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.