¿What On Earth Am I Doing Here?

Agra

2009-06-17T08:16:00.001-07:00

I spent my last weekend in India visiting Agra with Liza and Gareth. My plan was to ease the transition between Hajipur and the USA by a luxury weekend in Agra. We visited the Taj Mahal, of course, as well as Fatehpur Sikri, capital of Akbar's Mughal empire in the 16th century. The luxury weekend was great, but I am not sure it helped make my transition back to the USA any less difficult.

Here are a few pics from the Agra weekend. At left, Liza in front of the Taj Mahal. Below, MSF-Spain Coordination Dream Team outside Amarvillas hotel, Agra, and several pictures of Fatehpur Sikri. I recommend William Dalrymple's City of Djinns for a brief history of the Mughal empire and Akbar's reign. The book actually chronicle's the history of Delhi; there is a chapter devoted to Akbar.

Frieden to Head CDC

2009-05-15T04:25:00.000-07:00

I was happy to read in the New York Times today that Obama picked Tom Frieden to head the CDC. Dr. Frieden went to medical school and did his residency at Columbia, just like a few other people I know. He later went on to work for WHO in India for five years on TB control. In 2002 he became the Comissioner of the NYC Department of Health, where he has made many bold decisions to protect the public's health. The NYC Department of health website says there are now 300,000 fewer smokers in the City than in 2002, which will prevent 100,000 premature deaths in years to come.

I like the following anecdote about getting things done quickly (from the Oberlin College Alumni Magazine, 2006):

Describing Frieden—then in his early 30s—as “driven and brilliant, with an incredible passion for public health,” Larkin was amazed by how quickly he took steps to hire new employees, greatly speeding up a process that had taken “months and months” before his arrival. “He brought applicants in on Saturdays to interview, and those who qualified would be offered the job that same afternoon. And then, when they arrived a few days later for their physical exams [another potential bottleneck], they discovered that the doctor who would be giving them their physicals, quickly and efficiently, was none other than … Tom Frieden.”

Calcutta

2009-05-04T06:41:00.000-07:00

I spent a relaxing three-day weekend in Calcutta. I realize that it might seem like an unlikely choice for an escape from Bihar--given that the city has an international reputation for extreme poverty--but in fact there are lovely spots in Calcutta. I had plenty of opportunities to pamper myself: I stayed in a luxury hotel, ate Chinese and Indian food, drank espresso, and browsed in bookstores. I am told Calcutta is the last Indian city that still has hand-pulled rickshaws (pic upper left). The man in the upper right pic is a Paan-walla, he makes Betel-nut, spice, tobacco sweets rolled up in a leaf. Below left is a lassi shop where they serve chilled yogurt drinks in the stacked clay cups.

Civil Unrest and Communicable Disease Control

2009-04-26T00:48:00.000-07:00

The current issue of Lancet Infectious Disease has a news story on the continuing neglect of visceral leishmaniasis.

The author makes the point that war and civil unrest are major impediments to control of endemic communicable disease. This article uses the example of the political situation in Sudan hampering programs for treatment of leishmaniasis.

This is only one example of many, of course. Regional elimination of disease is impossible if even one country in an endemic area has an ineffective government program. An even better example is the onchocerciasis control program (OCP) in West Africa. The OCP was a major effort to eliminate onchoceriasis in West Africa in the 1970s-1990s. In many countries the OCP worked to control onchocerciasis and prevent river blindiness. However, despite international investment, aggressive vector control, and coordinated government/NGO treatment programs, the OCP failed to eliminate onchocerciasis from West Africa primarily due to the decades of conflict in Sierra Leone.

Heat Wave Hits Bihar

2009-04-22T04:26:00.000-07:00

We did not think life in Bihar could get harder, but our local staff assure us that it can. From the Patna Daily Today:

The current heat wave gripping much of the state forced most people to stay indoor on Monday as temperature soared to 42° Celsius (108° Fahrenheit), at least 5° more than the average around this time.

Those who were forced to step outside their homes were seen covering their faces with scarves and towels while making frequent pit stops at roadside vendors to grab a cold glass of sugarcane juice, watermelons, or 'sattu' drink to quench their thirst.

I like the rickshaw driver in the background of this pic. Can you imagine driving a bicycle rickshaw in 108 degree heat?

You must have a browser that supports iframes to view the BBC weather forecast

Something "More Personal"

2009-04-18T21:25:00.001-07:00

The people at El Periodico asked me for something "more personal" for the kala-azar blog. I am not sure what they want, but this is what I sent them:

In this entry, I describe a typical day as a field doctor in India. I hope this helps convey what it is like to work as a doctor in with MSF in Bihar.

7:00 am- I wake up to the noise of my ceiling fan. The fan functions more as a noise-making machine than a cooling device. It also turns the room into a dust storm. The mosquito net over my bed started out white, but now it is a dark shade of grey. I take a cold shower. As soon as I dress, I start to sweat.

7:30 am- While I am eating breakfast, Sara--the field nurse-- comes into the room. She is doubled over in pain. She says that she started getting diarrhea and abdominal pain at 11pm last night. She looks terrible. I am responsible for the medical care of all expat field staff. I advise her to drink a lot of water mixed with oral rehydration solution and to hold off on taking any antibiotics. She tells me that she has already started herself on antibiotics. I advise her to rest all day in bed. She tells me that the medical order is due in the capital today, and that plans to work on it whether she is sick or not.

8:00 am—I walk down four flights of stairs and arrive at our office, which is located on the ground floor of our apartment building. I rejoice that the internet connection is working again. I check my personal email account. There are six SPAM messages, two or three work-related messages, and no personal messages from friends or family. I feel depressed.

8:15 am- I have almost two hours to work on administrative issues before I need to leave for the hospital. I review the medical coordinator’s report on his recent visit to the field. I write a memo to the project epidemiologist and medical coordinator about reorganizing our follow-up visit system. I make a list of essential medical books for our project library. I work on the national doctors’ rotation schedule for Sept-Dec 2009.

10:15- I arrive in the hospital for ward rounds. We round as a team of 4 nurses, 3 doctors, and a ward attendant today. The ward is almost full; there are about 40 patients inside, and ten patients on cots in the hallway. I feel bad for the patients outside; it is 40 degrees C and they are covered in flies. There are many complicated cases. Some patients may have typhoid that we have misdiagnosed as kala-azar. We suspect many patients are coinfected with tuberculosis. There are a couple patients who I think have neither kala-azar, enteric fever, HIV, or tuberculosis, but they are spiking fevers and look sick.

3:00pm- National staff nurses, doctors, health educators, and logisticians gather in the office for a brainstorming meeting on how we can improve our activities in the rural facilities. There is active participation in the conversation. Several good ideas are discussed, clarifying our priorities for the next 18 months of the project. Marlies—the project field coordinator—and I agree that the meeting has been productive.

6:30 pm—My commute from office to home takes less than a minute. I want to exercise, but it is impossible to do anything outside. Rafa and Marlies are doing yoga in the room where I often jump rope in the evening.

7:30 pm—I am having trouble getting work-related thoughts out of my head. I feel trapped inside the house. We are not allowed to walk outside the house alone in the evening or drive the car. When yogis are finished, Marlies and I convince Rafa to turn on the generator for three hours so we can watch a DVD.

10:30pm-- By the end of the movie I feel more relaxed. It has cooled down enough to make sleep a possibility.

El Periódico

2009-04-09T03:51:00.000-07:00

El Periódico--a Spanish newspaper-- is publishing a filtered and distilled version of this blog. I wrote it to help publicise MSF´s work on the neglected tropical diseases. Here´s the link. It´s in spanish (translated by MSF-communications in Barcelona).

Obama on Community Service and MSF

2009-04-04T20:41:00.000-07:00

Obama gave press conference/town hall meeting in Strasbourg on April 3rd. I like what he said about community service. And he mentioned MSF! Thanks dad, for telling me about the speech.

Question: wanted to know if you -- did you ever regret to have run for presidency till now? I mean, well, did you ever ask yourself, am I sure to manage -- yes.

PRESIDENT OBAMA: Yes, it's a good question. (Applause.) Michelle definitely asked that question. (Laughter.) You know, there are -- there have been times, certainly, during the campaign, and there have been times over the last several months where you feel a lot of weight on your shoulders. There's no doubt about it.

During the campaign, the biggest sacrifice -- the thing that was most difficult was that I was away from my family all the time....You also lose privacy and autonomy -- or anonymity. You know, it's very frustrating now -- it used to be when I came to Europe, that I could just wander down to a café and sit and have some wine and watch people go by, and go into a little shop, and watch the sun go down. Now I'm in hotel rooms all the time and I have security around me all the time. And so just -- you know, losing that ability to just take a walk, that is something that is frustrating.

But having said all that, I truly believe that there's nothing more noble than public service. Now, that doesn't mean that you have to run for President. (Applause.) You know, you might work for Doctors Without Borders, or you might volunteer for an -- or you might be somebody working for the United Nations, or you might be the mayor of Strasbourg. Right? (Applause.) I mean, they're all -- you might volunteer in your own community.

But the point is that what I found at a very young age was that if you only think about yourself -- how much money can I make, what can I buy, how nice is my house, what kind of fancy car do I have -- that over the long term I think you get bored. (Applause.)

I think your life becomes -- I think if you're only thinking about yourself, your life becomes diminished; and that the way to live a full life is to think about, what can I do for others? How can I be a part of this larger project of making a better world?

Now, that could be something as simple as making -- as the joy of taking care of your family and watching your children grow and succeed. But I think especially for the young people here, I hope you also consider other ways that you can serve, because the world has so many challenges right now, there's so many opportunities to make a difference, and it would be a tragedy if all of you who are so talented and energetic, if you let that go to waste; if you just stood back and watched the world pass you by.

Better to jump in, get involved. And it does mean that sometimes you'll get criticized and sometimes you'll fail and sometimes you'll be disappointed, but you'll have a great adventure, and at the end of your life hopefully you'll be able to look back and say, I made a difference. All right.Thank you, everybody.

ARV Therapy and HIV Elimination

2009-03-27T23:46:00.000-07:00

I'm waiting for my train in Ernakulum in an internet cafe that must be 40 degrees C. While sitting here sweating, I noticed a January 2009 Lancet article that has generated a lot of debate. The article (vol 373, issue 9657: 48-57) uses a theoretical model to asses whether testing everybody for HIV, then starting all positives on immediate ARV would eliminate HIV. [Note that the word "eliminate" does not mean the same as eradicate. They define eliminate as incidence of transmission less than 1 case per 1000 per year.] The idea of treatment as prevention is not new, of course, but this article takes it to the extreme. From the accompanying editorial:

In The Lancet today, Reuben Granich and colleagues (including two of us, KMDC and CFG) use mathematical modelling to assess the impact of expanded HIV testing and earlier antiretroviral therapy (ART) on HIV transmission.1 These researchers evaluated a theoretical programme of annual universal HIV testing and immediate treatment on HIV diagnosis, irrespective of CD4+ cell count, in an HIV epidemic with southern African population dynamics. The exercise suggested that HIV transmission could be substantially reduced within a few years. Elimination of HIV transmission, defined as an incidence below one case per 1000 population per year, could be achieved within a decade, and the overall prevalence of HIV infection reduced to below 1% before the middle of the century. Compared with current practice of starting ART at a specific CD4+ count, deaths would be halved between now and 2050.

The article generated a lot of interesting correspondence, some of which is published in vol 373, 9669. For me, the most important issue was raised in the letter by Jaffe et al:

In their important and provocative article,1 Reuben Granich and colleagues argue that universal voluntary HIV testing and immediate antiretroviral therapy, irrespective of the degree of immune suppression, could eliminate HIV from countries where the infection is highly prevalent. However, we agree with Geoffrey Garnett and Rebecca Baggaley2 that this approach could strongly shift the benefits of treatment from the individual to the population.

Although current HIV treatment guidelines favour earlier treatment, the risks and benefits of treatment for people with CD4+ cell counts above 350 per μL are unknown. Trials of therapy for patients with higher counts are yet to begin.

Within the field of communicable diseases, we are aware of little precedent for the approach of “treating for the common good”. Treatment of diseases such as tuberculosis might have the effect of decreasing transmission, but the primary goal is to decrease morbidity and mortality for the affected person. A better analogy might be found in immunisation programmes—eg, rubella vaccination of infants and children aims to reduce exposure among pregnant women. However, there is still a clear benefit and minimal risk for the individual vaccinee.

The World Medical Association international code of medical ethics states that “A physician shall act in the patient's best interest when providing medical care.”3 If we are to deviate from this basic principle, we will need a robust ethical model for balancing individual and societal benefits.

World TB Day 2009

2009-03-25T22:15:00.000-07:00

World TB day came and went a few days ago, while I was stuck in Bihar up to my neck in kala-azar. Now I'm in Kerala, where nobody has kala-azar, but people are coughing up clouds of mycobacteria to my left and to my right. MSF access campaign published a beautiful summary document on the current challenges to TB control.

The White Tiger

2009-03-22T04:30:00.000-07:00

I read The White Tiger, Aravind Adiga´s novel that won the 2008 Booker prize.

From the New Yorker review:

In this darkly comic début novel set in India, Balram, a chauffeur, murders his employer, justifying his crime as the act of a "social entrepreneur." In a series of letters to the Premier of China, in anticipation of the leader’s upcoming visit to Balram’s homeland, the chauffeur recounts his transformation from an honest, hardworking boy growing up in "the Darkness"—those areas of rural India where education and electricity are equally scarce, and where villagers banter about local elections "like eunuchs discussing the Kama Sutra"—to a determined killer. He places the blame for his rage squarely on the avarice of the Indian élite, among whom bribes are commonplace, and who perpetuate a system in which many are sacrificed to the whims of a few. Adiga’s message isn’t subtle or novel, but Balram’s appealingly sardonic voice and acute observations of the social order are both winning and unsettling.

The narrator of the book was born in Bihar--which he calls "the Darkness:"

I am talking about a place in India, at least a third of the country, a fertile place, full of rice fields and wheat fields and ponds in the middle of those fields choked with lotuses and water lilies, and water buffaloes wading though the ponds and chewing on the lotuses and lilies. Those who live in this place call it the Darkness. Please understand, York Excellency, that India is two countries in one: an India of Light and an India of Darkness. The ocean brings light to my country. Every place on the map of India neaer the ocean is well off. But the river brings darkness to India--the Black river.

Which black river am I talking of-- which river of Death whose banks are full of rich, dark, sticky mud whose grip traps everything that is planted in it, suffocating and choking and stunting it?

Why, I am talking of Mother Ganga, daughter of Vedas, river of illumination, protector of us all, breaker of the chain of birth and rebirth. Everywhere this river flows, that area is the Darkness.

One fact about India is that you can take almost anything you hear about the country from the prime Minister and turn it upside down and then you will have the truth about that thing. Now, you have heard that the Ganga called the river of emancipation, and hundreds of American tourists come each year to take photographs of naked sadhus at Hardwar or Benaras, and our prime minister will no doubt describe it that way to you, and urge you to take a dip in it.

No!--Mr Jiabao, I urge you not to dip in the Ganga, unless you want your mouth full of feces, straw, soggy parts of human bodies, buffalo carrion, and seven different kinds of industrial acids.

Kidnapped MSF Staff Released in Sudan

2009-03-15T08:03:00.000-07:00

What a mess! A few days after MSF-Holland and MSF-France were ordered to leave Sudan last week, four staff members of MSF-Belgium were abducted. The Guardian report on the kidnapping is here. According to MSF´s press release, the four kidnapped staff members were released yesterday. Unfortunately, more MSF projects will evacuate after the kidnapping, and more IDPs in Darfur who depend on International Aid will suffer.

Follow-ups

2009-03-14T22:31:00.000-07:00

As I mentioned in the last post, we see our patients at 3 months and 6 months after they have been discharged from the hospital. If fever and splenomegaly are still present at the follow-up visit, the patient may have relapsed. These patients need to come into the hospital for a splenic aspirate. Most patients are symptom free; these patients have been cured.

Despite the cost and the hassle, approximately 80% of our patients come back to the hospital for follow-up visits. If they don’t come back, we go out and look for them.

I went out with our follow-up team last week. It turns out that finding each patient is more difficult than you might think. The process involves going to nearest town and asking directions to the village. When we find the village, we need to ask if the patient is known there. Half the time, this involves a long discussion of the father’s name, the grandfather’s name, etc. A child is sent off to the fields to bring back the patient. Sometimes the person found is not the person we are looking for (e.g. same name but different age, height, etc). It took, on average, an hour or two to find each patient from the nearest town.

I enjoyed the follow-up visits, particularly because it took me from urban India to rural India. At each village, everybody stopped what they were dong to watch; there’s not much privacy in village life. Within minutes there was always a big crowd around us. Our health educators took each opportunity to educate the people about kala-azar. There were many questions.

Childhood Malnutrition in India

2009-03-12T19:52:00.000-07:00

In the New York Times today, an article about malnutrition in India. MSF-Spain started a project last month in Darbhanga Bihar to treat malnourished children. I hope to visit the project while I am in Bihar.

Response to Treatment

2009-03-09T21:15:00.000-07:00

In this project we are using Liposomal Amphoteracin B (brand name Ambisome) to treat kala-azar. We use this treatment because there is a high rate of resistance to SSG-- the standard first-line treatment—in Bihar state. The L. donovani parasite is exquisitely sensitive to Liposomal Amphoteracin B. Our treatment protocol uses four infusions of Ambisome; each dose is 5 mg/kg body weight. By the end of the second infusion, there is a dramatic improvement in the patients’ status. The fever curves pictured above are typical. [The temperature in degrees F is plotted on the y axis vs time on the x-axis.] In fact, if a patient remains febrile after the 2nd or 3rd dose, we are suspicious that the patient has another source of infection. The speed and magnitude of response is unusual in infectious disease treatment. In most bacterial infections, we see a much more gradual response to treatment; the peak of fever usually decreases gradually over the course of several days.

The response to Liposomal Amphoteracin treatment is also enduring. Of the first 2000 patients we treated in Bihar, 98% of patients are symptom free at the end of treatment. In order to demonstrate the efficacy of this treatment over time, we are careful to follow-up the patients we treat 3 months and 6 months after treatment. Careful follow-up is not the standard of care in Bihar. Most patients who feel well do not return to the hospital for check-ups. The journey is too long and expensive; it requires time away from childcare and work. Despite the challenges of follow-up, we work hard to find each patient in order to prove to skeptics that patients treated with Ambisome do not relapse after cure. In the first 250 patients treated in this project, we managed to find and examine 201 of them at 6 months. 96% of these patients were still symptom free, which satisfies our definition of complete cure of visceral leishmaniasis.

Aid Agencies Expelled From Darfur

2009-03-06T05:31:00.000-08:00

I have not seen the news for the past few days. I just found out that MSF and 12 other aid organizations were expelled from Darfur. What an outrage! NPR's coverage here. MSF's press release here. Kristof's NY Times column here.

Stress Reduction

2009-03-06T04:49:00.000-08:00

We cannot exercise outside in Hajipur. Locals would gape at us and laugh. The streets are crowded with traffic and sewage. Without exercise, I am at high risk for takeover by my dark side.

Anne and Othman hired a local yoga instructor to come to our house. He gives them lessons three times per week at 6:30 am. The only words of English he knows are “relax” and “leg.” The rest of the lesson is in Hindi. I tried some sessions, but I find that the stress from the language barrier outweighs the benefit of yoga. I’ve been jumping rope instead.

Still alive

2009-03-03T05:48:00.001-08:00

I have not been able to post anything lately because our internet connection has been broken. I hope it stays alive long enough to upload this two sentence reassurance to family and friends: I´m surviving Bihar. Earplugs are serving me well. I miss you.

Acting Pharmacy Director

2009-02-16T19:58:00.000-08:00

I have felt important for the last few days. Anne-the field nurse—has been away since Saturday, leaving me in charge of the pharmacy. Managing the pharmacy is a big part of all MSF projects. Every project is different, but most require: hundreds of pharmaceuticals, ready to use foods, IV fluids, needles, cannulas and plastic tubing, gloves and sterile dressing materials, laboratory reagents and tests, vaccines, and all the other equipment necessary to run a medical ward. Storage and management of the equipment is more complicated than it looks; it involves inventory, meticulous organization of materials, quarterly domestic and international orders, and temperature control. Our project requires importation and storage of liposomal amphoteracin B, which requires strict cold chain from the factory in the UK to the patient’s bedside.

I have never managed a pharmacy before. Even though it was only for three days, and I did not have to order or take inventory, I was still nervous when the hospital nurses told me they needed IV infusion sets, mosquito nets, dressing materials, and sterile water for injections. Which bottles are those? Do you need the size in the red package or the size in the blue package or the size in the green package? Are they in the room with the medicines or the room with the tubing or the room with the dressings? How many come in a bag? How many bags in each box? What's the difference between a lot number and a batch number. Where do I record the expiry date?

I also had to send the Ambisome to the hospital each day in cold chain. I’m proud to say that I mastered this without too much difficulty. All I had to do was ask the nurses how many patients were due for infusions that day, then estimate the number of vials per each patient. I checked the thermometer on the pharmacy refrigerator, packed the vials in coolers lined with ice packs and insulation, and noted down how many vials I sent out each morning and got back each evening.

Noise Pollution

2009-02-09T01:01:00.000-08:00

One of the hardest things for me to tolerate in Hajipur is the noise. Traffic is part of the problem. There is 24-hour gridlock in Patna and Hajipur: walkers, bikes, mopeds, bicycle-rickshaws, motorcycles, auto-rickshaws, 3-wheeled tut-tuts, four-by-fours, buses, trucks, ox-carts, camels, and elephants share the road. There appear to be no traffic rules, other than that each driver must hold down his horn at all times, whether or not there is room for anybody to move.

The rest of the noise comes from festivals. I do not understand significance of each festival, but the order of events seems to follow the same general pattern:

1. Statues representing gods and/or religious figures are built out of concrete, clay, and paper

2. Statues are decorated with paint, textiles, and jewelry

3. Faces remain covered with cloth or newspaper until start of festival

4. After the ceremonial part of the festival, caravans parade through town. Caravans consist of: (1)cart loaded with loudspeakers and bullhorns blasting Hindi techno music, (2) throng of Indian youngsters gyrating in trance, (3) large generator for power to speakers, (4) cart carrying god-statue.

5. Dozens of caravans parade through the streets of Hajipur for 1-7 days. At the end of festival, each statue is tossed into the holy Ganges river, which is conveniently located at end of our street.

Luckily, I brought a 24-pack of earplugs with me to Bihar. I wear earplugs when I eat, when I sleep, when I read, and when I am in the car. Of course, cultural education and immersion are part of the reason I do this type of work in the first place. But sometimes I miss the peace and quiet of Manhattan.

HIV in India

2009-02-04T03:52:00.001-08:00

Robert Steinbrook’s March 2007 essays in the New England Journal of Medicine helped me understand more about HIV/AIDS in India, as well as global HIV/AIDS epidemiology. Steinbrook reports that in 2006, UNAIDS estimated that there were 5.7 million people HIV positive people in India. This was shocking news at the time, as it meant India had more HIV positive people than South Africa, which was estimated to have 5.5 million in 2006. Of course, the HIV prevalence in India would have still been much lower than South Africa (0.5-1.5% of 15-49 year-old Indians infected, verses 16.8 to 20.7% of 15-49 year-old South Africans infected), but given the sheer size of the population in India, the raw number of HIV positive people would have been the largest of any country in the world. This brought a lot of attention to HIV/AIDS in India, and expansion of India’s National AIDS Control Organization (NACO).

In 2007, UNAIDS revised the prevalence data for India based on new survey data. As of late 2007, UNAIDS estimates that India has 2.5 million people living with HIV/AIDS, less than half of the 2006 estimate. In fact, the correction of India’s estimated HIV prevalence was the major reason for the 16% reduction of estimated people with HIV/AIDS worldwide in 2007. In the 2007 report, UNAIDS estimated that there were 33.2 million people living with HIV/AIDS worldwide, 16% less than the estimate from 2006 (39.5 million). From the 2007 UNAIDS report:

The major elements of methodological improvements in 2007 included greater understanding of HIV epidemiology through population-based surveys, extension of sentinel surveillence to more sites, and adjustments to mathematical models from better understanding of the natural history of untreated HIV infections in low and middle-income countries. Although prevalence has stabilized, continuing new infections (even at a reduced rate) contributed to the estimated number of people living with HIV. HIV prevalence tends to reduce slowly over time as new infections decline and through the death of HIV-infected people; it can increase through continuing HIV incidence and through reduced mortality of HIV-infected people on ARV treatment.

Steinbrook’s essays on HIV also say that the tradition of female sterilization as a form of contraception in India is a barrier to HIV prevention efforts. In many Indian States more than 50% of woman use sterilization as a method of family planning before they turn 30, the article says. It is nearly impossible for sterilized women to negotiate for condom use. The article quotes Broun of UNAIDS, who says “In Africa, a woman who is not pregnant is probably using condoms as a method of contraception, so is therefore also protected against HIV. In India, a woman who is not pregnant is probably a woman who has been sterilized and her behavior toward HIV is not known. “

Rab Ne Bana Di Jodi

2009-01-30T04:18:00.000-08:00

Bollywood movies are not my favorite genre of entertainment. But among Bollywood movies, Rab Ne Bana Di Jodi is the best I´ve seen. The movie is set in Amritsar, site of the Golden Temple in Punjab, Northwest India. It stars Shahrukh Khan, king of Bollywood. Everybody I´ve met in India has seen the film.

Here is a link to a New York Times review published Dec 13 2008. I believe the movie is still playing in America and Europe. Running time: only 2 hours and 47 minutes.

Aid Workers in Chad

2009-01-24T04:10:00.000-08:00

The Jan 5th issue of the New Yorker has an essay on aid workers in Chad. This part of the reporter´s interview with an employee of an unnamed "large well-known humanitarian organization" hits a little too close to home:

One night, she took me to a tiny restaurant run by two Chadian women. She drove through the dark, chaotic streets of N’Djamena in her agency’s jeep, past sheds and mud-brick buildings where groups gathered around small cooking fires, past an endless procession of people along the road, all coming into view and going out again as the headlights swept by. The restaurant was in a dim, stony courtyard lit by kerosene lanterns, and consisted of a few plastic tables and chairs. She knew the women who ran the place and greeted them warmly. She ignored the cold stares from a table of men drinking beer in the shadows.

Over a meal of fried plantains and bony fish from the Chari River, she told me that, among the variety of aid workers, two broad categories stood out: the runners and the seekers. The runners were fleeing their past lives; the seekers were looking for adventure or enlightenment. She was a runner, she said, but offered no details.

She went on to say that she had reached a point in her life where she must make a choice. She was thirty-three, young enough to return to her country and try to establish a life with marriage, children, and a home. Or she could continue on as she was, with reassignments every few years and little chance for marriage and children. “Look around,” she said, “and you’ll see that this business is full of women thirty-five to forty-five who are strong, competent, good at what they do, and single.” She had never had a long-term relationship. She must make a choice, she said. It seemed to me that she already had.

Rounds on the Kala-Azar Ward

2009-01-23T03:46:00.001-08:00

I round with the team in the kala-azar ward every morning, unless I need to travel to one of the distant clinic sites. The kala-azar ward in Hajipur hospital has 55 beds. In the high season--when it is hot, before the monsoons-- the ward is often full. The patients rarely complain. They don’t tell me they have pain or vomiting or diarrhea or cough unless I ask them specifically about each symptom. In addition to kala-azar, we see a lot of malnutrition (body mass index < 16), severe anemia (Hemoglobin < 4), as well as protozoal and helminth (worm) infections. We also see plenty of tuberculosis/kala-azar coinfection and HIV/kala-azar coinfection.

Kala-Azar Expats in Bihar

2009-01-22T04:52:00.000-08:00

There are four expats working on the kala-azar project in Bihar. Anne (left) is a nurse from Berlin. Marlise (middle) is our field coordinator. She is from the Netherlands, but has most recently lived in Madagasgar where she worked with UNICEF. Othman (right) started with MSF as part of the National Staff in Colombia.

There are 45 Indian National staff members on our project, including five doctors and six or seven nurses.

Kala-Azar Basics

2009-01-15T04:21:00.000-08:00

Leishmaniasis is a protozoal infection that is transmitted by phlebotomine sandflies. The disease is usually classified into two main groups: cutaneous leishmaniaisis (CL), which causes a skin rash or ulcer, and visceral leishmaniasis (VL), a disseminated form of the disease which causes a systemic febrile illness. VL is sometimes called Kala-Azar, which means “black sickness” in Hindi. Most CL is found in Central/South America and the Middle East, whereas most VL is in South Asia and Africa. More than 90% of the world’s kala-azar cases are in India, Bangladesh, Nepal, Brazil, (about 60% of cases in India, Bangladesh, or Nepal). More than 90% of Indian cases occur in Bihar State, the Kala-Azar capital of the world!

The CDC cartoon above diagrams the leishmaniasis lifecycle. When an infected sandfly bites a human, it injects the promastigote form of the protozoa. The promastigotes enter macrophages in the blood, then change into the round amastigote form. Infected macrophages travel to the spleen, lymph nodes, bone marrow, and other organs. The amastigote form multiplies inside the macrophages. Infected macrophages eventually burst, releasing amastigotes into the tissue. When a non-infected sandfly feeds on an infected patient, it ingests macrophages filled with amastigotes. The amastigotes turn into promastigotes in the gut of the sandfly. Eventually the sanfly feeds on another person, which spreads the disease. Pics below are of amastigotes inside macrophage on a biopsy sample, and of the type of sandfly that transmits VL.

I had never seen a case of kala-azar before I came to Bihar. Patients with kala-azar usually present with high fever, weight loss, and weakness. On exam, the spleen is enlarged. Often the patient has low white blood counts, red blood counts, and platelets. It is important to rule out malaria, tuberculosis, and typhoid, which are diseases that can look similar to kala-azar. [The picture below is an African child with massive splenomegaly. Not all patients have such dramatic spleens.]

The gold-standard for VL diagnosis is a spenic or bone marrow biopsy that shows macrophages filled with amastigotes. We do not routinely do white blood counts or biopsies for diagnosis, , as they are time consuming, expensive, and require lab facilities and trained technicians. We diagnose the disease based on the patient’s clinical history, splenic enlargement, and results of a rk39 blood test. Rk39 tests for the presence of VL antibodies. It only requires a few drops of blood, and results are available in 15 minutes. The availability of the rk39 test is one of the reasons we are able to have a successful treatment program for Kala-Azar in the field.

The traditional treatment for visceral leishmaniasis is a drug called sodium stibogluconate (SSG), a toxic IV infusion that requires a 3 week hospital stay. In Northern Bihar, much of the VL is resistant to SSG. Amphoteracin B, a potent antifungal, is another drug effective against VL. Ampho B is nicknamed “ampho-terrible” in the USA due to its many side effects. It also requires several weeks of IV treatment. In this project MSF is providing the liposomal form of Amphoteracin B, which is better tolerated, requires a shorter course of treatment, and is effective against SSG-resistant VL. It is also expensive. At current prices, India cannot afford to treat all VL patients with liposomal ampho B. Advocacy for generic production and price reduction of Liposomal Ampho B is an important part of this project.

Hajipur

2009-01-08T06:57:00.000-08:00

It has been a challenge to adjust to my new life in India. Bihar is one of the poorest and most corrupt States in the country. The infrastructure is crumbling or nonexistent. We live in a town called Hajipur, which is about 20 km from Patna, the State capital. Because rickshaws, cars, bikes, and cow-carts gridlock the road, it takes more than an hour to drive the 20 km between Patna and Hajipur.

I had prepared myself for dirt, noise, and chaos, but Patna and Hajipur have exceeded my expectations on all fronts. The hygiene is the worst I’ve ever seen. The roads are lined by pools of water /sewage filled with garbage. Pigs and cows and children wade through the garbage swamps. Open defecation and urination are common. The road often cuts a canyon between mountains of garbage and plastic refuse on either side.

Hajipur is considered a “small town” in India—about 300,000 people. The locals are unused to Westerners. People gape or shout at us when we walk outside the house. There are no comfortable restaurants or bars nearby, and no greenery or peaceful outside retreats.

Still, my discomfort is a small price to pay for the opportunity to work here. The complexity of Indian culture and religious, ethnic, and socioeconomic diversity are fascinating. I’m getting a lot of hands on experience in tropical medicine and public health, which complements the book and lab-based learning that I did in Liverpool.

My India Stint Starts with an Adventure

2008-12-30T02:12:00.000-08:00

I was supposed to fly from NYC to Delhi via London, leaving JFK Sunday Dec 28th, arriving in Delhi on Tuesday Dec 30th at 2am. Fifteen minutes before landing, the captain announced on the loudspeaker that he could not land due to the poor visibility. The plane would be diverted to Mumbai.

Now I'm now stuck at a hotel in Mumbai until further notice. It was a bit scary to arrive in the middle of the night, 2 hours by air from my destination. One billion people in this country, and I don't know anybody! Luckily, I was able to contact the team in Delhi to let them know what happened. I will fly to Delhi as soon as British Air is ready, brief with the team in Delhi, then fly to Bihar state the following day.

Bihar India

2008-12-25T18:16:00.001-08:00

In three days, I will leave for Bihar India to work on another MSF project. Bihar is one of the poorest States in India. It is in the Northeast part of the country, just south of Nepal and West of Bhutan. The project is on diagnosis, prevention, and treatment of visceral leishmaniasis (also known as Kala-Azar). Kala-Azar is a protozoal infection transmitted by the sandfly. More on this disease in future posts.

I first heard about the project just two weeks ago, when I was in Liverpool, finishing up my tropical medicine course. I have not had enough time prepare for this trip, but I am excited nonetheless. I feel lucky to have the opportunity to work in Asia (my fourth continent in three years!).

Leptospirosis Outbreaks in Triathletes and Adventure Sportspeople

2008-12-08T09:57:00.000-08:00

Leptospirosis is a bacterial infection of rats and other rodents. It can be transmitted to humans when they swim in fresh water bodies contaminated by rodent urine. Although many American doctors regard this disease as an exotic tropical infection, leptospirosis infections actually occur world-wide. The organism is a spirochete-- a coiled bacteria similar in shape to the organisms that cause syphilis and lyme disease (see electron micrograph pic at left).

Most people who get leptospirosis have a non-specific flu-like illness about a week or two after exposure. About ten percent of patients get serious complications, including kidney and liver failure (Weil's disease). Textbook cases present with subconconjunctival hemorrhage (red eyes), but of course this symptom is hardly sensitive or specific.

I was surprised to learn that there have been several outbreaks of leptospirosis in triathletes and adventure sportspeople. The largest outbreak in the United States was after a triathlon near Lake Springfield in 1998, when 12% of participants reported a post-triathlon febrile illness. Of 474 participant blood samples tested, 11% were spirochete positive (Clin Infect Dis. 2002 Jun 15;34(12):1593-9. Epub 2002 May 24). ] In 2000, there was an outbreak in Athletes who competed in the 10-day Borneo "Eco Challenge 2000, multisport endurance race." The event included jungle walking, swimming, kayaking, spelunking, climbing, and mountain biking. About half the athletes got leptospirosis. There's an interesting report of the epidemiological investigation in CDC's Emerging Infectious Diseases, Sejvar J, Bancroft E, Winthrop K, Bettinger J, Bajani M, Bragg S, et al. Leptospirosis in "Eco- Challenge" athletes, Malaysian Borneo, 2000. Emerg Infect Dis [serial online] 2003 Jun. The CDC suggests that athletes who participate in these events might want to consider taking Doxycycline for pre-adventure sport prophylaxis!

Hookworm

2008-12-07T04:18:00.000-08:00

Hookworm is a major cause of anemia-related morbidity in the developing world. The Ancyclostoma Duodenale hookworm species looks scary under the electron microscope. Actual size is only 8-11 mm. The worm sinks those teeth into the wall of the small intestine and drinks blood from the capillary rich mucosa.

Each adult worm can consume up to about 0.25ml of blood per day. Many patients--especially children--are heavily infected. An infection of 100 worms could cause 25 cc blood loss per day, which is one unit of blood every 10 days. On top of HIV, tuberculosis, malaria, sickle cell, and poor nutrition in subsaharan Africa (all causes of anemia), it is easy to see how hookworm-related anemia is a big problem.

Kristof on XDR-TB

2008-12-07T03:51:00.000-08:00

Kristof has a column in the New York Times today on XDR-TB in Armenia. Nothing new here, but I find it reassuring that other people are getting as worried about this as I am.

Excreta Control and the VIP Latrine

2008-12-02T01:47:00.000-08:00

I am reviewing the water and sanitation module this morning. One of our practice essay questions: "describe briefly how you would provide an excreta control programme in a refugee camp during the first few weeks of an emergency."

Let's see... well, I would definitely pull out my Sphere Project Humanitarian Response and Minimum Standards in Disaster Response handbook. The sphere project was started in 1997 by a group of humanitarian NGOs. They collaborated on a comprehensive disaster response handbook, which is free and downloadable from www.sphereproject.org. WHO also publishes a "Guide to the development of on-site sanitation." Of course there is always MSF's "Refugee Health: An Approach to Emergency Situations,"also free and downloadable.

These resources say that at the start of an emergency, you might only have time to build shallow trench latrines, which are essentially shallow pits that are covered by a thin layer of soil after defecation.

After a day or two, you will need to build something mroe permanent, such as a simple pit latrine, or better yet a Ventilated Improved Pit Latrine (VIP). A simple pit latrine is just a slab with a hole over a pit that is at least 2m deep. The bottom of the pit needs to be at least 1.5 meters above the water line under the soil, so that the excreta doesn't leak into the surface water supply. There should ideally be at least one latrine for each 20 people.

The ventilated improved pit latrine (VIP) has several clever features that make it a better option than the simple pit latrine. There is a superstructure over the latrine part that keeps the it darker inside than outside. There is also a ventilation pipe that exits the latrine roof. Odors from the latrine exit from the pipe. Flies and mosquitoes are also attracted to the light of the pipe, rather than the dark of the pit. You can put a trap at the top of the pipe to kill the insects as they fly towards the light. Image from Water Aid, an International Charity that helps poor people gain access to safe water, sanitation, and hygiene.

The Dispensary

2008-11-30T04:54:00.001-08:00

I've been studying a lot for our upcoming exams, but I've still had enough time to get some medicine from The Dispensary.

NYC Public Health and Human Rights Event Dec 5th

2008-11-26T11:25:00.000-08:00

I wish I could be in New York on December 5th for this Public Health and Human Rights event sponsored by the Johns Hopkins Bloomberg School of Public Health and Physicians for Human Rights. The speakers will discuss progress since the UN adopted the Universal Declaration of Human Rights in 1948, and the many challenges that remain. The list of speakers and the panel discussion topics look promising. It should be an interesting afternoon. The full program and list of speakers is here.

Giardia Trophozoites

2008-11-25T08:22:00.000-08:00

Giardia protoza can cause chronic diarrhea in hikers and travellers who drink contaminated water. The trophozoite attaches to the mucosa of the small bowel, preventing nutrients from being absorbed into the bloodstreem. To my eye, the trophozoites look like cartoon characters. At right, a Kohn stain, below left, a giemsa stain (pics from CDC DPDx).

Practice quiz

2008-11-18T05:45:00.000-08:00

Try your hand at three questions that were on our Vector Biology Revision Quiz.
Hit the "comment" button at the end of the post to see the answers.

Q #1: What is this?

Q #2: Pic at left. Which mosquitoes may commonly be associated with this environment? What mosquito-born infections may be transmitted by these vectors?

Q#3: Which two insect vectors breed in this environment (pic below)? What diseases do they transmit?

World Trip Practical

2008-11-15T01:44:00.000-08:00

In our lab practical yesterday we were assigned the stool sample of a patient who took a trip around the world. He came back to Liverpool with 22 gastrointestinal parasites. I was only able to identify 10 out of 22 species in 45 minutes. My paper was graded "average marks," which is english for C+, I believe.

Afterwards, they told us the stool contained:

Bastocystis hominis
Entamoeba coli
Entamoeba histolytica/dispar
Endolimax nana (below left)
Chilomastix mesnili
Giardia duodenalis (below right)
Iodamoeba butschilii
Taenia species
Diphyllobothrim latum
Hymenolepis nana
Schistosoma mansoni
Schistosoma japonicum
Opisthorchid group
Paragonimus westermani (above left)
Fasciola
Ascaris lumbricoides
Trichuris trichiura (above right)
Capillaria philippinensis
Hookworm
Enterobius vermicularis
Strongyloides stercoralis larve

International Night

2008-11-13T12:02:00.000-08:00

One of the biggest nights of the year for the liverpool DTM&H course is International Night, a multiculti food and entertainment extravaganza. Students dress up in traditional dress from their country of origin, bring typical foods to a potluck dinner, and entertain fellow students with music and dance from their country of origin. The American contingent was weak; I wore jeans and brought a bottle of bourbon. The other three were just as half-hearted. The Germans outdid themselves with a marzipan and traditional cookie desert table. The Indians coreographed an elaborate Bollywood number. Below, three Scot Internists. At left above, Nigerian, Indian, and Italian pediatrician trio.

Congo

2008-11-01T04:22:00.001-07:00

The BBC world service has a lot of information about what's happening in Congo. Warning: It's upsetting.

Mosquito classification

2008-10-27T06:04:00.001-07:00

I have been working hard on my vector biology. To be honest, the vectors are of less interest to me than the diseases that they transmit, but I'm trying nonetheless.

A few tidbits on the classification of mosquitoes:

1. To determine the sex of a mosquito, look at the antenna. If the antenna are "plumose" (hairy), the mosquito is male. If the antenna are "pilose" (not very hairy), the mosquito is female (see diagram above)

2. To determine the genera of medically important mosquitoes, look at the palps (sensory organs just lateral to the proboscis, the stick-like organ that punctures the skin for blood meal). If it is a female mosquito with long palps, the mosquito is Anopheles. If the mosquito is female with short palps, the mosquito is Culicine.

3. To assist with genera identification: Anopheles mosquitoes rest and bite with their bottoms up (approximately 45 degree angle to the skin). If you see a mosquito biting you with it's bottom parallel to the skin, it is not likely a anopheles, and you can rest assured that you won't get malaria from that bite (although you could get Yellow Fever, Dengue, Fillariasis, West Nile virus, or another mosquito-borne arthropod virus. The diagrams of Anopheles and Culex below were downloaded from CDC's National Center for Zoonotic, Vector-Borne, and Enteric Diseases
I won't go into the details on how to identify and classify mosquito eggs, larvae and pupae, but I do know how, believe it or not.

Health and Human Rights

2008-10-24T01:15:00.000-07:00

The Journal Health and Human Rights, published by the François-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health, has recently gone online, with full text of all articles accessible for free.

In the current issue, Gavin Yamey has an essay on the importance of free and open access of the biomedical literature:

Arthur Ammann, president of the nonprofit organization, Global Strategies for HIV Prevention (http://www.globalstrategies.org), tells the following story:

I recently met a physician from southern Africa, engaged in perinatal HIV prevention, whose primary access to information was abstracts posted on the Internet. Based on a single abstract, they had altered their perinatal HIV prevention program from an effective therapy to one with lesser efficacy. Had they read the full text article they would have undoubtedly realized that the study results were based on short-term follow-up, a small pivotal group, incomplete data, and unlikely to be applicable to their country situation. Their decision to alter treatment based solely on the abstract’s conclusions may have resulted in increased perinatal HIV transmission.1

The physician in southern Africa could not afford to view the full text article due to its exorbitant cost. The full text version of a research article in a medical journal typically costs US$30 to download, while an annual subscription to a journal usually costs several hundred dollars. Hence the physician was forced to rely on abstracts alone (abstracts of some research articles are made freely available in the online database, PubMed, at www.pubmed.gov). The full text versions of most biomedical studies — an essential treasury of life-saving knowledge — are locked away behind access barriers. These access tolls bring enormous profits to the traditional corporate publishing industry, but at the same time make it impossible for many people worldwide to access the biomedical literature. The imposition of such tolls arguably violates the spirit of the Universal Declaration of Human Rights, which states that everyone has the right “to share in scientific advancement and its benefits” (Article 27, section 1).2

Sleeping Sickness

2008-10-14T12:53:00.000-07:00

Trypanosoma brucei, the agent that causes sleeping sickness, is my new favorite protozoan. The African tsetse fly is the vector for both species of typanosoma: T. brucei gambiense, which causes sleeping sickness (Human African Trypanosomiasis, or HAT) in West and Central Africa, and T. brucei rhodesiense, which causes a different form of HAT in East and Southern Africa.

As I learned today, the best way to identify the tsetse fly is by the "hatchet cell" shape framed by wing veins 4 and 5 (seen upsidedown in upper wing in this pic), and by the characteristic way that resting fly holds its wings, folded over the abdomen in a "pair of closed scissors" formation. [Medical entomologists are a mad bunch, no?]

Both male and female tsetse flies inject the metacyclic trypanomastigote form of the parasite into the human host when taking a blood meal. In the peripheral blood, the trypanomastigotes multiply by binary fission, to form three different forms: the "short-stumpy" form, the "long-narrow" form, and the intermediate form. All of these forms look a bit like worms smimming in the blood stream, but of course they are single-celled organisms, not worms. What looks like the eye of a worm is actually a bit of mitochondrial DNA material called the kinetoplast. The tail of the worm is the flagellum, that ungelates for motility.

The clinical maifestations of HAT are as bizarre as the parasite morphology. The T. brucei gambiense form of the disease is much more insidioius and chronic than the T. brucei rhodesiense form, which progresses rapidly towards death. In both forms, the patient may present with a chancre or ulcer at the site of the tsetse bite. Multiple non-specific symptoms follow the bite, including: fever, fatigue, wasting, lymphadenopathy, rash, and itching. Once the parasite enters the central nervous system, the patient may get confused, then fall into the reverse sleep pattern of daytime somulence and nighttime agitation that gives the disease its nickname. If left untreated, the disease is uniformly fatal.

Like most diseases that occur only in poor countries, HAT has no decent treatment options. The only drugs available are toxic compounds that cause debilitating side effects (and 5% chance of mortality from the drug alone). All of the drugs were developed decades ago. There are few or no other options in the pipeline.

I was always taught that HAT is a rare disease, but our professor told us that it is actually prevalent and wide-spread. The 50,000 cases that are reported to WHO every year are probably at least a 12-fold underestimate. He believes that HAT and "nagana," which is the animal-version of the disease common in horses and livestock, are the reason that European colonists "gave up" on their conquest of Africa. The livestock ranches in the colonial era failed miserably due to illness of colonists and their herds, he says.

David Livingstone was onto the same idea way back in 1857, when he published a description of nagana in Missionary Travels, the narrative of his famous mid-century African expedition. Soon after, the colonists started calling the sleeping sickness syndrome "negro lethargy." They called HAT by this name until the white colonialists started getting sick too, at which time the Royal Society sent an expedition to investigate. In 1903, they identified the trypanosoma parasite in the blood and CSF of sick patients. They even managed to infect monkies with the agent, proving that typanosomes cause sleeping sickness disease.

Famine in Somalia

2008-10-11T02:57:00.000-07:00

Another depressing story about the famine in Somalia.

Refugee Camp in the Heart of the City

2008-10-10T12:01:00.000-07:00

MSF's "Refugee Camp in the Heart of the City" exhibit, will be in California over the next couple of weeks. People who saw the exhibit last year in Manhattan and Brooklyn recommeded it for both adults and for families. It takes about an hour to tour the whole thing. Admission is free. The schedule is:

San Francisco, Little Marina Green Park
Oct 15-19

Los Angeles: Griffith Park
Oct 22-Oct 27

Santa Monica: Santa Monica Pier
Oct 31-Nov 2

San Diego: Balboa Park
Nov 6-9

Much more information at www.doctorswithoutborders.org, or by clicking on the above link.

World Mapper

2008-10-07T08:33:00.000-07:00

The World Mapper Collaboration has more than 350 of these "density-equalising maps," on its website, www.worldmapper.org. Each cartogram re-sizes countries according to the variable being mapped. For example, the cartogram above left shows the relative prevalence of HIV worldwide. The map categories include: goods, services, resources, work, income, housing, education, poverty, health, disease, disaster, death, polution, violence, and many others.

Small quiz: of the maps below, which shows relative malaria deaths? Which shows military spending in 2002? Which shows electronics exports?

You can download pdf posters of all maps for teaching material. For more information on the map-making technique, see worldmapper website, or Michael T. Gastner and M. E. J. Newman (2004) Diffusion-based method for producing density equalizing maps Proc. Natl. Acad. Sci. USA 101, 7499-7504. Maps copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

Myiasis

2008-09-29T05:15:00.000-07:00

is not a topic that was taught in my medical education prior to this course. I'm sure about this, as it is the kind of thing that I would certainly remember. Here in Liverpool, we spent a whole precious day on myiasis. Medical Entomology for Students is on my bedside table.

Myiasis refers to the invasion of mammalian tissue by fly larvae (more commonly known as maggots). There are many species of fly larvae that cause myiasis, some of which burrow deep into healthy tissue and some of which infect already necrotic tissue.

I will not post any gross pathology pics of maggots in human tissues, as I know that it's not the kind of thing that everybody likes to study as much as I do. At left is a light microscopy image of an ear infected by Dermatobia hominis (human bot fly) larvae, which is endemic to Central and South America. [The larvae are the three yellowish cone-shaped structures buried in the pink ear tissue.] The botflies have evolved an ingenious way to infect their hosts. They lay sticky eggs which glue onto the bodies of biting insects (e.g mosquitoes). The eggs drop off onto the tissue of human hosts when the carrier takes a blood meal.

Apparently there has been a recent upsurge in interest in "maggot therapy" in developed countries. This therapy uses sterile (lab-grown) larvae of Callifora and Lucilia species (bluebottle and greenbottle blowflies) as a means to debride chronic wounds. Again, I will spare you pics. For additional reading: Parnes, A et al "Larval therapy in wound management: a review." Int J Clin Pract, 61, 488-93.

Identification of Parasites in the Lab

2008-09-24T08:38:00.001-07:00

The teaching lab at LSTM is massive. On the first day, they issued each of us a lab bench, microscope, and lab coat. Every day we prepare blood smears and/or stool smears from unknown samples on our lab bench. At the end of the session, the faculty tell us the pathogens in the unknown samples. Below, a pic of the students at my bench.

The CDC has a fantastic reference website for parasitic disease diagnostics. They have lifecycle diagrams of every important organism, as well as an image library to help with diagnositic microscopy.

Genius Doctors

2008-09-23T04:03:00.000-07:00

Two doctors I admire won MacArthur Foundation grants today. Wafaa El-Sadr (right) is an Epidemiologist and Infectious Disease doctor at Columbia University and Harlem Hospital in NYC. She has probably done as much or more for expanding HIV and TB treatment worldwide than any other single person. She is the PI for some of the largest HIV treatment studies. She also advocates for access to treatment in the poorest and most vulnerable people worldwide. She is the first person who taught me that HIV and TB are "evil stepsisters," who often travel hand-in-hand.

Diane Meier (left) is a geriatrician who works at Mount Sinai hospital in New York. She specializes in palliative care, which means care directed at comfort, rather than cure, at the end of life. The MacAuthur website says:

She recognized that modern medicine’s focus on curing disease and prolonging life failed to treat the physical and psychological distress of patients in both early and advanced stages of serious illness. Her studies found that a high percentage of seriously ill patients in hospitals were experiencing limited communication between patients and clinicians, poor management of pain, and insufficient support and social services for family caregivers. To fill these voids, Meier established the Hertzberg Palliative Care Institute at Mount Sinai, a model program that assists patients and families in navigating the complexities of illness and devises strategies for managing pain and other symptoms, such as anxiety, depression, sleeplessness, and loss of appetite.

While many doctors recognize these challenges, Dr. Meier does more to resolve them than most. I have heard many talks about palliative care, but I have never heard anybody speak with such wisdom and empathy as Dr. Meier. Her work will both save money for the American health care system, which spends an inordinate amount on the last two weeks of life, and spare patients and families pain that comes with useless tests and treatments at the end of the end.

University of Liverpool

2008-09-21T12:46:00.000-07:00

I am a student at the University of Liverpool School of Tropical Medicine for the next three months. My course has exceeded my expectations so far. There are about 90 doctors from more than 25 different countries enrolled in the course. Half of the students are from UK and half from other parts of Europe, Asia, Middle East, Africa, or North America. I've found the other students like-minded. Almost everybody plans to work in the developing world or works there already. The curriculum is focused on what we need to know in order to practice in low-resource countries in the tropics. Many of the sessions emphasize exchange of information among the students who have practiced in different countries, so we can learn more about the nuts and bolts of practice in various settings.

I love the old school crest (at left above). They replaced this logo with a hideous new one, but the old school building (at right above) still has stained glass windows with the historic crest.

MSF nurse dies in Nigeria

2008-09-17T11:10:00.001-07:00

This is terrible. The MSF website reports that a nurse died last week in Nigeria on the first day of his first mission. He was electrocuted while in the shower.

My Last Weekend in Kenya

2008-09-14T12:30:00.000-07:00

This was over a month ago, but I've re-discovered these pics and want to post them here. In mid-August I spent my last weekend in Kenya at the family homestead of our housekeeper Margaret, near Nanyuki in the Great Rift Valley. Margaret and I took a mini-bus 3 hours from Nairobi to get there. Margaret's mother Ruth lives in this house, along with several of her 14 children, and a few great-grandchildren. Margaret is shown in the fabulous red and pink dress below.

I was priviledged to stay as Mama Ruth's guest for the weekend. The family welcomed me. In fact, Mama Ruth insisted that I sleep in her room. Although I offered to go to a nearby hotel, my hostess would not hear of it. She slept in the house's main room along with eight other people. Nevertheless, she seemed delighted with my visit. She and the rest of the family would burst into Kikuyu prayer every hour or so. Of course I couldn't understand what they were saying, but "Nelly" was mentioned several times per session, so I assumed they were happy I was there. Pic of Mama Ruth in Blue at right.

The Culture Shock Begins

2008-08-20T06:09:00.000-07:00

Thanks to a computer error, I somehow got upgraded to Business class for my flight back to New York. I am now hanging out in the British Air Executive Lounge at Heathrow. The African immigrants are serving me watercress sandwiches and sparkling water with lime. My memories of roast goat and ugali are fading into the background. I'm going to go check out the shower-spa.

Superbugs

2008-08-15T00:35:00.000-07:00

Jerome Groopman has an essay in the New Yorker about antibiotic resistant bacteria (sometimes called “superbugs”). These bugs will infect my life in 2009-2010, when I will be an infectious disease fellow in the Bronx. NYC tertiary medical centers must certainly be the epicenters of multiresistant bacteria. According to a doctor-friend who works at a hospital in NYC, if you leave your coffee unattended in the morning, there will be a layer of MRSA on the surface by lunch....

Goodbye Kenya

2008-08-10T23:55:00.000-07:00

It's my last week in Kenya. I am saying my goodbyes (pic by Rebecca).

Crocs in Haiti

2008-08-02T03:25:00.000-07:00

On the Partners in Health Website, a story about a donation of colored plastic clogs to prevent tungiasis. [Partners in Health is the Boston-based NGO founded by Paul Farmer and Jim Kim.] Tungiasis is a foot infection caused by a burrowing flea. I can't recall even a second devoted to this disease in medical school. Hopefully, I will learn about it at Liverpool.

More Aid Workers Killed in Somalia

2008-07-20T07:22:00.000-07:00

The New York Times ran a story on the murder of aid workers in Somalia. This is truly depressing, as the famine in Somalia continues to worsen, and nutrition projects like MSF's feeding centers can barely function due to the security situation. I saw a story on Al-Jazeera that had shocking pictures of starving people. It looked a lot like the pictures of the Ethiopian famine in the 1980s.

Celebrity

2008-07-05T04:00:00.003-07:00

I'm featured in a story in the esteemed periodical Internal Medicine News.

2008-07-05T04:00:00.001-07:00

Buy This Book

2008-06-30T01:47:00.000-07:00

Sexy cover, sexy author, sexy book! Nothing to do with Africa! It won the Lambda Literary Award for Lesbian Debut Fiction, but you don't have to be a lesbian to love it. The Washington Post called it “post-gay” and The New York Times called it “engaging” and “delightfully lyric.”

Buy it from your nearest independent bookstore, or simply by clicking on this link.

Doctors Dysphoric

2008-06-18T23:13:00.000-07:00

There's a decent article in the New York Times about discontent with clinical practice in the USA. Nothing new there-- but it is gratifying to hear somebody else describe the same discontent that you've struggled with. The article quotes a doctor on Long Island:

I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.”

When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.

“But managed care is like a magnet attached to you,” he said.

He continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ”

Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. “Ninety percent of doctors I know are fed up with medicine,” he said.

I am not working in a convenience store, but negotiating with Kenyan bureaucrats is not exactly clinical medicine either. If American doctors choose to work in convenience stores or the developing world rather than primary care practice, isn't it time to reform the American health care system?

Liverpool School of Tropical Medicine

2008-06-18T03:50:00.000-07:00

We are facing some major challenges to our research study. However, rather than dwell on the pain, I will try to look to the future. Specifically, I am getting excited about the 3-month Diploma in Tropical Medicine and Hygiene course that I am going to take September-December 2008.

Liverpool is a major center of tropical medicine. According to the website:

the school was founded in 1898, becoming the World's first institution devoted primarily to tropical health. It has extensive links with UN organizations, health ministries, universities, non-governmental organizations and research institutions worldwide and is involved in numerous programmes to control diseases of poverty and to develop more effective systems for health care. The School prides itself on its links with developing countries and is committed to increasing such partnerships.

Sounds right up my alley. Back in medical school, believe it or not, I was one of the most gifted students at looking for ova & parasites in stool samples under the microscope! Ro can vouch.

Forkless

2008-06-08T06:55:00.000-07:00

I was in Busia town earlier today, about 3 km away from home, when my bike fell over and hit the ground. The rusty old fork split right in half. I started walking home, carrying my bike, when a fundi (skilled worker) appeared out of nowhere. He pulled a new fork out of his tool box, and proceeded to replace my fork, adjust my spokes, and tune my breaks. I felt like a bicycle racer with my own team of professional mechanics. After a half-hour overhaul of my bicycle, he gave me the bill: 250 shillings (4 USD) for the new fork, and 40 shillings (65 cents) for the labor. This seemed absurdly underpriced, given that he provided the exact service I needed at my desperate moment of need (5pm on a Sunday afternoon, no less!). When did I become so lucky? Has an albino crossed my path?

Albino Body Parts

2008-06-08T03:42:00.000-07:00

I just read a grisly article in the New York Times online about a wave of Albino murders in Tanzania. Apparently, witch doctors have been spreading the word that Albinos are good luck. A market for Albino body parts has grown in the area around Dar Es Salaam. The article reports 19 albinos have been killed in recent weeks. Why are Albinos suddenly good luck? The article also mentions that albino-killing is spreading to Kenya. I will be especially careful, as mzungu could easily be mistaken for albino, I would think.

Tourists Without Borders

2008-06-01T01:49:00.000-07:00

I visited the Maasai Mara game park in Southwestern Kenya with Rebecca last weekend. Maasai Mara is famous for the diversity of wildlife in the park, as well as the yearly wildebeest migration, where 1.6 million beasts trudge back and forth from Serengeti to Maasai Mara and back again. The wildebeests come to the Mara in July and August, so we missed the spectacle. However, we saw some unforgettable sights. This bunch of zebra crossed the Mara river right in front of a hungry croc. There was also a lioness waiting on the far shore! Also, two cheetahs jumped onto our safari-mobile. This pic isn't even zoom! She was that close....

Traditional Birth Attendant (TBA) Training

2008-05-21T22:26:00.000-07:00

Traditional Birth Attendants are essentially local midwives in rural villages. Many of them have no formal medical training, but have worked their whole lives delivering babies and assisting women through difficult pregnancies and deliveries. Because the majority of our patients deliver their babies at home, the Rural Health team designed a training for the TBAs on Prevention of Mother to Child Transmission of HIV (PMTCT). The training was packed. More TBAs showed up each successive day.
The curriculum included the importance of universal precautions, types of perinatal ARVs, and how to monitor for signs of opportunistic infections and drug side effects.

I love these photos. Nelson, one of our clinical officers, took them on the last day of the TBA training in Madende. The women were delighted with the T-shirts and certificates that MSF gave them. (Note cheering TBAs in the background in the picture above.)

Rebecca

2008-05-04T01:58:00.000-07:00

Rebecca works for MSF as a “flying” sexual violence reference person. She has been to MSF projects all over Africa, helping to set up or to improve the response to sexual violence in the communities where MSF works. Our project is lucky to have Rebecca's help for several weeks. She’s a gifted public speaker. One of her talks was so good that even one of our drivers asked for copies of her slides so he could remember everything she said.

Lucy and I are particularly fortunate that Rebecca is staying in the house where we live. She tells us stories about her work in Liberia, Chad, Uganda,and Eastern Europe. She's also side-splittingly funny and cooks a lovely macaroni and cheese. (Those buff arms are thanks to yoga, by the way).

Long Rains

2008-04-27T11:59:00.001-07:00

The rainy season in Western Kenya is called the "long rains." It lasts from April through August. Our neighbors have planted their crops and are busy weeding and hoeing the land. In this region the women are responsible for tending the fields (and the shopping, and the childcare, and the cooking, and the cleaning). I took this pic from our front door.

Frustrations

2008-04-27T03:53:00.000-07:00

There are plenty of challenges at the moment for our research study here in Busia. Delays by the Scientific and Ethical Committee have prevented us from starting our data collection. Meanwhile, we are busy with preparations. It takes ages to get even the smallest things done in the middle of nowhere. After three weeks of daily reminders to logistics, we finally got the file cabinet we ordered four months ago. When it finally arrived from Nairobi, the top was dented and the screws were lost. It won't close or lock. Now I've dented my head by banging it against the wall too much...

Found on Living Room Floor, the saga continues

2008-04-16T02:17:00.000-07:00

I am back in rural Western Kenya. What better way to celebrate than another exciting episode of Found on Living Room Floor? Last night I got up in the dark for a glass of water. I walked to the fridge barefoot, and haplessly cruched hundreds of dudus (Swahili for bugs) that mysteriously appeared between bedtime and midnight. Lucy says the dudus are flying termites. The Kenyas here like to eat them. They sell for 20 Kenyan Shillings per small cup at the market. At right, friend and lab wizard Juma eats a spoonful of dudus.

Nairobi

2008-04-10T07:27:00.000-07:00

I'm back in Kenya, just in time to watch the coalition government grind to a halt. The New York Times ran a story yesterday about the stalemate in the Cabinet Minister appointment process. There was an outbreak of violence yesterday in the Kibera slum outside of Nairobi and in Kisumu. Apparently things were quiet today.

I've been working in Nairobi all week on the organization of the operational research study that is the focus of my work these days. The study is on patients who are failing antiretroviral therapy, and on HIV drug resistance in this population. More details in future posts, perhaps.

I leave for Buisa tomorrow morning.

Back in Barcelona

2008-04-05T10:35:00.001-07:00

I am in Barcelona, for the fifth or sixth time in the last two years. This is still my favorite European city, despite Amsterdam´s alure. One of the perks of my current job is the opportunity to pass through Barcelona on the way and the way back from each mission.

I had the good fortune to meet up with several people who I worked with in Guatemala. The pic at top is our reunion in the Plaça Reial. The news on the Guatemala team: Conrado (Colombian sexpot) is working in Cambodia as a nurse on an HIV-AIDS project with MSF-Belgium. Rafa (Basque logistician) just came back from a long mission in rural Colombia with MSF-Spain. Angeles (Spanish logistician) is somewhere in the middle of the Atlantic ocean, sailing her small boat from Rio Dulce Guatemala to Cadiz Spain. Lola (Field Coordinator) is working as a nurse in Barcelona, as she plans a mission as Medical Coordinator in a yet unknown African Capital city. Nuria (Field Coordinator) is getting ready to leave on a short mission as a nurse for a meningitis outbreak in Niger. Montse (Spanish Doctor) is with MSF-spain in Congo. Patricia (Head of Mission in GUatemala) is working on a temporary assignment in the Barcelona MSF headquarters, until she leaves in July for Kenya. Finally, Oliver (French financier) is heading to Paraguay with his family. They are an adventurous bunch.

I leave my hotel tomorrow morning at 3 am to catch a 6am flight to Nairobi.

United States

2008-04-01T15:25:00.000-07:00

What on earth have I been doing in the United States over the last month? Running up and down the East coast, with a quick jaunt to the West:

New York, NY
Philadelphia, PA
Baltimore, MD
New Haven, CT
Boston, MA
New York, NY
Oakland, CA
Los Angeles CA
New York, NY
Baltimore again

I'm keeping the MTA and Amtrak in business. Now I'm going back to Africa, where I can get some rest from this "vacation."

MSF leaves Somalia

2008-02-02T04:41:00.000-08:00

When I was in Nairobi earlier this week I met several members of the MSF-Spain Somalia team who had been evacuated to Kenya after a bomb killed three MSF staff in Kismayo Somalia on Monday. The team I met had also been evacuated in late December, after two members of their team were kidnapped from their project in Somalia. Thankfully, the Spanish doctor and Argentinian nurse were released after a week in captivity. This story gives a few more details about the kidnapping.

The twice-evacuated team seemed exhausted and fed up by the situation in Somalia. They did not know whether they were going back to their project or not. Yesterday, all MSF sections decided to suspend their activities in Somalia until further notice. Prior to this decision, MSF worked in Somalia continuously for over 16 years. Fourteen projects have now been stopped, and 90 expats sent home or redirected.

Kakamega Forest

2008-01-27T22:32:00.001-08:00

I spent my last weekend in Kenya at Kakamega forest. Apparently, just 400 years ago the forest stretched all the way across Equatorial Africa. After years of heavy cultivation and deforestation, it is now 2400 square km, a tiny island to the west of the barren Rift Valley.

Kakamega is famous for its biological diversity, especially the bird population. Lucky for me, Lucy is an expert bird-watcher (although she downplays this, in her modest fashion). But even Lucy paled next to our guide Wilberfource, who knows the habitats, flight patterns, facial wattles, and calls of each of the 430 avian species in Kakamega. We saw 43 bird species, including the famous Great Blue Turaco, which looks like a prehistoric beast. Lucy’s favorite is the Black-and white-casqued Hornbill. The Hornbill makes a racket--the Helm Field Guide describes its call as a “spectacular and musical bugled waah or waaah, which develops into a cacophonous din.” We also saw 2-meter Forest Cobra, which crossed our path approximately 5 meters ahead. The pictures above show Lucy standing on a hill with the forest canopy in the distance, and Wilberfource resting on a bench, East African bird Field Guide in hand.

Kids At Work and Play

2008-01-27T06:40:00.000-08:00

The kids in our neighborhood make their own toys out of recycled wire and other bits of garbage. These two boys in Busia made some cool cars-on-sticks. The other picture is of kids in Kakamega forest who are hauling out large bundles of firewood on their head.

Re-repatriation

2008-01-21T23:01:00.000-08:00

I am leaving Busia in just one week to return to the USA via Barcelona. The work I was doing in November and December has been on hold since the election in December.

Prior to the election, I had been working on an Operational Research project in our clinic. The study is about resistance to antiretrovirals, a subject about which there is relatively little known in Africa. This is an interesting topic, and I was learning a lot about how to organize a clinical study. Unfortunately, the Barcelona MSF headquarters decided to put the project on hold until the post-election violence subsides. Perhaps I will come back to Kenya to work on the study if and when it starts up again. Or else I will come up with another life plan. Suggestions welcome.

Meanwhile, I will go back to New York and California to see friends and family and readapt to life in the big city.

After the sunset...

2008-01-17T23:36:00.000-08:00

There have been demonstrations throughout Kenya for the last three days. The ODM political party (opposition party) organized them to protest the Kibaki administration. The demonstrations in Busia have been mostly peaceful, but apparently Nairobi and Kisumu have seen violence. I took these pics yesterday through the peephole in the gate of our house.

Sunset Over Busia

2008-01-17T23:18:00.001-08:00

Lucy says the clouds in the upper right corner look like they are giving us a kiss...

Primary Care for Internally Displaced People

2008-01-14T22:35:00.000-08:00

I did medical consultations in one of the nearby refugee camps today. The work was different than my usual daily activities as technical reference/supervisor for the HIV/AIDS clinic. The work today had more in common with my old job in NYC:

Most common chief complaint in Kenyan refugee camp: back pain.
Most common chief complaint in Upper Manhattan primary care practice: back pain.

Biggest challenge in Kenyan refugee camp: skin rash in the under-five crowd.
Biggest challenge in Upper Manhattan primary care practice: multiorgan failure in the over-80 crowd.

Medicine most commonly dispensed in Kenyan refugee camp: Acetaminophen.
Medicine most commonly dispensed in my upper Manhattan primary care practice: Acetaminophen.

Average documentation per consult in Kenyan refugee camp: one line (hand-written).
Average documentation per consult in Upper Manhattan primary care practice: two pages (typed, 10-point font).

Average number of medicines dispensed per patient in Kenyan refugee camp: one.
Average number of prescriptions per patient in Upper Manhattan primary care clinic: seven (likely a gross underestimate in my clinic, aka Polypharmacy Central).

Functional Genomic Screen of HIV

2008-01-13T00:49:00.000-08:00

The New York Times Science Times reported on a new study of HIV proteins published in Science this week. I have not read the study, but it sounds interesting. [Science charges an arm and a leg for on-line access- this makes me so mad!]. The authors call this type of study a "functional genomic screen."

From what I can tell, the research team used bits of RNA that they call Short-Interfering RNAs (SiRNAs) to interrupt immune cell function. They added different SiRNAs to healthy immune cells, in thousands of small plastic laboratory wells. Next, they added HIV to the mixture. If the HIV could not replicate within the SiRNA-modified cells, they concluded that the SiRNA interrupted the function of a vital protein that HIV needs in order to function. They called these proteins HDFs, or "High Dependency Factors." The NYT cartoon helps explain the study.

Hopefully, further work will help determine how the HDFs help HIV live in human cells. Once they understand this better, pharmaceutical companies can develop better drugs. Luckily, I have a dad who knows proteins like I know Tusker beers. Dad will explain all of this in detail. More to follow after I hear from him

Tribalism In Kenya

2008-01-13T00:08:00.000-08:00

The BBC website has an article today on ethnic divisions in Kenya. It is essential to understand the tribal divisions in order to understand politics. The sentence in the story that really says it all: "tribal differences in Kenya, normally accepted peacefully, are exploited by politicians hungry for power who can manipulate poverty-stricken population." The BBC map of ethnic group distribution in Kenya is copied above.

Cursed Looters

2008-01-09T09:14:00.001-08:00

The BBC reports that people throughout Kenya are returning stolen goods to stores after hearing of a curse on looters. The story says that Kenyan looters have been struck by fecal and urinary retention. Apparently news of the curse has traveled quickly throughout the countryside; fecal and urinary retention are no fun.

Repatriation

2008-01-09T00:38:00.003-08:00

We are back in Busia Kenya. It has been calm here for over a week. Apparently there is still violence in Nairobi and Kisumu, especially last night, when Kibaki announced his cabinet.

Busia seems to be almost entirely back to normal. We have not seen any of the food shortages that have been reported in other parts of the Western Province and Rift Valley. Fuel and mobile phone scratch cards ("airtime") are in short supply. I depend on the airtime for my external dial-up modem, so I have to strictly ration my internet connection time. Thanks again to Aoibheann and Inez for that short wave radio. Long live the BBC world service.

Our clinic is open. Apparently patients came everyday during the week were were closed--even while bullets were flying! Many of them walked or biked more than 20 km from their villages to the clinic and back so that they could get medication refills. We've scared them senseless with our lectures on antiretroviral adherence.

Election, Evacuation

2008-01-05T02:38:00.000-08:00

The last two weeks have been tense in Kenya. Presidential elections were held on December 27th. Our wise MSF boss anticipated the peri-election violence. She arranged for us to cross over to Uganda on December 26th.

As votes were counted in Kenya on December 27th and December 28th, doubts were raised about the voting process and the validity of the results. All hell broke loose on December 29th. When the disputed election results were formally announced, shots were fired and houses were burned. At least seven people were killed in Busia town. For more background on the election, post-election violence, and the deterioration into chaos, see today's NYT story or the BBC coverage.

After the violence erupted on December 29th, our team set up a base in Busia Uganda. We are holed up in a hotel that is just about 4km from our home, just over the border. Of course we are happy to be safe, but I want to go back to Kenya soon. Groups of displaced Kikuyus are congregated in schools at police stations on both sides of the border. MSF can help set up clean water points and latrines. Malaria and diarrheal diseases will likely become a concern. I also want to reopen our clinic. Our patients need antiretrovirals and medical attention.

Food Scarcity and HIV in Uganda

2007-12-25T06:06:00.000-08:00

The New York Times published an article today on Food Scarcity and HIV in Uganda. It's actually more of an opinion piece/narrative than a true news story. The author is a grad student in Public Health who is researching whether food scarcity and transport costs affect health outcomes in HIV patients. Duh!

As obvious as the answer to this question is to Mr Tuller or to me, I agree with him that it is important to study and publish the results. Otherwise Aid money will not help pay for food in patients who do not have enough to eat, much less for transport costs. How can we afford hundreds of dollars per patient per year for ARVs, but not a few dollars per month to help cover food costs?

Our program in Busia does not help patients with food costs and does not pay for transport to clinic. Most of our patients do not seem to be hungry, but I would say the majority of them have trouble scraping together enough money to get to clinic for scheduled visits. They often request less frequent appointments. This puts us in a difficult position; we would like to see new ARV starters weekly, rather than monthly, but often the patients cannot afford to get to clinic even once per month. On the other hand, the Kenyan Ministry of Health does not cover the full cost of medicines dispensed by public hospitals, much less the cost of food or transport. Some people would argue that Aid organizations should not cover costs for medicines, services, food and transport because such programs are not sustainable once the aid dries up. Complicated issues come up when you are dealing with poverty and chronic care. I think this is why MSF prefers to stick to natural disasters or conflict situations. It's less complicated when you can just come in during an emergency, help patch things up, then leave.

Lucy

2007-12-23T02:00:00.000-08:00

is my new colleague and housemate. She is a nurse from London who has been with MSF on and off for the last seven years: Congo, South Africa, and somewhere else I can’t recall. I can’t help but contrast Lucy to the nurses at my old job in NYC who always seemed to be out on break. She is bright and hard-working (shown discussing PMTCT with Gabriella at left above). She uses funny expressions like "bips and bops," as in: "I'm going round to the office to collect the bips and bops I've left there." I think it means odds and ends.

Lucy knows more about tropical medicine and HIV than most of the doctors I’ve met in academic medicine. It makes me happy to think about the HIV negative babies who might have been born positive if Lucy had not been in charge of the Prevention of Mother to Clild Transmission program (PMTCT).

Top 10 Humanitarian Crises of 2007

2007-12-22T01:14:00.000-08:00

I always love year end "Best Of.." lists, especially Jenny Davidson's annual best books list, and Brooklynvegan's collection of links to year's best indie rock albums. On the not-quite-so-lighthearted-side, MSF-USA publishes an annual top 10 most underreported Humanitarian Crises list.
The "top ten slideshow" is also worth a look. The picture of a the mother in blue from the Central African Republic is particularly electric.

Ebola

2007-12-15T01:42:00.000-08:00

There is an Ebola Outbreak in Uganda. WHO reports that there have been 93 cases since early December, with 22 deaths so far. MSF sent teams from Barcelona and Switzerland to help with infection control. Kenya set up a tent at the border--just 3 km from our home-- to screen people entering the country from Uganda. We were called by a public health officer last week and rushed over, but it was a false alarm. I think I was the only disappointed member of the team. A case of Ebola! Now that would toot my horn.

Ebola is one of the filoviruses. It's clinical syndrome was detailed in The Hot Zone, a popular press description of the Ebola outbreak in monkeys in Virgina in 1989. I've read a few medical textbook descriptions of Ebola haemorrhagic fever which do not sound anywhere near as dramatic as the monkeys in the Hot Zone, who bled from every hole, crack, and crevice. Apparently the true clincal picture is much more akin to garden-variety septic shock, perhaps with a few scattered hematoma or petecaie thrown in. This leads me to wonder how a clinician practicing in Congo or Uganda would ever suspect ebola in the first place. Surely you can't go crying ebola over every fever, sore throat, headache and hypotension that walks into your waiting room.

According to Manson's Tropical Diseases, there have only been 20 or so Ebola outbreaks since the virus was first characterized in 1976. Manson says that primates probably are not the natural reservoir for filoviruses because they always get sick after infection, just like humans. A true natural host would have "latent infection," which means that the animal could harbor the virus without getting sick. There have been innoculation studies in bats that show asymptomatic viremia, which might indicate that bats are natural hosts. I guess I will stay away from bat infested caves if I ever get up to Uganda again.

Happy Hanukkah Hoboken

2007-12-04T09:18:00.000-08:00

If I were in the States right now, I would be celebrating Hanukkah the way I usually do--front row center at Maxwell's in Hoboken for the eight annual YLT Hanukkah shows. Celebrating as the only Jew west of Kisumu just doesn't feel the same...

World AIDS Day 2007

2007-12-01T01:04:00.000-08:00

Last year I posted a link to this picture on World AIDS Day. This year I thought I would post the actual picture. I don't exactly have permission to post this image, but I hope that Partners in Health (PIH) would not be mad, because I always use it to help patients in the spirit of PIH's treatment model of free health care for the world's neediest patients. We actually have posters on the walls of our clinic in Busia with this same picture along with explanations in Swahili of the benefits of ARVs for patients with AIDS.

The picture is of a Haitian man with HIV and TB who was (and presumably still is) a patient in the Partners in Health clinic in central Haiti. The left is a "before" image, when he was sick with HIV and TB. The right side is the "after" image, taken just six months later, after he was treated for TB and started on antiretrovirals (ARVs). I generally show this picture to patients before starting them on ARVS. I think it expresses the power of ARV treatment better than any speech I could come up with.

Amsterdam

2007-11-26T09:44:00.000-08:00

is too good to be true: picturesque waterways, restored townhouses, tolerant Dutch people zipping around on their bicycles. I didn't make it to many of the museums-- too distracted by the endless bars, cafes, and coffeeshops. The average corner cafe has a wide-selection of Belgian beers on tap, smoked salmon and watercress sandwiches on thick brown bred, and homemade apple cake. Three or four of those establishments on a single block! With so many pubs to patronize, how can anybody be expected to get anything done? We ate (dad with college roommate at candlelit restaurant, at left below) and shopped (wide-eyed sister at bonbon-central, at right below).

I'm back in Busia now, dragging the odd feelings that come with rapid movement between sleek European capital and rural Kenyan village. Downtown Amsterdam vs. downtown Busia pictured below.

Holland

2007-11-17T11:37:00.000-08:00

I'm on vacation in Amsterdam! I'm in heaven. I suddenly don't want to go back to Busia again. I'm going to stay in Amsterdam forever. More to follow.

Stephin Merritt on Project Song

2007-11-11T02:48:00.000-08:00

I'm sick of thinking about global poverty. This article about Jeffrey Sachs pushed me over the edge. One billion people living on less than one dollar a day? I need to block that stat out until I can deal with it. Instead, I'm holed up in our office trying to forget that I'm smack dab in the middle of a community that fits that definition.

I'm entertaining myself with the new NPR music website. I'm not usually a big NPR fan. It's probably just a rebellion thing, because my parents always had it on in the car when I was little. But this new NPR music website is the coolest! They have music reviews, mp3s for download, musician blogs, live concert streams, and "project song" reports.

In Project Song they give a musician 48 hours in a fully equipped studio to write a song that is supposed to be based on a word and a picture. Stephin Merritt, the brilliant lyricist of the Magnetic Fields, wrote a song based on the word 1974 and the picture above left. You can watch a video of the creative process or hear the All Things Considered report here.

By the way, the Magnetic Fields have a new album coming out soon. They are also playing in NYC's Town Hall in February. I want to go if Lola or Yu will go with me.

New Look

2007-11-03T05:34:00.000-07:00

I was just trying to change the margins for a quote on that last post, but the code in the template style box gave me a headache. I changed the whole template instead. I like the colors in the new template, but the margins are still wrong. The body text is too long and skinny, and the side bar is too fat. There's no going back though, this is my new look, at least until tomorrow. Does anybody know how to change the margins? Lola, where are you when I need you?

PLoS Medicine- Poverty and Global Health Issue

2007-11-03T03:55:00.000-07:00

Check out PLoS Medicine's October 22nd issue on global poverty and human development:

We asked a wide variety of commentators worldwide—including clinicians, medical researchers, health reporters, policy makers, health activists, and development experts—to name the single intervention that they think would improve the health of those living in poverty. We also asked four individuals living in poor, rural agricultural communities in the Santillana district, province of Huanta, Ayacucho, Peru to give us their response to the question, “What do you think would do the most to improve your health and the health of your family?” (The four community members were Severino Rojas Poma, Mercedes Vargas Soto, Julián De La Cruz Chahua, and Martín Rojas Poma). Our October 2007 Editorial discusses this debate further.

Of note, now that I live outside the ivory tower, I appreciate PLoS's open access publishing. What's with medical journals charging $30 to download scintific studies that were funding by taxpayer money in the first place? This is just another hurdle for students, researcers, medical schools, doctors, and hospitals in poor countries that can't afford subscriptions to scientific journals.

PLoS Medicine believes that medical research is an international public resource. The journal provides an open-access venue for important, peer-reviewed advances in all disciplines. With the ultimate aim of improving human health, we encourage research and comment that address the global burden of disease.

PLoS Medicine (eISSN 1549-1676; ISSN-1549-1277) is an open-access, peer-reviewed medical journal published monthly online by the Public Library of Science (PLoS), a nonprofit organization. The inaugural issue was published on 19 October 2004.

Mama Chapati

2007-11-01T10:38:00.000-07:00

sits right near our office every morning from about 6am to 10am.She makes these delicious things called chapatis, which are like a cross between tortillas and naan. When I walk past her on my way to work she shouts "Karibu Chapati," which I think translates to "welcome chapati," or maybe "you are welcome to chapati." My colleage at work said to to be careful of them, because apparently they "go straight to your hips." I buy one every morning nonetheless. They are definitely worth it.

Send your old digital camera to Sue Johnson

2007-10-27T01:14:00.000-07:00

My friend, the lovely and talented photographer Sue Johnson, has been working with a photography collective in South Africa for the past 3 years. I met Sue in 1987, right after she left St. Cloud Minnesota for college. She had a perm then, and looked a lot like Meg Ryan back in the When Harry Met Sally era. she doesn't look like that anymore, but she still has huge blue eyes and amazing legs. She's married, with two small children who were both born in South Africa. Sometimes she collaborates with her husband Joe on his Radio Diaries documentaries. Haven't heard Thembe's Radio Diary about living with HIV in South Africa? Go immeadiately to www.radiodiaries.org

Back to the photography collective: It's a mix of young people and long-time street photographers. They have been documenting their lives in the townships, one neighborhood at a time. Click on the link above to see their work.

Sue says the group is growing and they need more equipment. They are looking for
used:

* used point and shoot or SLR digital cameras (3.2 Megapixels and up)
* Battery chargers
* Flash Cards or Memory Cards
* laptops
* hard drives
* firewire cables and power chargers
* photography books for the library

If you have any of the above equipment lying around since you bought a newer model, consider donating it to Iliso Labantu. E-mail Sue at sue@suejaye.com, and she will arrange to get your donation to South Africa.

Iliso Labantu -- The Eye of the People

Neighbors

2007-10-18T01:50:00.001-07:00

These women sell roasted corn-on-the-cob at the side of the road near our house. They were delighted when I took their picture (at left above), and even happier when I gave them the hardcopy that I ordered from www.snapfish.com (at right below, with picture in hand). The woman in the middle called me "a nice mzungu." Now everybody on the block wants a picture.

Found on Office Floor

2007-10-13T06:39:00.000-07:00

Actually, right at the office doorstep. James the guard chopped it in half with a stick (note protruding innards). James doesn't know what this type of snake is called in English, but he assures me that it is dangerous.