fake a prescription for a pain medication on a script I write him.

Macha and its mission hospital seem further away from here than just the two to three days of travel required to get there, but day by day "here" is feeling more like home.

Leaving Macha

Mark Abramson — Thu, 25 Feb 2010 00:10:11 GMT

Leaving Macha

Today is the day that we left Macha and departed for Livingstone, Zambia, for a visit to nearby Victoria Falls in the coming days. We made arrangements to travel to Choma, some 70km away from Macha via the Malaria Research Institute’s vehicle on Wednesday morning at 6am. Depending on how many people or how much equipment needs to be transported, they take a different vehicle. Today, we would be taking the very large flat-bed truck to Choma. Anna managed to get situated behind another few people inside the cab designed for three people. I was in the back with another gentleman, both of us sitting on a crude wooden bench nestled up against the very front of the 4 meter-long truck bed. Our other “bed mates” were car parts: wheels with suspension linkages still attached, a bumper, and other parts from what looked to be a Toyota pickup. I was not looking forward to a particularly comfortable voyage, but it seems that this was the mode of long-distance motorized transport for the vast majority of Zambians (of course not counting the significant, 100km+ journeys regularly made via foot and bicycle of the hospital patients).

Anna contemplates taking the last seat in the cab or one in the flatbed

We started along the dirt road at a reasonable pace until we got to the edge of town. Then my bench-mate informed me that the car parts were from the recent tragic accident in which four people from the Malaria Institute were killed, stunning the entire village. The car parts were in transit to the insurance appraiser. Once outside the village limits, our rate of travel increased to what I would consider “breakneck.” Given the fact that there were the remnants of another fatal accident right in front of us, I was admittedly a little nervous for the voyage, especially since we were traveling at well over 100km/hour on loose, sandy roads. In fact, I was imagining the various ways how things might end if we careened off the road or encountered a herd of cattle or goats around a blind corner. The more immediate travel issue though was the constant jarring of the potholes and jumping of all of the car parts in the back of the truck. We slowed for the most severe rough patches in the road, and I quickly learned to dread any time the driver applied the brake. About 40km of “improved jeep trail” lent another air of hardiness to the locals, who regularly take this into Choma. Dang, they are tough stock!

Flatbed contents: two humans, luggage and car parts

We did of course survive the journey, and it gave me a true appreciations for how remote Macha actually is. We arrived after two flat tires under cover of darkness, but now the Zambian countryside was illuminated the entire way. In short, Macha is “about an hour from the middle of nowhere.” John did mention how Macha came to be way out in the bush, but there is no other town or large village for many kilometers in every direction. There are simply small villages of three to five clay or brick huts with thatched roofs. There is the occasional school and church alongside the road, with students pouring in for their morning lessons. After several weeks with semi-regular electricity, mostly running water and a corrugated roofed brick duplex to stay in, I lost my appreciation for just where we were: a small village in the remote bush of Zambia.

After 30 minutes of driving, the remoteness of Macha really sets in

Not shown: white knuckles

About halfway towards Choma, the road incredibly turns to pavement, one of the few paved roads in Zambia. While this meant ever increasing rate of travel, the road was smooth and we quickly zipped into Choma. So many houses! Look at the stores! Where did all of these cars come from? We were stopped at a police checkpoint for having too many people in the cab of the truck – but no mention of the people sitting on the edge of the flatbed – and were issued a ticket. The irony was not lost on us as numerous other pickups and flatbeds zipped by with their beds overflowing with passengers.

Once in Choma, we are stopped by the poilce who promptly issue our vehicle a ticket

Dropped off at the bus stop, we purchased our tickets to Livingstone and could stretch our legs (and many other sore parts) after the first leg of our journey. We had a little time before the coach bus came, so I took a stroll around town to pick up some provisions. We found incredible bananas from a young street vendor and I found the Spar Supermarket. By usual Western standards, this was a small market. But the amount of choice just in the cracker section was mind boggling. I did not heed the warnings that going home would require adjustments, and my reaction surprised me when faced with 12 different flavors, sizes and shapes of crackers: I couldn’t make a decision! With some simple crackers and a candy bar (!) in hand, I returned to the bus stop.

We patiently waited for the coach bus to arrive and gawked at all of the hustle and bustle. Choma is the largest town and trading center for quite a ways and this all plays out in front of you on the street. People are often seen piloting enormous wheelbarrows with 200kg of corn meal, car parts, furniture, farm equipment or a combination of these. Street vendors sell anything they can get their hands on from bananas to cell phones to hack saws to leather belts. It felt like the Canal Street of Zambia.

We have exchanged the remoteness of Macha for the bustle of Choma

The large, full-size coach bus arrived and we hopped on board after putting our large packs underneath in the cargo hold. There was a lot of activity putting in large sacks of cornmeal, tools, machinery and more, and thankfully our luggage successfully made it with us for the entire journey without getting stuck between oily engine parts. We boarded the bus and it was incredibly comfortable. We felt truly spoiled with our own comfortable seats, a nice view of the Zambian countryside, and only a couple of stops between Choma and Livingstone. Once underway, we noticed the televisions on the bus were showing terrible kung-fu movies which we thoroughly enjoyed. The time ticked by and soon we were approaching Livingstone on the potholed detour from the main road through Zambia.

Once on the comfortable coach bus, we are treated to kung-fu

We had to fight through a throng of cabbies all clamoring for our fare to meet our ride to the lodge where we stayed in Livingstone for the night before heading down for a brief safari in Botswana. We kicked off our shoes, took a constantly-warm-temperature shower, put on our cleanest clothes and sat by the pool with a cold Mosi-Oa Tunya (“The Smoke that Thunders”, the national Zambian maize-based brew named after Victoria Falls) and couldn’t believe the extent we were pampering ourselves.

Week 3 of Clinical Work at Macha (by Anna)

Mark Abramson — Tue, 23 Feb 2010 11:54:21 GMT

As with any hospital or clinic, there are busier weeks then others. During the past week, despite my best effort to discharge patients from the ward, more and more patients crowded in until every bed of the Female ward, entry way, veranda, and side room were filled. The majority of the cases were fairly serious or at least complex, all requiring more than an easy diagnose and treat plan. Additionally, I decided to use my hour of the physician group meeting this week to discuss chart documentation and operational improvements, so I was motivated to use my best handwriting and comprehensive note writing. Unfortunately, while all the other wards were enjoying a low or normal census, I think there were upwards of fifty women to see and make a plan for. This occurred between the hours of 0800 and 1300 every other morning. I’m also charged with a continued care ward of 24 additional men and women who I am to see once a week or so, also using my best handwriting and documentation skills and constant teaching to set a good example and make my time here have the most impact.

The wards took up the majority of my time, free and otherwise, but on the non-rounding days I was asked to step-in for a few absent providers in the ART (HIV) clinic. This is a growing sector of outpatient care dedicated to keeping the HIV population enrolled and healthy, in a highly specialized setting. On my prior visit, the HIV patients were seen on several days a week out of the same room as the outpatient department clinic patients. In the past year, a new building dedicated to HIV positive health was built, special files and specialized software, dedicated staff, vehicles and computers are now decades ahead of the rest of the hospital to manage the devastating epidemic that is still sweeping the sub-Saharan countries.

My first clinic day at the ART clinic was intimidating. There were not enough translators for myself and the two other clinicians (a Zambian medical resident doing an elective from Lusaka, and a senior clinical officer). Since there are so many languages in Zambia, many of the patients need help speaking the local Tonga language. Additionally, not to state the obvious, but I’m neither an infectious disease specialist, outpatient physician, nor a pediatrician, so I was a bit overwhelmed by the experience. With only three days of operation per week at Macha and two days of regional village visits, Tuesdays are the busiest days, and my intimidated mounted as I had to fight through a mob of patients to get into an office to start my work. In the initial years of HIV care in rural Zambia, patients were very reluctant to come for HIV testing and care. Many people died, this was described as a “time of many funerals.” In the past several years, the community decided that too many have died to stand idly by, that their only choice was to come for treatment. And then they came.

The Tonga people have a fairly structured and close knit community, but for an outsider, it takes some getting used to. Many of the men have several wives, and the wives have four to six children each. Most people live with and remain very close with their parents and siblings, as well as the children of the siblings. An HIV diagnosis can result in divorce, temporary separation, death of parents and spouses, and other complexities in this community structure. As with any medical interviewing, you only receive the answers to questions you ask, so a translator is really important in working out the fine details of the relationships of the many people that flock into the room together. Even more importantly, all women under age 40 have small bundles tied to their back: a baby who may or may not have acquired the HIV virus from her mother.

Only a small portion of the population can afford to buy premade food such as bread, and a small portion of those people can afford formula for babies. This means most babies are breast fed up until 18 to 24 months regardless of maternal HIV status, as otherwise they would simply not survive. Women who are unable to breast feed for various reasons attempt to use cow milk or peanut milk in months old infants, resulting in malnutrition, diarrhea, and developmental delays. The WHO recommendation for women in such impoverished areas is to breast feed without interruption while taking HIV medication treatment which can prevent transmission. The babies are also enrolled and maintained on daily ARVs while breast-fed, then later tested to know if they have HIV or if they are safe until potential exposure later in their life. The estimated burden of HIV ranges from 12% in the rural areas to 30% or higher in the city centers. The extent of immune deficiency at time of diagnosis limits the ability to start HIV targeted medical management since the patients may be too sick to start a anti-retroviral regimen. Their survival is threatened by opportunistic infections such as cryptococcal meningitis, pulmonary and extra-pulmonary tuberculosis, toxoplasmosis, severe anemia, severe wasting, Kaposi’s sarcoma, cervical cancer. Despite the grimness of all of these facts, the number of patients who first presented deathly ill and are now recovered enough to work in the fields to feed their family, are working in clinics to educate their fellow Zambians, and are taking care of other’s children orphaned by HIV, is inspiring and motivating for me as I faced the day.

Everyone piles into the Land Rover for the 40km voyage to the regional ARV clinic

Loading and unloading leaves no room wasted on the vehicle

I admitted the first five infant patients I saw in clinic to the hospital, and then decided I was going to stick to seeing adults and let the pediatric experienced physicians handle the humans aged 5 and under, since there were well over 100 people to see and that would make me much more efficient at my job. The first day turned out to be very long with only a short lunch break; I saw over 50 fairly complex patients with much more going on than just HIV. After several more days of clinic, once I became more comfortable with the medical management of adult HIV outpatients, I was asked to go on a trip to a regional village ART clinic with the staff. The number of patients requiring anti-retroviral testing and therapy is so high and the area covered by Macha Mission Hospital spans up to 100km in any direction, there are now several monthly satellite clinics held by an outreach group from the hospital.

At least three patients per bicycle gives a quick count of our patient load today

On Friday morning, I joined 13 people as we stuffed ourselves into a Range Rover, piled medications and lab supplies on the vehicle roof, and went on an off-roading adventure to a town 40km away. We anticipated 70 to 90 patients, but well over 100 came. Many humans and bicycles crowded around the clinic; stray chickens and hopeful dogs patiently awaited a scrap of food to be tossed their way. While getting set up to see patients, I noticed small children repeatedly running by me. They would run by, turn around, hide in bushes, hide behind each other and emphatically point at me. To them I look ridiculously pale. Sitting in the van with the nurses, nursing students and phlebotomist, I noticed again, the car surrounded with little cheerful faces, jumping up on one another shielding their mouths in disbelief. This was amusing to no end for me. I live in a very culturally diverse world where few physical features would as much as result in a raised eyebrow. Here, I am an anomaly, a minority of sorts. A strange and valuable moment I had already forgotten from my last trip.

Patients being patient

The rest of the day was spent working through the enormous group of people who greeted us in unison when we arrived. These are hard working farmers and their children who have been losing weight during the hot spell that has killed their crops. The reality shows such as Survivor and Big Brother attempt to depict life in the raw, where losing means not eating or having to do some “hard chore.” This land is the real-life Survivor, where food and water run out, people lose their life and limb to accidents and trivial infections that are not treated or not treated correctly. There are only a small number of health professionals that are widely spaced in the bush villages. It may take years to understand and incorporate into the world here, but all we do here is by choice. Our reality is that we can evacuate if it gets too difficult for us, but those that live here must cope with the world that meets them daily. The doctors, nurses, interpreters, clinical officers, hospital staff, and patients welcomed me to Macha, teaching me their language and culture in return. And for this I am grateful.

A good friend made in Macha

Information Technology at Macha Mission Hospital

Mark Abramson — Sun, 21 Feb 2010 21:47:28 GMT

The first IT-related opportunity to help here was pretty exciting: help the pharmacy department keep track of its inventory. That first day was spent touring the pharmacy, investigating the three bulk storage rooms and the dispensary, talking to the stakeholders to identify the key requirements and there is a great deal of management support for the project. It appeared that everything was in place for a successful technology project! Little did I know that this all would be derailed by overwhelming and time consuming computer “help desk” tasks.

Hark, is that the every-popular LinkSys DD-WRT2 Wifi-Router?

That first day brought to light that Macha Mission Hospital is a rural and growing medical center. As such, it has growing computer and network infrastructure and support needs. While the computing infrastructure here is very similar to many other businesses, how this infrastructure came to be is anything but. Computers are new here, having been either donated or provided for in grants from the many NGOs here and abroad. The computers were put in place without much provision for maintenance or a plan to update them over time. While this has brought about significant gains in capability and productivity, the support burden is to the point where it is a threat to these very same capabilities and productivity.

You've Got Mail! I mean viruses. Lots of them.

Where to start? There are challenges with the network infrastructure, internet access, desktop hardware and software support, computing policies, training for users and my new personal favorite – anti-virus and malware. The inventory of equipment is on the order of 40 desktop computers, a mix of wired and wireless switches and many USB thumb drives. Software is almost all Windows XP and Office 2003, with one install of QuickBooks Pro and a few workstations with SmartCare, the Zambian Government’s Anti-Retroviral (ARV) patient records system.

You have to respect this throwback to the old school days

I was introduced to Dunny who has been working under a contract with the ARV clinic and I proceeded to work with him to remove viruses, update computers with the latest service packs and patches, and provide general maintenance to as many computers as possible. Luckily, he is quite familiar with computers and learns fast.

We soon found that the computers with internet access were the worst offenders. Some had over 700 viruses on them (!) and required a complete format and re-install. In fact, every computer we worked with required a format, although we were able to extract much of the user data after scanning it with no less than four different anti-virus and anti-malware tools. It turns out that any computer with an internet connection is such a hot commodity that people will find a way to convince someone to get access to it. With this comes USB thumb drives, malicious websites, downloads and a torrent of viruses and other nasty stuff.

Such a familiar sight, so far from home.

A few days into this process, I met with Edgar who manages much of the general infrastructure for the hospital. He is also the x-ray and ultrasound operator. In his spare time, he is also studying to become a chaplain. We had a great discussion about the issues and put together a general plan based on our observations:

Develop computer, data protection and internet policies
Install quality anti-virus, spyware and malware tools on each new and newly-formatted computer
Devise a data backup strategy
Write a job description for the computer support person (every day they do x, every week they do y, every month they do z, etc.)

This, we decided, would be a “good start.” The SmartCare system is a basic electronic medical record system, though the medical director does not see a universal EMR system being implemented anytime soon. A comprehensive EMR system, of course, requires a talented support staff and reliable electricity to be considered as a replacement for the paper-based systems they currently use. But I kept wondering aloud what I might do if I were here for 6-12 months, and it could entail:

Compile a suite of software and hardware spare parts, tools and utilities
Overhaul every computer and build a standard "image" of each type of computer with Terabyte Image For Windows, Ghost, TrueImage or similar
Assemble a robust network with managed gateway for internet access
Provide basic computer courses and application-specific courses
Identify and train new computer technicians among those who take a keen interest in computers
Build out a basic data center with redundancy and backup systems
Explore open-source OS and application alternatives
Opportunistic projects to support specific needs
Apply for grants to support the above
Recruit and train the next generation to take over all of this

By some back of the envelop calculations and creative use of off-lease and eBay purchases, I estimate that the cost could be less than $10,000 for all of the above. The hard part, of course, is finding the person to drive this bus forward. Feel free to apply directly to MMH if interested :-)

Lastly, here's a shot for the FAA & NASA crowd: ABFA Airport

Bikes of Macha

Mark Abramson — Fri, 19 Feb 2010 20:28:23 GMT

There are a lot of wild rides here in town. Here is a more picture-based post, of course dedicated to everyone at USA Cycling.

Waiting at the front door of the hospital, a patient rode themselves (or carried someone)

Check out the sweet kickstand

Three guys strike a pose in the marketplace

A re-appropriated and re-purposed bucket makes for a nice cargo bike

A couple passers-by gawk at us on our first day with our cab's first flat tire

One of the many parking lots beside the hospital, the bikes enjoy the shade

Our friend Stanley made sure his cell phone would be part of the picture

The open air bike shop reminded me of Ace Wheelworks in Somerville, MA

Lots of visitors keep the shop lively at all hours

They do not allow the lack of workstands to get in the way (Note: hacksaw)

Showing the expanse of the area's bike shop

More detail of work and socializing being done

This bike brand is "UNIX", others include "RoadRunner," "Hobo" and "Tata" (Note: double top tube)

One of the many bikes that may have traveled 40-60km to the hospital

Reads "Eagle - Product of Tata Zambia" Perhaps this is the Tata Motors of Zambia?

We'll leave you with this final picture. Yes, that is a live chicken strapped to the rack.

This Week's Clinical Update (by Anna)

Mark Abramson — Sun, 14 Feb 2010 18:13:09 GMT

I have been in charge of the “female ward” for most of the week now. This was exactly what I hoped for, but never-the-less it is a daunting amount of responsibility. Three times per week, I round with an American medical student (this is her second time here) and several nurses on 35 or more patients. The women’s ward patients have a wide assortment of medical problems, not a single one to be trifled with. Most of these are related to infectious diseases of the very poor and very malnourished, and HIV. The ward itself consists of a large room with the beds lining two of the walls and the length of an enclosed veranda, with maybe two feet of space between each bed. There are neither dividers nor white noise machines to provide privacy for any conversation or exam. We round by walking bed to bed, picking up charts and talking with the women. Their family members and bed neighbors help answer questions, such as, “I saw her walking,” or, “She’s not eating, and only drinking a bit.” I don’t speak the local Tonga language here and very few people in the villages speak English, though it is one of the official languages in Zambia. There are about 30 local languages, and English is not taught in school until the upper grades which are very expensive and not possible for most. A nurse or translator typically helps with both social and language translations for our conversations. This all may seem a horrendous breach of privacy, but in the words of the chief medical officer here, “In western culture, if you see me walking out of a hospital and ask ‘what’s wrong’ I would think you’re meddling. In Tonga culture, if you don’t ask, they will think you don’t care.”

Along with the actual patient in each bed, there is usually a female family member or sometimes a husband sitting on, under, or near the bed (or on a Tonga stool). Patients very rarely come to the hospital alone. Each woman is accompanied by several members from her family village to cook for her at “the fires.” The fires are simply a big open field settled by people while awaiting an appointment at the outpatient clinic or for their ailing family member. People come from distances as far as 100km away to be seen by the doctors at Macha. They are referred from the clinical officers (a two-year degree with some medical training, providing ninety percent of medical care to the people of very rural Zambia) for unclear diagnoses, for surgical needs, for medication shortages, and for those patients that keep coming back with the same problem and “pestering” their clinics. These patients would not be able to cover the distance, carry all the necessary provisions for a several day travel and stay, or make food without their support team. Additionally, women typically have five children each, so someone has to come along to help tend to the children as well for the ailing mothers. Over the years, the fires have become more developed; there are now half-open long shacks that are used for storage and shelter from the weather. Around them, a food and goods market has popped up, as all these guests will need supplies for the week to month long stays. Visitors outside of the permitted one or two are only allowed during meal times This allows for medical attention to be rendered by the doctors and nurses without literally hundreds of people crowding in the one room wards. Meal time is announced by beating of stick on a pan, and immediately followed by a rush of people carrying bags and bowls of food they have been slaving over at the fires.

My last visit was during July and August of 2007, during the Zambian winter. This time it is the peak of summer in February and the sun is unforgiving here. During my many hours of rounding, I drip sweat and constantly have to right my glasses that constantly slide down my nose as I inspect patients and write. I wear my white coat because of its many useful pockets and to prevent anyone from seeing me sweat through my shirts. The nurses dress in all white and some with a sweater vest as a fashionable addition. Patients wear layers of skirts covered by several chitongas (cloth material used to carry babies, clean ground, clean children or dishes, etc.). Their loved ones cook and live at the fires cooking over open flames in kettles balanced on sticks. I can barely survive cooking rice on an electric stove due to “the heat in the kitchen.” I complain about the hard bed and chairs around our lovely small brick apartment here; my patients’ families sit on wooden stools or concrete floor without shifting. I am amazed at the endurance and stoicism of these people.

After attempting not to faint from heat during rounds, I go to the outpatient clinic (the “outpatient department” or O.P.D.) to see countless more patients for the balance of the day. I have also been precepting three physician assistant (PA) students and a medical student who are also here, thus I am “seeing” maybe twice as many patients as I would on my own. The outpatient experience is equally interesting; we are essentially all crowded into one room and see the referrals or local patients that are too medically complex for the clinical officers here. These range from simple high blood pressures and blood sugars, to unusual bodily swells and masses requiring further thought or study, or adults and babies requiring admission or surgery. The more complicated cases are discussed among those in the room, x-rays reviewed by whoever happens to be around. Patients are questioned and seen by several of us at once while other patients and interpreters standby if a particularly unusual or complex situation arises. Once again, there is little privacy. On the other hand, these patients are given the most expert care and consideration outside of the capital city of Lusaka. For more specific medical details, feel free to send me an email for the “clinical notes.”

On a non-medical note, my free time is usually shared with Mark. During the two-hour break at 13:00, we go to the market, cook, read or hang out. He knows where I am working each day and we are staying a brief five minute walk away. He stops in to say hi if he’s working at the pharmacy or just happens by. We go for longer walks at night when it’s a bit cooled off, mostly in search of the mini-safari experience offered by the lizards, bugs, and birds in the numerous trees and bushes. We carry two cameras to capture interesting sites and document the many faces of sunset that the big Africa sky has to share.

Family members prepare meals and provide support

Hospital laundry is done in the infield

Patient transport?

A nice example of how the women use chitonga wraps

Busy Week for Both of Us

Mark Abramson — Sat, 13 Feb 2010 18:49:13 GMT

It was a busy week for both of us here in Macha. Anna saw about 100 patients per day with a few very challenging cases and I was tied up with the pharmacy, although not in creating an inventory control system as I had hoped. I turned into more of a computer helpdesk kind of guy as their computers were plagued with computer viruses, spyware and malware from months of people dropping in and using them for miscellaneous internet browsing. Needless to say, I am now schooled up in unified threat management, although didn't make much progress towards automating the inventory tracking.

We did, however, make some headway towards our premeditated plans of creating a package of information to pass along to others who are considering a trip to Macha to ease the travel and preparedness factor. Needless to say, there are some great opportunities to get involved with some groundbreaking work at the hospital. There are opportunities for statistics people, computer folks, medical, nursing and more with some incredible opportunities coming up with HIV/AIDS research and treatment.

More posts are in the works but for now we'll leave you with some pictures.

Without a city for a few hundred km, the night sky here is like no other
410F1810lg.jpg (1.12 MB) - large version required to really appreciate it!

Fresh maize, okra and basil were conveniently growing behind our house

Porch interloper seeking a sympathy snack

Neighborhood alarm clock that rings at 6:00, 6:03, 6:05, 6:09...

Rainbow and cows, what more can you ask for?

A passing storm makes for a spectacular sunset

Can you help at the Pharmacy?

Mark Abramson — Sun, 07 Feb 2010 20:19:27 GMT

John had mentioned that there were a couple of important items that he wanted me to take a look at: A) some sort of inventory control and reports for the pharmacy and B) the broken distilling machine that they use to make their own IV saline solution.

The Pharmacy Building

At first I wanted to get a clear idea of the roles of each of the various stakeholders and what they thought were the problems that needed to be solved. This started with John, a physician, who introduced me to Abraham who runs the pharmacy department, who in turn introduced me to Kaliba, a pharmacy tech.

John is a very busy guy with a hospital and a few different departments to run and a constantly changing staff and patient population. There are often shortages of medical supplies, drugs and money and this often requires shifts in care and management of patients and their conditions. He is always trying to keep up to date on what is available so that he can tailor his plans accordingly. Further, he expresses dismay at having to discard expired medications when they could have been used if only he had known that they were about to expire. And finally, John often coordinates the arrival of doctors from the US who sometimes bring supplies and drugs along with them. He sometimes has specific requests for things that are out of stock or difficult to get here in Zambia.

Inside the Pharmacy

Abraham runs the pharmacy department and is also a very busy guy. He oversees a staff of perhaps 5-8 members. The pharmacy maintains the inventory of drugs and medical supplies and provides them to all of the other departments in the hospital. His department also includes the dispensary where patients pick up their prescriptions. A big part of the challenge for his department is keeping the items in stock despite a once-per-month restocking trip to Lusaka; government mandates that they can only maintain a three month supply of drugs at any given time; and the fact that they must destroy all expired medicines immediately. He knows that occasional inventory stockouts occur and these are painful, as the order only happens once per month. He would love to know what the situation is each day with his inventory, medicines about to expire, the cost of replacement and the cost of substitute medicines. And in his "spare time," he also compiles statistics from the entire hospital on patient visits and conditions.

The Bulk Storage Room that supplies the rest of the hospital

Kaliba is the pharmacist technician who is "on the ground" in the stock rooms and in the pharmacy. He manually keeps track of the inventory via paper stock status cards tucked underneath each drug or medical supply on the shelves and uses these cards to compile reports to guide the ordering process from "Central Supply" in Lusaka once per month. He knows the system quite well and keeps track of the monthly orders in Excel spreadsheets and performs a monthly physical count of each medication. There are "maybe 500" ("less than 1,000, more than 200") different medications that they regularly stock. There is a lot of public and budgetary emphasis on Anti-Retro-Viral (ARV) drugs for HIV/AIDS, and natuarlly these receive attention more regularly. As the one compling the orders, he needs to know how much to order each month, what is soon to expire, and respond to the need to distribute the medicines throughout the hospital departments.

Detailed stock accounting sheet tucked under each med

In the next installment, I'll dive further into the requirements, more details of the people and processes and a few suggestions gleaned after just the first day of meetings with Abraham and Kaliba. Unfortunately I was plagued by a computer virus (Win32.Rungbu.a/Hijack.System.Hidden, ignored by Norton (thanks!) but finally fixed by Spybot S&D plus Malwarebytes Anti-Malware) from one of the pharmacy computers that infected my USB thumbdrive and today was largely spent disinfecting my computer. Tomorrow I'll fix the pharmacy computers and then get back to the task at hand.

A busy day, but we still have time to get out for the beautiful sunset

The beautiful sunset (this picture was actually taken by Anna)

Return to Rural Medicine at the Macha Mission Hospital (by Anna)

Mark Abramson — Sun, 07 Feb 2010 18:30:35 GMT

Upon finally landing our feet in Macha, my thoughts turned to work. I immediately recalled the first day of work here three years ago, when I arrived at the “operating theater” and an hour into assisting a surgery, I experienced what can be described as “a near fainting.” The rest of the day was quite eventful, but I did manage to keep it upright. This time, I prepared myself and the medical director by warning that I was likely to make my first work day only a half-day. The medical director looked surprised that I was planning to work right away, he must have remembered my first near-syncopal day. Despite the jetlag, we managed to go to bed at the reasonable hour of 11pm, so I was prepared to hit the ground running.

Finishing my commute

As planned, I got up and out the door to join rounds 8ish. Unfortunately we had not been organized to make breakfast, and since I’m not a fan of the taste of the filtered water, I hadn’t had anything to drink yet. I did manage to take my Doxycycline prophylaxis for malaria. On my 5 minute walk to the hospital, I felt a little woozy and my head felt stuffed with cotton balls. Hoping for a quick recovery from these strange “illusions,” I pressed on to rounds and joined the doctor currently in charge of the women’s ward which I will be covering during his vacation next week. There was also a nice medical student from the states, Adrienne. After our introductions (“Doctor, Doctor. Doctor, Doctor…), I went straight to seeing the patients and feeling enthusiastic about the task at hand… for about 5 minutes. A wave of severe dizziness followed a more severe urge coming from my stomach. I was able to contain myself control long enough to make it to the front garden of the hospital, where I promptly expunged the contents of yesterday’s dinner. My witness was a concerned-appearing small man wearing galoshes to whom I explained in English that I had been travelling on airplanes and buses for over 2 days. I doubt he neither cared nor understood my language, and based on my previous experience, he probably was not aware of airplanes or where they took people.

Needless to say, the rest of the day that was supposed to be clinical was spent napping, pampered by Mark, who has never known me to be weak of stomach, but knew that this was perhaps my most dreaded bodily revolt. I decided to avoid water and food to avoid any more incidents, which immediately led to forced feedings and plea bargains regarding my likely inability to return to work at any point if I continued my general food strike. I grudgingly accepted milky, orange-flavored water and the last of our Czech chocolate cookies.

I awoke to my second day less enthusiastic than the first. After a hearty breakfast I headed in to the hospital without knowing the schedule or plan, but luckily encountered the Female Ward doctor who was kind enough to round with me on the veranda patients. The “Veranda” is reserved for patients with pulmonary diseases, mainly tuberculosis. The 10 or so beds were occupied by two women with cryptococcal meningitis, four women with pulmonary tuberculosis, one woman with advanced metastatic cervical cancer, one with severe candidal esophagitis, and one woman with psychosis from amitryptaline used to treat HIV neuropathy. All of these are complications related to AIDS, but here, there is almost no point in mentioning something so obvious and common. Equally as interesting is the way medicine is practiced. The veranda is as it sounds, an open air balcony holding roughly 15 beds which now has glass windows. Here, as in the rest of the hospital, there are no dividers of any kind between the beds, only tied mosquito nets hanging from the corrugated metal roof.

Using the solar-powered x-ray viewer

Rounds consist of walking bed to bed, picking up a piece of paper which acts as a medication record sheet and daily temperature recording. The nurses distribute paper charts that consist of two pieces of heavy-weight construction paper covers revealing off-white pages inside. These are reusable by crossing out the current patients name at the end of a hospitalization and writing a new patient’s name until the all of the pages are filled. On the inside sheets the doctor makes an artificial divider, writing the assessment on the left side of the sheet, and plan and orders on the right side. The nurses are supposed to be close at hand to immediately record the orders and hear the plan, but usually are huddled about four patients back socializing while waiting to be called. The other patients calmly look on at the doctors, nurses, other patients and visitors without much emotion. Many patients are just spoken with and not physically examined, although when we approach to examine them, they quickly sit up (if they are physically able to do so) quickly remove their shirts and make themselves available for auscultation.

After rounds finished at 10am, I went home to hang out with Mark for an hour at home. He was visibly tickled by me popping in during the morning, since back home I usually try to call him on my lunch break at about 4pm and otherwise maintain radio-silence as I try to dash through my hectic days. We both walked back towards the hospital at 11 for the start of “OPD” (the Outpatient Department) which, like most things except church, starts leisurely when convenient for all involved.

OPD is conducted from one room with three tables and a multitude of chairs and benches. The Tonga people do not typically do anything of importance in solitude. If I am seeing a patient, there is likely at least one family or community neighbor lurking in the waiting room and perhaps five more waiting by “the fires” (to be explained in more detail later). The language and social translators dart between conversations in the room, as there can be up to four healthcare providers administrating care to four sets of families at any one time. For brevity sake, I will summarize the major complaints of the 20 or so people I saw during the morning session: rheumatic heart disease, diabetes, hypertension, asthma, HIV, tuberculosis, pneumonia, pediatric developmental delay, and several admissions for new or serious diagnosis of those above. In the U.S., this would be an unusually exciting week of diagnoses. The afternoon session was roughly the same, though at a much slower pace than usual due to the torrential rains that are a hallmark of the rainy season here.

The rest of the afternoon was spent reading “Getting Stoned With Savages” by J. Maarten Troost, his sequel to “The Sex Lives of Cannibals.” Both books describe life on remote South Pacific islands, which is a strangely similar life to that which we are currently enjoying in the landlocked country of Zambia. However, I was unable to stay awake much past 6pm due to the 10 hour jetlag.

Making ourselves useful

Mark Abramson — Fri, 05 Feb 2010 19:45:11 GMT

For Anna, this is straightforward since she is a practicing physician and there is a hospital here that serves the surrounding 100+ kilometers. For myself, it is a matter of looking around and getting into adventures while trying to be helpful to the various efforts here at the hospital and its important research in HIV/AIDS and Malaria. Over the years, they have made some incredible epidemiological breakthroughs with treatment and social management of these diseases.

Today I used good old pen and paper to document the power requirements for the new ARV clinic, which may one day get a number of new computers for an electronic medical records system. The building is about one year old and was designed by the Chief of Medicine here, John Spurrier. They are currently looking at adding a number of computers provided by various grants for HIV/AIDS research here, and of course they need an adequate backup power system for their electronic medical records! The power here is getting better, but is not entirely reliable and only recently became available at all times during the day. Making the leap to a paperless system is daunting for any medical practice, but in a facility with these sort of electricity issues, it's a serious risk.

The job today was to document the electrical load of the facility. It has a number of fluorescent lights, ceiling fans and some existing computers that are used for data entry of medical records. In the past, I have gone over the deep end to determine electrical load in the datacenter, going so far as to wire up my own load meter with a multi-meter, current clamp and my own "extension cord" with each conductor independently wired so that the current (via magnetic field) can be measured with the current clamp (if you put this on both the hot and neutral wires, they cancel each other out). As it turns out, our high performance workstations draw from 100-130 watts and our rack mount servers about the same. Large LCD panels are about 45 watts.

Unfortunately I did not bring this equipment along with me but was able to reasonably estimate the total load on the building using my experience, labels on the equipment and a few searches online:

48 fluorescent strip lights (40 watts)
14 ceiling fans (45)
5 desktop CPUs (100)
5 LCD panels (35)
1 hot water heater (4500)
2 laser printers (400)
1 small fridge (475)
2 2700-watt a/c units
Other misc. devices

All told I estimated the load at about 15kW. They have used UPS units in the past for individual computers, but with regular stress the batteries only last about a year. My understanding is that they are going to use a solar backup system without the solar - basically a building-wide battery backup system that is kept charged by the regular electrical system.

The juice flows in next to a mw antenna

In addition to the electrical requirements, there are going to be some networking needs to string up the building. Almost everything here is of masonry construction (brick and concrete) so cabling is a bit tougher than snaking across a drop ceiling. My guess is they'll need a couple 500' spools of plenum, a 24 port switch and plenty of long masonry drill bits. Luckily they are working with some technology experts from the CDC on this project, but I'll roll up my sleeves on this tomorrow and at least share my thoughts.

Working Remotely

Mark Abramson — Fri, 05 Feb 2010 08:53:51 GMT

About to run off to the new ART Clinic building to do an assessment of their electrical and network systems for a future solar backup installation. But for those wondering about our setup to work remotely, here is a brief rundown of what we carried halfway around the world:

Equipment of Note

1 Sony Vaio Laptop
1 Sony Vaio Laptop (old one, as a backup)
Multiple power adapters (Europe, UK/Africa), though converters not necessary since power supplies are multi-voltage
2 Wireless USB adapters (in case our internal notebook wireless adapters weren't up to the task)
2 Wireless routers (MSI and Rosewill), each with 4-port hub built in to ease networking the two laptops
Various network cables
Trusty wireless mouse

Software of Note

Standard development suite installed/configured on both machines
RingCentral Voice-over-IP (VOIP) call controller
Skype
Subversion version control / file sharing client (to connect to svn repositories in our data center at home)
Outlook (to connect/sync with Exchange server, and thus Blackberry, hosted by Rackspace)
Variety of web browsers
Cisco VPN client, which has held up well even on lossy connections

Things have been working reasonably well as far as connectivity and electricity. The village has made a lot of progress in wireless coverage in the past two years when they first started to have internet connectivity via a microwave line-of-sight link. And they have reliable GSM network coverage via the Zain network. Not bad!

Seating by Herman-Miller

The Last Mile to Macha (by Anna)

Mark Abramson — Wed, 03 Feb 2010 19:13:36 GMT

The feeling of packing up before a trip to the known unknown is great exercise. Weight and cubic inch restraints artificially limit the number of “needed items” one can have and thus is both less and more stressful.   The experience of my past visit to Macha helped to decrease the number of items to 3 skirts, 3 shirts, 2 different weight sweaters, one pair of earrings, and 2 pairs of shoes for the month. The rest of my bag was stuffed with medications and supplies that didn’t fit into the box of medical supplies given to me by REMEDY and a couple very kind people. Once finally packed, I paced through the house trying to clean in the minutes before the scheduled taxi arrived.   Dressed as if I were going for a photo-shoot for the LL Bean catalog, I dashed out of the house carrying my 40lb box of medical supplies, followed by a 40lb bag of my travelling gear and more medical supplies, an a 20lb carry-on bag with “just in case my actual bag gets lost” as the unsympathetic taxi driver watched. Twenty minutes late and not particularly enthusiastic, my driver deposited me with 10 minutes to ponder the landscape along 101 overlooking Mill Valley.   Several women were dropped off by more exotic automobiles, well dressed and well cared for, eyeing our well-experienced moving box (this will be its fifth and final move) with fleeting curiosity as we awaited the bus. The 1-hour bus ride to the airport was uneventful, as was the 2-hour wait in the airport, highlighted by a personal search prompted by my otoscope.

The actual closing of the distance gap started with a prayer-inducing, very turbulent plane ride to Paris. The highlight, in addition to my survival to landing, was watching a 3 hour movie about the life and death of Gandhi. Very inspiring and motivational for me to both do great work and read more about Gandhi.   I once again was searched intensely for both explosives and other weapons, after which a nice bag x-ray operator emphatically pointed to the otoscope stashed in my bag, mildly disappointed to see the unimpressive instrument in real life. After several hours spent reading David Sedaris, I was joined in Paris airport by Mark. We boarded an almost empty plane to Johannesburg, grateful for several hours of sleep in 3 seats each.   In the Johannesburg airport, we perused stores, ate at a café, re-checked Mark’s luggage and took a bus to an airplane to Livingstone where our adventures would really start.

In Livingstone, the almost open-air airport was equipped to handle maybe 5 flights per day with 2 pleasant and very relaxed visa and passport workers at the counter and only 1 luggage conveyer belt. With the proper visas and shockingly enough, all of our luggage in tow, we were stopped by a nice man who wanted to know what was in “the box” and our freakishly large travel bags. I handed him a short list of medications and encouraged him to look into the box, only if he had tape. Another nice woman worker came, they discussed the box, the list, looked over me and my invitation from Macha Mission hospital and agreed to not open the box since they didn’t have tape and Macha was really far away. Next we were assailed by taxi driver representatives acting as professional middle-men who introduced us to several potential matches, instructed us how to take out money and told to wait for “our guy Frank.” After almost an hour of trying to be as relaxed as the locals, we insisted on getting another guy and were quickly shuffled into a cab and whisked toward town.

The van getting ready for another half-dozen passengers.

In Zambia, virtually every transaction is a team effort. Almost nothing happens without someone knowing someone who knows someone. We drove around town stopping by stores, street corners and visiting other people in search of a SIM card for our GSM phone. Finally we found someone who had a stash of SIM cards in his backpack, the official telecom shop being out of stock. Then we drove around looking for a bus to take us up to Choma. This was where our cabbie was extremely helpful and brought us by every transportation option on the market. The coach bus had left and he warned us of the process of getting a shared van, so we went to check the trucks leaving for Lusaka. Our cabby was pretty irritated when a potential driver of an empty truck asked to charge us 400,000 kwacha (about $80USD) for a trip that was on his way. Instead, we paid a bargain 100,000 kwacha to stuff ourselves and our belongings in a mini-van bus along with 7 other people, waiting almost 2 hours to sufficiently fill the small van to overcapacity of 17 people, for the bumpiest 190 kilometers of our lives.   In addition to spending half the voyage on the wrong side of the road passing large trucks, the voyage was punctuated by additional stops at the roadside to fill the van with gas, pick up and discharge passengers, have local vendors offer their goods and other stops just to say hi to friends. We arrived in Choma well cramped but thankful for making it at all.

Negotiating cab fare

The final leg of the voyage from Choma to Macha used to be the most broken down dirt road I have ever seen outside of a BMX dirt jumping course, but has recently been partially leveled and paved by a Chinese company. We were surrounded and hustled into a taxi who agreed to take us for a “fair price.” Two nice gentlemen put our oversized luggage and a spare tire in the back and we were off to make better time than expected.   Unlike most cabbies in other parts of the world (including our van driver), the young man driving was slow and cautious. To save fuel, he would frequently turn off the ignition and coast along any level or slight downhill. His driving companion entertained us and asked us many questions. After a while, the car began to rumble and shake. Could it have been a loose tie rod? The answer came in the form of a gunshot sound and this was flat tire number one. We proceeded at 20km/hr after this, but still flatted the replacement tire only minutes later after getting onto the portion of road that had not yet been paved which resembled a jeep trail. By this point, the sun had set and we decided to try out our new Zambian phone. The adventure finally ended when the medical director John and his wife Esther came to our rescue about 1 hour after we called. Our taxi friends stayed behind to sleep with their downed vehicle, with friends coming from Choma with a spare tire in the morning.

Flat tire numero uno

We arrived in Macha at about 10:00pm very thankful that our journey had, at long last, come to an end.

Adventures ahead

Mark Abramson — Thu, 28 Jan 2010 03:14:54 GMT

Tomorrow, We begin our journey to Macha, Zambia (via Cyclocross Worlds in Tabor, Czech Republic for Mark).

(Map courtesy Vayama.com)