Originally published in Roll Call.

A decade ago, as I was beginning my time as Senate majority leader, bipartisan consensus in Washington helped launch a new era of progress in global health just when it was sorely needed. Twenty years had passed since I first saw AIDS patients in Boston, though at the time we didn’t even have a name for this savage disease. Advances in treatment and technology were helping control HIV in the United States, but AIDS was decimating communities worldwide. There were tens of millions of infections, yet only 400,000 people in low- and middle-income countries had access to lifesaving antiretroviral therapy, meaning only a tiny fraction were able to escape death.

World leaders united to tackle AIDS and other scourges through an innovative financing tool — the Global Fund to Fight AIDS, Tuberculosis and Malaria. President George W. Bush and Congress made a founding pledge of $300 million to the international initiative. Bush, with bipartisan support from both chambers of Congress, also established the President’s Emergency Plan for AIDS Relief, the largest program ever to combat a single disease. President Barack Obama has similarly embraced this program and America’s role in eradicating this disease.

U.S. leadership at the Global Fund, and bilateral health programs such as PEPFAR and the President’s Malaria Initiative, signaled a renewed commitment to a core facet of our country’s greatness: compassion for those most in need. Understanding that improving global health is good for national security, economically prudent and — most importantly — the right thing to do, the U.S. taxpayers made an unprecedented investment in the world’s future.

That investment is paying off.

As we mark the 10th anniversary of PEPFAR this year, the number of people on lifesaving treatment has increased more than twentyfold. HIV infection rates are down. The number of malaria cases has plummeted by more than 50 percent. Tuberculosis mortality rates are falling steadily. The Global Fund alone saves an estimated 100,000 lives each and every month, working in more than 150 countries. These health gains were once unimaginable.

A new chapter in global health begins this month as visionary leader Dr. Mark Dybul takes the helm as executive director of the Global Fund. With so much gridlock in Washington, Dybul’s appointment is a reminder of what we can accomplish by reaching across party lines.

Dybul, who began as a physician treating AIDS patients in the early years of the pandemic, helped transform the fight against the disease as the architect and leader of PEPFAR. Now at the Global Fund, he will lead the charge to defeat AIDS, malaria and tuberculosis. Armed with scientific expertise and dedicated to a mission that goes beyond political ideology, there may be no one better suited for the job.

Today there is real hope in this fight — but it’s far from over. We have the science to help people with HIV live healthy lives, but millions still lack access to the treatment they need. We can detect and treat TB, but drug-resistant strains represent a growing threat, and disease respects no borders. And malaria still takes countless lives each year, though it can be stopped with basic, incredibly cheap prevention.

The next two weeks I found myself much better able to engage in the hospital system. Now I had learned the names of Benson, Mugo, Humphries all clinical officer or medical officer interns. It became my pleasure on night and weekend call to lead them through surgical triage or procedures. On subsequent calls I was able to help one of the medical officer interns through two chest tube placements. These patients had spontaneous pneumothoraces, but were not in extremis, thus I could take my time and coach the intern through the procedure. By the second placement, Mugo was able to anesthetize the patient appropriately, make the incision, and perform this life saving procedure. He remained a bit tentative, but I had seen vast improvement by this second time. These guys and gals are the front line of the Kenyan medical system, and are seeing patients in isolated places with no surgeons, or even residency trained physicians available. Teaching Mugo to place a chest tube well could benefit multiple Kenyan patients in the future.

We also had opportunity to entertain these learners in our home. We got to learn of some of the struggles they had to overcome. One resident commutes nearly an hour each morning and evening for the benefit of her family. Other interns come from extremely poor or difficult circumstances. The Kenyan health care system relies on these young men and women.

Jason Axt with staff

Another sad and challenging case that I encountered was that of D. He is 45 year old man who had been diagnosed with appendicitis over a month prior to my meeting him. He had been taken to theater for an appendectomy at an outlying hospital. When I met him he was post op day 2 and 3 from a second laparotomy for peritonitis and periappendiceal abscess. He had succus pouring from the lateral portion of a “hocky stick” incision. It seems he had been diagnosed with a post appendectomy abscess, and the medical officer (almost certainly not a surgeon) had encountered dense adhesions as he or she had attempted to drain this abscess. The operation had resulted in multiple enterotomies and now enterocutaneous (EC) fistulas. He likely had generalized peritonitis after his first operation or maybe at the time of his first operation. EC fistulas are difficult problems in the United States; here an EC fistula is devastating and likely fatal. We took him to theatre and did a diverting ostomy while closing or resecting the 5 enterotomies or anastomoses that had been left. We placed him on TPN – a rare and expensive resource here. We were unable to close his abdominal fascia, and settled for closing the skin.

He remains alive now 1 ½ weeks later. He remains on TPN after an episode of central line related sepsis and partial opening of his abdominal wound for infection. D. is an example of advanced surgical care done amidst quite austere and resource limited setting. He also is an example of a patient who would have fared much better with initial treatment by a well-trained surgeon. Simple ultrasound guided abscess drainage could have avoided this morbid procedure in this patient, but is available here in a limited fashion. D. remains very grateful for his care and is asking the hospital clergy and medical staff to pray with him and for him. Surgery in Kenya is far different from that at home. Learning to work and teach amidst the resource constraints here has been a stretching and eye opening experience. 

FGHL Blog: Jason Axt - Extreme Medical Issues in the Field

Warning: This post contains graphic medical images.

Feb 28 2013

Warning: This post contains graphic medical images.

This week started with an orientation to the hospital. I learned where the theatres were, where the clinic patients were and the location of the wards. Patients were housed in common sleeping rooms with 4 – 20 patients per ward, with men and women housed separately.  I was introduced to Dr. Irungu, the Kenyan consultant whose service I would join. 

I quickly realized here that the practice of general surgery is far broader than what I am used to. One of the first cases I scrubbed into was a transcystic suprapubic prostatectomy. This is a case that is seldom performed in the US but is frequently done here. This man had disabling enlargement of his prostate that had resulted in urinary retention and renal failure with a creatinine of nearly 4. His renal failure resolved after the placement of a foley catheter and monitoring for several weeks. After confirming by biopsy that the prostate was not enlarged due to cancer we removed his prostate by this transabdominal procedure. He was extremely thankful when we discharged him four days later sans catheter and urinating on his own. This basic surgery had transformed his life and reversed the process that had resulted in his renal failure.

I encountered a disturbing patient early in my second week. During clinic we see about 80 to 100 patients between two consultants and two residents. I met and admitted a young man from a large refugee camp. He had initially had a “leg blister” two weeks prior. When I met him he had at least 15% body surface area total skin loss to his left leg. It was a lesson in muscular anatomy, as all the muscles were completely in view. The joint capsule was open, seeping a mixture of pus and synovial fluid. He had had a debridement procedure elsewhere, but it had been wholly inadequate. Although not in critical condition or septic shock, he would need extensive debridement and at least an above knee amputation if not a disarticulation of the entire leg. Regardless, he would require weeks to months of rehab even given an expeditious amputation with skin closure. We took him to the theater the next day, and our fears were confirmed. There was extensive soft tissue loss with residual deep infection. He would require leg disarticulation. 

Jason Axt Patient Leg

The man refused to consider amputation, stating that he was young, needed to work, and could not do without his leg. He and his friends demanded discharge so that they could go to look for another surgeon who would be able to save his leg. Reluctantly we released them, telling them we were more than willing to help them if they wanted to return. The needs are large, the presentation was late, and the die was cast. I hoped that this was not the last that we would see from him, because I am sure he would progress to generalized sepsis and death without amputation.  

Spoiled. That’s the only way to describe how I feel heading back to the states. I feel that I had the opportunity to practice medicine the way my 6-year-old-self imagined it while in Guyana and I couldn’t be more thankful for the experience.

Reporting from Les Cayes, Haiti

January 13

I can’t believe my time here in Haiti is over—but it is. I’m  
writing this from my guesthouse in Port-au-Prince, in preparation for  
my flight home tomorrow.

I would like to thank Senator Frist for forming the Frist Global  
Health Leadership Program, and for allowing me to have come to Haiti  
to work at HIC. I’d also like to thank the many people at Vanderbilt,  
Dartmouth, and HIC who helped me make the needed connections and  
organize the details of my trip. Last but not least, I’d like to give  
a special shout-out to my boyfriend, for supporting and encouraging me  
to leave him—and the U.S.—for three months and go work in Haiti.  
Thank you.

Although there were certainly nights that were incredibly difficult,  
there were many more that were amazing, and I am so very thankful for  
having been able to work at HIC. I was able to learn from so many  
experienced, kind, patient doctors and (mainly) nurses. They opened  
their hospital and the maternity ward to me, and were willing to teach  
me and make me an infinitely better midwife. I know that my time at  
HIC will forever impact how I care for my patients, and how I look  
upon all of the resources available to my moms and babies back in the  
U.S. Additionally, working here has further solidified my desire to  
work internationally, and has given me a clearer idea of what that  
life will be like.

I sincerely hope that if Senator Frist had come to visit HIC that the  
staff and the patients I interacted with would have said I was worthy  
of being a Frist Global Health Leader.

This last picture is of me and an auxiliary nurse (kind of like an  
LPN) named Mrs. Lorcey. Mrs. Lorcey works most nights, and so I worked  
with her more than any other provider during my time at HIC. I was  
always pleased when I'd arrive to work and see Mrs. Lorcey there  
because we worked well together and respected each others skills as  
providers. Although at first Mrs. Lorcey didn't trust me--as she  
shouldn't have--as I slowly proved myself and my skills she let me do  
more and more on my own, and helped guide me through interventions  
that I'd never done/seen before. By the end of my time at HIC I know  
that she believed in my abilities, and let me work as independently as  
I wanted. I worked with Mrs. Lorcey on my last night at the maternity  
and in the morning when it was time to leave she gave me a big hug--
something I didn't see that often in Haiti--and told me she'd miss me.  
I will certainly miss her,  her smile and her quiet, calm  
encouragement when I was stressed or unsure of what I was doing.

January 5

Happy New Year!

Apart from working at the maternity this week—and getting to celebrate the arrival of 2013 with laboring women and their new babies—I’ve been busy completing the list of HIV+ women who have been lost to follow-up.  From March of 2009 until November of 2012 there were 240 women who started receiving HIV care at HIC, but now no longer are doing so. I really hope that the social worker and the community health workers will make use of this list and that some of them will be found and restarted with their HIV care. I am however, not incredibly optimistic that many women will be located. The social worker and community health workers are already very busy and to try to track down 240 women—with little more than their names, dates of birth, and possible addresses—seems very ambitious. But I feel that if even one or two women are found and are restarted in care that my work on the list was worth it. 

Along with the lost to follow-up list I’ve also been working on an “opposite” list—collecting information about those women who are still receiving HIV care at HIC. The hope is that with both lists, providers at HIC will have a better sense of whether or not there are differences between those women who are lost to follow-up (LTF) and those who are active. Maybe it’s the timing of enrollment in the HIV program, or whether or not a woman gives birth at home or in the hospital, or her age that is a significant factor in whether or not she stays in care. With that information the providers at HIC may be able to modify certain aspects of their program (i.e. enrolling women earlier if that was shown to make a difference) or focus on certain “at risk” women (i.e. if older age is show to have increased LTF risk, providing more education/support to those in that age range), thus—hopefully—decreasing the programs LTF rate and ensuring more women (and their babies) receive the important HIV medication and care.

This week I also went into the capital and had the pleasure of meeting a woman who is running GHESKIO’s Nurse Practitioner program. (GHESKIO stands for the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections, and was the first institution in the world dedicated to the fight against HIV/AIDS. It has provided continuous free medical care in Haiti since 1982) I talked to her about what can be done to better define the role of an NP in Haiti—to distinguish NPs from the nurses and doctors, and to make sure that the doctors don’t worry about NPs “taking their jobs”. I also got to meet three women who have already graduated from GHESKIO’s NP program who are working as NPs at GHESKIO. All of the women that I met were amazing. They were all very motivated and open to improving the NP program and striving to provide the best care they possibly can for their patients. 

 

I returned to Samaria with a Clinical Officer, Waweru, in tow to staff Samaria for the week in Susan’s absence. Susan has an obligation to attend training and program review for her participation in Tunza the family planning program supported in part by USAID. If Susan is not able to find a substitute during her absence, then she must close her clinic. In this case it would have been for 4 ½ days, difficult on the patients and Susan’s income. Even so, engaging a substitute adds costs to clinic expenditures, that may or may not be recouped from leaving the clinic open. This underscores the difficulty that private clinic nurses have in taking time away from their practice if they are the sole practitioner. It is difficult to engage in continuing education, a must for any clinical practitioner, if the economics and finding a trusted substitute are onerous.

So off Susan went Monday afternoon to a suburb of Nairobi for her meeting. And then the rains began! Waweru and I were busy with patients until it was time for him to head home to Nyeri. I realized that this relative “city boy” came to Samaria without gum boots or an umbrella. He trudged out in the rain in his dress shoes for what turned out to be a 4 hour commute back to Nyeri. This trip in dry weather is about an hour. Happily Waweru showed up the next day despite the rain and the convoluted travel requirements to avoid impassable roads.                                    

Gum Boots

 Waweru and I established a good rhythm in seeing patients and had time to share reflections about our respective training and commonalities and differences, which I will address another time. It is still raining!                                                                                            

Eight am the next morning I am called by Waweru that due to a family emergency he would have to go to his family home in Nakuru. He was trying to find me a substitute but to no avail. Hmmm. Given my knowledge of Kikuyu, it was going to be a real challenge alone in the clinic. Susan made some noises about coming home but in the end, it was me with the frequent  translating services of her sister Nancy for those patients  who remained perplexed by my words. There is nothing like being thrown into the deep end to bring you up to speed. Oh yes it is still raining, so realistically Susan would be hard pressed to make it home.

Fortunately no real emergencies arrived at the clinic. Patients were gracious and patient with my attempts at Kikuyu and communicating with them. Others were forced to use their English skills that otherwise might not have had Susan been there. Oh yes, it is still raining- I introduced the term “raining cats and dogs” to the local colloquium that week. It is very impressive rain.The first two days alone were busy despite the rain and while I tried to establish a rhythm of seeing patients, assessing for health complaints, being the pharmacist to fill the medications I prescribed, collecting payments, and entering patient visit information in the various registers, as required by the Ministry of Health.                                                                        

The MOH required registers

The “Well Child Visit” crib is a good perch after a long day.

 

I did use the early morning re-reviewing the MOH guidelines for managing childhood illnesses for under 5 years and various reference books on treating worms, amoebas, malaria, and typhoid. I was very glad that I also brought my Sanford Guide to Antimicrobial Therapy. During nursing school I did not fully appreciate the wealth of knowledge this guide supplied, despite its impossibly small 4 point character font! My roommate during the summer also recommended a midwife’s pocket guide that proves to be illuminating for this family nurse practitioner.

Susan returned home Friday night after an adventurous travel home that required hitching a ride with an ambulance on the main road which in fact got stuck and required 13 young men to push it out, after Susan promised to pay them each 50shillings the next day.

I was asked by one of my male blog readers what do the men. Well, in this area many young men wait along dirt roads waiting for vehicles to get stuck. Once stuck the men negotiate a fee, usually 50 shillings, and then push the vehicles out of the mud and muck. Kenya’s unemployment is estimated at 40% (of 39M) of which a large percentage is “youth”, resulting in many idle young men. As you may recall, I was told by more than one man that the construction work on the dirt road that was causing all the stuck cars was too back breaking to be worth the 250 shillings a day for men, however apparently not so for women. Pushing vehicles pay more with less effort. Others are using motorcycles to provide taxi service for people and goods in the smaller communities, that has improved some men’s income. I have asked whether there are co-ed groups or men groups engaging in micro-lending projects as an alternative. In this area there is beginning to be interest by men but it is a challenge I am told to build trust among the male participants. I see lots of entrepreneurial opportunities for men and women, however, there perhaps a lack of mentoring by successful men or men in leadership roles to pursue some of those opportunities.

Back to Susan’s journey: Susan was dropped off by the ambulance to walk about a mile up a hill across farms and along the so called road to Samaria without gum boots. She made it by 10:30 PM. And yes,  it is still raining.  In fact, I was to return to Mariine Maternity Home and Josephine on Sunday the 3rd and was delayed until Wednesday because of the rain.  I did manage to take advantage of a break in clouds on Saturday and Susan volunteered to add a little color to my hair.                                                                                                                

 

                                                                                                                             

December 28

As I mentioned in my last post I’ve struggled with practicing as I’ve been taught and believe is best while also trying to respect how my Haitian counterparts were taught and what they believe is best practice.

There was a woman who came in in labor this week and when the doctor examined her he said that she would need an episiotomy (cutting the perineum to make the vaginal opening bigger) in order to give birth (this was long before the baby was even close to being at the perineum when something like that could really be evaluated). I had labored for most of the evening with this woman and thought of her as “my patient,” and was more than a bit frustrated at the prospects of her having an episiotomy. I told the nurses I was working with that I didn’t think she needed an episiotomy—and explained that in the U.S. the literature shows repairing lacerations is better than repairing episiotomies—and that if I caught her baby I wasn’t going to perform one. Needless to say, I was not allowed to catch the baby and she got an episiotomy (and actually had quite severe post-partum bleeding, I believe in part as a result of her episiotomy).

I know that the nurses where just doing what the doctor ordered them to do (as is appropriate), and that they believed that performing an episiotomy was best practice, but it was still very hard for me to watch. I however, see no easy way to reconcile our differences in practice. Although I’ve tried to talk to the nurses about why we in the U.S. don’t perform episiotomies (and various other practices), at least in this type of society behavior change needs to come from the top (i.e. the OB/GYN chief) and not the bottom (i.e. night nurses). And although I feel very strongly about the issue I’m reticent to go to the head of the OB/GYN department and try to lobby for such a change. Part of that that is me being scared and non-confrontational, but it’s also hard given that this is what is believed to be best practice and still taught in the medical/nursing schools, and I’m “just” a visiting foreign new midwife lucky enough to have been allowed to work at HIC for these 2.5 months. So, I’ve done nothing—except never perform an episiotomy and have had many moms with no lacerations (when I was told an episiotomy would be needed) or well repaired ones. I know that’s not enough and that I’m not serving my patients as best I can, but it’s all I feel comfortable with doing at this point. 

Reporting from Les Cayes, Haiti

December 22
 
As the providers at HIC (i.e. the nurses) have become more comfortable with me and my abilities I’ve slowly begun to help teach the nursing students who are present during my shifts. This week I got to help a couple of the students do deliveries, which were rewarding experiences, though ones I’m not (yet) totally comfortable with. In many ways I still feel like a student myself—I graduated from nursing school in May 2012 and this is my first job practicing as a “real” (as opposed to “student”) midwife—and so it’s a bit odd for me to already be put in a teaching role. That said, I really do enjoy guiding the students and helping them grow more confident with and skilled in catching babies.
 


Nursing students in uniform before their graduation


One of the hardest things about trying to teach here is that there are some birthing practices that are standard in Haiti that aren’t viewed as best practice in the U.S./developed world (i.e. they always clamp and cut the cord immediately, in the U.S. it’s recommended to typically wait at least 2 min, they perform perineal massage while pushing, in the U.S. that’s not recommended, they perform episiotomies very frequently, most midwives in the U.S. perform them very rarely). So although I may be coaching a student through a delivery, advising her using recommendations from the U.S., often times one of the nurses will “correct” the student and tell her to do something very different than what I’ve just said. So that is sometimes frustrating for both the student and me. I’ve now started saying, “in the U.S. we do this” and trying to explain why I recommend doing something “my” way versus the “Haitian” way. And after hearing my explanations and watching me practice, some of the providers/students are slowly adopting at least the delayed cord clamping, which I’m happy about.
 
This week I was doing the admitting paperwork on a woman who came in in labor. I know how to ask some basic questions in Creole (How old are you? What’s your name? How many babies do you have? etc) and so went through those with her.  For the more “complicated” question (Where were you born?) I switched to French, hoping she knew how to speak it—which she did. Her reply—Jamaica—surprised me, and prompted for me to ask her if she spoke English—which she did also. So throughout my night laboring with this woman we had conversations in a mix of Creole, French, and English, which made me smile. I know for Haitians and most people around the world speaking multiple languages is nothing exciting—and I mélange French and Creole normally with all my patients—but having that English thrown in (with her great accent to boot) was a treat.

Subscribe to our newsletter to recieve the latest updates.