Thoughts on two weeks of rural primary care in Mexico

Update: I go to Jaltenango today enroute to Refoma, the second community that I am working in.  From what I understand, it is both more rural and yet closer to Jaltenango.  It is apparently also a community of many Jehovah's Witnesses.  

My last night in Laguna was marked by an after-dark walk to the pantheon/cemetary to try and get phone reception in order to talk to the main office about a case.  All the lights are gone, which is unsurprising after the three days of gloomy cold rain.  It also means that I haven't showered in two days because it is too cold to envision an icy bucket bath.

I've learned a tremendous amount about how I have (mostly subconsciously) learned to practice medicine by being here.  Today, we had a female patient who has a history of gallstones and who clinically seems to have progressed to pancreatitis.  As usual, the question arises of whether she is safe to stay here in the community until Monday, when her family can take her to the local hospital with surgical capabilities.  And the answer as to whether she is safe, as with so many things here, is that I haven't a clue.  I know how to risk-stratify pancreatitis in a hospital, where I can get labs and imaging.  I can fearlessly quote mortality statistics.  Here, I'm fairly certain of our diagnosis, but without the laboratory confirmation that I've learned to rely on, I feel paralyzed with doubt on how to treat people.  My pasante is so much more fearless, having gotten used to trusting her instinct without needing multiple (or any) forms of confirmation of her clinical instinct.  Somewhere in the middle is probably best for patients.

How can I tell how likely it is that our patient's chest pain is angina without ever getting an EKG, or lipids?  What is the pretest probability in a rural Mexican farmer who has never smoked but who probably inhaled tons of smoke in an indoor kitchen?  How do I treat him without access to a stress test?  How applicable is the Framingham Risk Score (or pick your favorite) to him?

I've learned that, in the absence of the screening tests that the majority of my patients get, I tend to suspect cancer at every turn.  I blame this in part on three years at BWH, with all our Dana Farber patients.  But in every abdominal pain in an older man, I see colon cancer and I fret about every woman with pelvic pain having cervical cancer.  I hadn't realized how much comfort I personally take in having an easily accessible screening panel.

In addition, so much of my practice at home is based on not missing anything.  We will get chest x-rays and labs for the lowest probability events.  So often, we use the language of 'ruling something out.'  Here, as testing is so hard to come by, you have to be pretty darn sure that you need something before you make someone travel.  

In my last day, we had two children who clinically looked like they had hepatitis A (one of whom's mom actually said, "his urine looks like coca-cola and his eyes are yellow."). How many kids in the past two weeks with diarrhea and abdominal pain actually had hepatitis?  Are we sitting on an outbreak?  Do you need the serological confirmation?  All these questions are new ground for me.

On an unrelated note, here's my pasante, myself, our neighbor's daughter and one of a thousand local dogs.

-Sarah Kimball, MD

Health related graffiti in Jaltenango, Mexico

I'm a total sucker for health-related graffiti.  There seems to be an HIV educational campaign in Jaltenango, which makes for some amusing artwork.

"HIV/AIDS.  Bring me, look for me, use me!"

"HIV/AIDS can only be aquired by means of sex and blood.  And a mother can transmit the virus to her child during pregnancy, delivery and breast feeding."

And my personal favorite:

"If you want to have sex, you should protect yourself with a condom."

-Sarah Kimball, MD

Primary Care in Chiapas, Mexico

Some of these posts are backdated, due to poor internet access in Chiapas.  But in short, thanks to funding from the Partners Center of Excellence, I'll be spending the next month in rural primary care clinics in Chiapas, Mexico with Compañeros en Salud, the Mexican arm of Partners in Health.  While I work on my Spanish (starting from a place of fumbling with many years out of practice), I'm hoping to get a sense of how primary care is practiced in a place where routine health exams are not the norm, and where people come without good access to the health care system.

My role here is as a medical consultant to the Mexican pas antes who are stationed here for a year.  They do six years of schooling, including a year of hospital training.  As a payback to their community (because medical school is paid for by the government), all pasantes do a year of community service.  My first post is in Laguna de Cofre, high up in the mountains of Chiapas, and about two hours from Jaltenango.  We have a small house next to the clinic where my pasante and her nurse live along with anyone else who comes along and needs a place to crash, like me.

On our first day, we left Jaltenango at 7am and headed straight for clinic, as the line was already getting long by the time we arrived at 9:30  From what I understood from my broken, aching Spanish, today's clinic included (in semi-medical speak)

Pts 1-4: pregnant mother and there kids, there for HIV testing.  Kids negative, mother positive.  Presumably from father, who travels back and forth to Tiajuana for work, as HIV rates are quite low here. 

Pt 5: well pregnancy check

Pt 6:  woman with pain in multiple parts of body, likely from stress.  IUD placed. 

Pt 7: woman with RA, who was getting dexamethasone injections and developed Cushings Syndrome and diabetes.  Now off steroids, but in lots of pain.  No clear other medication options available.

Pt 8: 60 yo man with exertional chest pain. No EKG or stress test easily available.  No clear idea of protest probabilities without lipid testing. Opted for nitrate trial diagnostically.  

Pt 9: 70 y.o. man with hypertension and vision changes.  As a side note, he was as tall standing as I am sitting.  

Pt 10: 70 y.o M with hemorrhoids and hearing issues.  Clearly no colonoscopy, but they have hydrocortisone suppositories with lidocaine in them.  Brilliant!

Pt 11: hypertension and sore throat

Pt 12:  well pregnancy check.  23 year old with three other children

Pt 13: sick kid (eeek! I don't know what to do with kids!) with diarrhea.  Fortunately, the wonderful

Pasante that I am working with knows kids may better.

Pt 14: teenaged boy with facial dermatitis

Pt 15: urosepsis in a 70 y.o. man with a permanent supracatheter.  Looked bad.  IV fluids, abx, monitored, no labs.  Will see tonight and tomorrow (he lives across the street) to make sure he doesn't need to be shipped to a local hospital (which he almost certainly does, but it is such an issue here to make happen)

Pt 16: told by a naturalist doc that he had bladder inflammation that he healed.  Wanted to talk to someone else, which is good because the story didn't make sense.

Pt 17: young girl with diarrhea

Pt 18: very depressed 15 y.o. girl who walked 2 hours to get to clinic.  Her problem is, in short, that she is a female in a a village in Chiapas without the ability to get out.  Not something sertaline will help, but that was what we had,

Pt 19: 19 y.o. lady with constipation

Pt 20: 15 y.o who was pregnant.  Wanted an abortion, but it is illegal in this state.  More about that later, which I find baffling and angering.

Off to this spot, which is my bed for the next ten days.

And our kitchen, which is barely functional but doesn't really need to be.

-Sarah Kimball, MD

First Aid Response Training in Mbrarara, Uganda.

Uganda 

Arriving in Rwanda

After a 3 yr hiatus, I am getting back on the road (or plane if you will). Last time I was abroad, I was so anxious to one day be able to go back into the world with a little knowledge under my belt. My year abroad taught me so much, but it was frustrating for me to not have the medical experience to be able to give back. I was a little medical student following the Senegalese/ Laotian resident around. I am now returning as an MD. A little baby MD with training wheels still on, but a Doctor nonetheless.  I am very excited but also nervous to get back on my travel horse. Although I have traveled a great deal, it is still scary to jump on a plane to a unknown land and culture. Here we go once again!

 May 2, 2014

 I started of my adventure with a 21 hour journey from Boston to Uganda (Boston -> Amsterdam -> Rwanda- > Uganda), which was followed by another 13 hours on the ground until I reach my final destination of Mbarara, Uganda. I arrived into Kampala, the Ugandan capital, at 10pm. It was a surreal experience to be setting foot in Africa again. My first hour here, from the airport to the hotel, was one giant flashback. It made me truly miss Senegal. I have kept Senegal very close to my heart since I left. It will forever be my first time in Africa and first time I went out into the world completely on my own. Uganda had big shoes to fill. As I walked out of the airport, all I could see and hear were the Senegalese taxi drivers yelling to get your attention in French and Wolof. I remembered those butterflies in my stomach, the sweat in my palms, and the feeling of my heart racing that I felt when I first landed in Dakar 3 years ago. I was so scared back then. All I kept thinking was to keep walking forward and seem as calm as possible, when all I really wanted to do was crawl in to a little ball and be teleported back home with my Momma. This time it was different. I knew what to expect, and my appearance of calm was not a facade but reality. It made me a little sad.  You only get to have your first kiss once, and you only get to be a 24yr old girl during her first time in Africa once too. As I looked up and saw the million stars in the sky, I smiled and thought to myself, “ Hi

Africa, I’m back!” Uganda is very beautiful. Senegal is in the middle of the Sahara, so it was nothing but desert and Boaboa trees. Uganda is dead center on the equator. It is about 80 degrees year round, so it is very green, a little humid, and filled with valleys.  All the nervous feelings I had as I prepared for my trip disappeared on my way to the hotel. It was like riding a bicycle. I immediately adjusted to the stores on the side of the road, the aluminum roofs, and old concrete or brick. The familiar smell of 1970s cars mixed with fresh air and old world was all around me. I was thinking of how wonderful it was to be able to come back to such a beautiful part of the world, when we arrived to the hotel gates with a security guard holding a machine gun the size of a small child. It was reality reminding me of where I was in the world.   

May 6, 2014

Mbarara

It has barely been 2 days, and I already feel like I have been here a week. Right away it is very obvious that this trip is unlike any trip I have taken. I have always gone abroad to study or work on a project.  Yet, my trips have always been focused on me learning. Even when I have gone abroad to complete a project, no one was depending on my results for anything. The expectation was that I get out as much as I could out of the trip and my experience in order to further my knowledge that specific field or topic. This trip is different because I have very real responsibilities. There are both Ugandans and Americans that are depending on my work and the results I obtain. It feels like the first trip of the rest of my life and career. I feel like my previous trips were done in preparation for this trip and the work I will do from now on. It is both daunting and very exciting.

May 7, 2014

A&E = Emergency Department

Working in the A&E ( accidents and emergencies), which is the Ugandan version of the emergency department is going to be such an incredible learning experience. I have been working hard these last 2 years as a resident to learn as much as I could and gain as much experience as possible as a clinician. It has been a very steep learning curve. Going from an oblivious little intern to now an up-coming PGY-3, the difference in my skills as a doctor are incredible.  On my first day of residency, it took me an  hour and a half to see and complete the evaluation of my first patient. I still remember his face, the room he was in, and his chief complaint. I was so scared to prescribed Tylenol because I knew that if I put in the order, the nurse would actually give it. It wasn’t like medical school, where everything is practice and things have to be approved by your senior resident or attending. Although I had plenty plenty of support and help if I needed it, my orders for medications and interventions would actually be given. Anyway, so I went from getting butterflies from prescribing Tylenol  to being able to confidently treat septic patients,  

Procedure Room

strokes, doing intubation, placing central lines, and ordering medications that could rapidly and drastically alter someone’s physiology as well as having the ability of being responsible of as many as 15-20 patients at the same time on my overnight shifts. I still have a lot to learn, but the difference is mind-boggling. 

Type and Crossing

 Well, I came from that back to step one again. Being here in the Uganda A&E, I don’t know where any of the medications are, how the system works, the extent of the capabilities of the department, or how to simply write a note. My first day, it took me 2 hours to complete the evaluation and admission of 1 patient. Obviously, some of that had to do with how the system works, but the intern had to talk me through how to write a note and work up a patient. I felt like a day 1 intern all over again. I was learning more from the Ugandan doctors and interns than they were learning from me. Me, the American doctor being trained with “advanced” techniques and was here to teach them a few things! Because they do not have the tools and technology we have available to us in the west, they rely mostly on their skills as clinicians and physical exam. It is an art that is quickly fading in the west due to our growing reliance on technology.  

Blood Bank

I needed it, my orders for medications and interventions would actually be given. Anyway, so I went from getting 

It reminded me that I have to always be paying attention. There is no difference between me and the 13yo boy I say in the A&E the other day, who was hit by a boda boda. He came in with a head injury, cuts, and a very large open wound that involved the entire left side of his abdomen. He was lucky because it didn’t involve the part of the body that keep your organs and intestines inside. He was sutured up and discharged home later in the day.

May 8, 2014

I wake up at 630am-7am every morning and have not been able to go to sleep until about 11pm every night, not much difference than my days back in the US. Well, I little different. I don’t think I will have to take-on strings of days/weeks of getting 5-6hrs of sleep per night.

I have already had two amazing experiences. On Tuesday, I tagged along with a field team who deliveries HIV medications to rural communities. We drove out about 1 hour from Mbrarara into the tiny huts and houses that are in the middle of banana plant fields and miles from anything remotely modern. It was awesome!! I was honored to be the guest into their homes and sit in the one chair or bench of their home. The houses are usually made of clay, using old palm tree leaves as the structure backbone of the clay walls. The roof is usually made tin or dry palm leaves weaved together.

View of Mbarara Regional Referral Hospital

Today, I accompanied one of the internal medicine residents who is also here to a rural clinic that was 4 hours away from Mbarara. In order to get there, you have to drive through Queen Elizabeth National park, which is the main game reserve here in Uganda. There we were, making a very ordinary drive out to the clinic while seeing elephants, water buffalo, water bucks, and exotic birds on the way. No big deal. Just another part of our day! I couldn’t help but laugh and smile about the life I am lucky enough to live. 

The clinic experience was eye-opening. These patients are so far away from any major city, that this clinic is all they have for medical assistance.  There is no doctor. There is a chief medical officer, who was trained for 3 years after high school and is responsible for every patient, and a team of nurses. The clinic has a catchment area of about 40, 000 people, so it is no small task. He is able to work with limited medications to treat diseases that would require entire medical teams in the west. It was very humbling.

May 11, 2014

This first week was all about getting to know my environment, the people, the culture. I spent months trying to plan out my project, but it is so different to actually arrive and to start doing it. The beginning stages of organizing the first aid course have started. I have a specific plan of action. The program coordinator, Sarah, has been here for about 2 years so she knows the system very well. I had the curriculum and overall concept of the course planned out in my mind, but she is helping me adjust it to the setting in which I am working. Next week will be very busy. We are implementing the course in 8 days. It is not a lot of time to implement a course that I have never executed before in a setting that I am just getting familiar with. Yet, I know that we will get it done. We are going to start off small. We are planning to have only 40 participants this time around. My hope is that this course will grow and develop to become a city-wide event. 

Central Market

Chickens for sale at market.

Roadside Rest Stop

Elephant on my way to rural clinic.

Lake Bunyonyi

Ugandan kids

Healthcare for All at Hospital San Carlos, Altamirano, Chiapas, Mexico

With the incredible nuns of Hospital San Carlos.

The evening prior to my departure from Altamirano, the Hospital San Carlos nuns invited me to join them for dinner in their community.  As I mentioned in my prior entry, they are a truly incredible group of women.  Each has unique and important responsibilities in the daily functions of the hospital.  Among them include: Sor Rosario, determined hospital director and fearless leader; Sor Edith, wise clinical supervisor and xray technician; Sor Genoveva, director of nursing and nursing education; Sor Paz, pharmacist; Sor Consuelo, near to my heart, head pediatric nurse; Sor Rosaura, head medicine nurse; and Sor Anita, the most senior of the group, tireless nurse anesthetist.  Though each came to Catholic sisterhood through distinct paths, they all share a deeply religious and loving dedication to the poor and marginalized.  A story they shared that evening highlights the irreplaceable role that they and the Hospital play in providing care to so many families throughout Chiapas amidst a sea of barriers:

During a weekend when I had taken a respite to visit the Mayan ruins in Palenque, a gravely ill five year old girl was carried through the doors of the hospital by her parents in the middle of the night.  She was in severe respiratory distress, with a fever, and a concerning murmur, likely decompensating from pneumonia superimposed on a previously undiagnosed congenital heart disease.  Francisco, one of the several new physicians spending his year of social service at the Hospital, immediately called Carlos, an outstanding family medicine physician from Spain who has served as the hospital pediatrician for several years. The patient was rapidly stabilized and survived the 3-4 hour long journey to the pediatric subspecialty hospital in Tuxtla Gutierrez, where she was intubated and placed on a ventilator. Francisco formed a special bond with the family, who, like him, spoke the indigenous language of Tzotzil.  Later the following week, he received a phone call from the parents, informing him that their daughter had died after several days of medical care. They had been profoundly impacted and upset by a question that a Tuxtla provider had asked them, “Why did you take so long to bring your daughter to the hospital?”  Perhaps a sign of a provider having trouble coping with the injustice of losing a young life, or perhaps willful ignorance with regards to daily injustices, including poverty and discrimination, faced by the indigenous communities of Chiapas.

Hospital San Carlos serves as a safe, accessible, and culturally sensitive and acceptable provider of inpatient, outpatient, medical, surgical, pediatric, and OB/GYN care for indigenous as well as autonomous communities throughout much of the state of Chiapas.  Of course, resources are limited.  Plain films and basic labs (which do not include cultures) are available during the day as well as at night in the case of emergencies. Bedside ultrasound skills are acquired by some of the physicians over time.  Outpatient subspecialty referrals can be challenging, whether due to lack of patient resources or long wait lists.  Inpatient transfers, such as for neonates who may need CPAP or intubation, are at times refused by the referral hospital due to lack of beds. 

One segment of the infant and toddler's unit.

Caring for patients in both the inpatient and outpatient pediatric units was truly an excellent clinical experience.  In addition to a handful of newborns, we typically had somewhere between 3 and 7 inpatient pediatric patients.  Admission diagnosis were reflective of two the top five killers of children under five globally, acute respiratory tract infection and acute diarrheal illness.  Probably about a third of infants and toddlers were admitted with bronchiolitis, pneumonia, and a surprisingly high proportion of bronchodilator-responsive bronchospasm, perhaps secondary to indoor air pollution from firewood use.  Another third were admitted with dehydration in the setting of viral gastroenteritis, dysentery, and parasitosis.  These diagnoses certainly have parallels with those that most commonly lead to admission to MGHfC; however, the superimposed stunting and/or wasting among most of the patients clearly demonstrated how chronic and acute malnutrition might contribute to 50% of under-five mortality around the world. 

I learned a number of infectious disease-related clinical pearls during my month: one should assume that all children with severe acute malnutrition have a severe bacterial infection whether or not they have signs or symptoms such as fever; iron repletion for anemia should be deferred until treatment of bacterial infections (e.g. infectious enteritis, see: BMJ 2002;325:1142) has been completed, as there is a theoretical risk of worsened infection; congenital tuberculosis exists (see: N Engl J Med 1994; 330:1051-1054); and the management of fever without a source in well-appearing newborns/infants in the absence of culture data can rely significantly on clinical suspicion. 

Abnormal L5

The remaining one third of admissions encompassed an interesting mix of subspecialty issues. These included: a 12 year old boy with anasarca, ascities, pericardial effusion, and pleural effusions secondary to nephrotic syndrome; a 3 year old girl with >50% partial and full thickness second degree scald burns, one week out from injury, who was transferred AMA from government hospital; a 7 month old boy with tachypnea since birth and failure to thrive, without murmur, but certainly with a yet undetermined congenital heart defect, admitted with worsened respiratory distress; a 3 month old girl with severe stunting, presenting with vomiting since birth, found to have hemoglobin of 4 and guaiac positive stools; an 18 year old boy admitted after intentional ingestion of Gramaxone (aka Paraquat), an almost universally fatal herbicide without effective treatment nor antidote; and a full term, newborn boy with perinatal asphyxia, low apgars, who developed clinical seizures on day two of life, requiring phenobarbital.  I also encountered a good deal of developmental delay, including a 2 year old boy who presented to clinical with a URI and who apparently could not walk, stand, nor really sit appropriately.  He had bilateral ankle clonus, lower extremity spasticity, bilateral Babinski, and these apparent findings on physical exam and plain film:

Violaceous mass over lower lumbar spine.

Hospital de Especialidades Pediatricas - Tuxtla, Gutierrez

I was frequently left with the desire to teleconsult my MGHfC attendings and fellows and, in fact, did speak with one of our wonderful cardiologists, Dr. Manuella Lahoud-Rahme regarding one of our CHD patients.  Wait times for consultations with subspecialists at Hospital de Especialidades Pediatricas are often prolonged, and the prospect of enduring the costs and opportunity costs of travel make the trip all the way to Tuxtla Gutierrez prohibitively expensive for many families.  Performing an echocardiogram while Dr. Lahoud-Rahme watches via Skype, is just one example of the potential for telemedicine to advance access to subspecialty pediatric care at Hospital San Carlos.

Helping Babies Breathe - Workshop 1

In addition to the clinical and community-oriented aspects to my trip, I spent some time working in the realm of formal medical education and quality improvement.  I gave a chalk-talk on a variety of neonatal health issues for the physicians during one of the biweekly morning conferences.  This was perhaps more of a learning experience for me, as my audience helped me grasp the many adaptations necessary to take care of newborns in a low resource setting. Continuing with the theme of neonatal health, Dr. Jennifer Kasper and I prepared an abbreviated Helping Babies Breathe^© training for nurses, nursing students, and auxiliary staff at Hospital San Carlos, in collaboration with Sor Genoveva. 

Nursing students at their capping ceremony.

There were 42 participants who attended one of two, two-hour sessions that focused on the Golden Minute of life and practicing scenarios with NeoNatalie newborn mannequins. About 3 weeks later, I was able to schedule a follow-up refresher session, and while this landed at the tail end of vacation week for the nursing students, 31 learners participated in the workshop, including 10 new participants.  While I had intended to perform OSCEs to evaluate effectiveness of the first workshop measuring retention of knowledge and skills, this was ultimately not feasible in light of time and resource constraints.  Subjectively, the students expressed that they very much appreciated the opportunity to reinforce and practice their skills.  I could see that many were more prepared to revive their mock newborn patients, and to do so within the first minute of life.  The second session also gave me the opportunity to fine-tuning practices that I had observed in the delivery room during my month, for example: not delaying bag mask ventilation to attach oxygen to the self-inflating ambu bag and acting upon an emergency plan (i.e. calling Carlos) at the first sign of trouble, whether fetal distress or difficulty with ventilation. 

Carlos (pediatrician in-charge) and I.

Lastly, I worked with one of the hospital administrators and Carlos to create a self-evaluation tool for the pediatrics unit that could be used to highlight and select priority issues for quality improvement.  Drawing from hospital standards from the WHO, the Mexican General Health Council, and other resources, the tool asks doctors and nurses to respond to questions relating to seven themes using Likert scales: professional communication, medications and errors, rights of the hospitalized child, involvement and education of families, evaluation and treatment of pain, hygiene and prevention of infection, personnel and equipment, and trainees and continuing medical education.

I truly hope that I will have an opportunity to return to Chiapas and to Hospital San Carlos.  My upcoming fellowship program in pediatric emergency medicine is affiliated with two hospitals, UCSF and Highland, who send attendings and residents to San Carlos.  Now that I’ve had a chance to reflect on my trip, it’s time to get busy thinking of next steps.  Next steps in strengthening the Hospital’s referral capabilities, perhaps via telemedicine … next steps in ongoing capacity-building in skills such as neonatal resuscitation and pediatric ultrasound.  I’m so grateful to all my new, amazing colleagues in Chiapas, the sisters of Hospital San Carlos, Dr. Jennifer Kasper, Dr. Juan Manuel Canales, and Doctors for Global Health, who together made this experience as enriching as it was.  Many thanks as well to MGHfC Pediatric Residency Program and the Partners Center of Expertise in Global and Humanitarian Health without which this incredible experience would not have been possible.

Ashkon Shaahinfar, MD, MPH
MassGeneral Hospital for Children
Pediatrics, PGY3

The Spatial Epidemiology of Malaria - Part 2

In my previous post, I described the striking variation in the RDT positivity rate seen among different villages of the Bugoye sub-county. For example, from the village of Bugoye, we observed that 30% of RDTs were positive for malaria, while from the neighboring village of Izinga, the rate was more than twice as high. In fact, patients from Izinga accounted for nearly 20% of all positive RDTs at the health center. These differences suggest that local malaria transmission has a significant spatial component. In order to understand these trends, we must first understand the geography of the sub-county.

Cows crossing the Mubuku River near the Bugoye Power Station

For the last six months, my partners from the Mbarara University of Science and Technology (MUST) and I have been using GPS devices to construct a map of the sub-county. Guided by members of the local community, we record the locations of village health workers, community leaders, and health centers, in addition to outlining political boundaries. We have journeyed hundreds of miles up and down the hills and valleys of the sub-county. On the narrow paths, we have learned a lot about life in the villages in ways we had not been able to understand or appreciate before. In doing so, we have gained new insight into malaria risk factors, infrastructure challenges, and health-seeking behaviors.

Last week, we visited Izinga. At the bridge over the Mubuku River, we met the village health team that would lead us around the village. As we walked, we learned that Izinga was essentially a low-lying island situated between the Mubuku and Kitakena Rivers. In addition, a spillway for the hydroelectric plant supplying power to the nearby cobalt mines runs directly through the village. These features make the village particularly prone to seasonal flooding. The cold, fast-moving rivers are normally unsuitable for mosquitos, but when the water surges over its banks, it creates thousands of pools of warm, stagnant water that are ideal breeding sites.

Woman walking across damaged bridge over the Kitakena River

In May 2013, massive flooding devastated many areas of the Kasese District, which includes the Bugoye sub-county. Tons of mud and stone came crashing down through the valleys, destroying everything in its path. Thousands of residents from places like Kilembe, where the district referral hospital is located, were displaced. The sheer force of the floods cut new paths through the earth, changing the course of Mubuku River and washing away homes, livestock, and crops. As the water receded, once arable areas were turned to “swamps.” Unfortunately, the flooding has affected more than just agriculture. Compared to the previous two years, more patients from Izinga are being admitted to the health center for severe malaria. At this time last year, immediately before the flooding, patients from Izinga accounted for only 7% of inpatient admissions for malaria. This year, they account for 20%.

The town of Kilembe after massive flooding in May 2013

The case of Izinga is a classic example of how geography impacts human health. Geography, however, is not destiny. One need only to recall the devastation that Hurricane Katrina wreaked upon the city of New Orleans to know that Western Uganda is not unique in its experience with natural disasters. The difference is the resources. In New Orleans, Blackhawk helicopters, which cost about $6 million dollars each, quickly arrived on the scene to rescue victims from rooftops. Later, the Army Corps of Engineers rebuilt the levies, reportedly stronger than ever before, at a cost in the billions of dollars. In Izinga, there are no helicopters or engineers and certainly no billions of dollars.

Standing water in Izinga

How, then, do we respond to this epidemic? Minimizing the impact of future floods is the long-term solution, but this requires infrastructure investment that is not realistic given local resource constraints. In the meantime, malaria transmission will remain high as the mosquitos continue to flourish and the parasites infect more and more residents. Soon, we may see the RDT positivity rates in neighboring villages begin to climb. With relatively modest resources, such as bed-nets and insecticides, we can prevent the situation from getting worse. Even these interventions, however, are beyond the means of the community. But now that we understand the problem, we can begin to argue for the resources.

Ross M. Boyce MD, MSc
PGY-2, Internal Medicine
Global Primary Care Program
Massachusetts General Hospital

Understanding the spatial epidemiology of malaria in Western Uganda

The Bugoye Health Center (BHC) is located in the Kasese District of Western Uganda. This health center functions as the highest level of care for residents of the Bugoye sub-county, serving a rural population of approximately 50,000. The closest higher-level facility, Kilembe Mines Hospital, is located sixty minutes away when traveling by motorcycle. BHC is staffed by clinical officers and nurses from the Ugandan Ministry of Health and provides care at no charge. In addition to the outpatient clinic, there is an inpatient ward of twenty beds and a small laboratory with trained staff capable of performing basic diagnostic tests. As in many other resource-limited settings, the health center suffers from an irregular power and water supply and often faces shortages of key medications.

Entrance to Bugoye Health Center, Level III

Even with these limitations, BHC is always busy. Total reported outpatient attendance was 18,722 in 2013; a number that translates to more than seventy outpatient visits per day. While accurate population statistics are not available, malaria clearly represents the major burden of disease. Like most of Uganda, the climate in Bugoye permits stable, year-round transmission. According to health center reports, there were 7,753 cases of malaria at BHC in 2013. Rapid diagnostic tests (RDTs) have largely replaced light microscopy for the diagnosis of malaria, and are used preferentially given the ease of use and time constraints placed on laboratory staff.

Examining blood smears for malaria parasites in the laboratory

Since their introduction in 2011, nearly 7,000 RDTs have been performed at BHC, two-thirds of which were performed in the last year as the supply became more reliable. Accordingly, the number of parasitologically confirmed cases has increased to 42% in the last six months. While there is room for improvement, the introduction of RDTs has resulted in a marked change from the past, when all febrile patients were presumptively treated for malaria. This approach, while simple, contributed to the over-prescription of anti-malarial drugs and the under-recognition of serious bacterial infections.

Outpatient Clinic, Bugoye Health Center

The RDT positivity rate, which measures the percentage of all RDTs that were positive and is often used as a marker of malaria incidence, was 33% in 2013, with monthly rates as high as 51%. Yet even within this small community, there is significant variation between villages. For example, over the past three months, the RDT positivity rate among patients presenting from the villages of Bugoye, Ndughutu, and Bunyangoni was approximately 30%. Among those presenting from the villages of Muramba and Izinga, the positivity rate was 45% and 68%, respectively.

Looking down on Bugoye from the village of Muramba

Why is the positivity rate in these villages, many of which border each other, so different? Understanding this question is central to my work in Bugoye, and ultimately to developing sustainable malaria control interventions. Given that much of life varies little from village to village, I believe that the difference is best explained by geography. The local terrain ranges from mountain highlands in the west, often reaching altitudes of more than 2,000m near the borders of the Rwenzori National Park, to the densely vegetated wetland areas along the banks of the Sabo and Mubuku Rivers. Many of these “micro-environments” are ideal sites for mosquito breeding, and likely fuel the local variations in malaria incidence. Of course, identifying these high-risk areas, especially in a setting where there are no maps, can be challenging. In my next post, I will describe how we are tackling this issue, drawing on our recent experience in the village of Izinga.

Ross Boyce MD, MSc
PGY-2, Internal Medicine
Global Primary Care Program
Massachusetts General Hospital

Bhutan Epilepsy Project 4/7/2014

April 7, 2014

Gasa, Bhutan

    Over the last two days, I had the opportunity to travel outside of Thimphu to explore epilepsy care in more remote areas of Bhutan.

    We left early in the morning, with our goal destination the town of Gasa, the main city in the Gasa district in the north part of Western Bhutan, and home to about 3,000 people. There is essentially only one route to Gasa, the final 18km of which was recently completed. Leaving early in the morning was an attempt to beat the construction road blocks that can close the road for up to 2hrs at a time. Though there are only 60-70km between Punakha and Gasa, that leg of the journey takes about 4 hours as the vehicle carefully weaves its way along narrow roads that cling to the sides of mountains. The views along this journey are spectacular, and I can only marvel at the challenge that road construction in this part of the world must represent.

View approaching Gasa:

     The town of Gasa hosts the town (and district's) health unit. We were pleasantly greeted by the staff of this facility, all of whom were no strangers to the challenges that care in this type of setting represents. The region has strong traditional beliefs and firm cultural roots. As such, the facility (similar to many hospitals in Bhutan) shares care with a traditional medicine service. The facility has access to diazepam, phenobarbital, and phenytoin. If patients need to be transported to a larger facility, they have to make a similar journey to our own.

Traditional Medicine Unit and Gasa Hospital:

     Neurocysticercosis is suspected to be a significant contributor to the burden of epilepsy in Bhutan, but the exact prevalence is unknown. This disease is primarily contracted via undercooked pork, and studies done in neighboring countries to Bhutan have shown a high burden of disease. Cysts deposit in the brain and act as a focus for seizure activity, particularly in the cortex. While healthcare workers in Bhutan are well aware of neurocysticercosis, in talking with local individuals in areas like Gasa, there is sometimes little awareness of this condition or the risk that consuming dried, raw pork may represent.

     Our trip to Gasa allowed us the opportunity to view medical care in more remote areas of Bhutan. The potential for telemedicine, particularly in the form of epilepsy care, has much potential for regions such as Gasa. Learning more about the topography of Bhutan, the cultural beliefs, and the range of access to medical care has been enlightening and will help strengthen the foundation of our project.    

Bhutan Epilepsy Project

April 2^nd, 2014

Thimphu, Bhutan

Greetings from Bhutan!

Flying into Bhutan, one immediately gains an appreciation for the unique position of the country. Nestled in the Himalayas, the flight into Paro requires a skilled pilot to navigate the beautiful mountains that surround Paro's airport. There are a limited number of flights that come into the country each week, and as such, the country continues to maintain a feeling of beautiful seclusion.

Bhutan is steeped in rich Buddhist tradition and culture. Over the last several years, the country has evolved while seeking to maintain firm roots in Bhutan's culture heritage. Walking down the streets, people can be seen wearing the traditional gho and kira, while simultaneously listening to the latest music hits from Lady Gaga and Katy Perry. Cars and taxis have become more common throughout the country, though the capital continues to be one of only two capitals in the world that does not have a traffic light, instead employing traffic guards at the city's hub.

It is a country of approximately 1 million people, many of whom live in rural areas separated by mountains and connected by narrow roads. The urban center of Bhutan is the capital, Thimphu, which also houses the country's primary referral center, the Jigme Dorji Wangchuck National Referral (JDWNR) Hospital. Medical care is free in Bhutan for all citizens, and all lab tests and imaging are also covered by the government.

JDWNR Hospital:

I was intrigued to learn about access to neurologic care in Bhutan upon my first visit to the hospital. There are no neurologists in the country of Bhutan, and most epilepsy care is provided by psychiatrists, who are very familiar with seeing referred cases of epilepsy from many parts of the country. According to the physicians I met at JDWNR, neurocysticercosis is a common problem in the country (exact prevalence unknown) and may contribute significantly to the burden of epilepsy. Neurocysticercosis is a disease caused by tapeworm cysts which infect the brain parenchyma, commonly transmitted via undercooked pork. In Bhutan, neurocysticercosis is primarily diagnosed by imaging. The JDWNR facility has an MRI machine (the only one in the country), a CT machine, and access to at least five different anti-epileptic medications. There is no EEG machine in Bhutan, and no epilepsy specialists that would be able to interpret such a test.

I am looking forward to learning more about epilepsy care in Bhutan during my visit, and I am grateful for the warm welcome I have received in this beautiful country.