Transfusion Medicine in Africa – SADC Visits Part I (February 24, 2012)

James Kelley, PhD, MD (BWH Clinical Pathology resident)

The Southern African Development Community (SADC) is a group of nations in southern Africa that share information, infrastructure, and trade regulations to spur regional growth and prosperity. Being based in Johannesburg, as the home office of my host organization (Safe Blood for Africa) and the home of the busiest airport on the continent, I toured the national blood services of SADC countries to learn about transfusion medicine in Africa, compare their capabilities in both urban and rural settings, and offer medical/technical advise when appropriate. Such a trip also allowed me the opportunity to teach blood safety to many clinicians, as this is a topic rarely discussed in medical training. Blood safety is particularly important in a region with high levels of transfusion transmitted infections (TTIs) such as HIV, hepatitis, and malaria. The WHO reports that only 43% of national blood services routinely test for these infections.

Lesotho – The Lesotho Blood Transfusion Service (LBTS) is based on a back hallway of a shopping mall in Maseru, their capital city. The main entrance to this shopping center was full of people selling phone cards, live chickens, fruit, lingerie, and tires. The manager of the LTBS is an exceptionally capable woman, who has led numerous improvements in the service including introduction of disease and compatibility testing. Their service collects and dispenses approximately 7,000 units per year from regional centers and blood drives. (For reference, BWH averages 68,000 transfusions per year.) The LTBS does not have a medical director to oversee or consult on operations, which complicates communication with other physicians and advising the Ministry of Health on needs. One striking feature of their blood service is that in the past five years, they have had no transfusion reactions, which occur in >1% of blood transfusion recipients in the US. Upon asking an internist in the hospital about the possibility of under-reporting or lack of awareness regarding reactions, I was told “God was generous to the Basotho people; we are very strong and do not have such troubles.”

Mauritius – The Mauritius Blood Service has impressive human capital with a clinical pathologist at the helm. They have an aggressive and innovative donor recruitment program that helps them deliver 45,000 units per year to an island nation of 1.2 million people. One constraint of working in a sovereign island setting is the isolation. Producing enough critical mass for training laboratory technicians, biomedical engineers to repair equipment, and medical specialists is difficult. For example, there are no clinical hematologists on the island. They also have surveillance programs for TTIs uncommon in the US such as Chikungunya. I was able to deliver their version of grand rounds, which is shared among all specialties, and discuss clinical use of blood.

South Africa (outside of Johannesburg) – I visited the National Bioproducts Institute located outside of Durban, which is the only fractionation facility in the continent. It was interesting to see how plasma is pooled by the thousands of liters and used to produce coagulation factors. I have also visited a rural hospital located in Piet Retif (Mpumalanga) in order to compare with the hospitals in Johannesburg. Again, I was able to discuss and lecture the medical staff on transfusion medicine. They were very concerned about the availability of blood products, which was surprising to me given the highly efficient South African National Blood Service (SANBS) located in Johannesburg. There are difficulties though in a rural setting, as the nearest blood bank to this hospital is a 3 hour round trip, which makes obtaining blood in an emergency difficult.

Swaziland – The Swaziland National Blood Transfusion Service produces 10,000 units per year in amazingly well equipped facilities. King Mswati III, their absolute ruler, has made friends and diplomatic recognition with the Republic of China (Taiwan). In return, they have provided advanced medical facilities including a four-story state of the art building dedicated to the blood service and new ICU facilities across the country. Swaziland lacks though in the human resources capacity to use fully these physical buildings completely. I was able to visit their main service, tertiary referral hospital, provincial hospital, and blood collection drives. Swaziland has one of, if not the, highest HIV prevalence in the world at 35%. They have to limit their blood donors to those under 18 where the prevalence is about 2%. This raises interesting challenges as all collections are at high schools and in donor clubs during the holiday periods.

Next stops … Mozambique, Botswana, and Namibia

Outcomes, HPV status, and Attitudes among American Indians in South Dakota with Head and Neck Cancer

He Sapa Wacipi (Black Hills Powwow)

Our first community event was the Black Hills Powwow, a cultural gathering with dancing, singing, and socializing. I am working closely with the Walking Forward Program, which is a community based participatory research program working to increase cancer cure rates for American Indians. Over the course of three days we administered over 100 surveys and performed 41 head and neck screening exams. 

Grand Entry for the Powwow

My husband setting up the screening booth

Dr. Petereit, a radiation oncologist, and director of the Walking Forward Program and I

A participant and I in the screening booth

My son after all the hard work 

Sunshine Dwojak, MD, MPH
Harvard Program in Otolaryngology

Amputation in Tanzania

I am a general surgery resident at the MGH who recently returned from a two week trip to Tanzania.  I kept a blog while I was there and it can be accesses here.

An American Pathologist in Malawi: Settling into a Rhythm

            It is always just a matter of time for someone to get used to his or her surroundings.  Even far away from home, I’ve come to establish a routine for my days.  The Malawian sun rises around 5:30 AM, seemingly perfectly timed to the cacophony of cawing crows and barking neighborhood dogs.  After enjoying some local breakfast of “Jungle Oats” and coffee, I take the short walk to the College of Medicine and arrive around 8:00 AM.  On most days, the slides and paperwork await.  On other days, there are no cases in our inbox for one reason or another.  There have been a few days where the college has lost water or power (or both), leaving the histology technician helpless to prepare the daily cases.  Even if the cases are ready, we need electricity to power the light in the microscopes and the computers to generate our reports. 

I’ve come to consider these issues to be minor hiccups in the lives of pathologists here.  This is compared to pathology back in Boston, where losing water and power aren’t usually an issue.  However, the routine problems encountered in Malawi are replaced by a slough of other issues that exist in the majority of larger institutions with more equipment, staff and cases (misplaced slides, misplaced paperwork, crashing computer servers, etc.).  It is sobering to see that no institution is perfect, regardless of the size of the facilities.

Cutting surgical specimens with a
Malawian pathology registrar

            I have become used to other aspects of the Malawian department as well.  For example, I have settled into the method of teaching here.  There appears to be much more hands on training in the laboratory in the first years of medical training.  The medical students and rotating residents (called “registrars”) here are eager to learn, both at the grossing bench and the microscope.  I must admit it is quite enjoyable to watch them approach pathology with such enthusiasm. 

            By now, we have completely caught up with the backlogged workload, and are examining specimens that were taken just a few days ago.  Furthermore, my initial shock and awe at the severity of lesions biopsied here have subsided, allowing me to settle into a rhythm of diagnosing cases relatively comfortably.  We, as BWH pathologists, are very fortunate in that we have expertise available back home for unusual cases.  (We already have sent a few cases back to Boston to be looked at by the BWH subspecialty pathology services.)  For this reason, I have been afforded the opportunity to start an interesting teaching collection of rare cases to show my colleagues back home. 

            This has been once-in-a-lifetime experience so far.  I feel that my contribution here in Malawi has been worthwhile up to this point, and I have seen how much I can produce given the limited resources.  Accepting the challenges here and taking this worthwhile experience home will certainly help me overcome any challenges at home. 

Kevin Golden, MD/PhD

PGY-5, Surgical Pathology Fellow

Outcomes, HPV status, and Attitudes among American Indians in South Dakota with Head and Neck Cancer

Why does a trip to South Dakota qualify as Global Health?

Because certain populations within the United States have health outcomes that are as poor as those in the developing world. With average life expectancy five years lower than the average American, (72.6 years vs. 77.8 years), American Indians & Alaska Natives (AI/AN) suffer from significant disparities in health. Major medical centers, specialty care, and even primary care are frequently multiple hours away, effectively making this population as isolated and underserved as those observed in other parts of the world.

Cancer is one aspect of health where American Indians fare especially poorly. While cancer death rates for other Americans have been declining in recent years, AI/AN death rates have remained the same. In particular, American Indians in the Northern Plains (North and South Dakota, Nebraska and Iowa) have cancer mortality rates that are 30% higher than the rest of the US population.

My project is working to quantify these disparities for American Indians in South Dakota with head and neck (H&N) cancer via a chart review. Stage at presentation is one of the most important factors for cancer survival, and AI/AN historically present with later-stage cancers. To help understand why, I am also administering a survey at two large community events to gauge knowledge of the risk factors and early signs and symptoms of H&N cancer. Alongside the survey, we are offering a free head and neck screening examination.

Sunshine Dwojak, MD, MPH
Harvard Program in Otolaryngology

Landscape near the Pine Ridge and Rosebud Sioux Indian Reservations

Implementation of basic oral health care delivery systems in Haiti (Trois)

Cap Haitien, Haiti

Since the rocky start at the Justinian, I'm pleased to report that the rest of the clinic days were largely a success. As part of the mobile dental clinic program, we visited a variety of clinical sites including Limonade, a girls' orphanage, and Shada. The Tauzin Clinic in Limonade, a municipality about an hour from Cap Haitien, was accessible by tap-tap, the communal "taxis" in which passengers are transported in the bed of a sometimes decorated pick-up truck. We set up the clinic in a large barn used for a judo club, with four stations for patient care. A sterilization table was designated, and instruments were sterilized with a betadine soak and heated in a kitchen pressure cooker. Universal precautions were a bit of a reach, as we had no barriers and supplies were very limited. Patients were lined out the door, as they had arrived very early in the morning to take a number for treatment. It became quickly obvious that access to care was a major issue for the patient pool in this community, as many of them had extremely poor oral health care and presented with acute issues. We mostly performed extractions with this population, and a number of the children presented with abscesses and cellulitis. Pediatric care was quite a challenge in this clinic setting, as I could not employ the usual psychology and distraction techniques used in the States due to a gap in communication with my French and the locals' Creole. At one point, several of the Haitian dentists had to bolster down a screaming, kicking 7 year old as I extracted her grossly decayed teeth and drained her abscess to prevent it from manifesting into an airway-compromising submandibular space infection. Another point of contingency was the inability to check blood lab values before performing extractions, especially with patients that exhibited extensive post-op bleeding. With most of the adult population, who likely also suffered from multiple undiagnosed and uncontrolled systemic issues, I was uneasy to proceed with extraction without relying on my usual boundaries of INR and absolute PMN values. I have to admit that while we used Surgicel and sutured to obtain primary closure, I would have preferred to have some sort of follow-up with the patients. I wondered how they would get care if complications did occur, seeing that the hospital was over an hour away and transportation was oftentimes too expensive to afford.

Food For the Poor orphanage was another clinical site where we treated orphaned girls ages 3-13. Most of the children lost their families due to the 2010 earthquake or TB/HIV. We were informed that a number of the girls were affected with pre- or perinatal HIV. There were approximately 50 girls in the orphanage, divided into 4 buildings with one house mother per building. We set up in a similar manner with stations. For this demographic, I was surprised to find that most of the children were nourished, well cared for, and exhibited decent oral hygiene. Most of the treatment was through atraumatic restorative treatment and preventative sealants using a novel effective material- Fuji IX glass ionomer. This is a durable self-cure fluoride-releasing resin that I have only recently had experience with in using with our stem cell transplant and chemo patients who require elimination of all infection prior to admission. This method of restoration only required one instrument and a simple base-catalyst set up and resulted in efficient and effective outcomes. Hand instrumentation of decay was a elegant answer to a clinical setting with no access to water or electricity, much less a high speed turbine drill. Though this method does not remove 100% of the bacteria, the literature has shown that by sealing off the lesion with Fuji, the hope is that the oxygen required for the intraoral aerobic bacteria (namely S. mutans) would be eliminated and therefore demineralization arrested.

Perhaps the most poignant clinic site visited was the neighborhood of Shada, the most impoverished community in Cap Haitien and, in my experience, the worst living conditions that I have ever encountered in my travels. Children made up the large majority of the population, with a number of them exhibiting dental abscess and facial trauma. We treated over 70 patients, while having to turn down another 30 due to running out of essential supplies and materials by the end of the day. Walking through the village, one waded through excrement and trash, and were followed by a mob of children barely clothed. At one point I was looking into the river filled with the neighborhood waste, and noticed that all of our biohazard materials- contaminated gloves, gauze, sharps- were all dumped by the locals into the only source of drinking water in town. It was an appalling and moving sight, as I knew that there was no infrastructure for garbage removal nor way of dealing with sewage and sanitation. I remembered how I had been cautioned that the experience of Haiti would be a rollercoaster of highs and lows, wins and losses, and the recognition of how difficult life is in Haiti with the Creole saying: "beyond the mountain there is another mountain." It is with these observations that each of us must carefully construct our own framework and understanding of this country to share with the international community.

Haïti est une terre de grande beauté et grande souffrance. Piti, piti, wazo fe nich li.

[Haiti is a land of great beauty and great suffering. Little by little the bird builds its nest.]

Transfusion Medicine in Africa: Johannesburg, South Africa

James Kelley, PhD, MD
Department of Pathology
Brigham and Women’s Hospital

Like most visitors to southern Africa, my first stop goes through Johannesburg – the “city of gold”. This megalith of 7 million people conjures images of apartheid and armed home invasions; however, the people are as friendly and warm as its summer weather. After all, this is the home of Nelson Mandela and the World Cup. Everyone I meet welcomes me to South Africa and seems genuinely interested that I enjoy visiting their country – even a man walking down my street with an AK47 on his shoulder did not rob me but simply said “whatzit” with a smile.

Jo’burg is a city of contrasts: I have visited townships where ninety families share one portable toilet and have browsed through shopping malls with Gucci and Prada. I am living in Sandton, a northern suburb that generates over 10% of the GDP for all of Africa. The wealth, quality of living, and flashiness here make Boston look like a poor provincial town. My guesthouse has a large garden with digital cable, wireless internet, and uniformed maids cleaning and cooking for me. Not the typical global health experience. However, it resembles a self-imposed prison situated behind a ten-foot concrete wall with electrified fence that hums like a mosquito zapper.

Of the multitude of things on offer in Johannesburg – transfusion medicine is one that is limited. It doesn’t really exist as a field in Africa. Physicians who specialize in blood banking are usually internists who took an interest in the subject and learned informally. There is only one postgraduate program in transfusion medicine on the continent, and it is a distance learning part-time course.

Given the paucity of formal blood banking expertise, I was curious as to how blood banks function given the financial constraints, government corruption, widespread transfusion transmissible disease prevalence, and cultural attitudes in Africa. I am lucky to be hosted by an organization, Safe Blood for Africa, a non-profit group based in Georgetown with their operational office located in Sandton. They have networked me with various hospitals and blood services throughout the continent to visit and experience the realities and challenges of operating a transfusion service in Africa. I am also working with them to help develop educational programs for training clinicians in proper blood banking practices.

Trauma bay at Milbank Hospital (Johannesburg, South Africa).  This is a private hospital that caters to those who can afford private medical insurance and foreigners.

They have told me stories of aggressive surgeons barging into a blood bank and taking a unit for transfusion without appreciating that the ABO group did not match and of nurses hanging a bag of blood for a child, transfusing half the unit, putting it back in the refrigerator in non-sterile conditions, and then transfusing the rest of the unit to another patient later in the week. Both resulted in fatalities. Developing programs to educate clinicians could save numerous lives.

The first stop on my tour was the South African National Blood Service (SANBS). This organization has resources and expertise atypical of the rest of the continent. The medical director is a board certified internist trained in Washington. Their standard of care is more similar to what we offer in the US. They perform serological and nucleic acid testing for HIV, HBV, and HCV on all donors, reducing the risk of transmission to about 1:400,000 transfusions. (We advertise rates of 1:2,000,000 at the Brigham with our procedures; however, we don’t have a HIV prevalence of 20% in our general population.) They separate blood components and provide advice to clinicians across the country regarding transfusion reactions and blood products.

I was able to watch their testing and component processing and compare it to our procedures at BWH – all were very similar except their equipment was slightly older. Their physicians also remotely oversee therapeutic apheresis and stem cell collections, which will be driven back to their main offices, processed, and driven to the recipient’s hospital for infusion. I observed the apheresis clinics and again found their equipment and protocols almost identical to what we use at BWH. However, I am assured that the standard available in South Africa and Johannesburg in particular is not typical of the rest of the continent. I am excited to find out for myself ….

Therapeutic apheresis clinic in Auckland Park (Gauteng) South Africa.  We had just finished a hematopoietic stem cell collection.

Implementation of basic oral health care delivery systems in Haiti (Deux)

Cap Haitien, Haiti

Today we packed our supplies and equipment and headed to the clinic in the Justinian University Hospital about 10 blocks away.  The Justinian is the main public hospital in town with 250 beds serving almost a million people in northern Haiti. 

At the oral maxillo-facial surgery/dental clinic in the Justinian, my site mentor had set up an educational day session where we train local Haitian dentists and nurses in restorative techniques practiced in the States.  We dragged in box after box of materials, equipment, and supplies and eagerly dove into seeing the waiting room full of patients.  It didn't take long for the day to take a downward turn.  Let me explain.  Modern dentistry in America is a smorgasbord of products, with every procedure requiring specific instruments and materials.  You want a simple clear filling?  Of course, just go get the high speed drill, low speed drill, 330 bur, 245 bur, #6 round bur, 2% lidocaine with 1:100,000 epinephrine, 20% topical benzocaine, local anesthetic syringe, 27 and 30 gauge needles, cotton tips, 2x2 gauze, patient bibs, high speed suction, low speed suction, air/water syringe, mirror, explorer, endo ice, barrier tape, Fuji liner/base, mixing spatula, mixing pad, curing light, phosphoric acid etch, Optibond Solo, applicator tip, A3 Herculite composite, plastic instrument, Mylar strip, wedge, composite finishing burs both flame shape and football, college pliers... and yes, this is the basic setup for one restoration.  All these materials need to be laid out and prepared before the actual procedure due to the setting times of the materials resulting in a race against the clock.  Imagine the flurry of activity in the small, two-chaired room as we realized mid-treatment that we were lacking essential instruments and materials in the very specific procedures we were performing.  This was complicated by the malfunction of the overhead lights, compressor breakdowns, and a flood of constantly leaking water, which resulted in moisture leakage in restorations requiring dry fields.  A primitive "sterilization room" was set up across the hall, but mostly we wiped down handpieces et al with extra masks and a dollop of Purell.  In addition, most of the restorations we performed were heroic efforts to save what remaining structure was left in symptomatic patients who essentially needed more complicated procedures but could not due to time, supply/equipment limitation, and finances.
Facial trauma also fell under the auspices of the clinic, as seen in the photo below of a woman 4 days s/p motorcycle accident.  The local dentist explained to us that in the past 3 years, motorcycle usage and thus accidents had increased exponentially in Cap Haitien.  For this patient with a through-and-through philtrum/upper lip and infraorbital laceration, only one interrupted 1-0 nylon suture was available to close the lac.  Having just come from rotation at MGH oral maxillo-facial surgery, it was a different world to say the least.

In addition to the mechanical complications, the dynamic between our team and the local health care providers had to be handled with utmost delicacy, as we were careful to emphasize a symbiotic learning relationship instead of imposing a foreign "know-how" attitude.  At the end of the day, all the biohazard waste was dumped outside next to the steps of the clinic.  Our team looked at each other, defeated.
We had a long discussion with our site mentor, who revealed that this day was constructed to reveal the gaps in our approach to public health, specifically when we apply our American protocols to a situation that cannot be translated in Haiti.  Despite our best intentions, a 30-piece setup with reliance on dependable water, electricity, high technology, and sterile fields are not completely reasonable nor at times appropriate.  Sometimes it is necessary to forgo our strict tutelage and employ a more practical philosophy.  It is the unspoken rule in Haitian healthcare- rules are meant to be broken.
This was further emphasized during dinner with a local urologist, who told us stories of water leaking from the ceiling into his sterile field in his ORs, making molds for amputees' leg prosthesis from 2-liter coke bottles, and chickens running through the surgical wards of the hospital.  He told us how after 20 years of work in Haiti, he leaves every trip questioning his contribution and purpose.  It is after days like this and conversations like this that make me understand Haiti and the draw of Haiti more- that this piece of land with its complicated history, politics, and tensions makes it into the Rubik's cube of the public health universe.

Implementation of basic oral health care delivery systems in Haiti (Un)

Cap Haitien, Haiti

Bon jou, s'ak passe, salut.  There are many ways to greet someone in Haiti, a true mélange of cultures and opinions in one small but electric country.  Haiti has been a "hot topic" in a variety of forums- international media, politics, and of course inside the walls of the Brigham.  As a longtime Partners in Health fan and global health enthusiast, my goal is to investigate the process of implementing an oral health delivery system in Haiti that is sustainable, appropriate, and affordable to deliver.  Using the World Health Organization guidelines as set forth in the highly under-used Basic Package of Oral Care as our model, we hope to merge education and direct care in one program that integrates the local population but can be applied globally.  Additional aims of this directive are as follows:
Ensure that the oral health care provisions established are sustainable by training local Haitian nurses to be dental assistants.
Implement and utilize the Atraumatic Restorative Treatment method, which allows for restoration of dental decay in basic accomodations without electricity or water-dependent equipment.
Provide direct oral health care to Haitian residents including emergency relief, preventive care, and comprehensive dental services.
To establish a continuing education, referral, and teaching center for the North Haiti Dental Association (NHDA) doctors.
Vision and supplies were packed into checked luggage and I set forth to Port-au-Prince, a maze of rebuilding and tent cities slowly regenerating two years after the devastating 2010 earthquake complicated by lack of infrastructure and a cholera outbreak.

Port-au-Prince: Cholera public service announcement found on most public buildings in Haiti.  From the capital, we flew on a verified joyride to our site in Cap Haitien on a small 15-seater over the mountain ranges Massif du Nord and Montagne Noires.

Re-usable airline ticket to Cap Haitien.  The airport consisted of a one-room terminal.  The waiting room for the airport was outdoors.  We were transported to and from the airport in the bed of a pick-up truck, which was actually a delightful experience.
I was told by a local source that there are approximately 10,000 NGOs in Haiti, with a good portion operating in Cap Haitien, a large city nestled between mountains and sea in the northeast of Haiti.  We were de-briefed on our program and schedule of visiting several clinical sites in addition to various didactic lectures. 
From my time in Cap Haitien thus far, I have made a few observations about this dynamic culture.  One, there is a palpable charisma throughout the entire place that understandably attracts the international community.  Two, there are no trash receptacles to be found, and every type of disposable waste ends up on the street, in the ocean, or on the beach [picture below].  The grime on the streets is in stark contrast to the dignified manner and careful grooming of the Haitian people, best visualized in church, which is well-attended.  Religion is engrained in the core of the culture; when driving down the street one passes "Lord the Savior Auto Repair" and "Jesus Christ the Good Shepherd Barbershop."  Walking down the circus of dirt roads, you hear the roar of motorcycles narrowly dodging pedestrians, the smell of petrol and burning, and the coating of dust all synthesized together in a term my site mentor coined as "a potpourri of poverty."  However, I have seen such developmental potential in Haiti as we passed by miles of pristine beaches, leafy mountains, and quaint landscape ripe for economic opportunity.  The situation here is truly unlike any other that I have seen in previous global health experiences in Nicaragua, Bolivia, China, and Botswana.  I am both intrigued and energized to immerse myself in this clinical and educational experience.

An American Pathologist in Malawi: A Tale of Two Cities

Kevin Golden, MD/PhD

PGY-5, Surgical Pathology Fellow

The infrastructure for most of Malawi’s pathology is set in the country’s two largest and most populous cities: Blantyre and the capital, Lilongwe.  They are separated by 366 kilometers of mud-soaked highway, speckled with farming villages and local markets along the entire route.  This translates to about a four and half hour bus ride, which doesn’t seem like a long length of time to squeeze into the seat, unless that person (me) was six foot five.  Nonetheless, outside of my leg falling asleep and the bus having to swerve around the occasional stray goat in the road, our journey was an uneventful one. 

Pathology laboratory in Lilongwe

The hospital in Lilongwe is set at the top of a hill overlooking part of the city.  We, as pathologists, don’t have a large amount of daily exposure to patients, so our tour started and ended in the pathology laboratory.  I entered the lab with similar expectations as to what I had seen while working for the last two weeks in the College of Medicine in Blantyre.  I quickly found out that this was not the case, however, as this pathology lab looked something like out of a catalog: clean, shiny metal workbenches with all new automated equipment, imaging software attached to the computer, and, as spoiled as this sounds, air conditioning.  (Although the open-air pathology sign out room in Blantyre has a nice cross breeze in the afternoons, there is something about a cool 73 degrees that allows one to have better focus on the task at hand.)