Sunrise, sunset

I can't get over the beauty of these African sunsets over the ocean, where the exact moment of the sun's disappearance can be marked on the horizon.  Mountain-westerners are used to beautiful skies, but rarely if ever does the sun literally melt into the horizon and never in such the fast sinking way it does into the ocean.

Doing some quick calculations at dinner, this is the 10,608th sunset of my life.  With most of mine recently occurring during working hours outside the hospital, I am all the more appreciate and mesmerized by these painted but morphing skies at dusk.  Such a great, grand thing this sky of ours, that gives one a little sense of wonderment if we'd just take time time to look up.  What a Masterful Painter to make such a colorful delight.

Medical Mondays #4: Central Hospital

Hospital Central de Beira is the main hospital in the city. We send the patients to the hospital to get x-rays, blood tests (CBC, BUN/Cr, etc), biospy samples, sputum cultures, and obviously to be admitted if the patient is in dire need. It has been said not to trust that the patient will be seen immediately (even if in dire need) so whatever treatment means we have at the clinic - im injection of antibiotics or first course of antimalarials - is to be given prior to sending the patient.

After being here for some time, I decided it would be really awesome to see the large hospital and follow-up on knowing what things were like on the other side. It is interesting to note that many cities in Portuguese colonial towns were set up with the hospital as a central location. Even today, it is one of the key places to catch public transportation and a helpful way to navigate the city is by knowing where it is.

For the visit to the hospital, Dan and I met up with Quetunga (a graduate and doctor from the medical school associated with the clinic.) He spent a good hour or getting paperwork completed to officially permit our visiting the hospital. In the meanwhile we met docs from Italy, Mozambique and Cuba.



















Touring just the Medicine Ward IV was truly eye-opening. Three people to a room, with mosquito netting hanging above each bed, it was a far cry from western hospitals. We saw patients recovering meningitis, pneumonia, diabetics after DKA, multiple HIV+ complications... As emaciated (truly these patients needed to be hospitalized) as some of them were, I will never forget a young 22 year old looking no more than 12 laying flaccid, weak, who began to cry when our doctor explained we just didn't have enough blood to treat her severe anemia. When I say severe, I mean a Hemoglobin of 2.4 (you and have numbers above 11). Her mother was asked why she couldn't ask her neighbors to come donate. She said no one could come.

Beira city highlights

Beira is a large city and is widely spread out.  The best way to get around is by chapas - but I hadn't really explored much until today.

Club Nautico, which has recently been redone and has a nice overlook of the ocean, is expensive.  They have good pizza and a private pool (which costs 375 mets ~ $14/day).  I was deterred by the cost to go swimming - also there was too much else to do today. (!) 

Club Nautico

Have you noticed a lot of beaches?  It's kind of the neatest geographical element of Mozambique - such a long beautiful coast.

If you look close enough there are lots of canoes in the water with fishermen

 First stop on way into explore is to grab an 'African pineapple'!  Which is basically a peeled pineapple you eat like a carmelled apple.

'African pineapple' DELICIOUS!

Praca de Municipio "Coke bottle plaza"

Family getting photographs for youngest's 3rd bday

 I wandered the city with Dan, a 3rd year family medicine resident from Alaska, who is here for 3 weeks doing a rotation at the same clinic.  He is living with Peter (my preceptor) and Peter's wife Emily.  He and Emily had already been down to this same area before and so he showed me around today.

While enjoying a cafe - we saw multiple wedding parties coming to take pictures at the Praca

Chapa ride

Praca de Municipio

Dinner at the Millards!

Sometimes when it's hot, we wear swimming suits to dinner :P

Bananagrams

We also went to Praia Nova Market but didn't buy anything.  On the chapa ride back we randomly ran into the Millards who invited me over for Peter's special pizza.

When helping helps

Just a prescript - internet and electricity are still intermittent so please be patient with correspondence!!!

Perspectives #3: Halfway through the wonderful read “When Helping Hurts.” I not only agree that it is a book that all Christians should read before they go into missions, but I would even argue it’s a good book for already well-seasoned missionaries.

Most foreigners and wealthy Mozambiquans employ various servants. The couple I am living with are no different in that they have an embregada (maid who cleans, irons, etc) and guards (sometimes sleeping but in charge of watching the house, gardening, washing cars, etc). Our embregada has HIV, as does one of her brothers likely, and she infrequently has to miss work because of the large sores she gets on her legs. I write that only to give you a picture of how health needs from the clinic are just as common at home as at work.

Claude and Marilyn asked me to look at our guard’s foot this morning as we were leaving. It was definitely warm, with pus visibly oozing from a wound in the webspaces between his 3^rd and 4^th toes, with a well-circumscribed erythematous edema covering half his foot with visibly tightened skin. Not unlike what I’ve seen multiple times at the clinic, I could have written erythromycin and paracetamol for him if I’d had a prescription on hand. (People here can buy whatever medication they want over the counter, so really I could have just told him what to buy.) Yet it occurred to me that I would just be a quick fix and that essentially the man in front of me needed a much more fundamental prescription. Here indeed is what sustainable missionwork is all about. I, as the wealthy foreigner with supposedly all the answers, by circumenventing the entire clinical set-up of native medical workers, would have done more harm than good by a quick prescription. What the man in pain in front of me needed (tied with medication) was a lesson in trusting his own people in a healthy clinic to treat his medical problems long after I left. He needed medical help that neither witch doctors with their scarring marks nor neighbors’ recommendations of over-the-counter antibiotics would help with. He needed to see a doctor who could be trusted to give him a full exam that he could trust to visit the next time, and the next time, and the next time that he gets an infection or gets sick. 

The line from the book that resounded so much to me today was: “Avoid paternalism. Never do for someone what they can do for themselves.” In this case, it was not to do for the guard what his own country’s doctors could do for him. The Chinese proverb is: “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.” It takes longer to teach a man to fish than to give a fish. Similarly it took longer to take our guard to the clinic with me, to walk with him as he limped across the field. I got quizzical looks from the medical students and staff who wondered why I had brought him instead of treating him at home. He waved to me from the waiting room as I stood talking to other physicians but didn’t even seem to notice me as he was visibly engrossed with talking to his doctor when I randomly stepped into his visit to grab a blood pressure cuff. Indeed I became invisible as sustainable aid surrounded him with care. Isn’t that one of the points of medical missionwork? Not to put a “bandaid on a broken leg” – but to teach people how to diagnose and how to heal with their resources so that they can continue to heal long after the mission has ended.

You know what, our guard still got his medications. Beyond that he also found out he has HIV and will now undergo treatment. Instead of getting treated for a day by me, he will indeed be treated for life. And I hope he has a long healthy life.

Chapas

From the back of the chapa :)

I thought I would write this, since some of you have been asking whether I got a scooter yet. They’re rather inexpensive, but mostly imported and rather cheaply made. My friend Jabulani helped me look into it, but unfortunately the best stores only have full-fledged motorcycles, no scooters. I have been deterred by reasoning 1) likely to break down quickly since even the one I tried at the store (unused) had a broken battery they had to replace before I could even test drive 2) car vs moto (moto loses!) 3) it’s the rainy (monsoon!) season here 4) I’ve become comfortable with local transport…

Welcome to chapas. They’re vans revamped to drive as many people as they can fit. The US Consulate website says its embassy workers are disallowed from using them because of accidents in Maputo. The joke is that you’re lucky if you walk out with clothes on because of high rates of pick pockets. (Good joke.) They have their various destinations/routes on the front windshield. Estoril-Macuti, for example is my route. One ride to wherever is a flat rate at 5 meticais (~20 cents.)

Today was my second ride (back from work). My first ride was aided by a patient’s mother (seen the week prior) who randomly rode from my house with me, and who told me when to get off. Today I began talking to another woman as we waited for the right chapa. Little did I know as she got off before me, that she paid for me additionally in advance. So much for losing my clothes on the chapa – instead I made a friend. Such a kindness is no small trifle when 5 meticais is how much a loaf of bread costs. Thanks Mozambique, for the kindness of strangers and for unexpected friends.

Medical Mondays #3

Malaria

Woman with malaria

500 million clinical cases annually

1.5-3 million deaths annually (largely African infants and young children); 90% of deaths in Africa

5 types of protozoan species; P. falciparum is the worst because of how it quickly creates a density of # in the blood and sequestration in microvasculature (severe malaria)

Transmission
Anopheles mosquito transmits the sporozite through its saliva. This travels to the liver cells and becomes a schizont. The liver cell ruptures and releases thousands of merozoites which infect red blood cells causing all the symptoms and signs of the disease.

Characteristic	P. falciparum	P. vivax	P. ovale	P. Knowlesi	P. malariae
Incubation period (d)	8-11	10-17 or longer	10-17 or longer	9-12	18-40 or longer
Severity of 1’ attack	Severe	Mild-severe	Mild	Mild-severe	Mild
Periodicity (h)	/	48	48	24-27	72
Untreated duration (wk)	2-3	3-8	2-3	unknown	3-24
Untreated infection	6-17 mo	5-7 yr	12 mo	Not available	20+ yr
Parasitemia (per mm2)	>= 20000	10000	9000	Unavailable	6000
Anemia	Frequent,severe	Mild	Mild	Mod-severe	Mild
CNS	Yes, severe	Rare	Rare	possible	Rare
Nephritic syndrome	Rare	Rare	No	Probably common	frequent

Diagnosis: blood smear or rapid antigen detection (RADs) tests but have less accuracy and false positives; also RAD's can be falsely negative in the first 24 hours

P. vivax P. ovale P. malariae P. falciparum P. knowlesi

Child with malaria

Acute symptoms: Classical paroxysm (3 stages) lasts 6-10 hours
1.‘Cold’ stage- rigors and shaking
2.‘Hot’ stage – T > 40’; restless, vomiting, convulsions
3.Sweating stage – sleeping

For 3 days possibly asymptomatic, or with headache, cough, myalgias, fever, chills, diarrhea, mild jaundice, vomiting, nausea, anorexia

Chronic symptoms: Anemia, hepatosplenomegaly, weight loss, diarrhea, increased susceptibility to other infections
2’ complications: Burkitt’s Lymphoma, Hyperreactive Malarial Splenomegaly, Quartan malarial nephropathy

Same child but trying to capture typical way to carry babies

Pregnancy: low birth weight, fetal distress, premature labor, stillbirth, congenital malaria along with common side effects in the mother of anemia, hypoglycemia, and acute pulmonary edema

Severe malaria is most serious outcome
Cerebral: 20% mortality with retinal hemorrhages, coma, convulsions, focal neurological symptoms. Sequelae can be transient or permanent with hemiparesis, cerebellar ataxia, cortical blindness, hypotonia, mental retardation.

Treatement:
Thanks to Dr. Chris Milner, an English doc who has the most amazing encyclopedia brain of fun facts I'm going to talk a little about the history and making of what is really an incredible treatment for malaria.

Malaria treatment goes back to the 200 BC when Chinese herbalists used the herb artemesia.  In the 1970's a Chinese researcher stumbled upon the derivative artemisinin in wormwood and found that it had an amazing ability to clear malarial parasites from the blood.  Apparently the herb has been used on and off throughout history as even in the 1840's French troops were using it in fortified wines to treat malaria.

Fun Fact #2: The same family of herbs is used in martinis, so if you've ever had Absinthe, you've had a wee bit of an antimalarial concoction.  Even though I've never liked martini's it's an interesting fact they have health benefits in some ways.  :)

Now, because of increasing rates of resistance, artemisinin is used in combination treatments or "Artemisinin- Combination Therapy" (ACT).
-Standard treatment used to be chloroquine at 25 mg/kg for 3 days, but it has had increasing resistance and is no longer used in many parts of world.  Additionally, it doesn't work for the hypnozoite stage of the lesser common types of Plasmodium for which primaquine at .5 base, .325 mg/kg dosing is used.  Primaquine is an antioxidant contraindicated for G6PD deficient folks.
-Coartem (Artemether/Lumefantrine) at 6 doses of 4 tabs each for 3 days is completely efficacious here and our standard treatment here in Mozambique.  The national policy requires a positive rapid antigen test (which can be negative for the first 24 hours) in order to treat.
-Artesunate/Mefloquine is also effective but expensive
-Artesunate/Sulfadoxine-pyrimethane has high resistance and less used now.
-Artesunate/amodiaquine is only effective in West Africa
-In pregnancy: Quinine/Clindamicine in the 1' Trimester after which any standard ACT is okay
Severe Malaria:
-Artesunate IV - decreases relative risk mortality by 35%
-Quinine IV - careful use because hyperinsulin hypoglycemia especially in pregnancy and special renal dosing
-Artemether IM has irregular efficacy
-Quinidine - cardiac monitoring, yes this is an antiarrhythic usually (note its enantiomer cousin quinine usual use in malaria)
-or the ever possible rectal dosing of artesunate

Prophylaxis
-Atovaquone-proguanil (Malarone) - expensive
-Mefloquine - can be used in pregnancy not in neonates, and watch out side effects
-Doxycycline - sun sensitivity, GI side effects, no preggers
-Primaquine- no go preggers or G6PD
-Proguanil - resistance limited
-Chloroquine - no, don't really use this.

Zimbabwe

On the drive to Zim

Little did I know when I got a multiple entry visa that the maximum amount of time stayed in a single entry to Mozambique would be 30 days at a time. So, in order to avoid a heavy fine and also so that the Meyers could get a work visa, we left the hot coastal city of Beira for the mountains of Zimbabwe.

The drive into the mountains took us past cornfields, mud huts, cement huts, stick huts, palm trees, and into lovely green hills crested with wispy clouds. The roads weren’t pleasant with potholes and a 300 km journey took us 6 hours at 60-80 kph (or 120 km with Claude’s fast pace). Going through customs was a $30 visa to enter and the Meyers had to pay another sum for the car.

Driving up to Leopard Rock - looking out over Burma Valley

Leopard Rock

Leopard Rock Golf course

Vumba/Bvumba/Vumbai Valley drive

Mutare, city proper

Mutare, Zimbabwe is about 30 degrees cooler than the coast. It’s much more developed, more clean, and a second world country (if that exists?) People hurried on the main streets in Mutare, (as opposed to in Beira where there’s no point really in hurrying anywhere.) We stayed at a nice hotel called the Wise Owl just outside the village. We also visited Leopard Rock Hotel (at $250 a night, only the bus of Zimbabwean Parliament members could afford to stay there.) Apparently Queen Victoria stayed there in 1952 and it had a golf course that made me want to pick up golf (I know, what?) It was a pleasant afternoon in mountains that reminded me a little of Wyoming and Colorado with some of the red sandstone marks on the mountains, but more of a Hawaii and Switzerland mix with huge escarpments of rock and beautiful clouds hovering over the mountains.

It was a great respite!!

Mutare Post Office

In other news... with power outtages and intermittent internet access now, I will be back-blogging a bit to edit and update. Sorry if I dont get to emails right away either!!

Medical Monday #2

S: 6month African female presented emaciated with failure to thrive.  Mother is HIV+.  Mother says baby has been losing weight regardless of normal appetite.  Patient has had a nonproductive cough for 4 weeks and fever on/off with diarrhea.  Pregnancy history and delivery unremarkable.  Mother is unsure of sick contacts and TB exposure.  Mother denies pertinent past medical diseases, surgeries, family history, allergies, or current medications. 

O:  VS: Temp: 38.4, RR: 22, HR: 92, BP: not taken, wt: 3.5 kg (birth weight 2.2 kg)
General: extreme cachexia, alert
HEENT: Normocephalic, mildly depressed fontanelles, non-injected conjunctiva, no scleral icterus, EOM grossly intact, normal pupillary reflex, CN 2-7 grossly intact.  Pharynx nonerythematous with sublingual pallor
Chest: Lungs - CTAB; Heart: RRR, no murmurs, rubs, or gallops
Abdomen: Non-tender, non-distended, no palpable masses.  Hepatosplenomegaly.
Extremities: no gross abnormalities

Labs: Malaria rapid antigen test - negative; HIV rapid test +

A/P: 1.  HIV/AIDS - given the mother's seropositivity and HIV+ test this is the most likely cause of the baby's failure to thrive.  Other causes on the differential of FTT would be social (lacking food, neglect), cardiovascular abnormalities, metabolic abnormalities, liver and kidney problems.
 - CD4, hemogramma, Cotrimoxazole prophylaxis (refer to hospital central)
2.  Failure to thrive - Patient is well below the 5th percentile in weight only 7.5 pounds at 6 months
-nutrition supplementation


Perspectives: 7.5 pound baby at 6 months old.  We dont know hunger and we dont know suffering like this.

Ghonºs complex, right middle lobe in child

Possible Kaposiºs sarcoma in HIV+ pt

Superficial infection "pioderma" seen frequently

Pt treated for Pottºs disease - TB infection of bone (lumbar region x-ray)

Happy African birthday, MLK Jr and me!

Perspectives

Martin Luther King Jr and I share the same birthday some 54 years apart and we share many ideals.  He was so well-spoken on the topic of inequality, injustice, and true freedom... topics so pertinent to Africa today that as I celebrate my own birth and blessings in Africa it makes me consider how his efforts changed America and how a similar effort still needs a mouthpiece like him in Africa now.  Tomorrow Americans celebrate his day (his real birthday is today, just so you know) and yet Africans unaware perhaps of his significance, go about a normal work day tomorrow. 

Dinner with Lisa last night

What MLK realized, which is different than many relief efforts that take place throughout third world countries, is that real long-term change is rooted in essential change of the heart, mind and soul.  His call for liberty in America grew out of a knowledge not just of personal injustices and a desire for those to be righted, but out of a very biblical view of where justice, equality and goodness arise.  Martin Luther King Jr, named after Martin Luther a Christian reformer known for refuting rituals and false doctrines by returning to the Bible as the irrefutable source of truth, knew the Bible well.  He knew that manmade definitions, constructs, and relationships were faulty outside of a person's right relationship with his/her Maker.

Birthday bfast with waffles and omelettes!

His most famous quote is "Now, I say to you today my friends, even though we face the difficulties of today and tomorrow, I still have a dream. It is a dream deeply rooted in the American dream. I have a dream that one day this nation will rise up and live out the true meaning of its creed: - 'We hold these truths to be self-evident, that all men are created equal.'"  Which is followed in the Declaration of Independence by "...that they are endowed by their Creator with certain unalienable Rights..." - all of which is based on a Biblical view of all men being made in the image of God.

Formerly a 5 star hotel... many buildings have assumed this look

Any other view of men is wrong, not because MLK Jr says it is so, not because I want it to be so, and certainly not because I have been persecuted (like MLK Jr and so much of the African world I have encountered) and am seeking vindication.  It is wrong to allow injustices, because in the Sunday School answer that MLK Jr also believed, 'The Bible says so.'  Some people follow the UN Declaration of Human Rights, others daily read the Human Rights Watch, different people donate to various wonderful charitable organizations like International Justice Mission.  None of those things are efficacious or good without recognizing 1: nothing apart from the Bible

Zionists are a large religious group here.  (left)

is infallible and as it says 2: your and my heart are the beginning of what is wrong with the world so 3: to change other hearts and lives, we must first change our own.









If you're interested in reading more of where the Bible supports viewing all men as equally valuable, calls for us to fight injustice, and why our hearts need to be changed see below:
Gen 1:27 So God created man in his own image, in the image of God he created him; male and female he created them.

Prov 14:31 Whoever oppresses a poor man insults his Maker, but he who is generous to the needy honors him.

Jeremiah 22:3 Thus says the Lord: Do justice and righteousness, and deliver from the hand of the oppressor him who has been robbed. And do no wrong or violence to the resident alien, the fatherless, and the widow, nor shed innocent blood in this place

Psalm 12:5 “Because the poor are plundered, because the needy groan, I will now arise,” says the Lord; “I will place him in the safety for which he longs.”


Romans 12:2 Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect.

Jeremiah 7:5-7 "If you really change your ways and your actions and deal with each other justly,  if you do not oppress the alien, the fatherless or the widow and do not shed innocent blood in this place,
and if you do not follow other gods to your own harm,  then I will let you live in this place, in the land I gave your forefathers for ever and ever"

1 Cor 6:9-11 Or do you not know that wrongdoers will not inherit the kingdom of God? Do not be deceived: Neither the sexually immoral nor idolaters nor adulterers nor men who have sex with men  nor thieves nor the greedy nor drunkards nor slanderers nor swindlers will inherit the kingdom of God. And that is what some of you were. But you were washed, you were sanctified, you were justified in the name of the Lord Jesus Christ and by the Spirit of our God.

Who says north is up?

 This had me laughing a bit today not just because of the content but because of the reaction.  My preceptor (Dr. Peter Millard, far left) brought an "upside-down" map of the world back from the states with him.  When the land masses are depicted southside up, the words in english read correctly.  The students, I believe, thought it was a mistake the printers made, and wanted to hang it with north=up.  Here you have Jabulani in the middle trying to tell Peter, it's okay if the words are backwards, let's still hang it normally. 

Finally hung - and Africa is central.  hahaha!