January 11, 2010

From: PneumoALERT at preventpneumo.org

Call to USAID to Take Action on Pneumonia and Diarrhea

Dear Colleagues,

I am excited to tell you that on January 7, 2010, Dr. Rajiv Shah was sworn in as USAID Administrator. This is a great opportunity to welcome Dr. Shah to his new leadership position and to call on him to take up the cause of pneumonia and diarrhea, the world's two leading causes of child mortality.

Dr. Shah has led and worked with many of the initiatives that are defining best practice in the field of development, including the Global Alliance for Vaccines and Immunization, the Global Fund for AIDS, TB and Malaria, the Alliance for a Green Revolution for Africa, and the Bill and Melinda Gates Foundation. His tireless efforts to immunize children around the world have helped save countless lives.

Please take a moment to sign and submit a letter welcoming Dr. Shah as he begins his important work as head of USAID and to bring to his attention the need to increase support for child health. Dr. Shah is now at the center of the important US aid effort to help families around the world in their struggles against poverty and disease.

Millions of lives can be saved by increasing access to antibiotics and vaccines against pneumonia and diarrhea, the two leading killers of children under five. By taking on these two common and preventable killers, the US can save millions of young lives and send a powerful message to countries everywhere about our ability to protect the health of the world's youngest citizens.

In November 2009, nearly 100 leading global health organizations joined forces to commemorate the first-annual World Pneumonia Day. Close to 100 events took place in over 30 countries across 6 continents. As a partner of the Global Coalition against Child Pneumonia, we urge individuals to capitalize on this momentum by sending this letter to Dr. Shah.

Please click here to sign and submit the letter. Please forward this link http://www.change.org/actions/view/call_to_usaid_to_take_action_on_pneumonia_and_diarrhea  to any colleagues or friends you think might be interested.

In December 2009, we announced the launch of a new International Vaccine Access Center (IVAC) at Johns Hopkins School of Public Health. We are pleased to have the opportunity to bring together a group with diverse skills and perspectives to accelerate access to lifesaving vaccines in populations that need them most through the development and implementation of evidence-based policies. I invite you to continue checking IVAC's new website for information on projects and new findings.

Thank you for your action and support.

Orin S. Levine, PhD
Executive Director, IVAC
Johns Hopkins Bloomberg School of Public Health
Follow me on Twitter @orinlevine
Read my blog at www.huffingtonpost.com/dr-orin-levine



by Danielle Dittrich

December 17, 2009

This week one of my prenatal patients that I had been caring for since I first arrived here in Xela had her baby. She was a gestational diabetic, so although she had had her last 5 children at home with a comadrona she agreed to go to the public hospital for the delivery. She borrowed a cell phone from her neighbor to call me when she started went into labor and decided to go to the hospital. I met her there as soon as a finished seeing my patients at the clinic. I couldn't play any major role at the hospital, but I think it was good to see a familiar face; she cried when she saw me at the OB triage station.

The public hospital has a bad reputation, which is seemingly fitting. The hospital looked pretty similar to the hospitals I visited when I interned for the public health department in the Dominican Republic. I assume that most public hospitals in developing countries look similar. The largest problem with that being that due to lack of space and resources, patient rooms are dormitory style with 10-15 patients depending on the unit. In peripartum units this is not as much a problem because women with the same chief complaint, such as postpartum are bunked together. However, I remember this being a huge problem in the Dominican Republic on general medicine floors where lack of resources would lead to immuno-compromised patients being placed in the dorm with respiratory illnesses and other infectious diseases, leading to cross contamination; I have heard that it is the same at the hospital here in Guatemala. But developing countries are called developing for just that reason. The hospital looks like what I might imagine a hospital in the states to look like some 30 plus years ago, and the equipment is just as antiquated as the original building structure.

But despite whatever image or feelings the description may conjure up, it is not the physical building, but the people that work there that gives it its reputation. The majority of the patients that visit the public hospital are indigenous. The hospital is only a last ditch resort after all herbal medicine and traditional healers having failed. It is incredible to me how life just 20 minutes outside the city can be like living in a different world, but it is in fact the way it seems. The indigenous rural women only come into the city to go to the market, to buy or sell their goods or agricultural products. There is a lot of racism that still exists against the indigenous Maya; some of it still remains of the civil war. Most hospital staff including doctors and nurses is not indigenous and therefore this racism seems to permeate the services provided. The patients are often not respected and instead are rather looked down upon, seemingly passed over and ignored.

I remember distinctly, one of my most vivid memories from the time that I lived in the Dominican Republic, one of the other girls that I interned with was told by the doctor to administer an injection. At that point, over 2 years ago, neither she nor I were trained as nurses or in any medical capacity at all. She politely declined giving that reason exactly but the doctor responded, "It doesn't matter he is a Haitian". The overt racism in the Dominican was absolutely unbelievable to me. It's execution easy, due to the blatant difference in skin color. In Xela, this distinction is more difficult and may mostly rely on the preference of indigenous clothing. However, as I spend more time here, it seems that the roots of racism may run deeper than I had imagined.

When I arrived at the hospital the patient had already been laboring for a few hours. The patient did not have any of her prenatal records with her; however I was shocked to find out that the doctors were not treating her diabetes, the exact problem that she was being sent for. I spoke to the doctors for a while, to find out why. Apparently, they had asked her if she took any medication during her pregnancy. She said yes but she did not know the name of the medication because she cannot read. Rather than asking what the medication was for and investigating further, her affirmative answer was just ignored. (There seems to be a very high illiteracy rate among the adults in the Valley of Palajunoj. It makes it difficult to give medication instructions. Often times we are forced to rely on pictures or the assistance of children or neighbors). When I arrived and told them the medication and about her diabetes, they quickly scrambled to pull together the diabetic services previously ignored. Unfortunately, I was not permitted to stay past visiting hours and had to leave the patient, still laboring, at about 4 o'clock.

In the morning, I went to the corner store where her sister works to find out about the baby. She had called her late that night to let her know that the baby was born. I returned to the hospital that afternoon to hold the adorable 6lb baby girl in my arms. The patient was having trouble breast feeding so the baby still hadn't eaten. She had asked for help, but once again it was ignored. I sat there with her while she tried a few more times until eventually successful. I sat around with her and her sister for another hour until visiting hours ended. Unfortunately, no one had made it clear to her that she couldn't eat anything if she still wanted to get her tubes tied that day. I informed the rounding doctor, which meant that she would have to wait a whole other day to have the surgery and go home.

Yesterday I visited the patient at her house. The 5 brothers and sisters seemed very excited about their new sibling. The baby looks a little jaundice so she is taking her out in the early morning and late evening sun for an hour. I promised to visit again today and to check on the baby.



December 15, 2009

by Kelly Tschida

Nyamata, Rwanda

The last few weeks I have been leaving the Nyamata Hospital to work in the community health centers. Getting to the centers often entails a few hours of travel in a four-wheel drive over rough, dirt roads.  There are 11 centers in the Burgessa district and more than 400 in Rwanda

These health centers are the front line healthcare for most Rwandans. Each center is responsible for a population of roughly 20,000 people. Patients using the public hospitals must start at these community based centers. If the case is complicated, they are transferred to a district hospital like Nyamata. The staff care for sick patients, deliver babies, provide vaccinations, distribute food given from the government and non-governmental organizations. They also have daily classes on topics such as family planning, gardening for nutrition, and proper sanitation and food preparation. These centers are truly the best hope the country has in the areas of disease prevention and early intervention. 

Sitting with the nurses to consult the patients has been interesting. The majority of patients have diarrhea caused by intestinal worms or they have malaria. Both are easily treated at the center. I am reminded how different the patients’ lives are from mine every time they leave the room. Because they have lived their whole lives in crudely constructed houses, they have often difficulty figuring out how to use the door handle. 

 I am always amazed by how long patients wait to come to the clinic. I saw one patient who fell down a well. She had a dislocated shoulder and could not see out of one eye because she had hit her head. She told us she was in the well for four days before someone found her. When I asked when it happened, she said 11 years ago! This was the first time she sought treatment. It is common for the patients to try treatment with a traditional healer before coming to the centers. Traditional treatments often involve scarring the body with a red-hot piece of metal. It is sad to see advanced medical cases that could have been avoided if the patient would have come to the center first.  

The centers see 80-160 patients everyday, which means they are usually running at full capacity. I am currently partnering with a member of the Access Project, a non-governmental organization that aids the Rwandan health centers by providing management, training, and infrastructure. Through this collaboration we are searching for a ways to increase the health centers’ capacity without adding more costs.   

The nurses do incredible considering their education and lack of resources, but there is only so much they can do. I feel fortunate to have been able to work with them and teach them some more advanced skills.


December 11, 2009

by Jenny Eaton Dyer, Ph.D.

Do you remember the story of Olken Foncime? He was the Haitian orphan who had congenital heart disease and received surgery from Dr. Christian Gilbert in October.

We just received a photo and an update. His doctor reports that since the surgery, he has gained 10 lbs. and has a remarkable increase in activity. He's doing really well.

Thanks to Dr. Gilbert for the update!

Worlds AIDS Day

Vanderbilt University


December 1, 2009

by Jenny Dyer, Ph.D.

Last night, Senator Frist spoke at Vanderbilt University's Student Life Center to over 250 friends, students, faculty, and guests in honor of World AIDS Day. The title of the talk: "Celebrating Life, Mourning Death: Continuing the Fight against Global AIDS" focused on where we've come from and where we're going, especially in terms of policy. Recounting his personal experiences in Africa with the AIDS pandemic and how he was able to use those experiences to shape and inform President Bush's decision to move forward to commit historic funding to fight a single virus, the Senator relayed the beginning of the President's Emergency Plan for AIDS Relief (PEPFAR) in 2003.

The Global Fund and the Millennium Challenge Corporation have also been important components to combat HIV/AIDS and other preventable disease.

The good news? Because of these historic initiatives, over 3.5 million people are now on ARVs (in 2002, only 50,000 Africans were on life-saving ARVs).

The bad news? The number of the globally newly infected continues to rise.

We have learned that the "health systems" approach is the best method. We cannot simply confront individual preventable illnesses in isolation. The world is interconnected, and that demands an integrated approach to global health.

Rooted in this principle, President Obama has put forth a comprehensive Global Health Initiative budget request for $63B over 3 years. This plan begins to focus attention on broader global health challenges, including the following: child and maternal health, family planning, neglected tropical diseases, cost effective intervention for HIV/AIDS, and a more integrated approach to fighting diseases, improving health, and strengthening health systems.

We are excited to announce that Hope Through Healing Hands will be sponsoring four Frist Global Health Leaders for 2010-2011 from Vanderbilt's School of Nursing, School of Medicine, Vanderbilt International Anesthesia, and Emergency Medicine.

World AIDS Day reminds us that there is much work to be done in terms of continued awareness, action, and advocacy. We encourage you to join us in the fight.

This Christmas, consider supporting one of our Frist Global Health Fellows. They are doing amazing work around the world saving lives. We are proud of our students and their care for the world's poorest.

 Sankofa, The Blair School of Music's African Performing Ensemble

December 1, 2009

by Kelly Tschida, Vanderbilt School of Nursing

I have now transitioned to working with the physicians. Each physician is responsible for admitted patients on one of the floors and seeing patients in the outpatient consultation area. This change has been eye-opening.

Each morning starts at 7:00 with prayers, singing, and a short sermon. Watching my colleges sing and dance is an incredible way to start the day. By 7:30 we start rounds. There are usually about 40 patients to see and it has to be finished by 9:30 when the outpatient consulting begins.

Outpatient consulting here is like combining your general practitioner's office and an emergency room. We see seven or eight patients an hour and you never know what will come in next. I've seen snake bites, scurvy, leprosy, severe malnutrition, and even a suspected case of Ebola virus. 

Malaria accounts for probably one-third of the patients. Most are not complicated cases and can be treated easily, but this is not always the case. Malaria patients can come in unconscious, delirious, and in desperate condition. A few days ago a six-year old boy was brought in with malaria. He was unconscious and was barely breathing. We ordered medication and oxygen to improve help him breath. To my horror and dismay, we were told the hospital was out of oxygen.

Probably sixty-percent of the patients have stomach problems, usually due to parasites. Sometimes they come in specifically because their stomach is bothering them, often it is just in addition to another problem.  Sadly, with proper hand washing and food preparation most of these cases could be avoided. The severity of the illness ranges from mildly bothersome to life threatening.

I work with the medical doctors both to learn and to teach. I have been able to see diseases here I might never see in the U.S. I'm also learning how illnesses are treated when there are very few resources. In return, I am able to provide the most current guidelines for treatments, offer diagnoses that are not commonly considered here, and share different assessment techniques.

Perhaps one of my biggest contributions is simply providing a different perspective. For example, an infant with a high fever and having seizures was transferred to us by one of the community centers. The records were unclear as to what medicine had been given already. The physician was torn between risking an overdose and not giving lifesaving medicine. He decided not giving the medicine was safer. When I suggested he call someone at the health center he stared at me blankly for a few seconds before realizing how simple it was. Cell phone coverage in rural Rwanda is relatively new so physicians were unable to contact health centers in the past. In the end the infant received desperately needed medicine and the physician learned a new way to help patients.


December 1, 2009

by Danielle Dittrich, Vanderbilt School of Nursing


Everyone in Xela is getting geared up for Christmas and consequently the patient load throughout the clinic is winding down. This week marks the last week of women's group meetings for the year. They will start again in January. I lead the closing project with the Tierra Colorada Baja group today. We made fertility necklaces out of brown, black, cream and red wooden beads. The placement of the different colors on the necklace indicate when the woman is most fertile and can be used either for family planning or to help conceive. The project was a big hit, but most importantly it sparked some interesting conversation and important questions.

Women in this conservative, traditional, Mayan, catholic (or evangelical) region have been more open to methods of family planning than I had anticipated. This includes hormonal methods of contraception. You wouldn't think that at first, based on the typical family size; every family has 6-7 children. However, the patients never understand why anyone would only want to have only 2-3 children as is common practice in the US. The only disadvantage is after 5 pregnancies, the woman enters the category of grand-multiparous which puts her at risk for pregnancy and postpartum complications such as placenta previa (when the placenta lies over the opening of the uterus preventing the baby from delivering vaginally without hemorrhaging) and postpartum hemorrhage. I vividly remember when I was working in Nashville with a lot of Latina immigrants, specifically many Guatemalans, a patient recounting her labor story. She had no information to give us about the child's birth on the intake questionnaire. She gave birth at home in her small village. She bled a lot, causing her to go into shock and unconscious. She didn't wake up for over a week and when she finally woke up the baby had passed. Luckily, I have not heard of anything like this with my patients here in the Valley of Palajunoj. However, I will say that this story served as a large motivation to come to Guatemala.

So although many women are willing to use contraception, access to contraception is still controlled by the man. Most of my patients tell me that they have to discuss their treatment plan with their husbands and come back in for a second consult once they decide, even if the plan does not pertain to contraception. Unfortunately, this has hindered some women from getting the treatment that they need.

However, despite the women's reluctance to participate in family planning by themselves we were able to discuss some important points. There are many myths circulating in the community about miscarriages. I have devastated patients come to me after miscarrying stating my auntie told me it was because I ate X or my mother-in-law told me it was because I looked at Y while I was pregnant. Whatever the reason they give ends up being, it always puts full blame on the pregnant women. Ridden with guilt, the patient usually tries to get pregnant again immediately. However, it is advisable that after a miscarriage that the pregnant woman waits a few cycles to get pregnant allowing the endometrial lining (where the fertilized egg will implant) to replenish so it can sustain a healthy pregnancy. The reality is that 1 out of 4 pregnancies end in miscarriage. This is the body's way of preventing the birth of babies with genetic defects that are not compatible with life outside of the womb. I am trying to turn around some of these notions of guilt and blame as women in the community are always held accountable for the child's health even when the child contracts a simple cold virus.

Although my time with the women's group is coming to a close, this is not just a time to tie up loose ends. With a month remaining in my time in Xela there is still time for new beginnings. Today the new group of medical students from San Carlos University arrived and I led a two hour discussion on the basics of obstetrics and gynecology. It is amazing to me that the last group of med students have already come and gone. This new group is very tentative, as is only natural in the first few days. The last group of medical served as a good practice run. But with only 3 weeks until the clinic closes for Christmas, I will have to teach the new medical students in 3 weeks what I taught the last group of students in 2 months. These medical students will serve as the future of the women's clinic in the month of January at least until we figure out how to stabilize the women's health program after I leave at the end of December (too soon).

By far the most exciting new thing that has happened is my collaboration with one of the community midwives (comadronas). After knocking on a few doors we came upon her house. She is well respected in the community as a traditional healer. She is the president of the association of comadronas in the Valley. In addition to being a midwife she also treats children. She specializes in illnesses such as the evil and uses only herbal remedies. Despite the image that this may conjure, she is very well trained and I respect her work as a health practitioner. She received training at the local hospital and rotated on the labor and delivery floor for some time. She is also a certified provider of APROFAM, a great women's health organization in Guatemala with very progressive ideas and projects. Through APROFAM, she is provided with and certified to administer contraceptive injections.  However, she insists that her patients get a pap smear and bring her the results before she will administer the injection. Though she does not perform pap smears herself, it is her way of incentivizing the women to seek a women's health service that she knows to be important in the prevention of cervical cancer.

When the women's group meetings pick up again in January, she will be coming to speak to the women about her work during the segment on leadership, as she is a recognized leader in the community. The collaboration is very important as there are some things that she can't heal with traditional medicine and there are some things that we can't heal with western medicine. I have no idea what to do with a return patient who is not getting better because she is convinced that she must first be cured of the evil eye. I have really come to understand how much faith plays into the idea of wellness, or at least alleviation from pain and suffering.

The commadrona works with some western equipment. She showed me her fetoscope, blood pressure cuff, etc. She understands how important high blood pressure can be for a woman in labor (signs of pre-eclampsia/eclampsia) and knows that with high blood pressures she needs to bring her patients to the hospital in the city. At the end of last week I dropped off some few remaining supplies that she needed replaced including a stethoscope, sterile gloves and drapes and new scissors for the umbilical cord. She will be attending the birth of a patient that I have been providing prenatal care. I have been invited to come to the birth. Her due date is December 15th so hopefully she will give birth before I leave on the 18th. This partnership will hopefully allow us to perform better prenatal care in the valley with a more fluid transition to the birthing process which currently is very disjointed.

November 22, 2009

by Jenny Dyer, Ph.D.

Belmont University: From right to left--Senator Bob Corker, Dan Haseltine, Bill Hearn, Dave Barnes

Belmont University hosted an event today with Senator Bob Corker announcing his co-sponsorship of the Paul Simon Water for the World Act of 2009. Joining Senator Corker included water activists Dan Haseltine and Jars of Clay with Blood: Water Mission, Dave Barnes with Mocha Club, and Bill Hearns of EMI for Healing Water International.

Global Health Activists, students, media, and others came out for the event to celebrate all the great work on global water issues being done and supported out of Tennessee.

On behalf of the Global Health Coaligion, we are proud of Senator Corker's leadership on Clean Water issues and Child Survival around the world.

For more on the event: Click Here.

by Kelly Tschida

November 18, 2009

Nyamata, Rwanda: Today

Although the Rwandan genocide occurred fifteen years ago, I see its impacts everyday in the hospital. The region I live in was an area of great violence. There is a memorial site here in Nyamata were 10,000 people crammed into a small church seeking refuge, only to be killed. It is hard to believe that the reserved, kind spirited people I know went through such a horrible event.

I never ask about peoples' experiences, but the genocide is brought up many times a day. Medical histories are incomplete for many young adults because they are orphans. Patients come in with disfiguring scars, old bullet wounds, and HIV as a result of the violence they experienced during that time. Sometimes they say it happened during the genocide, mostly they say it happened "15 years ago". I have been told the mental health floor gets very busy with post traumatic stress disorder during the same months that the genocide occurred. Other stress related illnesses, such as stomach ulcers are common complaints of our patients.

One consequence of the genocide that has made a big impression on me is how the Rwandan people react to death. I noticed when patients die the family members never show outward emotion. There is no crying, no awkward silence or loud outbreaks, and no consoling of one another. They seem to concentrate on packing up the belongings and taking care of business. When I asked one of the nurses about it, she said that is the way Rwandans are. I thought she meant it was cultural, so I said "So it is normal?" She replied "No, it's not normal. It's because we saw too many things in the genocide."

The hospital staff deals with genocide related problems the way they would for anything else; no sorrow is shown or empathy given and no further questions are asked. They take note of the history in a professional manner and together we all simply move on to find the best treatment.


 Inside the Nyamata Church Genocide Memorial. Each bundle of clothes belongs to a victim.

Milles Collines, the real Hotel Rwanda.

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