by Rebecca Cook
Vanderbilt School of Medicine
Kijabe, Kenya

cook baby E

These last two weeks at Kijabe I've been working on the pediatric service. I've worked on a fabulous team in pediatrics. My main "partner in crime" is a Kenyan clinical officer who loves kids and has a tremendous fund of knowledge and experience. Between the two of us, we see all the patients every morning in preparation for team rounds, write their daily notes and orders, and see outpatient pediatric consultations and admit patients in the afternoon. Everyday we go on rounds with a short-term family practice volunteer doctor from the US with years of experience, and a brilliant Kenyan pediatrician who trained at the top national hospital in Kenya.

Although I didn't spend much time in the nursery, I also interact with the nursery team: an amazing American pediatrician who has spent the last 15 years working in rural Uganda and a pediatric resident from India with an incredible bedside manner. We round with a nutritionist or a nutrition intern who not only provide great plans in how to get our babies gaining weight, but also spend a lot of time with families, often informally serving as ad hoc social workers/counselors. One of the best aspects about working at Kijabe has been the diversity and richness of the people I get to work with and learn from everyday.

I've had an amazing range of patients from the "bread-and-butter" babies with bronchiolitis and viral gastroenteritis that are fairly easy to admit and care for, to some really sick little babies with multiple serious medical problems and some surgical conditions I may not see twice in my lifetime. These are the ones that you really get to know and worry about. One in particular is Baby E. He's a 7 month old baby who came to the hospital about a week before I started on pediatrics in a coma, severely dehydrated and really sick. My first day, he had just transferred back to our pediatric ward from the ICU and his condition was still tenuous. Baby E is Massai, one of the most traditional people groups in Kenya; his family lives in fairly remote part of Kenya and eeks out a living through raising cows. I cannot even begin to imagine what it is like for his mother to be in the hospital, a day's travel away from her 8 other children for 3 weeks, she definitely had her moments of discouragement, but at the same time she displayed incredible graciousness and generosity to me as her "baby's doctor."

One morning when I came to examine Baby E she said, "I want to give you a Massai blessing," reached out her hand and gently slid a vibrant beaded Massai bracelet onto mine. Baby E was still in the hospital when I left and to be honest, I don't know his long-term prognosis, he has devastating neurologic sequelae. We were very honest with his family about the extent of the damage and that we did not know how much he would recover in the long-term. I internally struggled in caring for baby E with the tension between providing the standard of care for this individual patient and taking into account the tremendous financial and social burden on this family, especially when the ultimate outcome was so uncertain. By advocating that baby E stays in the hospital to get the oxygen and nutrition support to give him the best possible chance of recovery, what am I doing to the 8 other children this family has at home? Their mother is not with them to care for them or feed them and they are accumulating a hospital bill that is possibly even more than a year of this family's average income. These are impossible dilemmas and it was easy to become discouraged. At the same time, I had to keep reminding myself that despite the hardship for the family he is my patient and my greatest obligation is to do what is best for him.

My final afternoon at the hospital I had a glimmer of hope for baby E. I saw a three year old girl in the outpatient pediatric clinic who had been severely ill at 5 months of age with tremendous neurologic damage but who was now not only still living, but was thriving; she had some muscle weakness on one side of her body but she was a happy, playful three-year old . I hope and pray that this will be true for baby E.

Despite the numerous challenges in the US health care system and the fact that I have taken care of many patients in America without insurance and with tremendous needs, my time in Kenya has been the time of greatest personal awareness (and anguish) of the limited resources of my individual patients and the impact on their care. I have learned good lessons about being creative and ways to reduce waste; I have also had more personal heartache over my patient's dilemmas that I hope will shape the contributions to individual and population level care I have in the future.

by Rebecca Cook
Vanderbilt School of Medicine
Kijabe, Kenya

I've spent my first 2 weeks at Kijabe Hospital working on the internal medicine team of the men's ward. Inpatient medicine at a tertiary care hospital is a quite a change of pace from rural primary care at Lwala. We have more diagnostic and treatment abilities, but also "sicker" patients. The variety in what I've seen has been tremendous – everything from the "bread and butter" medicine cases I see in the US like COPD, CHF, and diabetes but also lots of infectious diseases (HIV/AIDS, TB infections in every manifestation (brain, lung, abdomen), meningitis). I've taken care of men as old as late 80s and as young as 15 (the cut-off for pediatrics here is 12). I work on a team with a medical officer intern (equivalent of an intern in the US), a clinical officer (equivalent of a nurse practicioner/physician's assistant), along with two family practitioners that come on attending rounds with us once a day and are there for "back-up" if we need it. Besides my amazing patients, my favorite thing about Kijabe is the people I work with. The medical intern and clinical officer on my team are really bright, hardworking, and compassionate Kenyan women; they have tons of experience, especially with physical diagnosis skills and they're a pleasure to work with. The hospital always seems to be at or above capacity, basically our 80-bed men's ward almost always has beds in the hallway. The wards are fairly public with 10 beds in a room. The advantage is that many times when I get stuck with language I have a built in interpreter in the bed next door, or if I'm trying to gauge the progress of one of my patients a brain infection and altered mental status, his neighbors will chime in and tell me how he's doing. They often times really look out for each other. Yet this "built-in" community does also bring the challenge of maintaining confidentiality and privacy for patients; for example when a patient is newly diagnosed with HIV, they often have not yet decided to disclose their infection to their family, much less the stranger in the bed next door.

A few firsts for me this month:

-Being the one to share with a previously healthy 51-year old police officer that he has advanced cancer, follow him and his wife through 10-days in the hospital while stabilizing him from acute kidney failure only to have him pass away while traveling to the national hospital for chemotherapy

-Performing my first lumbar puncture (and second, and third)

-Seeing my first case of rheumatoid lung, TB pericarditis, HIV cardiomyopathy, cryptococcal meningitis, thyrotoxicosis, among others....

Sometimes the limitations in terms of nursing staff, diagnostics, or therapies are frustrating. At the same time, I'm amazed by how much can be done, and how often patients and their families fill the gap in care. Once a week all of the hospital staff gather for a chapel service and I've found this time to be important. It's a time when titles don't matter, when the lab tech and a nursing student may be leading the singing, and we're all just there to renew strength and hope when we reach our own limits.

Senator Bill Frist, M.D. is board member of the Kaiser Family Foundation.

The Kaiser Family Foundation has released a collection of new resources examining global health and HIV/AIDS funding in the Obama Administration’s budget plan for fiscal year 2012.

On global health, a new fact sheet breaks down the $9.8 billion in the budget request for the Administration’s Global Health Initiative (GHI), a proposed six-year, $63 billion effort to develop a comprehensive U.S. government strategy for global health. The fact sheet reviews proposed funding for the initiative, including breakouts by program area (HIV/AIDS, malaria, etc.) and by agency, including trend data where available.  It also examines support for the President’s Emergency Plan for AIDS Relief (PEPFAR).  The Foundation also has updated its Global Health Budget Tracker to reflect the President’s proposed fiscal year 2012 budget; the tracker will be updated to reflect changes as Congress considers and acts on global health appropriations.

A second fact sheet examines the $28.3 billion in proposed funding for HIV/AIDS programs both within the U.S. and overseas.   On the domestic side, the fact sheet breaks out support for programs that provide health care, drugs and other services to people with HIV or AIDS, as well as prevention and research funding.  The global budget examines spending for HIV/AIDS through bi-lateral and multi-lateral efforts.

In addition, the Foundation has updated the relevant Kaiser Slides charts to reflect the President’s budget proposal.  The charts can be downloaded for use in presentations or slide decks.

The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible information and analysis on health issues.

by Steve Badger, M.D.
Vanderbilt International Anesthesiology
Kijabe, Kenya

badger kenyaLate one evening about 4 months ago, Josephine, a 31 year old Kenyan female, was riding home from a long day of work on the back of a motorcycle. An oncoming vehicle swerved directly in front of her to pass another vehicle. As the motorcycle swerved to avoid a collision she was thrown to the ground, severely fracturing her right ankle. She was taken to the hospital, where she underwent surgical repair of the ankle. Following the operation, she continued to have pain and weakness, to the point that she could not bear weight and had to walk with a crutch. After a repeat evaluation, she was referred to Kijabe Hospital, in Kijabe, Kenya, for ankle fusion.

Kijabe hospital, a mission hospital located an hour northwest of the capital city Nairobi, has a vast number of medical missionaries from all over the world serving the residents of the area and training locals in the practice of medicine and surgery. One of these missionaries, Dr. Mark Newton, is the only full time anesthesiologist in the region, and runs a training program for Kenyan Registered Nurse Anesthetists. The hospital, which is one of the most respected mission hospitals in the country, relies on donations of time, financial support, and supplies in order to maintain an exceptionally high quality of care. One such donation came approximately one year ago, in the form of a state-of-the-art ultrasound machine used specifically for the practice of regional anesthesia (peripheral nerve blockade). Ultrasound guided regional anesthesia is an advancement that is relatively new in the United States, and unheard of in East Africa. Though the overall resources and supplies in Kijabe are slim, hundreds of patients have benefited from improved post-operative pain control with the practice of peripheral nerve blockade, which involves injecting local anesthetics around large nerves of the arms and legs causing a portion of the limb to become numb. A single injection can last 15-20 hours, during which time it can provide complete pain relief following a surgical procedure. When the local anesthetic effect subsides, patients begin taking intravenous or oral pain relievers to control their pain.

Josephine, as mentioned above, had a severely injured ankle and was to undergo a very painful surgical procedure. We were readily equipped to provide excellent pain relief for her for 15-20 hours with an ultrasound guided peripheral nerve block, but we knew that when the block wore off she would still be in severe pain. Luckily, some supplies had just been donated to the hospital by Dr. Randy Malchow from Vanderbilt University Medical Center, including some peripheral nerve catheters, which allow the anesthesiologist to leave a catheter near a nerve and either attach it to a pump for a continuous local anesthetic infusion or give repeat daily injections through it while the patient remains in the hospital. Peripheral nerve catheter placement is an advanced form of regional anesthesia - many medical centers and university hospitals in the U.S. have yet to develop such programs - but through generous donations even a remote hospital in Kijabe, Kenya has the ability to provide this service in special situations, such as Josephine's. The decision was made to place a popliteal sciatic nerve catheter, which was done just prior to her going to the operating room. She then underwent operative fusion of her ankle. Following surgery, her ankle was completely numb and she had no pain. She was smiling from ear to ear because she remembered having terrible pain after her previous surgery. The following morning, her ankle remained numb, and she continued to have no pain. She was surprised at how well the nerve block continued to work. Later that day, she began to feel the numbness subsiding, and started to feel some gradually increasing pain in her ankle. A second dose of local anesthetic was injected through the nerve catheter that was taped to her leg and her ankle again became numb, with her pain disappearing completely. The nerve catheter remained in for 3 days following surgery, during which time she recieved one daily dose of local anesthetic and remained very comfortable, always smiling and thanking us for helping her. When the catheter was removed on post-operative day 3 and the numbness resolved, her pain was only mild and was able to be controlled well with oral pain pills. She was extremely satisfied with her experience.

It is amazing to realize that medical advances have progressed to the point that patients are able to undergo normally very painful surgical procedures with only minimal pain. What is even more amazing is that through incredible generosity by so many individuals these advances are able to be shared with patients like Josephine, living in a remote location such as Kijabe, Kenya.

See how the Clinton Bush Haiti Fund's grant to Inveneo is empowering rural and underserved communities in Haiti with information and communications technologies.

Their grant will accelerate the development of sustainable, high-speed wireless broadband connectivity to 20 population centers in six rural regions across Haiti, which will in turn stimulate economic growth and support decentralization of the country. Inveneo works with several Haitian ISPs to deliver training programs that will prepare its partners to manage and take full responsibility for the network. Inveneo also provides training programs for Haitian Information and Communication Technology (ICT) entrepreneurs.

Visit www.ClintonBushHaitiFund.org to get involved.

See how the Clinton Bush Haiti Fund's grant to YouthBuild International, partnering with IDEJEN, will put young people back to work in Haiti and give them the skills necessary to rebuild their country.

The centers will serve at-risk youth (ages 16--28) by providing them with vocational training in construction and leadership skills for the future. The grant will also be used to provide a two-to-one match of trainees' savings contributions, support leadership training for the Build Back Better Youth Corps. The program also provides six months of follow-up support as trainees seek viable employment opportunities or pursue self-employment.

The first training center, JENKA, was built in Leogane, the epicenter of the earthquake where nearly 90 percent of the buildings were destroyed. This first of 12 centers is where the project's local implementing partner IDEJEN (Haitian Out of School Livelyhood Initiative) is now recruiting staff and students.

Clinton Bush Haiti Fund money enabled YouthBuild to get construction underway quickly while other projects in Haiti have stalled due to funding delays.

Visit www.ClintonBushHaitiFund.org to get involved.

See how money from the Clinton Bush Haiti Fund has provided sales and marketing support for local artisans.

Their funds also helped these local business people rebuild their workshops, damaged during the earthquake. Through our support, artisans were able to complete their order to Macy's for its exclusive "Heart of Haiti" collection, inspired by the courage and culture of the Haitian people.

Clinton Bush Haiti Fund's recent loan to Fairwinds Trading, will expand this support to artisans in three additional communities and increase employment opportunities for Haitians — particularly women. This could sustain the employment of 740 artisans and artisan managers and provide secondary employment for 185 additional individuals.

Follow-up orders from Macy's could provide income to support 4,544 individuals.

Visit www.ClintonBushHaitiFund.org to get involved.

February 15, 2010

Tuesday night Senator Frist was in New York at an event for Harvard Medical School, "Conversation: Exploring Global Health." Moderated by 60 Minutes' Byron Pitts, the event was a conversation about the history and direction of global health with Dr. Paul Farmer, who among other things leads the Department of Global Health and Social Medicine at HMS and co-founded Partners In Health one of the most influential, visionary and effective international humanitarian organizations, and Dr. Joia Mukherjee, who was just named the Director of Global Medical Education and Social Change at HMS. Listen to the whole thing or just the first few minutes for my introductions.

by Emily Matos, charity:water

Below is the three month update for breaking ground in Uganda, Liberia, and Ethiopia with funding we raised through The Water=Hope Campaign on the Brad Paisley H2O world tour.

Spread the good news!

Amount granted to charity: water

Country

$5,000

 UGANDA

Project Start date

Status

October, 2010

In Progress

           

 

Country Overview:

Uganda lies in Central West-Africa with Lake Victoria as its only water source. Uganda is a landlocked country surrounded by Kenya, Sudan, DRC, Tanzania, and Rwanda.

Northern Uganda, specifically, has suffered from a 20-year rebellion led by the Lord's Resistance Army (LRA). The insurgency has displaced approximately 1.7 million people in the Acholi and Lango sub regions. There is now relative peace in the North as the LRA has abandoned its efforts in Uganda and has moved the conflict to the Democratic Republic of Congo, South Sudan and Central African Republic. As the threat of attacks on Ugandan citizens has diminished, many Internally Displaced Persons (IDPs) have had the opportunity to return to their home communities to try to rebuild their lives.

Region Overview:

Water=Hope campaign funds will serve a community in the Lango Sub Region of Uganda. Through a comprehensive Water, Sanitation and Hygiene (WASH) program, our local partners aim to reach the communities in Northern Uganda that were displaced during the LRA insurgencies, specifically those in the Lango sub regions. These sub regions were devastated by the conflict and the many communities faced prolonged displacement. Those who are returning home to these communities face extremely impoverished conditions, including lack of access to clean water and proper sanitation facilities.

 

Amount granted to charity: water

Country

$5,000

 ETHIOPIA

Project Start date

Status

October, 2010

In Progress

Country Overview:

Ethiopia is one of the 11 poorest countries in the world. Landlocked in the Horn of Africa, Ethiopia borders Eritrea to the north, Sudan to the west, Kenya to the south, Somalia to the east, and Djibouti to the northeast. The country's economy revolves around agriculture, which in turn relies on rainfall that is inadequate, unpredictable and uneven in its distribution.

Ethiopia averages 40% clean water coverage across the country, with higher rates of clean water clustered in cities and larger towns. In rural parts of the country one in three people have access to clean water while only 13% have access to adequate sanitation services. At any given time it is estimated that half of the country's population of 80 million people is suffering from an unnecessary water-related disease, and more than 250,000 children under the age of five die each year from diarrhea.

Region Overview:

Water=Hope campaign funds will serve a community in the Tigray region of Ethiopia. Tigray is the northernmost region of the country and is home to more than 4 million people and has less than 50% clean water coverage. While water availability varies greatly across the region, the majority of Tigrineans obtain their water from rivers, ponds, streams, and unprotected springs. They also have to share these water sources with livestock and wild animals, which results in a dirty, tainted water supply.

Amount granted to charity: water

Country

$5,000

 LIBERIA

Project Start date

Status

January, 2011

In Progress


Country Overview:
 
Liberia, located in West Africa, is rebuilding after a fourteen-year civil war (1989 – 2003) that destroyed what little infrastructure there was in the country. The conflict claimed the lives of approximately 150,000 civilians and internally displaced over 1 million people.

Post-war, the international community has rolled out a major humanitarian program to help stabilize the country and bring much needed emergency support to the population. Central to the long-term recovery plan is to provide essential facilities and restore basic social services in both urban and rural communities. Water points were among the many structures destroyed during the war and slow progress is being made yearly to rebuild access to safe drinking water and basic sanitation services. 80% of the population is still under employed and 76% is living below the poverty line on less then one US dollar/day.

Region Overview:

Water=Hope campaign funds will serve a community in Nimba County Liberia with clean and safe drinking water. Nimba County is in the North East of the country and has long borders with Ivory Coast and with Guinea's forest regions. Many communities in the Nimba County are remote, underserved, and have limited or no access to basic health, sanitation, clean water or other services.

by Rebecca Cook

Vanderbilt School of Medicine

Lwala, Kenya

rebecca cook

One of the unique aspects of the model of Lwala Community Alliance, is that while there is a clinic, the program is multi-dimensional, there is also a strong water, sanitation, and hygiene program (WASH), a education initiative that partners with schools and helps to provide secondary school scholarships based on academic merit and need, Umama Salama, an initiative to train community members on basic lifesaving skills to reduce maternal and infant mortality, and a sewing cooperative. The clinic staff goes on school outreaches at local primary schools which includes health education and free preventive care.

I've had the chance to participate in the training-of trainers in the WASH program, wrote the malaria curriculum and have attended the roll-out trainings for the Umama Salama initiative, and have attended two school outreaches with the clinic staff. I've loved the opportunity to interact with individuals outside of the context of the formal clinic setting. Community members often have more candid discussions about community issues and health-related questions they have than they may when they visit as a patient. This week, I was at an Umama Salama (safe motherhood) training attended by men and women ranging from late high school to grandmothers, some were pregnant or with young kids, some were leaders in their community. One of the attendees came with some powerful persuasion from neighbors essentially because they wanted her to get medical care. They asked me to talk with her. She was cachectic with a rattling cough and became short-of-breath with talking. I learned that she'd been sick for months but had resisted going to the hospital for multiple reasons, including fear, stigma, as well as financial and family burdens. While we don't provide medical services at trainings, we were able to build enough trust to get her to come to clinic and overcome the practical barriers with the help of her friends mobilize a motorcycle ride to the health center since she was too weak to walk the 30 minutes. While this was happening, the training continued; participants first learn the lessons through verbal teaching and drawings, and then the messages are reinforced with role-play, which they really get into.

The community work at Lwala, both in terms of educating and empowering people to prevent disease as well as enabling them to be informed advocates who can capably identify illness and assist in bringing patients to appropriate care will ultimately have the greatest impact on the health of this community.

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