Happy Birthday, Ken!

Ken na Rafiki

Today we celebrate Ken's birthday, who has been an amazing mentor, resource, and friend this trip. Thank you, Ken, for your dedication to this hospital, these people, and to the incredible learning experience for all students here.

PIzza Wednesday

It's finally Pizza Wednesday! We have been planning this evening for many days, giddy in anticipation for the gooey goodness of greasy comfort food. However, it marks a bittersweet night: the night before our beloved daktari Jane and Nurse DeDe and Mary will be leaving. This mini party will be a small going away party for these wonderful people. Jane and I had a fun rain run this afternoon, since last night's downpour encouraged a lazy morning this morning. We returned to a wonderful post-run feast of rice and peas, cabbage, pineapple, mango, and of course, Jane's Tony Chach seasoning.
We have spent most of our day preparing for our training sessions about Diabetes and Hypertension that we will present to the medical staff here at Ilula tomorrow and Friday. Yesterday was another incredibly stimulating and exciting day. Ken and I headed to a small village with the director of the Institute of Agriculture at Tumaini University, who sponsors the COmpanion Village Project, aimed at increasing the crop yield of villages through collaboration with the village pastor. We were able to fit in a small nutrition lesson, as well as a water purifying technique using the heat and UV rays from the sun. The villagers were very responsive and it was a very rewarding experience.
We distributed more Plumpy'nut today to malnourished children, whose parents were very appreciative. It is always a wonderful feeling to pass out this nutritional supplement, but you always wish you could do more for the family.
The Minneapolis weather is not at all inviting. How I wish I could stay in this sunny 85 degree weather forever. We only have one week left here in Ilula before 2 days in Dar, where we will fly out of. I am already dreading the transition back to reality, where chickens do not run wild and clothes are not hung to dry in the sun. The good news is, I have a feeling this is not my last time here.

Monday Good news- Bad news

Monday, 28/01/2013

Since Friday was a national holiday (Mohammed's birthday) and Sat & Sun the OPD clinics were closed Monday brought out the crowds.  There was standing room only in the OPD hallway and long lines at registration, the lab, and the Pharmacy.  

The 3 Dunguya friends referred by the Palliative care team on Thursday arrived via motorcycle in spite of the muddy road conditions.  Sunday brought a torrential downpour to the area.  And today we had more rain later in the afternoon.  Electrical power was intermittent for two days following.

Good news - bad news!  The first patient had a negative cervical cancer smear but the 2nd patient was HIV positive on re-testing.  

The first patient received antibiotics at no cost for a vaginal infection  ( paid for partially by the hospital "poor patient fund", CTC, and another donation by a MN visiting nurse ;).  Although the antibiotics were covered it took two trips to the community pharmacy to locate and purchase the correct amount as the hospital pharmacy was out of stock.  Although the order clearly stated  2 gm every day for 5 days, the clerk would only sell me 5 Gm the first trip.  So I walked back to the hospital pharmacy to re-confirm the dosage and learn a few more Kiswahili words to make my case that I needed 5 more vials.  Hurrah!  I was successful on my 2nd trip.  The general ward nurse inserted an IV catheter with an insertion port and gave the first dose.  Now let's pray the patient will return the next four days to complete the course.  She has no family in Ilula so will have to make the trip back and forth every day to that remote village by foot.  It will take her 2-3 hours each way.  

The other two patients were counseled and treated in CTC.   Healthcare in Ilula.  

All's well that ends well but in Tanzania the heart wrenching stories never end.  

Palliative rounds at Ilula

Ilula hospital palliative care rounds leave one astounded at the caring and commitment of the team.  Two nurses, a clinical officer (comparable to a physician's assistant in USA), and a chaplain travel to surrounding villages to visit patient's with terminal or chronic diseases.  They assess current and ongoing medical, psychological, social, and daily living needs.  These patients are cared for by family members- grandparents, grandchildren, children, spouses, siblings, cousins, etc.   Many times the patient is the sole care provider for other family members.  One I vividly remember was a grandmother with cervical cancer caring for her three orphaned grandchildren.  Another was an elderly woman with no means of support caring for her husband who was bedridden due to a serious hip injury 5 years ago.  Their eldest son had died of malaria when he was in college.  The younger two sons were unemployed and reportedly no help to the parents due to excess drinking. There was no food in the home when we visited.  We left our donuts and energy bars brought along for lunch.  

Another 35 yr old woman living with HIV was experiencing a two day illness with fever, headache, neck pain, coughing, and general malaise.  It was recommended that she go to the out patient clinic at the hospital to be tested for malaria but had no money for the registration fee of 2000 Tsh equal to $1.25 USD.  The chaplain gave her the money. 

On another day at a remote village one of the women living with HIV was experiencing some clinical signs and symptoms of an infection and was advised to be checked at the CTC (Clinton Foundation Counseling and Treatment Center for AIDS and HIV) on the Ilula Hospital campus.  Her only means of transportation were  walking (3 hours one way), riding a bicycle (she does not know how to ride a bike), hitch hiking (unreliable as cars rarely make it to this village due to washed out roads, or hiring a motorcycle which would cost 10,000 Tsh ($6.25).  That was a no brainer!  I could easily donate $6.25 for a motorcycle ride for this community volunteer who was recruiting villagers to be tested for HIV.    In the afternoon this admirable team split up so half could continue visiting patients in homes and the others set up a mobile HIV testing clinic.  20 patients ages 8-70 (12 F; 8 M) were counseled and tested for HIV. One was  indeterminate; one was reactive.  Both were referred to CTC; one for re-testing and the other for ARV treatment.  

Back in the hospital van we prayed the driver would be able to keep the vehicle upright as we curved around potholes, boulders, up and down into washed out sections , and over rutted trails.  Luckily there were only six of us in the back so we could have two buns each on the benches for balance.  On the way up to Dunguya we gave 7 young schoolchildren a ride home for lunch and on the way back we gave a woman a ride to a neighboring village.  They think nothing of squeezing 10-12 in the back and 3 in the front on these outreach trips.

Warm greetings from Tanzania.  Dede

Plumpy’Nut

 A Pastor friend, Bonnie Wilcox, a veteran of Tanzania trips, asked how Plumpy’Nut came to be at Ilula Hospital.  This is a story that bears endless repetition (if you ask me!), so I am happy to oblige.  She mentions an organization called Edesia that uses Plumpy’Nut around the world.

In 2011, one of our first med students, Kelsey Watt, MD, now a Pediatric Resident in Colorado, and I were the last to go home from Ilula.  While we were here, we were stuck by several very ill children.  I have photos of two of them, but truly, they are gruesome and for the eyes of medical personnel only.  You will need to use your own imagination, but I think you can hardly overdo it.  One of the children died 2 hours after admission.  She was two and looked like a bag of bones.  This is marasmus.  The other, about 18 months, was swollen all over, with puffy cheeks, puffy hands and feet and tremendously swollen genitalia.  This is kwashiorkor.  This boy was here for our entire stay.  I do not think we did anything for him that helped.  Both would have been fine with a six-week course of Plumpy’Nut.

Someone told us of this product.  Kelsey and I looked into it.  We even developed a talk centered around malnutrition.  Well, Kelsey did most of the work, I edited it, but I get credit due to being the “professor.”  Call or write me if you want to hear it!

I brought the story home to my congregation at St. James, who graciously had a special offering for us to share with our local food shelf.  In a conversation with my lovely mom, I told her the Plumpy’Nut story.  Her circle at Zion Lutheran in Anoka graciously made another contribution.

We were able to buy about ten cartons of Plumpy’Nut, 13.8 kg, each with about 150 sachets of the stuff.  For children between 6 months and 3 years, our target population, 1-2 sachets (packets) per day is the dose.  The full course is six weeks.  But only 2% of children die of malnutrition directly.  But it figures prominently I 80% of deaths in children under five.  Malnutrition kills by potentiating any other illness.

Of course, there are varying degrees of under nutrition, both acute and chronic.  The average need for Plumpy’Nut is about 2 weeks and one packet per day.

For Tanzania, the national statistic is that 38% of children under five are stunted (low height for age).  This is a sign of chronic malnutrition.  Thirty-eight percent! 

All children admitted to the hospital are nutritionally stressed.  And furthermore, since the families provide food for their loved ones who are patients, anyone undernourished when they are admitted are likely to remain so.

We developed a protocol for prescription of the Plump’Nut and a concept paper for a program, too long to present here, but a description of it might be good for another post.  Many children relapse in 3 – 4 months.  So treatment at the hospital is the easy part!

My dear church and others have provided enough Plumpy’Nut for about 1/3 of the need for the worst cases, but I would like to expand its use if possible.  For example, some of you have met Amri Lubawa, a young lawyer who is paralyzed and with terrible bedsores.  We think he looks wasted compared to last summer.  I was hoping to get a grant to supply it ongoing for Ilula Lutheran District Hospital, but so far no luck.  “I have not yet begun to fight!” to quote John Paul Jones.  (And I would gladly accept help and advice.) 

What the heck is this magical formulation anyway?  It is (by weight) approximately one part peanut butter, one part powdered milk, one part powdered sugar, one-half part oil, like sunflower oil and necessary micronutrients (vitamins, etc.).  Plumpy’Nut is a brand name.  The WHO has a recipe and I would love to see a version made here locally!

Anyone want to help or donate or point me toward the funding?

Human Interest Stories – an everyday occurrence at ILH

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Laura Brown is one of our Pharmacy Residents.  She was here last year as a student and came back!  Yesterday she became an “everyday hero.”

There was a 14 month-old child admitted with malaria and pretty typical symptoms of fever, lethargy and anemia.  The malaria can tear up the red blood cells.  This infant’s hemoglobin was 2.8.  Normal would be more like 15.8.  There are people wandering around with hemoglobin nearly this low.  Mostly they have pernicious anemia.  But they got there slowly.  When hemoglobin drops to this level quickly however, it is a disaster.  The body cannot transport enough oxygen to feed the tissues, let alone heal.  This little tike needed a transfusion.

After transfusion!

As Laura modestly put it, “There were lots of us willing to give a blood donation.  But everyone else had their immunizations before they came.  Mine were up to date from a year ago.”  So she donated a pint of blood.  Our little friend made a miraculous recover and today was standing by mama.  She isn’t done with her treatment, but she is recovering, thanks to Laura’s gift of life.  These stories are not just about the wazungu.  Many of the employees give blood when it is needed.  They are everyday heroes too.  It is a daily occurrence here.

Today Augustana Lutheran Church visited Ilula Lutheran Hospital, so I had the privilege of giving them the tour.  Then they feasted with us at lunch on Anna’s great cooking.  We went by the Private Ward, where Amri is.  You may recall the name if you read Iringa-Friends-2012.  He is still here and has been now for nearly a year.  He is still dealing with pressure sores.  The Augustana people were gracious and generous to give money toward his care and to the Poor Patients’ Fund.

They had a novel idea also: What would a donation of $10, $20, $50 or more supply?

I can put a face on some of that.  A full course of Plumpy’Nut (RUTF, “ready to use therapeutic food), a sachet (packet) per day for six weeks would be around $16.  (Not much, unless your entire annual income is $360.)  More typically, we would use for a couple weeks, so $5.  We will have about a thousand kids under five years of age admitted to ILH.  Of those, 38% are stunted, a sign of long-term under nutrition.  But ALL of the children are under nutritional stress.  Just counting the 380 kids who need RUTF for 10 days or so, now we have 3800 doses needed per year, just for the children overtly under nourished and not including any of the children who need nutritional support during their illnesses. 

I am proud and thankful to say that again tis year, St. James came through with enough donations for fully 1/3 of what the hospital needs.  Way to go, St. James!

Ruaha National Park

Meet Taja.  She was such a model for us and is just a glimpse of the amazing animals we saw on our Safari.  I'm sure more pictures will follow, but I know some people back home would love a sneak preview.  The weekend in Ruaha was outstanding and such a treat amidst a lot of hard work by the entire team here.  It was such a great way to send off the crew that is now on their way to Dar to fly back to Minnesota and to welcome Vandi to the team.