Charlotte and I spent a fair bit of last week in the TB unit. Due to financial and staffing constraints, the hospital has not been able to commit a dedicated staff member to running the program. Dr. Elspeth Young, who also runs the HIV/AIDS clinic, has been trying to give some guidance, but she is very stretched with many other duties and is supposed to be only part time. I think I mentioned earlier that she and her family will be returning to Australia this summer indefinitely to help their son (who has grown up here in Nigeria, as Elspeth did) transition into university there. Pip Mychael, an occupational therapist also from Australia, has also been helping- but they will be leaving for at least 6 months later this year as well. Char and I attended a one day TB training put on by the state TB program a couple of weeks ago which was quite good. The state program is designed to be largely implemented by primary health care workers who may not even have nursing training, based on WHO/STOP TB materials. We are lucky that there is a fairly good infrastructure in place to support the TB program, with free drugs (except when they run out, which creates quite a mess). Unfortunately there is no compensation to the hospital for providing the TB services, other than it being an important community service. Most TB services are provided through the state run primary health centres. So it has been difficult for the hospital to prioritize a dedicated staff member for the program. It ends up that whichever nurse is in the outpatient department when someone comes for meds ends up going to the TB room to dispense them, but since they are often not familiar with the intricacies of the program many things end up getting missed. It has reached a point that the state program has suggested that they may transfer the TB program elsewhere. Although we are able to get chest x-rays at the hospital here, in the smaller centres, diagnosis is just by sending sputums for AFB’s. We do not have the ability to do cultures (at least routinely), so that makes things difficult- also no bronchoscopy. Many of the HIV patients end up being treated for a suspect CXR alone. Apparently here ½ of the HIV patients presenting have TB, and 1/3 of the TB patients have HIV. Contact tracing consists of letting patients know that any family members who are also having prolonged coughing should come in to be evaluated. Very little prophylactic treatment is done, although I did see that one infant of a positive mother is on prophylaxis. Patients who have defaulted are not routinely followed up on due to lack of resources, although I am hoping we can work at that in the future. The medications being dispensed are not tracked or recorded, much information is missing from the treatment records, and the hospital does not keep a current comprehensive record of patients being treated (although the state may have a record). There is only a box with close to a hundred treatment cards, at least a third of which look to be defaulted. Charlotte has agreed to focus her energies on the TB program along with a community health extension worker, so I am hoping that we can spend the next few weeks doing some focused training and improve the clinic functioning. It is satisfying work, since I have a fair bit of knowledge about the different components of TB management from a public health perspective, the problems we are seeing are very fixable, and it will likely be of significant benefit to the individuals in the TB program as well as the community at large. So I am hoping to focus my energies here for the next while, although I am also starting to help with some things for the HIV/AIDS clinic.

Next Stage

We are now entering the next stage of our mcc assignment—although we plan to continue our studies in hausa. Randy and I are beginning to move into our work fields. Obtaining our licenses has been quite an ordeal. For instance, they require some original documents sent directly to their offices. This is difficult when one does not have good access to email and no fax machines. I was finally able to get a receipt from the ministry of health in jos—basically showing that I handed in the required info, application and paid the money for the license. I do not know if I will ever receive the license-from what I am told the nursing council of Nigeria (which is in lagos) does not have the funds to adequately complete the process for foreign nurses to receive the actual license. I am able though to practice because i received a receipt. Randy has made one trip to Abuja (which takes about 3 1/2 hrs by car each way) and returned with more papers to complete before trying again. I have started with attending workshops on home based care focusing on the hiv population. I have been impressed with the wealth of information provided with regards to nutritional needs, other illnesses associated with hiv, ethical dilemmas, and confidentiality and stigma issues for families affected with hiv and aids. It can be difficult at times to know how to treat a pt that has tb and then also develops hiv or vice versa. The combination of meds in their treatment can cause more havoc on their immune system. It is also difficult to counsel a hiv mom who has just delivered her baby as to the pros and cons of breastfeeding or formula. There is a fair percent chance of the baby getting the virus from the breast milk, but there is also a great risk of the infant receiving severe diarrhea from unclean water used with the formula. The dilemma is compounded because the hospital does not have the funds to reliably provide formula or clean water for the infants first year. The mom also does not usually have money to buy wood to heat water or pay for the dry formula. This next week I hope to start in the outpt dept which houses hiv and tb clinics, a small triage and assessment rms for incoming pts. Randy has started to shadow another dr in the hiv clinic but soon realized the need for him to do direct pt care. His long term goals are to work on a more program/community advocate level focusing on the hiv population-but is a little concerned with the black hole that will be left when one of the clinical drs leave in june. Speaking of randy, he was up most of last night retching and with diarrhea. I must confess I broke out into laughter after witnessing him on all fours in the bathroom with his head in a basin. It is a rempel trait-where we tend to enjoy watching close friends/ family members in pain. We took him to get tested this am and discovered he has malaria. We have another addition to our family- a cute little kitten. It is great fun watching our puppy and the kitten play with each other, although our dog at times would probably rather not have the kitten dangling from her face with its claws. Our electricity and water is still very limited or non-existent at times. We have had a few nights lately where we were forced to use candles or flashlights. Our water tank, which serves our house, has also emptied a few times these past few weeks. We then bucket water out of our storage bins from our bk courtyard. Our kids now leave our house at about 6 20 am-we felt this was the best option with the transportation angst we still have. They join another group of kids driven by an ex-retired military officer—which helps put our minds at ease. The girls did mention that they witnessed a girl about their age get struck by a motorcycle and was then dragged off the road by her feet due to oncoming traffic. Randy also witnessed a horrific recent accident on his trip bk from Abuja where few people were seriously injured. There was also a recent accident where about 15 young men were killed – three of them were brought to our hosp whom expired later in the operating rm. The motorcycle drivers are also required to wear helmets as of jan 1—also providing one for their passenger/s. It has been quite interesting seeing the diff types of head gear from sport helmets, hard hats to old race car driver helmets used by maybe about half of the drivers. Then I would say about half of them or less actually have them strapped on. I have been told that some of the passengers refuse to wear them because of the ju-ju spirits. They feel, I think that one can get an evil spirit from the last person who wore that helmet. The flowers are still coming out on the trees—quite amazing in this dry season. Mangoes and avocados are now coming in and some strawberries were available at one market. I tried a passionfruit recently—quite sweet and tasty. Hope all is well--charlotte