Local lunch

Kampala is filled with expats/muzungus/white people/whatever your word of choice, so there are quite a few non-Ugandan food options -- Italian, Indian, Ethiopian, Continental, even Korean.  However, eating local is way cheaper (~$0.80 for lunch vs. ~$11 - helpful when you're adjusting from finance income to aid worker income) and you meet more interesting people, so I've been trying a few places out.  The staples of Ugandan food for a non-meat eater are matooke (a mash of non-sweet plantains), pocho (corn mash), rice, beans, bitter greens, ground nut sauce (a bit like thinner peanut butter), and pumpkin. 
The first few times I had Ugandan food, it was really bland and barely edible.  Thankfully, I went with a Ugandan colleague to his favorite lunch spot one day, and it was a revelation.  It's in a small slum about a quarter mile from our office - pictured below.  Don't worry - everything is cooked through and the hygiene standard is pretty high given the surroundings. 

More on work

I've been working a lot lately (though thankfully work doesn't start at 6:45 anymore), and I'm finding it really interesting, so I figured I should write a bit about this work. 

My project looking at the period after a patient tests positive for HIV and before they are initiated on anti-retroviral therapy is going in an interesting direction (much better than when we thought any interventions would have to be simple and free).  We did a lot of analysis on the data we collected (well, most of it was collected before I came), and now we're meeting with potential partners who could help us implement some of the ideas we have about increasing retention during this period.  Some of the most interesting findings from our research:

• 54% of HIV+ patients are "lost" during this period.  Some of them may continue to receive care at another facility, but many stop receiving treatment
• The patients who stop coming early on (in the first 3 visits) are sicker than the patients who keep coming based on their CD4 tests (an immunologic test). This is worrisome both for treatment and for provention, as sicker people are more contagious
• At some sites, the amount of patient time with a doctor (assuming bi-monthly visits and based on number of doctors vs. number of HIV+ patients) was 2-3 minutes!

Despite the existence of some crazy barriers to good care like the last point there, there do seem to be some interventions that can really improve retention (and treatment and survival) that we might be able to work on.  One of them is implementing phone call follow up plans.  In another study CHAI was part of, they found that 74% of patients had access to a phone, and that using the phone to follow up with patients who had missed appointments was a very effective and inexpensive way to keep patients from being lost.  Another possibility is piloting an adherence support worker program like the one described in this research from Zambia, though that could be very expensive and complex.  I've been researching about the chronic care model of treatment developed by the University of Washington (here's a video explaining it in case anyone is really interested), and I would love to work on something that could bring that model into this context, but it is daunting since we are trying to work on a large scale with the Ministry of Health and the model would require many, many things to change in facilities.  However, it seems like partners (potential partners include USAID-funded groups, university funded groups, and others) are really interested in this type of work, so I'm optimistic that something good could happen and CHAI could play a big role in figuring out what a program would look like.

Isaac and I are going to be interviewing health care workers in facilities in the next week or two about the feasibility of programs we are looking at, what counseling and follow up programs they have in place, and other topics to get a sense of their current situation.  We're also going to be meeting with and presenting to more potential partners. 

And some pictures-- Isaac and Evan after our first potential partner presentation, my first picture of the Nile, and the waiting room at a hospital an hour and a half outside Kampala where we may pilot a project. 

Baby bat in the bathtub....

On Friday night, as I was recovering from food poisoning (Uganda is now the 8th country I have gotten food poisoning in...), I turned on my headlamp to find... a baby bat in my bathtub!  The picture doesn't quite capture it, but it looked like a cross between a frog and a mouse and was very alarming.  I had no idea what to do, but thankfully remembered that our night guard would be able to help with such issues. 

I knew to expect cockroaches, mosquitoes, and the like, but baby bats were not on my radar.  The next day, the landlord sent someone to repair a hole in my ceiling, so hopefully I won't have any more bat visitors. 

Another field visit

Last Thursday, I went into "the field" to Jinja with Isaac and Shira to do some groundwork for the hub transport system Shira has been working on.  It was a pretty eye-opening visit in that it challenged many of the assumptions that had been made in setting up the project and showed just how necessary it is for us to spend time getting to know exactly what the issues are that we want to address. 

However, I think the most interesting takeaway of the day was from a clinic we visited on our way home.  When we drove up, we saw the clinic was mostly shut down for a circumcision drive.  The truck pictured below had been brought into the lot and a tent was set up next to it.  The tent was completely full of grown men waiting to be circumcised. 

I remember reading about studies like this one showing that circumcision could reduce the female-to-male HIV transmission rate during intercourse by 60%, but I hadn't realized how much circumcision had caught on in Uganda and other parts of Africa.  Talking to some Ugandans in the office, they said that they knew many people here who had recently gotten circumcised.  They also mentioned that there was a growing fear that circumcised males would stop using condoms because of their decreased risk and that the net benefit of circumcision drives could be negative.  There's still a lot more research to be done on that, but it was pretty impressive to see so many people making an active effort to reduce their risk. 

Global Health Corps Reunion

Those of us living in Kampala were lucky enough to be greeted this weekend by a huge contingent of Global Health Corps fellows visiting from Rwanda and Burundi - they took 8 and 14 hour bus rides to get here!  We had a dinner for 25 (the picture below only captures half the group) at the only Korean/Chinese restaurant in town.  I got to use my hard-earned skills ordering Asian food to feed the group - it was a great success. 

One of the great things about being part of GHC is that we are constantly interacting with people from other health-oriented non-profits with very different philosophies.  It's very easy when you're working with and socializing with people with one philosophy and orientation towards the use of aid in the health sphere to think that orientation is the only one, when in fact I think it's important to draw from different ideas depending on the work you're doing.  For example, CHAI tends to be heavily oriented toward analytics and "big picture" thinking, but I think it's necessary to bring in the Partners in Health-style single patient-oriented mindset when thinking about the actual effects interventions might have. 

A couple articles/thoughts about HIV/AIDS

I've been reading and learning a lot about HIV/AIDS, and I thought I would share a couple articles of interest on the topic

• One interesting topic that has gotten a lot more attention recently is the idea of treatment as prevention.  When patients are on proper Anti-Retroviral Therapy, their viral loads become very low to the point that they are extremely unlikely to pass on the disease.  Without treatment, transmission rates vary based on the type of exposure, ranging from around 0.5% for heterosexual sex for males to 90% for recipients of a blood transfusion from HIV-infected donors.  There are ways of lowering all the risks levels (prevention of mother-to-child transmission methods, circumcision, condoms, etc), but for each type, one of the best ways is simply getting people healthier.  This article from the Economist gives a good summary of the recent research conclusively showing this and also a good summary of the state of HIV/AIDS transmission and treatment in the world now. 
• Another topic that is becoming more important is drug resistance among patients on antiretrovirals.  If patients are not adherent to their drug regimens (because of stockouts of drugs, inability to get to the pharmacy, lack of knowledge about adherence, etc), they can develop resistance to the medicines and they have to be switched to (much more expensive) second-line regimens.  A scary trend is when patients who have never received treatment for HIV/AIDS have drug-resistant strains because it means that these harder-to-treat strains are spreading in communities from people who have been treated before to people who have not.  This article shows that Uganda has a very high percentage of treatment-naive (have never received treatment) patients with resistant strains - much higher than other countries.  This may be because treatment was started earlier in Uganda or because treatment rollouts were started, then stopped or simply done poorly.  As we're working to get more people access to drugs, it's frightening to think about the potential effects of doing the job poorly - it could mean that people get a disease for which there is no treatment. 

Island day trip

I took a quick day trip this weekend with my roommates and a few of their friends to a small island (or quite possible part of a very long peninsula) in Lake Victoria.  It's not exactly swimmable, but it was a beautful boat ride and a nice break from the grit of Kampala. A few photos taken from the boat and on the island....

 

 

What I'm up to at work

After 2 great weeks of training with Global Health Corps at Yale, I'm now at work in Kampala with the Clinton Health Access Initiative (CHAI).  My Global Health Corps (GHC) partner, Isaac, and I are working on a couple of projects to start, and then our work will likely evolve from there depending how the results are. 

Right now, it looks like we're going to be focusing on two projects at first - one is the project I went up north to Gulu for, which is researching the period before HIV-positive patients start antiretroviral treatment.  We're trying to determine some of the reasons patients are "lost" to treatment, initiate ART too late (ie when their viral load is already extremely high and they have major opportunistic infections), and what some solutions to improving this period of care might be.  Unfortunately, we may be restricted to looking for solutions that are "simple and free" so it could get very frustrating. 

The second project is trying to decrease the turnaround time for patients receiving test results for early infant diagnosis, HIV staging, and other tests.  We're trying to build a hub system where one hospital with a lab is linked to surrounding village health centers by a motorcycle driver with a very specific schedule who will also deliver samples that need to be mailed.  I think that one could be very cool (if it works well) because reducing turnaround times for the tests makes it easier to get patients proper treatment.

With a few of the African fellows at training - Jean D'Amour, Morris, and Edmund

New York Times article on insufficient medical resources in Uganda

It was surprising (and really sad) to see this article as the top story on the New York Times last weekend.  I’m looking forward to hearing the views of people in the CHAI (Clinton Health Access Initiative) office because the work they (and soon I) will do is all focused on working with the Ministry of Health to strengthen their efforts and provide technical assistance. 

It is really disheartening to see how much the health spending by the government itself has been cut, though I’m not sure if I believe the magnitude of those numbers based on what I have heard so far.  Either way, there clearly needs to be greater priority placed on health spending – even if the government kept their spending levels stable, the money allocated to health doesn’t even come close to the level necessary to provide an acceptable level of care to citizens.  We’re talking about numbers well under $5 per citizen – there would be huge problems whether or not the government halved spending levels. 

When we were in Gulu, we had dinner with Anita’s sister who works at a private hospital in Gulu.  She talked about a patient who had come in with major cuts on her body – they tried to stitch her wounds, but she had lost too much blood to be saved by stitches alone.  They couldn’t get blood for her for several hours, and by the time the blood came, the patient had died.  She said they wouldn’t have even been able to stitch her had she not brought money for stitches – sometimes as a doctor she would have to choose to buy stitches for a patient who could not afford them because even something as simple as stitches was not provided by the hospital. 



Anita's sister and Isaac in Gulu-

Road to Gulu

Beautiful drive!  We crossed the Nile and drove by Murchison Falls park.  I didn’t get a picture of the Nile, but here are a couple pictures of Gulu and the villages along the way.  Sorry, the pictures don't really capture the beauty.

Trip to Gulu

On Wednesday, Isaac and I headed up to Gulu (in NW Uganda) to meet up with Anita and Simon from CHAI to help with data collection at the Gulu Hospital.  Anita is heading up a project studying patient loss before patients enter antiretroviral therapy (ART) when they are in the “care” phase where they are visiting the hospital regularly and being treated for any opportunistic infections.  When HIV-positive patients are “lost” or stop coming to the hospital, there is a good chance they will not start ART until they are already extremely weak or have a very high viral load.  If they reach that point, it can weaken them physically to the point that even if they are initiated on therapy, they may not live as long as they could have or worse, treatment could be started too late to save them.  (Please forgive my very un-technical and imprecise medical explanations….)

The project we are working on is collecting data from patient records up to the point that they initiate ART.  We’re trying to find possible reasons people stop coming and drop-off points in order to make recommendations for how this phase of care could be improved.  Patient records aren’t always pretty, and they definitely aren’t in electronic form, so it can be very tedious work.

Going through the files, you come upon notes like “also infected in household – co-wife and husband” or “visited patient at home – adherence is good, but family has abandoned patient and locked him in a room where one person is taking care of him” or “28 year old referred from Gulu prison.”  Some (most?) of the files just make you sad – the 7 year old boy who was infected at birth and has stopped coming to treatment or the 20 year old woman who comes diligently every month but is constantly fighting opportunistic infections. 

When we entered the HIV wing of the hospital (pictures below give the nighttime view) it was filled with patients who would then wait 2 hours or more to see a nurse or doctor. Nurses we spoke to complained about how under-staffed, under-paid, and under-supplied they were.  It’s hard to really get a full picture of the treatment patients get without actually sitting in the room with them, but it’s pretty obvious from the records and from spending time in the hospital that wait times are too long, insufficient time is spent per patient on counseling and examination, and medicine stock-outs happen all too frequently.

New House on Semawata Road

Here are some photos from where I’m living – it’s a brand new house on Semawata Road in the Ntinda neighborhood.  Some funny things (okay not funny exactly, but amusing to me) about my surroundings 

• The market two doors down.  It’s an open-air market with baby chicks running around everywhere.  Things that are sold at the market: beans, rice, eggs, eggplants, bananas, tomatoes, avocados, onions… and not much else.  I went there the first day and then went to the supermarket the second day – quite a contrast to have an extremely traditional and a very modern food store within just a few blocks of each other.  I think that could be said of many things in Kampala – it feels like a mix of a village and a modern capital.
• The open-air charismatic church that sets up shop right next door on Sundays from about 9am to 2pm (well actually, I’m writing at 2pm and it doesn’t sound like they are stopping).  They have a very loud microphone – this allows me to clearly hear the pastor speaking in tongues and the extremely tone-deaf singer repeating phrases over and over.  I am going to have to plan my Saturdays knowing that there is absolutely no way I’ll be able to sleep past 9am on Sunday.  
• Power outages.  For the past month or two, there have been rolling blackouts in Kampala.  So far, it’s every other day from 6pm-midnight.  I never thought I would be excited to come home and successfully turn the lights on, but oh it is exciting!  Coping mechanisms: 1) keep computer and phone fully charged at all times 2) always know where headlamp is.  It’s not that hard to get used to, just annoying and sad as a sign of how weak the overall infrastructure is. To my fellow GHC-ers in places where there is no hot water and power a maximum of 6 hrs a day, please forgive my small complaint.