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.



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.

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.

To be a practitioner in Guatemala, one needs to find harmony between western and traditional medicine. I had never thought about or tried natural herbal medicine before coming to Guatemala. Though I still don't usually recommend it to my patients, I have begun exploring the natural remedies so that I can hopefully help my patients to navigate their own health. The women's program teaches patients that if their symptoms do not improve after two days of at home treatment with herbal remedies, they need to go to the doctor for medication.

Many of the herbal remedies are geared towards symptom relief of aliments for which we do not currently have cures. For example, there are many herbal remedies for the cold virus, specifically for cough. In the states, there are anti-tussives, mucolitics and expectorants, but these don't cure the virus, they just alleviate or mask the cough. Though many patients request antibiotics, these target bacterial rather than viral illnesses and only lead to resistance and de-sensitization to medication. This is a specifically frightening concept when any Guatemalan can go into the pharmacy and buy any medication in any amount with less than the scribbled name of a medication written by their neighbor counting as a prescription. However, with Guatemala being among the poorest of Latin-American countries, the cost of western medications is a major deterrent leading to the preference of herbal medication in addition to its cultural implications. Many patients admit to filling half prescriptions due to the cost of medications or stopping medication regimens when they achieve symptom relief and saving the few remaining antibiotic pills for the next time they start feeling sick (of any sort).

It is terrifying to know that partial regimens is the way we have created and continue to create multi-drug resistant organisms, such as multidrug resistance tuberculosis which has been on the rise recently in Latin America. The fear of drug-resistance is a constant motivator, as we pass by the country's tuberculosis hospital daily on the way to the Primeros Pasos clinic. For this reason it is just as important that we educate the patients as it is to provide medical care. A good medication can be a weapon if used incorrectly; it is important to empower the patients to be responsible for their own health and healthcare, which is largely where herbal remedies come into play.

In the states, most Dr. Mom's would recommend a bowl of grandma's chicken noodle soup, a cup of tea and rest -- symptom relief. The idea is not too different with herbal medicine here -- herbal teas to alleviate the aches and calm the cough. Graced with the same viruses that my patients bring to the clinic, I was personally compelled to try herbal teas for my back to back stomach and cold viruses. I went to the local market with a Guatemalan friend and we sought out all the teas for cough. I was surprised by the number of plants and herbal remedies that exist. There are different teas for dry cough, productive cough and coughs with sneezes. Among the busy, hustling market, the herbal medicine vendor was one of the most popular. I do not claim an instant cure, but the effect was certainly soothing as the virus ran its course.

Balance between hot and cold is very important concept in Mayan health; a warm remedy is used to cure a cold illness. Health is not only viewed as freedom from illness, but also as general happiness and life balance. It has been important for me to begin understanding these concepts, so as to provide patient education and recommendations that complement rather than clash with their worldview.  It has been specifically important for the care of pregnant patients as many cultural concepts, which do not have an equivalent in western medicine, are said to affect the development of the baby. For example, newborn babies get sick when the mothers breast milk becomes cold from eating foods that are considered cold, which does not always correspond to temperature. 

In order to be respected as a practitioner, one must respect the viewpoint and frame of reference of the patient. Respect however, does not always mean agree. I believe that one of the most important things that I can learn in my investigation of natural medicine is to understand what herbal remedies may be dangerous to pregnant women. Certain herbal remedies are actually known to be incredibly potent. Something about this approach and mind-set has been successful, as my patients rapidly continue to increase in number. Though as a foreigner, my recommendations of herbal remedies would ever be taken too seriously, my warnings are generally heeded. Thankfully, there are many other traditional practitioners to provide these recommendations and I am seeking partnerships with them in order to incorporate their work into a more holistic model of patient care.

November 13, 2009

by Jenny Dyer

FROM Kaiser Family Foundation: The Foundation has issued its latest global health survey, Views on the U.S. Role in Global Health Update, which probes American public opinion about efforts by the United States to improve the health of people in developing nations. According to the poll findings, most Americans support current U.S. spending to improve health conditions in poorer nations despite the economic recession. Two thirds of the public supports maintaining (32%) or increasing (34%) spending on global health, while a quarter say the country is spending too much. More of the public prefers an emphasis on health infrastructure rather than fighting specific diseases. When asked to rank the importance of the two approaches, 58 percent say it is more important to emphasize programs that help countries build their health system infrastructure, under the theory that stronger health systems can better handle a variety of problems. In contrast, 36 percent say it is more important to emphasize efforts to fight specific diseases like AIDS and malaria because efficient methods for treating such diseases already exist and can save large numbers of lives. All the survey materials are available online.

This is interesting and great news given our economic climate that the majority of Americans still care deeply about helping those with the fewest resources worldwide. I find intriguing that the American public has marched forward from embracing the issues of HIV/AIDS and the global pandemic, or malaria and the need for bednets, to realizing the need for health systems, working together, to build infrastructure for smart, efficient use of assistance. Health systems and health infrastructure are far from sexy topics, but that is what is needed and needed now.

HTHH addresses the issue of health infrastructure through our support of training community health workers through our Frist Global Health Leaders program, offering health professional students and residents the opportunity to serve and train in underserved clinics around the world. We know strengthening health systems is key to moving toward the millennium goals.

by Bill Frist, M.D.

A couple weeks back, the Living Proof Project was unveiled in Washington, D.C. by Bill and Melinda Gates. The goal of this great project is to share the good news of the implementation of assistance. U.S. investments in improving global health are delivering real results. From significant declines in child deaths, to global eradication efforts against polio, to insecticide-treated bed nets that reduce malaria transmission, global health initiatives are working. At you can learn more from their progress sheets. Watch the speeches of these "Impatient Optimists."  I have the pleasure of serving on the Advisory Council.
The video below was shown yesterday at a Save the Children Survive to Five Council meeting in NYC. This is a great example of real results, combating infant mortality. Saving the life of a little one.


The end of October marked the end of my first quarter here at Africare and the start of the second quarter seems to have brought with it all types of change.  In the office we are currently in the midst of several big changes, the biggest being the addition of a new CDC funded home-based care project. Africare will work with some small Civil Service Organizations and existing community structures to provide home-based care for people living with HIV/AIDS. The start up of this project has required a lot of time and energy, including interviewing for about 20 new positions. With between five and ten candidates being interviewed for each position, you can imagine that this has been a very time consuming process. Everyone from the Country Representative, to the program's Chief of Party, to the junior staff has been pitching in to assist in the interviewing process. I've been working very closely with the Human Resources Officer to test the candidates' practical skills, compile summaries of interview results, and create briefings of panel recommendations to be reviewed and approved by the Country Representative and our headquarters in Washington, D.C. I even had the opportunity to sit on the interview panel for a few of the positions and it was quite a different experience being the interviewer instead of the interviewee. One of the new staff that has been hired is the new Program Assistant, Gloria.

She and I have worked together to create a new internal monthly newsletter, which was a hit in the office. We're also working together to draft Africare Tanzania's first Annual Report. The Africare organization as a whole puts out an annual report every year and some of the country offices also produce annual reports. Africare arrived in Tanzania in 1994 and has not produced an annual report yet. Gloria and I are very excited to be working on these new additions.

In addition to the newsletter and annual report, Gloria and I will be working with the Admin officer to create a resource center where staff can access reference materials in one centralized, organized space.

So, between the addition of a new project, lots of new staff members, a new newsletter, the creation of a resource center and the first ever annual report, this has certainly been a period of change for Africare Tanzania.

by Bill Frist, M.D.

Yesterday morning, I had the honor of speaking at both services at Christ Church in Nashville. Over 5000 people attended. The services were dedicated to the doctors and nurses in the community, recognizing all health care workers for their healing care. It was a wonderful opportunity to share the work of Hope Through Healing Hands at home and abroad. As you know, HTHH's selects Global Health Leaders, annually, to travel to underserved clinics around the world to bolster health care and training of community health workers for sustainability. Right now, we have Leaders in Tanzania, Rwanda, Kenya, and Guatemala. We are proud to support their efforts, using health as a currency for peace. As Martin Luther King, Jr. said, "We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly affects all indirectly."

Thanks to all at Christ Church for the warm welcome.



World Pneumonia Day Reception Remarks

By Senator Bill Frist, M.D.

Today, I joined Save the Children, the US Coalition for Child Survival, the World Pneumonia Day Coalition and Vicks at a breakfast reception on Capitol Hill to recognize the first annual World Pneumonia Day, a day for people everywhere to turn awareness into action to control the #1 killer of children under age 5: pneumonia. Each year, a disease which often starts as a cold, claims the lives of nearly 2 million children under age 5 -- more than malaria, AIDS and measles combined. Despite this staggering death toll, childhood pneumonia has never been a global health priority, and the current basic maternal child health programs --that need to be in place to control the disease-- are under-funded.

Pneumonia is easy to diagnose and treat if you have the right tools, but most children in developing countries don't get the care they need. We could save more than one million young lives each year with affordable health measures -- like proper nutrition and breastfeeding, antibiotics and vaccines. It's a matter of making these solutions more available to the children who need them.

As chair of Save the Children's Survive to 5 campaign and in my work with other humanitarian organizations, I've traveled to community-based health projects in Asia and Africa. I've seen firsthand how U.S. government investments in training community-based health workers in pneumonia prevention and treatment have significantly improved child health and saved lives.

In countries as different as Bangladesh and Mozambique, families face virtually the same obstacles to getting care for their children. Vaccines that we take for granted here to protect our children are not available in many of the countries that most need them. GAVI needs significantly greater resources to help countries integrate the new vaccines against pneumonia as well as diarrhea. A community-based approach to child health works. But if we are to make progress in combating pneumonia and other childhood illnesses, we need to scale up these efforts.

World Pneumonia Day is a call to action from national leaders, donors and international health organizations to rally their forces to control this disease. The time is ripe for action. Thanks to WHO and UNICEF's Global Action Plan against Pneumonia (GAPP) released on World Pneumonia Day, November 2nd, we will have a realistic six-year plan for the worldwide scale-up to control pneumonia, based on the following:

· protecting children by creating lower-risk environments;

· preventing children from developing the disease through vaccination; and

· treating children who become ill.

The United States has played and must continue to play a leading role internationally to save the lives of mothers, newborns and children through the protection, prevention and treatment of pneumonia. Current U.S. spending on maternal and child health, which includes spending on pneumonia, is just $495 million a year. The U.S. should at least double that investment, encourage other industrialized nations to do the same at next year's G8 summit in Canada. G8 leaders should declare that no country with a credible plan for newborn, child and maternal health should be thwarted for lack of donor resources.

We are pleased to see that child survival is a strong priority for the U.S. Congress. The Global Child Survival Act (S. 1966) was just introduced in the Senate, and the Newborn, Child and Mother Survival Act of 2009 (HR 1410) has 80 cosponsors in the House. What can you do? I strongly encourage you to call your congressional representatives today and ask them to cosponsor these important bills.

Subscribe to our newsletter to recieve the latest updates.