Bulwani

I spend most of my time at the Busia District Hospital in Busia town. After two months of begging, however, I finally got to go with the Rural Health Team to the Bulwani Dispensary.

Bulwani is a small village in the south of the Busia District. The trip to Bulwani from Busia township starts with a two-three hour drive over deeply rutted dirt roads. When we came to the end of the road, we stopped at a small dock area on the bank of a stagnant river. We boarded a motorized wood canoe. The boatman navigated our canoe slowly through narrow channels heavily covered with interlocking water weeds (pic above). We got stuck in the weed net a few times. The boatman jumped into the water and hacked away the weed cover with a stick. Thick vegetation lines the banks. Birds and butterflies parked themselves in the trees and fluttered overhead. We passed wood canoes loaded with locals gathering wood and fishing.(pic above.


After about a half an hour, we came to an open expanse of Lake Victoria. Free from the weed network, we sped across the lake for an easy half hour until we again entered a narrow passage.

The passage quickly tapered to a shallow trickle. When we could move no further, we jumped out of the canoe and continued on foot. The water dired up after about 200 meters. We walked on a dirt path that wound its way through small villages for about 45 minutes.

We passed a primary school. The students were playing outside. Within seconds I was surrounded by dozens of schoolgirls who all wanted to touch my weird white skin. A Mzungu must be a rare sight. I felt like a hybrid of red-carpet celebrity mixed with zoo-animal. I survived, however, and we finally made it to the dispensary. The one-way trip took more than four hours. And I thought Busiatown was the middle of nowhere!

World Music

I like the music in Kenya. The most popular kind of music in Busia is Zaire's Lingala. Lingala is energising dance music--lively vocals mixed with electric guitar, drums, and a a lot of percussion. Benga, the traditional Luo music from Western Kenya, also is also commonly heard around here. It's mostly drums and repetitive male vocals, with long pulsating electric guitar riffs. It's generally not as good as Lingala, in my opinion, but sometimes suits my mood when I feel like slipping into a trace.

Although I miss all the fun I had in Guatemala, I certainly do not miss all the high volume salsa, merenge, and reggaeton. I still listen to Buena Vista Social Club every once in a while and some of the Cuban music I copied from Conrado's collection. (OK, so maybe once in a while I dance around to Shakira's Hips Don't Lie, for old time's sake). Also Mano Chao, of course, who is in the top ten playlist on my ipod. Jenny Davidson linked to a good profile of Manu Chao on her blog.

More on MDR

I wish I was at the International AIDS Soceity Conference in Australia this week. They have a special HIV-TB track, where I could submerge myself in the alarming world of HIV-TB coinfection research. I've been thinking about MDR and XDR tuberculosis a lot lately, and actually worrying about it. This is quite unusual for me--I not a big worrier when it comes to things like germs or terrorism or death or other things that normal people worry about.

For those who need something else to keep them up at night, might I suggest a review of the HIV-TB coinfection literature? For lay readers, I recommend an article I stumbled on in the Yale Alumni Magazine . For doctors and scientific-types (that means you dad), the Nature Medicine March 2007 Focus (vol 13, no. 3) is loaded with good stuff.

For those who are too tired to click a link, I am copying John Bartlett's literature review of Neel Gandhi's XDR-TB 2006 Lancet paper below [Gandhi NR; Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa; Lancet 2006;368:1575].

The purpose was to assess the prevalence and consequences of multidrug-resistant tuberculosis (MDRTB) and extensively drug-resistant tuberculosis (XDRTB) in KwaZulu Natal, South Africa.

Methods: The authors increased surveillance for MDRTB with sputum cultures and drug susceptibility testing in patients with suspected tuberculosis. The analysis included genotyping of resistant strains and susceptibility testing for first and second line drugs.

Results: Sputum cultures for TB were done on 1,539 patients; this showed 542 (35%) were positive; of these, 221 (40%) were MDRTB and 53 (24%) of the MDRTB were XMDRTB. These results are summarized in the following table:

Total tested 1539
Culture pos 542
MDR M. tuberculosis 221
XDR M. tuberculosis 53
No prior treatment 26 (55%)
HIV pos/no tested 44/44 (100%)
Hospitalized < 2 years 35 (66%)
Mortality 52 (98%)
Median time to death 16 days
Genotype KZN 39/46


Analysis of the 53 cases involving XMDRTB showed only about 50% had received prior therapy for tuberculosis, 2/3 had been hospitalized within the prior two years, and all 44 who had HIV serology were positive. Of particular note was the observation that 52 of the 53 died and the median time to death among these patients from the time of the sputum sample was a median of 16 days.

Genotyping indicated 39 of 46 strains were in the KZN family.

Conclusion: The authors conclude that this study shows the presence and potential serious consequences of XDRTB in resource-limited areas with high rates of HIV, and they emphasize the need for "urgent local and international intervention".

This is an extremely disturbing report that was presented by Dr. Gandhi at the 2006 International AIDS Conference in Toronto; in this report he finished by warning that this strain of TB could undo all of the achievements to date in the international effort to treat and control the HIV epidemic in the developing world. KwaZulu Natal is a rural province in South Africa in which about 80% of patients with active TB have HIV co-infection; mortality rates in those with co-infection are reported as high as 40%/year despite treatment for TB. The authors of the present study note that the rate of MDRTB was only 1.7% when surveyed in 2000-02, but had increased to 9% in 2003-06. XDRTB is defined as MDR (resistance to INH and rifampin) plus resistance to at least three of the six second-line drugs. In the US, these account for about 4% of the MDR strains and up to 15-19% in reports from Korea and Latvia (MMWR 2006;55:301). This susceptibility pattern renders these strains virtually untreatable (Hopewell PC Lancet Infect Dis 2006;6:710). The authors of the report summarized above emphasize four needs:

There needs to be better surveillance to determine the full extent of MDR and XDR tuberculosis in the areas with high prevalence rates of HIV.
Treatment programs need to be strengthened to improve the rates of treatment including access to second line drugs. Infection control practices, especially those within health care settings, need to be enhanced with inclusion of protection of health care workers. There needs to be simpler and more aggressive testing to detect TB and drug resistance in resource-limited areas.

In a more recent editorial comment by Mario Raviglione and Ian Smith (N Engl J Med 2007;356:656) call attention to the unique features of this epidemic that emphasizes the important points noted above. This includes the fact that most of the patients in KwaZulu-Natal province had never been treated, most had been hospitalized suggesting nosocomial acquisition, and all who were tested had HIV infection. XDRTB has been reported in at least 17 countries. Their conclusion is that the "global threat of XDRTB has great significance for the public health field" and "its very existence is a reflection of weakness in tuberculosis management".

The lab

My work here in Kenya involves very little clinical work. I suppose "Public Health" is the best way to clasify it. Maybe "Program Development" is a good subcategory, or "Monitoring and Evaluation,' perhaps? I don't exactly know. Unfortunately medical education in the United States short-changes public health, in my opinion, so I'm kind-of trying to figure out this job as I go.

My job responsibilities include lab supervision. How do you supervise a lab? Hummmmm...... nonetheless, I've capitalized on my ignorance by asking the lab techs to teach me about what they do. How fun! Catherine (pic above) is my lab mentor. She has taught me how to do gram stains, and AFB stains for TB, and blood smears, and malaria smears, and CD4 counts, etc etc. Perhaps I should have gone into hematology, or even pathology! I managed to snap the weird looking pic above through the microscope. It shows a sliver of my healthy-looking red blood cells. No neutrophils are visible, but let me assure you that they all have lovely segmented nuclei.

Hippos

near the shore of Lake Victoria, about an hour away from Busia. I realize this looks more like Tourists Without Borders, rather than MSF, but in reality we actually work too. I'm trying to refrain from writing about our work. It's hard.

Isolated

I thought I could live without constant internet access, but it turns out that I cannot. Our internet connection is broken half the time and too slow for my impatient side the rest of the time. No TV either. Has anything happened in the world since May 29th? I feel cut off from the world. If anybody feels like sending me their already-read New Yorkers or Economists, I would be grateful.

It will probably get here if you write:

Isolated
c/o MSF-Spain-Kenya
Busia, Keyna
Africa

Or send it to the MSF-Spain Headquarters in Barcelona, and they will send it with the next visitor.

Rafting the Nile

Over the weekend I went white water rafting on the Nile. Several companies based in Jinja Uganda run raft and kayak trips starting from the Owen Falls Dam, which is where the Nile exits from Lake Victoria. The dam destroyed Ripon Falls, which is the site that John Hanning Speke deemed the source of the nile in the 19th century.

Digression: Speke originally "discovered" that Ripon Falls was the source of the Nile in 1862, after a 2.5 year schlep on foot from Zanzibar to Sudan. [I put discovered in parenthesis, because some local people get annoyed with this language; they say their ancestors knew that Lake Victoria/Ripon Falls was the source of the Nile long before Speke was a ovum in his mother's ovary.] Speke’s journey is described in detail in Alan Moorehead’s epic The White Nile. Thanks to my parents, I have all 1000 pages of Moorehead’s The White Nile and it’s prequel, The Blue Nile, here with me in Kenya. I know more than I have ever dreamed of knowing about the golden age of British exploration in Africa.

Back to my weekend: We left for Uganda at 6:30 am on Saturday morning. Including border bureaucracy, the drive from Busia to Jinja took more than three hours. Luckily, the rafting company was busy with 30 peace corps volunteers who chose to raft the same day. After signing waivers and forking over more money than the average Ugandan makes in many months, we divided into rafts of 6-8 people and started down the river (pic at left is with Sharon, a midwife from the United States, right before getting into our boat).

According to the Lonely Planet East Africa Guide (and Nile River Explorers promotional material), this 30 kilometer stretch of the Nile has some of the biggest rapids in the world. I'm not expert enough to confirm this, but I can safely say that the rapids are supermassive. Our boat flipped several times, spilling all seven of us into the Nile. Even if the raft stayed bottom down, at least one of us was likely to fly out of the boat on the class IV and class V rapids. On these occasions, we were washed down the river with the current until a kayaker on “search and rescue” duty fished us out and towed us back to the raft. Each time I ended up in the river, as I sputtered and gulped down Nile water and clawed my way to the surface, all I could think about was….. Schistosomiasis!

Despite the near-drowning episodes and the annoying overheard peace corps conversations, it was a great day, and I would do it all over again given the opportunity. We rode back from the take-out point through rural Ugandan villages in an open-backed truck, The kids waved and shouted "How are you Mzungu?" The rafting company supplied BBQ and beers at Bujagali falls afterwards (see pic at right).