A day in the life of a Malawian girl: a doctor’s perspective

[This post was submitted by UNC professor Ian B. K. Martin, MD. Martin is director of Global Emergency Medicine at UNC and recently returned from Malawi, where he was visiting UNC Project-Malawi and other organizations in Lilongwe.]

Ian Martin, MD

Saturday, November 28, 2009 — Picture it:  It’s 95°F and muggy in a small pavilion constructed of cement.  This is the Under 5 (U5) clinic at Kamuzu Central Hospital in Lilongwe, Malawi..  This enclosure is packed with children escorted by various adults.  Some are on queue to see the “P” clinical officer; s/he is ready to see the kids triaged as priority patients.  Others are in line to see the “Q” clinical officer who evaluates these patients prioritized at this lowest level.  But at one end of the structure is a walled-off area.  The door to this small room reads “Emergency.”  Inside are four beds for the sickest kids who require immediate attention.  This is where my journey with 7-year-old “Joyce” begins.

Joyce was brought in by two women—I’m still not sure how exactly they are related to her, if at all.  There she lay, listless, barely conscious, and struggling to breath.  On prying her eyelids open, I could see the yellow tint of her sclerae.  The accompanying adults added little more insight.  When asked about Joyce’s status, the guardian responded that she is HIV negative.

I was in the U5 clinic to visit with Dr. Jeff Robison.  He is an American pediatrician working with the Baylor HIV Initiative here in Lilongwe, Malawi.  Jeff plans a career in pediatric emergency medicine and as such has a tremendous interest in the acute care of children.  I was spending the day with him to see how he has affected the delivery of acute care to children.  But as the need arose, I jumped into action to lend a helping hand caring for patients.

The team, including a clinical officer, a nurse and another pediatrician from the UK, struggled to get IV access.  The British pediatrician and I finally secured two IV lines—one in the arm and the other in the neck.  Joyce’s pulses were fast and thready at times and she was clearly in shock.  What is from malaria or bacteria?  The blood smear didn’t reveal any parasites, but it could still certainly be malaria.  Fortunately, at this U5 clinic at Kamuzu Central Hospital, we could get a malaria smear, glucose and hemoglobin measurements, as well as a pulse oximetry reading right away.  Joyce’s glucose was so low that the machine read only “low.”  Her hemoglobin concentration was amazingly only about 2 grams (far below the normal range).  And her pulse oximetry read only 77% on room air with a heart rate of about 150 beats/minutes—both signs of a girl in great distress.  We needed to take action, or Joyce was going to die right in front of us!

Thankfully, Dr. Robison and his team have truly changed how acute care is delivered in this U5 clinic.  Those of us from the developed world may take this for granted, but any who have spent time in the developing world, particularly sub-Saharan Africa, know that quality emergent care is not commonplace.  At least at this hospital, a kid would usually wait in a long queue to be seen by a clinical officer (who is neither a nurse nor a physician).  In Joyce’s case, the clinical officer likely would have identified her as very ill and just directed her to the wards to be admitted—no further evaluation and no life-saving interventions!  But luckily for this little girl (and seemingly many others), things have changed at Kamuzu Central Hospital.

Clearly Joyce needed blood, and it was ordered from the laboratory.  In the meantime, we rapidly infuse lots of saline—bolus after bolus.  She doesn’t improve.  We infuse dextrose, but still, Joyce’s condition worsens.  She is given oxygen and broad spectrum antibiotics, yet her pulse weakens.  “Where’s the blood?” Dr. Robison asks and asks again.  Inside, I was thinking that if this girl didn’t get blood yesterday she’s as good as dead.  To make matters worse, Joyce has another seizure (two or three in total).  Just as hope seem to fade away completely, along comes Dr. Robison with the blood.  He had taken it upon himself to go fetch it from the laboratory while the team and I continued to care for our critical patient.

The nurse hung the blood—two units in all.  The clinical officer now infused quinine for the suspected malarial infection.  Joyce’s pulse improved with the blood.  She was responding, ever so slightly, to our critical interventions.  But her breathing became more labored, and she remained barely responsive.

In richer parts of the world, Joyce surely would have been intubated at this point, but that’s because there would have been a bounty of ventilators and good intensive care unit (ICU) support.  But here in Lilongwe, where could this critically ill child go?

I followed Dr. Robison to Kamuzu’s very small and modest ICU, where he pled the case for admitting Joyce to the unit.  You have to understand that this ICU only has four, maybe five beds—and more importantly—only four ventilators.  Resources in this environment have to be rationed very carefully.  Fortunately, one ventilator (the one used for kids) had just become available.  The ICU team was fearful, however, that the man who had just been extubated would not “fly” and would need the ventilator again.  One of the ICU team said, “Bring her by on a trolley on your way to the ward.”  We said OK.

We ran back to the U5 clinic where Joyce was still fighting.  We packaged her up for transport to the ward—and hopefully ICU.  Dr. Robison, a volunteer nurse from Spain and I pushed the trolley as fast as we could to the ICU.  I was literally holding the infusing blood above my head while helping to push the patient.  On arrival to the ICU, the intensivists came to evaluate Joyce.  They were clearly concerned about her condition and quickly assumed care.  First order of business:  intubation!

I visited Joyce in the ICU later that same day and again a day later.  She looks better and is breathing much easier.  I found out that contrary to what her guardians told us, she is HIV positive, which I suspected given the very fine texture of her hair.  I used to see this a lot in AIDS patients during my training in Baltimore some years ago.  The intensivists agreed with our assessment (septic shock of some sort) and were continuing to support her.  All we can do now is hope.

Science, not science fiction: two flu drugs studied at UNC

[Originally posted on the UNC Health Care blog and penned by Clinton Colmenares]

When Scott Pelley of “60 Minutes” asked HHS Secretary Katheleen Sebelius about political punditry critical of the public health response to novel H1N1, she pointedly said, “I tend to like to get my health advice from doctors and scientists.”

She’ll be getting some of her advice about treating flu from UNC. Charlie van der Horst and Christopher Hurt, from our much heralded Center for Infectious Diseases, are each leading the first studies of medications for IV treatment of influenza.

ID at UNC is known around the globe for groundbreaking work in HIV/AIDS and other scourges. They’ve identified who’s most at risk for HIV and potential ways to prevent infection. But this is the first inpatient flu study.

“We’ve never had IV drugs (for flu) before. Ever,” says van der Horst, who ran his first clinical trial in 1983 at UNC. “Each year in the U.S. 35,000 people die from flu … We’ve had nothing to offer these people,” van der Horst says. “We’ve routinely had patients die.”

Novel H1N1 put a scare in the medical community because, Hurt and van der Horst say, it resembled “Spanish” flu that killed tens of millions of people around the world from 1918 to 1920. Both bugs started in spring and made a come-back in the fall. If you get the flu now, you can bet it’s H1N1, van der Horst says.

Late-20th century medicine gave us the anti-flu drugs Tamiflu, Relenza and peramivir. Tamiflu is taken orally; Relenza is aerosolized. They prevent the flu or shorten its duration. So it made sense to provide them in IV form, which provides a more accurate, assurable dosage that goes directly to the bloodstream in people who are hospitalized and beyond the help of chicken soup.

Hurt is studying peramivir, a medication that had not been tested until recently. It’s only available in IV form, and the criteria for receiving the drug in the study are pretty tight; prior treatment with Tamiflu eliminates a lot of people.

But viruses mutate for a living, and novel H1N1 has beefed up its resume by showing some resistance to peramivir’s close kin, Tamiflu, in an isolated instance. One of the usual seasonal flu viruses from last year had widespread resistance to Tamiflu. Both medications operate by blocking the same protein to keep the virus from spreading.

So far, novel H1N1 hasn’t shown widespread resistance to zanamivir. And to get into that trial a patient has to be sick enough to be hospitalized for five days and, basically, have the flu. It’s open to pregnant women, people on ventilators, people who have received other flu meds, etc.

As for the protection against pundits, some are more innoculated than others. Van der Horst waves them off. “Vaccine and medication development in the U.S. is based on pure science, not science fiction,” he says.

UNC dental school looking to take global programs to the next level

[This post was sent in by Kevin Ricker,  president of the 2nd year dental students at UNC]

Last week I attended an interest meeting in the UNC School of Dentistry about creating the nation’s first student chapter of the International College of Dentists.  The meeting was hosted by Dr. Rick Mumford and represents a step towards unifying the school’s international mission work and creating a coalition of the various projects.

Ted Roberson, president of the American section of the ICD, an internationally acclaimed scholar in the world of operative dentistry and former dean of admissions at UNC, talked about the importance of international work and the value of meeting dentists coming from vastly different locations, both domestically and abroad.

Then UNC dental students took the stage to describe their own international work.  Paola Uceda and Patrick Galloway, both third year dental students, spoke about their experiences working in Mexico, where they received an illuminating view of the Mexican health care system.  They also showed slides from their work in an orphanage, where they provided oral health care to needy children.

The Malawi project was represented by Heather Hendricks and me, both second-year students.  Malawi  has been receiving teams of dental students from UNC for nine years.  The students performed needed dental work in both the capital city of Lilongwe and a variety of locations scattered across the countryside.  Refugee camps, rural district hospitals, HIV/AIDS support groups, and an orphanage all received the benefits of free dental care.

Second year students Ben Thomas and Sabine Schtakleff and third-year Cameron Blair talked about the Moldova project.  The students described what they did over their spring break, spending a week delivering oral healthcare with a team of dentists from North Carolina.

Luiz Pimenta, assistant professor at UNC, described the upcoming Brazil Exchange project.  UNC is beginning a formal student exchange program, which sounds like an exciting clinical and cultural exchange opportunity for students in both countries.

By creating a formalized coalition of these and the various other student international groups (including work in Honduras and Nepal), we hope to provide an excellent home for a student chapter of ICD.  This will help cement UNC’s role as a leader in international student missions to improve the world’s oral health.

-Kevin

AIDS in the U.S.: the patient profile has changed, so should testing practices

[Cross-posted from the UNC Health Care weblog]

There is growing sentiment, and evidence, that attention to HIV and AIDS has shifted so far abroad, to Africa and in developing countries elsewhere, that Americans have overlooked a growing epidemic in our own collective backyard.

But even in the U.S. we’re looking through bleary eyes. This isn’t the 1980s. We need to give our eyes a good rubbing and let them focus afresh. When we do, we’ll realize the “high risk” population – IV drug users, men who pay for sex and men who have sex with other men – has changed.

The question has been who to target for testing. When a diagnosis of HIV is made early people can start receiving care sooner, probably use fewer health care dollars, have a better prognosis and, hopefully, remove themselves from the sex pool.*

But it’s the wrong question. Everyone needs to be tested, says Yvonne Carter, MD, an ID fellow at UNC. Carter reviewed data for more than 200 black men and women in the rural South, where the epidemic is most rampant. They were 18-61 and denied IV drug use and male-male sex. After some fancy statistics she found that socioeconomic status, health insurance status and history of incarceration were not associated with having more advanced disease.

But there was a group whose rates of advanced HIV was twice as high as others’ – the men. Women, Carter says, usually have more interaction with a health care provider. Men, especially black men, she says, tend not to go to the doctor until they’re very sick.

“This stresses that HIV testing is important, and implies that we can’t hang our hats on this person or that person,” Carter says. She presented her study Oct. 30 at the IDSA meeting.

Carter, a black woman, was drawn to disparities research after a trip to Africa as a medical student at Maryland. She came to UNC to be mentored by Ada Adimora, one of our many top HIV/AIDS doctors. Adimora leads the Rural Health Project, which continues to provide important data, including that for Carter’s work.

In 2008 Adimora told Congress that AIDS in black men represents a national emergency. Black men account for more than half of all AIDS deaths, and about 45 percent of new diagnoses. But the question about “who” to test needs to change to “how” and “when,” as in, how soon and how can we test everyone, often.

- Clinton Colmenares

* Lisa’s note: The notion that people who are HIV+ must resign themselves to a life of celibacy is controversial, mostly because it’s so unrealistic.  Partner notification, 100% condom use, and other prevention methods, such as pre- and post-exposure prophylaxis with antiretroviral medications make it possible for people with HIV to have relatively normal sex lives.

A happy update on Patrick Kahuma

[post by Tom Hughes, originally published on the UNC Health Care blog here]

Back in May, I wrote about how Patrick Kahuma, an 18-year-old from Uganda, came to the N.C. Children’s Heart Center at N.C. Children’s Hospital for treatment from Dr. Elman Frantz to correct heart problems that had greatly limited the quality of his life up to that point.

Patrick Kahuma on the phone in Kampala

The procedures were a great success, and Patric returned to Uganda with a whole new world of possibilities open to him that had not been there before.

At the end of September, the same UNC surgical team that brought Patrick to Chapel Hill returned to Uganda themselves, under the banner of UNC Project-Uganda. While there, they’ve been performing more heart surgeries on more Ugandan children. They’ve been tweeting about their experiences here and blogging about it here.

And last week they saw Patrick again. Over the weekend I got an e-mail from Dr. Dirk Hamp, which reported:

We heard from Patrick Kahuma today. He called from Kampala as he was visiting with Dr Kocis and the UNC Uganda team. He was examined and according to Dr. Kocis, his heart is “perfect”. It was such a good way to start the day today.

Indeed, what a great way to start the day! And considering that I’m posting this on a Monday morning, it’s a great way to start the new week as well.

We’re launching our newsletter next week!

The Institute for Global Health & Infectious Diseases is happy to announce that it will launch its e-newsletter next week!  It will feature in-depth global health stories from across the campus and around the globe, as well as the latest news, event listings and special announcements.  To subscribe, visit globalhealth.unc.edu/subscribe.php.

Why Global Health Matters to North Carolina

This afternoon,  my colleagues and I will be attending and participating in an important forum highlighting North Carolina’s contributions to global health research and practice, including the  impact of these activities on the state’s economy.

The forum, “A Center of Excellence for Global Health: Why Global Health Matters to North Carolina” is co-sponsored by the Center for Strategic and International Studies (CSIS) Global Health Policy Center and the new Triangle Global Health Consortium, which will formally launch during the event.  The founding members of the Triangle Global Health Consortium include UNC, NCSU, Duke, Family Health International, IntraHealth International, RTI International and the NC Biotechnology Center.

The moderator for the event is David Hartman, a television documentary producer-writer and an original host of Good Morning America.

Speakers include:

Admiral William Fallon, former Commander of the U.S. Central Command and the U.S. Pacific Command
The Honorable Kay Hagan, Senator of North Carolina
Dr. Peter Lamptey, President of Public Health Programs, Family Health International
Dr. J. Stephen Morrison, Director, CSIS Global Health Policy Center
Dr. Michael Merson, Director, Duke Global Health Institute
Dr. Peggy Bentley, Vice Dean for Global Health, UNC Gillings School of Global Public Health
Dr. Pape Gaye, President, IntraHealth International

We will be live tweeting from the event at 3:00 pm today, follow us at www.twitter.com/uncglobalhealth, #globhealthnc.

- Lisa

Expanding the role of universities in global health

[This post sent in by the delegation that attended the event discussed below: Benjamin Mason Meier, JD, LLM, PhD, a new faculty member and UNC’s first professor of global health policy, Myron Cohen, Peggy Bentley, Pia MacDonald, Mamie Sackey-Harris (all UNC), and Prema Arasu (NCSU).]

On September 14-15, a delegation from UNC and NCSU took part in the first meeting of the Consortium of Universities for Global Health (CUGH). The invitation-only conference brought together administration, faculty, and students from around the world to discuss the future of global health and the role of the university in global health research, education, and practice.

Given overwhelming student interest in and unprecedented government commitment to global health, participants found this to be an ideal moment to come together for global health education.
There were keynote addresses from Francis Collins (Director, NIH), Ezekiel Emanuel (Office of Management and Budget), Eric Goosby (Global AIDS Coordinator), and Harvey Fineberg (President, IOM).

Their talks set the tone for faculty panel discussions on:
(1)    Global Health Challenges and Innovative Solutions in the Current Economic Milieu
(2)    Growth Opportunities in Global Health
(3)    The University President’s Perspective on Global Health
(4)    Interdisciplinary Innovation
(5)    North/South Collaborations.

UNC contributed two poster presentations which highlighted our innovative global health curriculum, faculty research, and medical library in Malawi.

In  2008 a preparatory meeting of the CUGH Executive Board met to discuss the goals of CUGH and published the results in a Lancet article titled, “Towards a common definition of global health.”
At the meeting, we met in breakout sessions to develop CUGH’s mission by enabling systems and platforms, creating global health education models, and promoting advocacy and governmental relations.

With global health scholars 57 universities, this CUGH meeting has jumpstarted an exciting year for collaborations in global health

Additional information on the meeting agenda can be found at http://www.cugh.org/sites/default/files/annual-meeting-agenda-general.pdf.

Also, you can view this video showing a recent discussion on Capitol Hill focused on CUGH and the trend of universities are organizing themselves and developing a global health vision and its implications.

More perspectives from Malawi: A small boy tackles a big illness

[More from guest blogger Charles Vorkas, who is on an FICRS fellowship in Malawi this year]

August 20, 2009
19:13
UNC Guest House

Off the tarmac there is a dirt path about half a kilometer long.  It ends at the Guest House of the UNC Project, after a few narrow twists and turns, two speed bumps and a curvy topography.

This is where I write.  At my desk, in an electric-lit, internet-connected room, fortunate with access to luxury, where surrounding neighborhoods have much less.  I see poverty on the faces of the patients seen at the partner Kamuzu Central Hospital, but I do not know where they live or of what their daily routine consists of outside of the Tidziwe Center where the clinics, laboratories and administrative offices of the UNC Project are housed.

Most of the patients come from far away to seek treatment.  It is estimated that more than 80% of the patients receiving care in the inpatient and ambulatory clinics are HIV positive.  Many of these patients receive their HIV care at the partner Lighthouse Clinic across the way within the same complex.

The HIV patients, many of them progressing towards intermediate and advanced stages of AIDS, have two main risk factors: unprotected heterosexual sex or being born to an HIV+ mother.

Perspectives from Malawi

I’d like to introduce guest blogger Charles Vorkas, a student at Weill Cornell Medical College who is spending a year at UNC Project-Malawi on an FICRS fellowship from the NIH Fogarty International Center.  He is working under the mentorship of Charles van der Horst, MD, professor of medicine, and Mina Hosseinipour MD, MPH, associate professor of medicine, both at UNC.

Charles was kind enough share some of his writings with us.  We look forward to hearing more from him.

-Lisa

September 4, 2009, 11:43
UNC Guest House

I just completed my first month in Lilongwe and a detailed communication is long overdue.  I am well and settling into a rhythm.  The skill set I need to be happy here are different from what I am used to.  While I am in the capital city, Lilongwe is more like a big town and I often feel like this is the suburban experience I never had.  While you can walk to the produce market, it takes about 40 minutes.  Since everything is spread apart, a car is a necessity.  As many of you already know, most of the world uses manual transmission (stick shift).  I have had a lot more fun driving stick.  I actually feel like I have full control of the vehicle.  Of course, driving here is more challenging because of the narrow roads and numerous obstacles.  Lot’s of bikes and pedestrians in the street as there are few sidewalks.  When you get out of the city, there are goat and cow crossings.  But, don’t worry Mom, I am driving slowly and safely!

As for my daily routine: I am splitting my week between research and clinical work.  I spend some mornings in the Kamuzu Central Hospital, which is Lilongwe’s largest clinical center.  There are several departments, including an operating theater and a surgical intensive care unit.  The care here is not particularly good and, as a medical student with minimal experience treating disease, it is a very frustrating and humbling experience.  Most of the time, I feel helpless.  But then again, I am more trained than many of the Malawian “interns” who have completed medical school, but have no hands-on experience.  Most of the patients on the medicine ward are HIV positive and many have progressed to stage 3 and 4 AIDS.  There is no isolation of airborne infection risks, so all the suspected TB patients are placed in a long well-ventilated corridor.  I brought a bunch of N-95 masks (thank you, New York Hospital), but it is just not practical to wear them as you are potentially exposed all the time.