Nanthanje Outreach Clinic

Nanthanje PIH Outreach Clinic (Posting Date 10.30.08)

I wanted to take a few minutes to reflect upon the Nanthanje clinic we went to on Tuesday morning. We all met at PIH, and after morning chapel, 6 of us piled in a jeep and drove ~20 minutes outside of town (I still haven’t figured out which direction is North!). Within 5 minutes on the road, we were in rural Malawi—there are certainly no suburbs here. We would pass several small villages, which usually consisted of a few round mud huts with thatched roofs, maybe a central kiln/brick stove, and usually a few random farm animals, mostly goats, wild dogs, and chickens. Often there were women cooking, and small kids following their parents around; occasionally a man or a child would pass by on a bicycle. While we were on a highway that was paved, all of these villages were surrounded/accessed by roads. Often, “minibuses” would stop on the side of the road at these villages and pick up a traveler or two.

We arrived to Nanthanje by way of a dirt road with very large “potholes”—worse than what you see in any city with a winter. Upon arrival, we parked beneath the lone tree in the medical complex, which consisted of three small brick buildings with windows and cement floors, along with one area for expectant mothers. Outside the first building, which was the primary care clinic, there was a line of about 20 mothers and children, all in beautiful traditional African prints wrapped around their waist, or around their backs with their children secured firmly. As a side note, the men dress much more western than do the women, except for businesswomen, who dress particularly modern, with pantsuits or suits with mini skirts and high-heeled, pointy toed shoes. But back to the clinic….

After getting a quick tour of the complex, we split up into teams, with Eri and I shadowing two of the clinical officers, people who are 1 level below physicians (maybe the equivalent to a nurse practitioner) but with a great deal of clinical and surgical expertise (ie: COs do deliveries, C sections, hernia repairs, numerous procedures, and run many of the clinics). Jessica, one of the Mzunga (white) nurses from PIH, and Anna, another nurse from PIH, checked in all the HIV patients, and ushered them to benches outside the exam rooms. Patients were seen in order, and the whole visit consisted mostly of an evaluation of the patient’s HIV history, their compliance with medications, and investigation into any recent complications. Because the volume was so high, rarely did we have time to do an exam, talk in detail about the psychosocial aspects of their disease, or do any meaningful amount of documentation. Instead, patients were often given refills of their medications, and their clinical status was documented in their health passport—a paper book about the size of a passport, that contained brief notes from all their clinic appointments. We had one patient with a new cough and a right upper lung consolidation on exam, and began treatment for pneumonia; we asked her to submit a sputum sample for the evaluation for tuberculosis, a diagnosis much more likely in her compared to community-acquired pneumonia. But other than this one patient, most of what we saw was fairly straightforward rural HIV medicine. That is to say, we don’t have the means to do CD4 counts frequently, and these patients in the rural clinics rarely ever have a viral load or HIV genotype done (both of these tests we would use frequently in the States to adjust treatment regimens). Now this limitation is mostly from a resources standpoint—Malawi simply doesn’t have the means to pay for these tests. In addition, Malawi only has medications for 4 types of HIV regimens. You see, HIV care is often like a buffet of food—you pick 1 or 2 meds from category A, add another from category B, and if they are doing poorly, add something from category C or D. Not so for Malawi. Currently, the Ministry of Health only purchases drugs for 4 regimens. Everyone gets the first line regimen called Triomune (a combo of three drugs); if patients develop side effects, or intolerance of the medications, they are switched to one of two alternative first-line regimens (1a or 1b), or if they develop resistance (virologic failure), they get placed on the second line treatment. There are no more options should someone develop bad side effects or fail the 2nd line treatment, which often happens over time, and especially if patients take their medications inconsistently. And unless you can find someone or some company to make a significant financial contribution, this will be the protocol for the next many years (probably through 2010).

In total, we saw approximately 30 patients that morning. We actually brought patient back with us to PIH for further evaluation, as she had developed a very bad skin rash to one of the meds in Triomune, a very common reaction requiring a change in medication. Because the local clinic did not carry this alternative therapy, she had to come to PIH for the medications, a trip that will be very difficult for her to do in the future, as it is several miles away, and she has no money for the bus. Talk about access to care…

Well, it is off to Mvuu camp and the Shire (pronounced Shear-ray) river safari, where we’ll see hippos, elephants, crocs, and lots of rare birds. In fact, over 260 species of birds live in the Liwonde National Park, where Mvuu camp is located. This camp is run by Wilderness Safaris, a group in Africa that is dedicated to keeping the wilderness of Africa pristine, while also reinvesting the proceeds from the organization back in the local community. For example, they built a school for the local children outside the Liwonde National Park. I’m sure it’ll be a blast, as long as I keep my hands inside the boat, and I hope to have many great photos to share. I’ll write more soon, and will try to post this weekend about the experience. Until then, be well, and have a great weekend!



Chase

First Photos

Hey yall-

I just added a few photos of my journey on Picasa. You can always find the link to the photos at the bottom of the blog, but here it is anyway: 

http://picasaweb.google.com/chasecoffey

Had a really good day today, going to Nathanje, a medical and HIV/AIDS clinic about 15 mins outside Lilongwe. It was absolutely amazing!! Mud huts with thatched roofs, goats and roosters wandering, villagers looking at the strange people from the city, but especially me; it was what I imagined rural Africa would be. I'll write more about this later tonite and post it soon--for now, though, I need to brush up on my anti-retroviral medications.

I was able to get some great photos, but sadly, I don't have the cord to connect the camera to the computer! But I'll definitely share those later.

Love to all, and feel free to share the link to the blog or photos!

chase

Days 1 & 2

Day 1—Arrival to Malawi (10.26.08)
The overnight stay in Joberg was somewhat refreshing. We got to exercise, take a nice long shower, and eat a meal that was average, but sure beat airplane food. We both crashed pretty early, and slept OK, but definitely could have used more sleep. Upon checking out Sunday morning, we were greeted in the hotel lobby by the hotel staff who had joined in chorus to sing wonderful, traditional songs. Sadly, I arrived during the last 2 minutes of the performance, and was only able to capture a photo of the group as they walked away, still in chorus. What a way to start a Sunday morning!!
We made it to the airport and through customs with plenty of time to spare. Eri and I hung out at the coffee shop nearby our gate and talked, practiced out Spanish, and shared observations of the journey so far. The flight to Malawi was smooth, and the plane was a beautiful mixture of black, white and asian individuals, and it made us curious why everyone on the plane was going to Malawi. Upon arrival, Perry Jansen and John Hamilton, the two clinic directors, greeted us and escorted us into town. Riding along the road, you pass numerous native Malawians on the side of the road—some riding bicycles, others farming small plots of land, others waiting for the mini-bus, and many just finding a cool place in the shade. We passed a few factories, one local school, and off in the distance, we saw some low-income housing projects and a Mosque, which, by the way, you can hear the call to prayer from our hotel in town. During the drive, Perry and John filled us in on the latest Partners in Hope/Partners in Malawi (PIH) projects, what they had in store for us, and how excited they were for us to join them. In fact, John mentioned that they had even been reading my blog, and that’s actually how he recognized me in the airport. We dropped Perry off at his place in Area 3, and got to stop in and meet his three kids, two dogs, and two mice. It was a very peaceful Sunday afternoon at the Jensen household, as the temps were held down by the light cloud cover, the ceiling fans were casting a nice breeze, and the house smelled like fresh brownies—Mrs. Jensen was baking angle food cake from scratch for Erin’s upcoming birthday—felt like home!
We visited for only a few minutes, and then made our way into town, to the Kiboko Town Hotel, where we will make our home for the next 3 weeks. The hotel has a hostel feel to it, but definitely a bit nicer. It is filled with foreigners who are here for various different reasons. I met one Brit who was at the bar, drinking a pint, and watching the Chelsea-Liverpool match (a great match, by the way). John helped Eri and I check in, and after unpacking, we went on a brief walking tour of the Old Town area near our hotel. John helped us locate the local grocery stores, banks and a few restaurants. We returned to the hotel to settle in for the evening. Eri and I are staying across the hall from each other, at the back end of the hotel, which is a comfortable place to be. My hotel room is also comfortable, with a day bed, a round trundle chair, and two twin beds. It does have a few windows, but there is precious little breeze here currently. The room also has a ceiling fan, which spins very fast, but doesn’t move any air! So the room feels quite stagnant—I’m going to the store to buy a standing fan just to have some air on me.
After resting a little while, and watching the Chelsea-Liverpool match, Eri and I went downstairs to Don Brioni’s for dinner. We had a nice table outside on the porch, where a nice breeze kept the bugs away and kept us cool enough. We met the owner, Brian, who is an ex-pat from Great Britian, who moved to Malawi ~19 years ago, and has run this bistro for about 11 years. The food was alright—there was enough garlic in my cheeseburger to make it palatable. As it turns out, there isn’t much beef around as the country just experienced a Foot and Mouth Disease outbreak.
After dinner, we retired to our rooms and relaxed. I watched more soccer, while lying perfectly still to stay cool. I then had to use my knot-tying skills to close numerous holes in my mosquito net over my bed. I certainly felt the fatigue and jet lag today, and after realizing that my luggage was broken into at Johannesberg, I was struggling to stay positive about the trip ahead. I’m confident, however, that some rest will do me good, and help me see things in a different light tomorrow.

Day 2—Orientation (10.27.08)
After getting a fair amount of rest last night, I felt well today. Had a nice breakfast at the outside café, with eggs and delicious fruit cocktail of mango, banana, melon, and papaya. Then it was off with John and Eri to the bank to cash our traveler’s checks in order to pay the hotel. We had lunch with Solomon, our Malawian Clinical Officer (CO), John, and Perry, where we learned more about PIH, it’s history, and about healthcare in Malawi. We then took off for orientation at PIH. We were greeted by very friendly staff, including a large hug by Anna, one of the favorite nurses; her smile and laugh light up the room. We got a quick intro to both the Dalitso (fee for service general medicine) and Moyo (free HIV clinic), as well as the numerous outreach programs that PIH helps coordinate and/or lead. After an emergency appointment for hypertension, we went off to Perry’s house for a nice dinner with several of the clinic physicians and clinical officers. We all had a very nice time, but I was definitely ready for a shower by the end of the evening after the constant “glistening” while walking during the day. Now it’s off to read a bit, try to cool off after the shower, and then call it a night. Tomorrow is a busy day, with a group of us heading to Nathanje, an outreach clinic outside Lilongwe.

Ready...Set...Go!!!

Well, the packing is all done, and my room no longer looks like a closet of junk! With the final zip of the zipper on my 4th bag (!), I am both anxious and excited for the adventure that begins tomorrow. At the same time, I am trying to keep my expectations low(ish)--but how can you NOT have high expectations for this trip?! I'm about to go to Africa!!

Clinically, this trip will provide an insight into how HIV/AIDS affects a country. Malawi is one of the poorest countries in Africa, and its plight is made worse by ~20% of its 13.5M people being affected by HIV/AIDS. The illness leaves children without parents, parents without children, and men and women too weak to work or farm for their living. There will be many more illustrations of how AIDS affects individuals, and I'll write about those as they arise. But this trip will also try to teach me how to practice medicine with limited (none?) resources. I'm leaving the comfortable, indeed luxurious, Ronald Regan UCLA Hospital, with its multiple CT scanners and MRIs, its fully-loaded pharmacy, and daily organ and bone marrow transplants. And I'll be practicing in the clinics of Partners in Malawi (http://www.partnersinmalawi.org), located in Lilongwe, Malawi. The contrasts are starkly obvious already--Malawi has 1 CT scanner for the whole country, performs no organ or bone marrow transplants, and uses anti-retroviral medications that are often suboptimal at treating the various HIV genotypes seen in Malawi. In addition, these anti-retrovirals often interact with other medications used to treat illnesses like malaria, rendering the anti-retrovirals less effective against HIV. This experience surely will stretch my comfort zones of the practice of medicine. But more about these issues later...

Personally, I'll be out of my comfort zone as well. Perhaps the most exciting and anxiety-provoking aspect about this trip is just how far out of my comfort zone I'll be. Gone will be the flat screen TV with HD cable and DVR, my car, the iPhone, and my airconditioning! In its place will be dirt roads, malaria nets, and spotty internet service. This experience surely will be a welcomed shock to my system, which has grone accustomed to seeing BMWs as the "entry level" car in west LA, hearing about fancy restaurants and clubs, and the strong drive many resident-physicians feel to start "making a living." I hope to become much more comfortable at "living without" than I am currently.

I leave tomorrow morning at 730am west coast time. Thank you for all the well-wishes/emails/phone calls. I'll try to write/post as often as possible to share more thoughts and experiences. Until then, be well, and remember to vote!!
chase

Picture: Street Artist--NOLA, 2008