Sunday, August 7, 2011

By Senator Bill Frist, MD
Chair, Hope Through Healing Hands

(WHF and Dr. Biden: 8.8.11)

Over 29,000 young children have died of malnutrition and disease in Somalia over the past 90 days. We are now on our way to the Horn of Africa to see what more we as a nation can do.

Early this morning, our plane left Washington DC bound for East Africa. I’m flying with Second Lady Dr. Jill Biden and USAID Administrator Raj Shah to study the famine affecting the lives of over 12 million people, many of them children.

In fact, it is now being called “The Children’s Famine.” 

Over the years, I have delivered medical care in refugee camps on a number of trips, both to camps in Darfur, in Chad (right on the border of Sudan), and in boy soldier camps in southern Sudan.  I went as a doctor. Providing age appropriate health care to the compromised and malnourished children and adults is crucial to combat rapidly spreading disease and death.

It begins with identifying the specific needs, which we will be doing, then ensuring access, which is a challenge especially in Somalia.

Aid agencies estimate that over $1 billion more is needed during this critical period to stop further deaths and get proper food, water, and health care especially to the children who are most vulnerable.

In the camps we visit, I will focus on the vaccinations given for measles, polio, and malaria; oral rehydration distributed to those suffering from diarrhea; and, vitamins for children to bolster their immune systems. These are simple, cheap interventions to fight disease in the malnourished.  I am eager to learn what is being accomplished and what more needs to be done.  America has done a lot which has lessened the unfolding tragedy in the region, but there is a lot more we can do to reverse the course underway.

We will learn much over the next few days.

I am on this trip to hear the stories of the families and their journeys, and I will share those stories with you. 

Please sign the ONE petition today to urge world leaders to provide the full funding that the UN has identified as necessary to help people in the Horn of Africa, and please keep your promises to deliver the long term solutions which could prevent crises like this from happening again.

by Megan Quinn
ETSU College of Public Health
Munsieville, South Africa

When thinking about public health in the developed world, we generally think about preventing chronic disease through behavior change.  However, in Mshenguville (the informal settlement/shack town in Munsieville), the public health needs are drastically different and much more basic.  One of the key issues in Mshenguville is the need for basic sanitation/waste management.  Illegal dumping around various sites in Mshenguville occurs because people do not think that there other alternatives and do not understand the consequences of poor sanitation. 

One particular dumping site is around the community water tap.  While this tap provides safe, clean drinking water, the environment surrounding it is ripe with health hazards.  The tap is surrounded by waste, including diapers, clothes, and general rubbish and serves as a food source for chickens and dogs.  Further, the tap does not have proper drainage and therefore provides a nice source of stagnant water for insects to breed in.  Luckily, malaria is not a major issue in this area due to the high altitude, however; other vector borne illnesses could potentially have high infectious rates during the warm summer months.  Not surprisingly, local have identified diarrheal diseases as a concern in this area of Munsieville.  Poor sanitation in this community elevates the risk for infectious disease, specifically in the vulnerable populations: children and the elderly.

With the assistance of the Councillor for this ward of Munsieville, Thapi Thage, and the local Community Work Program, we completed a community clean-up in this part of Munsieville on Tuesday July 26^th.  Over thirty people assisted in the clean-up and these efforts could aid over 250 people that live in Mshenguville.  However, the clean-up only served as a preliminary effort as we were not able to completely clean the entire area due to the immense amount of rubbish.  We need additional long-term, sustainable solutions to aid in providing proper sanitation and waste management to this community. 

Feedback from one of the focus groups we conducted with the children earlier this summer will be utilized to provide some solutions to this public health issue.  The children independently identified illegal dumping as a health related issue in their community.  The following solutions were listed: put a billboard up to signify “no dumping” in that area, put rubbish bins all over Munsieville, form a community worker program, provide a billboard that lists the rules of waste disposal and teaches people to take care of their community, require people to pay for the damage they are causing to their community.

Project Hope UK/The Thoughtful Path will continue working with Thapi and the municipality government to employ the solutions the children listed and provide the appropriate resources for proper waste disposal, including: trash bins for every household, community dumpster, and trash pick-up by the local waste management services.  Finally, community meetings in Mshenguville will be held to provide general education on waste disposal and the burden of disease due to improper sanitation, assess the community needs for proper waste disposal, and the barriers to effectively disposing waste.  Hopefully these efforts will provide a safe, healthy community and create a sense of pride for the people of Mshenguville and the overall Munsieville public.  Providing the basic public health needs in this community will effectively prevent infectious disease and reduce the morbidity and mortality of sanitation related diseases in vulnerable populations.      

by Omo Aisagbonhi
Vanderbilt University School of Medicine
Ogbomoso, Nigeria

We had orthopedic clinic today. Many of our adult patients presented with fractures secondary to road traffic accidents. The pediatric cases were more varied. Some of the patients seen included:

1. 2yo with hereditary neurofibromatosis; over here, neurofibromatosis is diagnosed clinically. The diagnostic criteria are the presence of two or more of the following: 1. six or more café-au-lait spots 5mm or greater in diameter; 2. freckling in the armpit or groin; 3. two or more neurofibromas of any type or one plexiform neurofibroma; 4. two or more Lisch nodules; 5. optic glioma; 6. distinctive bone lesions, particularly an abnormally formed sphenoid bone or tibial pseudoarthrosis; and 7. a first-degree relative diagnosed with neurofibromatosis using the above criteria. This two year old has several café-au-lait spots along with left leg hypertrophy, with left long being longer and wider than the right, due to both bone (femur, tibia and fibular) and soft tissue hypertrophy. She also has a lower limb deformity, genu valgus, which we plan to correct at a later date. Her mom has several café-au-lait spots (but no limb abnormalities) and her 5yo older sister has no café-au-lait spots, but hypertrophic left hand digits and left toes. Her mom and sister did not carry official neurofibromatosis diagnoses, but do now since she clearly has neurofibromatosis based on clinical criteria. Genetic tests are not readily available, but this is a classic example of variable expression routinely observed in autosomal dominant neurofibromatosis.

2. 4yo with club foot secondary to polio; we did her corrective surgery today. The surgery was interesting. First, we did an ETA (elongation of the tendo-achilles), in which the calcaneal (Achilles) tendon was identified and bisected in a Z configuration, then re-attached. Then, the bursa deep to the calceneal tendon was ruptured. Finally, a wedge resection of the cuboid was performed. Pins were placed to close the resected segment; subcutaneous tissue and skin were closed, and the foot was placed in a cast to help set it in the proper configuration.

3. 2yo M with bowed legs (bilateral genu varus). The big thing was to rule out Ricketts. This was assessed by checking for costochondrial rosary beading, wrist flaring and forehead bossing. The plan is to have him follow up in 6months. Follow up involves regular measurement of the intercondylar distance and varus angle; expect correction in physiological bowing. The orthopedic surgeons here have observed that an intercondylar distance <9cm is likely to correct itself with time; >9cm often needs to be surgically corrected.

4. 14yo with Blount’s disease (pathological bowing). She had very bowed legs that had been surgically corrected two other times in childhood, but became bowed as she grew. Plan is for one more correction in a year or so; she’s likely stopped growing and would no longer need corrections after this one.

5. 6yo with physiologic genu valgus expected to correct on its own with time; for valgus, the follow up is of the inter malleolar distance and valgus angle.

6. 2yo with foot drop and high stepping gait secondary to IM injection that caused damaged to the common peroneal branch of her sciatic nerve. Plan is for long-term physiotherapy and toe-raising splint.

7. 3mo with osteogenesis imperfecta which was clinically diagnosed on basis of neonatal femoral and tibial fractures as well as the presence of bluish sclera (she was compared to her healthy twin). This was quite interesting to me as I did not expect to see a child with OI in Nigeria. Anyway, the plan is to treat her fractures as they occur; babies with her type of OI (OI type I, not type II, which is so severe the babies die following the trauma of birth) usually do well as they learn to avoid doing things that will cause them injury.

8. 14yo with congenital absence of the R. proximal femur that walks by bending her left leg to compensate for the very short right leg; she appears to be kneeling/crawling as she walks, but she’s able to stand upright on the L. leg. The correction would be to amputate the R. lower limb and place a prosthetic; she does not want this.

9. Neonate with bilateral club foot due to congenital bilateral absent fibulas. We placed casts to begin serially correcting the clubbing.

10. 28yo with remote history of ectopic pregnancy, presented with bilateral hip pain. X-ray showed bilateral cystic lesions at the femoral head and narrowed interarticular space. We did a TB skin test (which is non-specific in this population exposed to BCG vaccine, but the more specific IFN-gamma release assay is also considerably more expensive), also sent her for HIV testing and her blood group was checked because people with sickle cell disease are prone to avascular necrosis of the hip (she’s AA). I think, given her h/o ectopic pregnancy, there is a likelihood of gonorrhea/chlamydia exposure and possibility of septic arthritis from gonococcus; but this would be an atypical presentation.

Later in the day, I attended morbidity and mortalilty conference where I learned that the most common admissions on the medicine service are due to cardiovascular/ cerebrovascular diseases and CHF; not infectious diseases though, in the month of July, one patient died of malaria and another of AIDS. Another thing that was interesting to note is that for some patients, cause of death ends up being undetermined. E.g. the case presented of a man who presumptively died of hypoglycemia secondary to metastatic liver cancer; assumed to have liver cancer because his liver enzymes were elevated and he had a bone tumor. However, he was initially diagnosed with bone TB in the ortho clinic, but did not receive TB treatment (again, here, TB diagnosis is non-specific due to BCG vaccination). He never had any scans to show or disprove liver tumor and did not have an autopsy at death. All we know is that he came to the hospital with hypoglycemia and his labs showed elevated liver enzymes. There is a need for better access to pathology.

by Megan Quinn
ETSU College of Public Health
Munsieville, South Africa

On Thursday July 14^th, 74 individuals came together and made the decision to change their lives and end hunger, malnutrition, and poverty in Munsieville , South Africa by planting gardens.  Many families in Munsieville struggle to have a well-balanced meal every day and building gardens will create a sustainable way to ensure that individuals do not have to go hungry.  Further, vegetable gardens will help to fight malnutrition in the children of Munsieville.  According to the World Health organization, malnutrition contributes to more than one third of all child deaths and can occur due to offering the wrong foods, inadequate breast feeding, and not ensuring that the child receives enough nutritious foods¹.  The people of Munsieville are going back to the soil to make sure their children and families are adequately fed and nourished. 

The 74 individuals were divided into 15 groups to begin building the gardens.  Group members will assist each other in building gardens at each of their houses and training other individuals in the community as well.  The keyhole garden method will be used to build the gardens in small spaces and use recyclable materials and water.  For more information about keyhole gardens, follow this link.  http://www.sendacow.org.uk/keyhole-gardens  Community members of Munsieville are very excited to begin this endeavor! Everyone should have enough vegetables to feed their families and maybe even sell the extras.  Additionally, once they start growing vegetables, some of the women would like to open a soup kitchen for the orphaned and vulnerable children in the area.

A few of the leaders of the community garden groups met on Wednesday, July 20^th to receive training about the keyhole gardens and develop plans to begin building.  These key leaders will assist us to ensure that gardens are built for all of the individuals participating in the program.  Additionally, we hope to utilize these leaders to train individuals to build gardens in other parts of Munsieville.    

We broke ground on our first garden on Friday, July 22^nd.  Roughly 10 women helped the “Star Garden” group build their first garden.   The women collected materials from around the community (bricks, straw, cans, and soil) and compost and seedlings were provided through donations from the United States.  This small garden, containing spring onion, beet root, cabbage, parsley, and spinach, will feed approximately 5-10 people and will change the lives of the owner and her family.  Further, plans were made on Friday for the next set of gardens to be built.  The women continued collecting materials over the weekend and plan to build several more gardens this week.  This small effort will make a huge difference in the lives of the community; providing healthy, nutrient rich foods to the people of Munsieville.   

1.  World Health Organization.  2011.   http://www.who.int/child_adolescent_health/topics/prevention_care/child/nutrition/malnutrition/en/  Accessed 7/22/2011.