Life in Yako, Burkina Faso

Not much has changed in Yako since my last visit in 2010. It was great to get back together with the people at SEMUS, and with Dr. Soma who is the physician that provides the medical care at the HIV clinic that SEMUS runs. Thanks to the enthusiasm with which my volunteer colleague Sarah takes photographs, I can give you a better idea of what things look like around here. Above is the classic view on the highway that runs through Yako. We are at the north end of town looking south towards La Grand Mosqué near the center of town. The mosque had been recently repainted when I was here last, but that doesn't last long around here with the wind blasting sand from the Sahara for half the year. As you can see below, the building is in need of maintenance, like most things around here.

Unfortunately, the economy has not changed much over the last two years either. The country was very much affected by the recession in 2010 which resulted in job losses for migrant workers in Cote d'Ivoire and in the local mines. Especially in this part of the country, most people continue to live in very rural settings as subsistence farmers, and have to travel for considerable distances to obtain services. Transport continues to be primarily by walking, donkey cart, bicycle or at best a motorized bicycle, scooter or motorbike. It is not unusual for ill people to have to walk for 20 km in order to be seen at a clinic. Cars are fairly common in towns and on the main highway, but they are still very unusual in small remote villages. Many villages have no roads leading to them, only paths.Yako continues to be a blend of rural and urban. Sewers from homes with often drain directly out on to the road. This large pig seems to be quite content with the situation. He actually blended in very well and startled Sarah as it moved when we approached.
As I said, the people here continue to be warm and friendly. The children are very interested in us wherever we go, especially when there is candy involved but also when we are just out and about. The adults are just as interested, often stopping us to ask how we are, how long we will be staying, etc. Above, Sarah is in an animated discussion with a group of kids
This stable runs along the exterior wall of a cluster of homes. Houses here consist of one-room buildings connected together by walls that run along the periphery of the property. The rooms open to a central courtyard where most of the daily activity occurs. In town, most of the properties are gated, but in villages the entrance way is almost always open. Extended families, often polygamous, live in these settings. The rooms are for sleeping and storage, and most of the living is done outside. Wood continues to be the main energy choice, which means that the town is very smokey come dinner time.
This is a very typical neighbourhood in Yako's west end. Here the streets have more trees lining them, and the houses are set off the road. It kind of reminded me of the suburbs in Calgary when my children were little, and they were always out on the street playing with their friends.


This young fellow wasn't sure what to make of us. As you can see, he continued to play with his tire while we approached, but he wasn't about to take his eye off of us.
Kids. They're everywhere. The median age of the population of Burkina Faso is just over 15 years (high birth rate and short life span - life expectancy at birth here is around 55 years). Life here is almost completely focused on children and family. When a woman here is diagnosed with HIV infection, her first reaction is almost invariably "what will happen to my children?" There has been some international news coverage recently regarding the use of child labour and you will often see them involved in farm work, carrying goods, selling things and driving donkey carts, but they also play a lot, smile and laugh a great deal, are usually clean and well fed, and are closely supervised. The law here states that children cannot work until age 15, but the only way that will ever happen is through economic development and better access to resources, not through international public disapproval.

One of the very enjoyable things to do around here is the candy walk. I brought 300 candy treats and Sarah, who is much closer to the age of these children than I am and has a much better understanding of what kids like, brought (in addition to candy) stickers, a few small toys like cars and skipping rope (big hit!), and small Disney princess ink stamps. Every few days we will take stuff out to the streets like this one and start handing them out. Needless to say, bedlam ensues. Once the party starts, it keeps going, even when the treats run out. They love to have their photos taken and looking at them on the camera display screen.


At first, I wasn't sure how the parents would react to having us hand out treats. I realized very quickly, however, that the parents were watching their children closely and loved to see them having so much fun. It is very much the same kind of fun that we used to have as children when the ice cream truck would come through the neighbourhood on a hot summer day.
The parents often get involved in the fun. A great sport for the adults is to slowly bring their small children close to us, and watch the child's reactions as the eyes would get bigger and bigger, then the child would burst out crying in fear of our white faces. I must admit, it seems a little mean but it is also hilarious.

These families were at the municipal water fountain, filling up for the day. They were very welcoming, and asked us to take a photo. They were clearly proud of their neighbourhood, particularly the brand new small mosque across the street.
Life in Yako is much better for me this time around compared to 2010. It helps to know what you are getting in to and to be a bit better prepared. A very nice woman prepares our meals and her 22 year old daughter Saili serves them to us in the hostel at the SEMUS site. I also was looking forward to the warm reception that I knew I would receive. People know that we are here for development and support, and see this as hope for a better quality of life. Solidarity in the fight against poverty and all of its implications is a critical thing here - without it, survival itself would be impossible.

More on the work we are doing here in my next posts. Stay tuned and be patient - internet access has been very "iffy" (our access was cut off for all of last week).

So then what happened?

So 2 years later I'm back in Yako, Burkina Faso and getting back to work, helping to develop a plan that will hopefully allow our partners here to bring effective, community-based palliative and end of life care to the people who are confronting a life-limiting illness. Last time you heard from me, it was January 2010 and I was still trying to make sense of what I was observing, hoping that I would be able to make a difference. I have to admit, it continued to be overwhelming on a daily basis for the rest of my 3 week term, and most days I ended up feeling very much the same way as I did that night. Meanwhile, my colleague Dr. Pierre Allard who is an Ottawa-based palliative physician was going through a very similar process in Bobo Dioulasso, which is Burkina Faso's second largest city. We had very little opportunity to communicate until I was able to travel by bus (another story) for 8 hours just to spend some time in Bobo comparing notes. Together, we were able to suggest a long-term strategy that would allow the two non-governmental organizations that we were working with (SEMUS in Yako and REVS+ in Bobo) to work together with other community-based organizations to develop a Center of Excellence in Palliative Care that would be a model for the development of palliative care competencies, and that would allow Burkina to provide leadership for the rest of francophone Africa. The center would be based in 2 sites. One, based in Bobo Dioulasso would develop, the capacity to train health professionals, while the program centered in Yako would develop the competencies required to provide support in rural areas (80% of Burkinabe live in rural areas) who are living with AIDS. As part of the continuing Medical Outreach Program undertaken by the Canadian Medical Association, Pierre and I have returned to Burkina Faso to continue working with these agencies with the support of Uniterra, a development program undertaken by World University Services Canada and CECI (Centre d'Étude et de Coopération Internationale) with support from the Canadian International Development Agency. On this trip we have acquired a new partner in the form of Sarah Lowden, a financial adviser working with the Canadian Medical Association and a dynamic young woman with expertise in finance. Her day job is as an advisor with MD Management, a financial services subsidiary of the Canadian Medical Association. Over several months prior to our departure from Canada Sarah (who is an avid single gear cyclist from Montreal) raised approximately $10,000CAN in order to purchase new bicycles and several bicycle ambulances (more later) for SEMUS. She will be helping SEMUS enhance their accounting procedures and will be very valuable in developing further funding for our project.

After the usual living nightmare of travelling to Burkina over 30 hours and three different flights, we were met at the airport in Ouagadougou (minus Pierre`s luggage that had decided it wanted to spend a night in Paris) by Simon who took us directly to the Hotel Yibi. Here we were able to get straight to the task of feeling sorry for ourselves, then heading to bed. Nice place all things considered, with one of the best restaurants that I have encountered in this city, at a very reasonable price. Sarah is one of those people who cannot resist taking photos of their food (my wife Jacqueline is another one). The one below gives you an idea of the pleasant but not overstated poolside atmosphere. This was of course an extra special experience as my home city of Calgary was just entering a dismal, dark cold spell when I left on January 15th. Ouagadougou is a typical capital city for a developing nation with terrible pollution, abject poverty and huge disparity between rich and poor. Burkina Faso remains in the bottom four nations on the UN development index, with only nations in conflict below them. Still, there are very pleasant spaces here, and this is one of them.

One day to recover from the trip and to deal with some details and we left Ouaga for Yako. I was surprised at how good it felt to leave the city for the rural area. Although the poverty becomes even more intense, the pace slows, and people are much more relaxed. Pierre had never seen the northern region of Burkina during our first visit here, and it was great to be able to show him around and have him see first hand how things were here. By that time Sarah had become the official photographer, thanks to her more advanced skills and her much better quality of camera. The two photos at the top of this blog are from Yako (my blogging skills are obviously rusty after two years).

Trying To Keep Up!

January 16, 2010 - Yako

As predicted in my last post, my focus was definitely improved after a night's rest. Still, the last two days have been overwhelming. Not only has it been busy, but there has been a great deal for me to try to comprehend in my first look at the health and medical services available for people in this region of Burkina Faso.

My mandate is to assess the activites of my host organization with respect to the management of care needs for people living with HIV, as well as their capacity to provide palliative care to those who are living with advancing disease. In order to do this, I must understand how the medical services that are available in the region are managed, how they are accessed by people in the community, the relationship between the state medical system and the community associations in providing care for people living with HIV, and how people manage their daily lives - all of this along with recommendations for developement, all before the end of the month. I try not to think too much about how I can possibly do all of this - I'm just going one day at a time.

I spent yesterday looking at the activities of the various departments of SEMUS, including their forestry and agricultural development programs. SEMUS is active in helping community organizations, cooperatives and associations in their capacity building by providing access to expertise, by bringing together different groups with simmilar goals, and by establishing linkages with international partners. With respect to care for people with HIV, they are active in prevention and screening for HIV, and have a clinic for follow up of individuals who have been diagnosed with HIV infections. Today, I began to tour the health care and medical facilities in the area. There is a local hospital (Centre Médical avec Antenne Chiurgicale or CMA) and several rural health centres (Centre Santé et de Promotion Sociale or CSPS). These are provided through the Ministry of Health and manage to function despite a severe lack of resources. The rural facilities have basic buildings with virtually no equipment and extremely limited medical supplies and medications. They are attended by a midwife and either a nurse or (more likely) an auxiliary nurse. They are in cell phone contact with the CMA in Yako and are able to keep patients overnight if required, but no longer than 2 nights. Serious problem (as far as I could tell, they were all serious problems - malaria, other infectious diseases, etc.) that could not be managed at the CSPS were transferred by ambulance to Yako. Ambulances are of course a scarce commodity in rural Burkina Faso, and they are dispached from Yako, which means a round trip of up to 80 km and considerable delay if they are dealing with a medical or obstetrical emergency.

Most of the CMA dates from the colonial era. Some of the buildings have been renovated somewhat, and the pediatric unit was recently built with funds provided by an international donor, but much of the hospital is falling apart, and resources are almost non-existant by western standards. I met a young woman who was brought to the hospital by ambulance with an obstructed labour. By the time she arrived, her uterus had ruptured and the baby was dead. She survived because of an emergency hysterectomy, but during her entire ordeal she had not received any medication to manage pain except for the general anaesthetic at the time of surgery, and some ibuprofen (Motrin or Advil) after the operation. She was now confronted with a dead baby, the loss of her fertility (which is devastating in a culture where family is everything), and her family now has to contend with a bill for her medical services that will likely drain their resources. When I saw her she was surrounded (and cared for, including nutrition) by her family who were very concerned for her, but she was withdrawn and clearly in severe psychological distress.

The images here are from the CMA in Yako. The bottom picture is the medical unit, with the doors to the patient room opening directly outside. The corridor is the emergency and urgent care clinic.

The dilapidated wall and gate lead in to the psychiatric unit. Inside, you see mothers caring for their children, doing the cooking over an open fire pit and the washing in buckets. The young woman is likely suffering from schizophrenia, and is chained to the tree by her right ankle in order to restrain her (her mother made certain that I saw this). There are virtually no medications available to adequately treat schizophrenia.

So This is Why They Call It Culture Shock

January 14, 2010 - Yako, Burkina Faso

Actually, it's just after midnight on the 14th and I should be in bed, sleeping. The late evening is the witching hour for me - the time when my energy is spent, when I am the most discouraged. I usually try to avoid writing at this time because of this, but I wanted to try and capture the feeling that I have right now. The trip to Yako today was uneventful. Yako is situated in an extremely dry area - I am told that even in the rainy season it is still relatively dry compared to the southern and western areas ot the country, and that desertification is a major issue. It is very rural and very African, but it is also reminiscent of every rural village that I have encountered. The people are very friendly and are curious about my presence here, but they are quite shy, at least so far. Westerners are fairly common here because of the many international partnerships with my host organization (association Solidarité et Entraide Mutuelle au Sahel or SEMUS, http://www.semus.bf/ ), so I did not feel like I "stood out." Shortly after our arrival in the late afternoon we had a meeting with the head of the department that coordinates community health issues and the HIV testing and treatment clinic, the managers of the various areas, a volunteer from Montreal who has been on site since November, helping with communication issues for SEMUS, the physician who is my liaison while I'm here, and the chargé d'affairs for EUMC. The program for the next two weeks had been worked out in advance, and I was anticipating that this meeting was to ensure that all were informed regarding the schedule of events. It was presented to me in a very detailed manner, outlining formal presentations by all of the organizations involved in health services delivery for the area, an opportunity to visit regional centres, and time with the physician during his clinics. I was then asked for my opinion. "What the heck do I know?" I asked myself. The discussion had been rife with acronyms and abbreviations with which I am still not familiar. I had no concept of how health care services were delivered and little knowledge of the community and customs. I had no objection to the plan so I thanked them for their efforts and agreed to proceed. It was at that point that the EUMC chargé d'affairs informed the group and reminded me that prior to our departure, Pierre Allard had asked for a day in Ouaga at the end of the mandate in order to review the observations and outcomes from both sites. She also made other suggestions that threw everything out the window. I had been told that such things did not happen in meeting in Burkina. I felt like a fish out of water while I attempted to follow the discussion. Thank goodness the young man from Montreal would frequently catch my eye, as if to reassure me that he knew how I felt. Eventually, a plan was set in place and although I was again asked for my opinion, I had nothing to add. My Montreal friend suggested that we take some time for orientation the next day and went home, and the rest of us walked a few metres up the road to an outdoor cafe that consisted of a few old outdoor tables and chairs in a dusty lot next door to the very basic building that housed the kitchen. There were a few light on in the buildings but where we were sitting it was very dark (now I felt like I stood out!). We ate grilled chicken and French fries from a communal plate, talked about football (soccer) as there is a major tournament underway in Angola right now, as well as local, national and African politics - all topic that I am famous for knowing nothing about.

Earlier in the day I had been shown my room in the "centre de hébergement." It was very hostel-like: small, with a bed, a desk and a chair, as well as a bathroom with a toilet (no seat), a sink and a shower. It was not until I returned from dinner that I realized that they had been working on the plumbing but had forgotten to turn the water back on. As well, my bed had only a single sheet covering the mattress. I'll be sleeping under my emergency airline blanket and I'll be scruffy-looking when I show up for work in the morning.

I am feeling defeated, but I remind myself that I know that it would feel this way. I hope that by tomorrow I will regain my enthusiasm and confidence.

I apologize for the stilted writing style that results from not being able to use people's names. As this is a public site I am obligated to not use people's names without consent, and I am way too tired to make up fictitious ones. Maybe next time.

The video is a view from the gate looking in to the SEMUS compound.

Arrival in Burkina

January 13, 2010 - Ouagadougou, Burkina Faso

Everyone who undertakes a long voyage has to complain about it for a while, so here goes. It was 30 hours of waiting, sitting and trying to sleep in uncomfortable positions. But we made it without any serious incidents (except getting taken by a mime at Charles de Gaulle Airport - maybe some other time) and so did our baggage.

We spent our first day here with the team at Uniterra in Ouaga. We had a chance to tour the city, and we are finally just beginning to understand the context in which we will be trying to get our projects underway. It is difficult to comprehend how few resources there are in Burkina for so many people. Still, the people are extremely pleasant, helpful and full of humour. The name of the country means "The Land of Men with Integrity" and the Burkinabé live up to their name very well (although the women have just as much integrity as the men). It has been delightful to meet the managers of the program here, but also to have a chance to speak to many ordinary people about their lives and also how HIV has affected them. No one understands when we discuss the issue of palliative and end of life care (there just isn't any) but everyone will tell you how HIV has affected their lives because of someone they know.

Today, we leave for our project areas. Pierre Allard is off to Bobo Dioulasso (the second largest city, in the western part of the country) and I am heading to Yako, a town in a rural area about one and a half hour drive to the north.

The photo is of the EMUC/CECI offices in Ouagadougou.

Leaving for Change

My name is Martin LaBrie, and I am a palliative care physician as well as an HIV treating physician living in Calgary, Alberta. I will be leaving January 10, 2010 to travel to Burkina Faso in western Africa as part of a project developed thorugh the Canadian Medical Foundation that is intended to enhance the capacity to provide palliative and end-of-life care for people living with HIV. I will be working with l'association Solidarité et entraide mutuel au Sahel (SEMUS) in Yako, Burkina Faso for the next three weeks.

The Canadian Medical Foundation (CMF) has partnered with Leave for Change (L4C) to deliver our international volunteer program. The program enables volunteers to participate in a two- to four-week volunteer assignment in a developing country. L4C is a component of the Uniterra Program, Canada’s largest international volunteer cooperation program, funded in part by the Canadian International Development Agency (CIDA) and implemented jointly by World University Service Canada (WUSC) and the Centre for International Studies and Cooperation (CECI).
In January 2010, the CMF is supporting six physician volunteers to go to Malawi and Burkina Faso to provide volunteer services in the area of palliative care as it relates to HIV/AIDS. More details regarding the project, the physicians who will be volunteering in Africa, and the Canadial Medical Foundation can be found at their website, www.medicalfoundation.ca.

Through this blog I intend to keep a record of my role in the project. I became involved with caring for individuals living with HIV early in my medical career. In 1983 I started a practice in family medicine in Calgary with a focus on palliative care in the home setting. The first diagnosed case of AIDS in Calgary was diagnosed that year, about four years after it was first described in the U.S. I saw my first patient living with HIV in 1985, and for the next decade I was involved in the care of very many individuals who were living and dying of AIDS. It was an extremely difficult time for me but those people taught me a great deal about living with a life-limiting illness. HIV disease is unpredictable, protracted, and affects every organ in the body. My palliative care experience to that point had primarily involved treating people with various forms of cancer. Cancer usually follows a fairly predictable course when it cannot be cured, with gradual progression leading to death that can be forseen weeks or even months in advance. The goal of palliative care was to ensure that pain and suffering were managed as well as possible during this disease trajectory. AIDS changed all that - now people were living for years with few or no symptoms, waiting for the ticking time bomb in their bodies to go off. When they did become ill, they often would manifest several medical conditions at the same time. Often we would expect people to be close to death, then see them recover dramatically, although temporarily. What impressed me most about these people was the sense of survivorship. At the time, these individuals were primarily young, previously healthy men who had not been contemplating end of life issues. The focus was on using every possible means to stay healthy for as long as possible, and to live each day. No one could tell these people to sit around and wait to die. It was a lesson that I took to the care of all the people I worked with who were confronting advancing disease, focusing on hope and life worth living no matter what was happening to them.

In 1996 everything changed with the development of effective treatments for HIV. We were now able to supress the growth of the virus, allowing the immune system to heal in most cases and preventing progression of immune system damage in those who were still not yet injured by the virus. It was a dramatic time, and at the time I likened what I was witnessing to people being released from a concentration camp, going from thin and weak to healthy and robust over a matter of weeks. Since then I have continued to be involved in HIV treatment for those who have the ability to adhere to complex treatment regimen and close clinical follow up. Palliative care in my world now involves individuals who are unable to access treatment because of other determinants of health such as chronic homelessness, Hepatitis C co-infection, addictions, mental illnesses, and other conditions that tend to marginalize some of us in our society.

Going to Burkina Faso means going back to the old era of HIV treatment. Burkina Faso has just under 15 million people. Almost 50% of the population lives on less than $1US per day, and most live on subsistence agriculture. Infrastructure for health care delivery is very limited, with very few doctors or nurses. The incidence of HIV infection is estimated to be between 5 and 10% of the population, and 8000 HIV-related deaths occur each year. This is in addition to the many other health issues such as tuberculosis, malaria, typhoid fever that people have to deal with. Health care has been a priority for the government of the nation, and the goal is to achieve universal access to HIV treatment. The country has extremely limited resources, however, and only a few thousand individuals have access to any HIV drugs.

I am very anxious at the prospect of trying to help people deal with a complex illness with very few tools available. My role will be to assess how care providers have confronted this problem to date, and advise regarding ways to enhance their capacity. I am certain, however, that I will be spending most of my time learning from caregivers who have had to make do with very little, yet still are responding to the needs of those in the community who are suffering. Maybe what I learn can be translated in to a better response from the disadvantaged individuals suffering from HIV in my own community. I hope that we all can learn together.