More Infectious Disease

Hello-

Here is the mandatory warning that this blog post is not for the squeamish and may leave you with unsavory images for some time (it certainly has me). We have been experimenting with some more infectious disease here that we would like to share with you (just via the web). In addition to more giardia and some sort of nasty cold that is circulating (don’t want to ignore the run-of-the-mill infections), one of the girls had noticed some increased anal itching, so her sister did an inspection. We found them trying to wipe away dozens of visible small white worms crawling in and out of the sphincter. We think it was either hookworm or whipworm (we’re not too good at our helminth identification). The females apparently crawl out the anus at night to lay 10-20,000 eggs before slipping back in to a comfy evening of sucking blood or secretions from the intestinal wall. We treated the entire family just to be on the safe side and haven’t had a problem since.

I have had my first encounter with the dreaded mango worm. The kids not too infrequently find one on the dog and pop them out like a giant zit (somewhat satisfying). We have been well cautioned to make sure that we iron all clothes (yes, particularly underclothes) to prevent infestation/infection with mango worms, which we have done faithfully. Nevertheless , I somehow ended up with 5 gradually enlarging lesions on my forearm which I initially took for mosquito bites that had become infected. As the days passed the pain increased, at times feeling like small knives stabbing my arm. Eventually I was able to “pop” one out along with the rest. “Cordylobia anthropophaga, the mango fly, tumbu fly, putzi fly or skin maggot fly is a species of blow-fly common in East and Central Africa. It is a parasite of large mammals (including humans) during its larval stage. At the site of penetration, a red papule forms and gradually enlarges. At first the host may experience only intermittent, slight itching, but pain develops and increases in frequency and intensity as the lesions develop into a furuncle. The furuncle's aperture opens, permitting fluids containing blood and waste products of the maggot to drain.” (Isn’t that a tasty description- For more information, see http://en.wikipedia.org/wiki/Cordylobia_anthropophaga. ) The lesions are gradually resolving, but all told it will be about 6 weeks of sporadic intense itching and pain. Here's some photos I managed to take:



On a sadder note, we had been thoroughly enjoying the surprise addition of 2 new kittens to our household. (You may remember we had tried to prevent her from becoming pregnant by asking our neighbour vet friend to help us- Apparently you can trick a cat’s hormones into thinking that it has been bred by use of a thermometer. Use your imagination, but let me just say that it was an experience I will never forget and I was not even on the business end of the thermometer.) Last week one of the kittens fell ill and died within 36 hours. A couple of days later the mother did the same. The vets seemed a bit baffled- kind of an uncommon presentation. Yesterday, just when we thought that the other kitten was out of the woods and not going to be sick, it also became ill and we expected it to follow the same course, but by this morning it very surprisingly seems to be well on the way to a full recovery, so we are hopefully optimistic at this point. Although the kitten had been promised to another family, they have graciously offered to let us keep this kitten that has survived.

School and work continue well. A team from Abuja (the capital) will be coming next week to do a quality assurance inspection tour of the HIV clinic in Vom. I’m sure we will learn a lot. Here are some pictures of our staff and a mom with her daughter (“Joy”) who said I can show their picture. Nvou, our clinic attendant, is in the sweater, who is doing her best to teach me some Birom, the local tribal language. She said to tell people that this is a picture of a "very fine Nigerian woman". Dr. Bot is our medical superintendent and my boss/support who works incredibly hard to keep everything running (from surgery to administration to clinic to filling the generator with fuel). Our pharmacy staff (Deborah, Dinatu, and Cabala) have some of the nicest smiles around. I'll leave you with a final image of "Joy" for this blog entry.

New Home

We are unpacking the last of our boxes as we move into our permanent housing for the rest of our term, and are very grateful to have had Matthew from our MCC team mobilize a team to help us move.

We spent the last 2 months only a short distance from here on another compound. Our kids had a great time playing with friends through the summer holiday- Tire swing, football (soccer), water fights, cooking lunches together, video games, ultimate Frisbee, another trip to the Yankari game preserve and warm springs, and watching old reruns on DVD in the evening (anyone remember the Flying Nun?). Just the kind of summer I would wish for them right now. The girls came out to the hospital a couple of times to help in the clinics and I hope next summer to involve all of the kids even more- lots to learn and the staff and patients really enjoy seeing them.

The last couple of weeks have once again seen more violence breaking out in northern Nigeria, although fortunately not in Jos. Sadly, there was quite a lot of loss of life. The clashes seem to have been mostly between a very fundamentalist Islamic sect and government forces.

We are still enjoying our work at Vom very much. I have increasingly little to do with the TB Unit as Charlotte and Nurse Vick become more familiar with the TB program. The HIV/AIDS clinic has added another day to see patients and we are hoping to open the expanded clinic space for use by the end of the month. The clinic functioning continues to improve as the staffing has gained more consistency. There are still lots of challenges, but it feels like we are moving forward. (You may recall that the primary physician, Dr. Young, who was instrumental to the clinic’s start and running, needed to move to Australia recently- So we are still very much adjusting to her absence as well.) We enjoy the deepening relationships with work colleagues as well as getting to know some patients, although we have also begun to experience seeing patients that we know dying from their illnesses.

MCC team meetings were held in Miango at a retreat facility at the end of July- It is a very relaxing place with good food and even a good electricity supply there. We had a nice time getting more acquainted with the other team members and their families. Our family had also been out to Miango with some other friends for a couple of days earlier in the month. Things are especially beautiful here during the rainy season. There are few things I enjoy more than to be working in the clinic during a downpour, with a fresh breeze blowing through and the sound of the rain on the zinc roof (OK- perhaps a Sunday afternoon nap, in bed with the cool breeze and the rain pouring down). Harvest is also coming in- lots of potatos and other things- some of which make tasty snacks sold roadside.

Our cat had kittens last month (in spite of our attempts to prevent that). She seemed too small and young but did very well with the 2 kittens she had. It was amazing how this somewhat cantankerous, finicky, “it’s all about me and what I want” cat suddenly knew exactly what to do and had never looked so happy in her life as she luxuriously curled around the kittens, purring away, taking perfect care of them. They’re now just old enough to start jumping around and are exploring the house- a pretty fun time.

Our new home is called “the Blue House”- in reference to its color, not mood. It is the second story flat on a Danish Lutheran compound, located at a very busy intersection called the Secretariat Junction. The flat is high enough that we have an
interesting view out over the hustle and bustle of city life, along with an unimpeded access to the hundreds of horn blarings that go on throughout the day. (Horns are used much more liberally here as they are in many countries. The Lorry drivers in particular like to announce that they are coming through and the horns can be quite piercing.) The view to other side is of the
beautiful compound- Mango, frangipanni and orange trees. We share the compound with a Danish family, the Lauritzens, that we are friends with. The flat below us is used by a couple who come sporadically throughout the year for short stays. We now have a generator and a bigger fridge that MCC has provided for us- We are very grateful. Electricity supply in Jos continues to be sporadic.

School has just started for the children. They were a bit anxious but are enjoying seeing their friends. I attended the chapel service yesterday morning- lots of new kids as well as staff. I guess that is an important part of life in such a mission community- getting used to people coming and going. We continue to be grateful for the opportunity for our kids to school with children from all around the world as well as Nigerians.

Hope you all are doing well where you are. Randy

Changes

Well, it has been an eventful last couple of weeks. The kids have completed their first year at Hillcrest- It was a good year for them all and a lot of work as well. It is a relief to not have to struggle helping them to get homework done every evening. Their hard work paid off, though; all did well and received recognition for their efforts. Westen also had the 8th grade banquet, I guess intended to mark the transition to High School. It is a very big event at Hillcrest and he went through the stress for the first time (likely not last) of asking someone and all that entails. We were happy that he seems to have shown good judgment for choice of companionship. (Hillcrest’s website is http://www.hillcrestschool.net/, for anyone who is curious.)
Rainy season is well under way, with rain coming most days now. The downpours are beautiful and refreshing and the green transformation is amazing as everything springs to life. The fields are full of people getting crops in. The amount of work that goes into transforming huge expanses of land into neatly hand-tilled rows is humbling. When we first arrived last fall we enjoyed watching the progression of crops being harvested, so we are now enjoying watching people and the land move through this part of the cycle. The mango trees are filled with an amazing abundance of fruit, which the kids are enjoying very much.

Unfortunately there was an armed robbery on the hospital compound a couple of weeks ago. (There was another one within the last year, but before we came). We are thankful that no one was hurt- the people who were robbed are good friends of ours. The dangers of the kids spending so much time on the roads here (traffic fatalities are very high with treacherous driving conditions) had us already considering whether a move into Jos would improve our family’s safety, so we decided our family would feel safer being in Jos at this point. Although we are relieved to be in Jos now, there are many things we will really miss by not living in Vom. Our own and MCC’s vision of service and ministry is very much about presence and connections, so not living in the community where we work will change how we are able to go about that. The hospital community has been very supportive of our family throughout our time at Vom, and continues to be very understanding and gracious in that support. Charlotte and I will continue to work in Vom and we look forward to maintaining our work relationships and assignments. Housing is scarce in Jos, so we feel fortunate that MCC has found us very nice temporary housing until the end of July when we will move onto another compound and will likely be able to stay there until the end of our term. Both places have friends of the kids, so they are enjoying having more playmates.

Our experience here will now be different than we had originally thought, but we still want very much to be in Nigeria and continue with our mission (i.e. sharing our lives in God through relationships and work in a mutually transforming way). The entire process has and continues to provide many opportunities for growth- Life rarely goes as expected, especially here in Nigeria. Even when I cannot control what is happening, knowing that God is always with us, every breath, has been very comforting- That is the fundamental truth of my life and it has been good to experience that at a deeper level again recently. Just as our entire time in Nigeria has done, the recent weeks have also enriched and strengthened our family relationships. We appreciate your thoughts and prayers.

Randy

Yankari Game Park

It has now been 6 months since we arrived to Nigeria. There are some things I have become accustomed to but still many things which require more effort. We are just now beginning to build some relationships at work which has been a big plus. I have learned more about how life exists for the majority of people here in Vom. Life would seem to be a constant struggle when hearing their stories, but I have been amazed at how well villagers continue on from day to day.
For the past 2 months I have been in the TB unit. About half of this population is HIV positive. I have heard many sad stories where a husband is HIV positive and has not disclosed this to his wife and it is only discovered after he dies. The wife then tests positive and is left with this stigma trying to raise children. In some cases the possessions along with the children are taken from her by her late husband’s family. There is much difficulty with the TB population to stick to their 6-8 month treatment regimen with limited cash flow in paying for transportation. The TB meds though are paid for by the state.
It is frustrating trying to work with a system where there is a shortage of staff, limited funds for equipment, and people not following through with what is expected. The nurse I am working with is still putting in time in pharmacy because they have not yet filled her position. It was expected that Sister Vic would be trained to manage the TB unit. Our local supplier of items for the TB unit states she will visit us monthly to replenish our stock but we have been left close to empty at times if not for Randy making a run into Jos. Water and electricity is in short supply. There have been days where we have had no water for pts to take meds so I have carried a bucket from home one day. Other days the electricity turns off and pts are unable to get chest x-rays. The hospital does have a generator but is only able to use it when urgent due to limited money for fuel.
Traffic is still a major concern for me to overcome. We still come across many accidents and every time we are on the road my body tenses up. Just recently on a trip back from Yankari we were side swiped by a lorry (semi truck). We were waiting to make a left hand turn across traffic and the truck coming toward us lost control of the steering and came into our lane, just glancing off the side of the car (luckily). The driver did not stop to check on us but continued on. I am so thankful that no one was hurt. Randy and the kids were also in a crash yesterday on the way home from school when a car came off the shoulder to do a u-turn right in front of them while they were traveling at highway speed. They glanced off the other car but then ricocheted across the oncoming traffic lane- luckily there was a gap in the traffic and they just continued on across without further collisions. No one was injured and the other person was very nice about arranging repairs, but it was still scary. Now that I work in the hospital I am constantly reminded of how unsafe the roads are with the motor vehicle crash victims coming in to be treated. One day, 3 people came in all bloody from head to toe and one man’s arm almost severed off. There are no ambulances so they come in quite fresh, usually in the back of someone’s pick up.
Our trip to Yankari wildlife preserve was quite exciting. We were lucky to see many different types of animals on our safari. At one point we saw baboons, monkeys, water bucks and elephants all in the same area. It was quite a privilege. At the accommodations baboons and wart hogs roam the grounds scavenging for food. One time I was on the step of our chalet and was startled when a baboon jumped up right next to me. I quickly opened our door and ran inside screaming. When I closed the door the baboon was wrestling with the door handle and pushing up against the door. Randy and Westen just sat there laughing at me while I was trying to bolt the door shut. We have even seen them attempting to open our window. They are quite aggressive. It is odd when one feels we have become the caged animal with baboons looking in the windows. The water springs at Yankari is quite inviting with the constant temp at 31 degrees Celsius. At our first swim Kezia yells out elephant. Sure enough there was an elephant grazing at the far end of the spring.
The temp here is still hot and sticky. Every so often it cools down and it feels like the rains are soon to come. The trees continue to bring forth wonderful flowers and I am surprised to see them bear new fruit. We are enjoying the mangoes. Right now though, I could go for a big bowl of chocolate ice cream.-charlotte

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

Holiday Greetings

Hello-

A belated Holiday greeting to everyone. We have had a pleasant Christmas break thus far. People have included us in numerous celebrations and we have had lots of time to play games with the kids. A Nigerian work colleague of Char’s from Winnipeg came to Jos to visit family last week and graciously carried along our new laptop for us. It is nice to have one again. (He also brought along a care package from Char’s family with chocolate, jolly ranchers, and the newly released Prince Caspian DVD- what a treat!) There are even plans for an internet café offering wireless access to be developed right next to our house in the next few months, so we are keeping our fingers crossed. Family Christmas gifts enabled us to have some extra meals out, an overnight stay at the Miango Rest Home, and a new table tennis setup for the children, which is a big hit with their friends here as well. Thanks!

On January 2-3 our Mennonite Central Committee had a team meeting here at the guest house in Vom. (We had originally planned to have a retreat in Abuja, the capital, but due to the crisis some felt that we should not be away from our homes for that long.) All the families of the national (Nigerian) staff as well as our family and the Hartman-Souders met. It was nice for us to get to know the families a bit and it now feels like we are really part of a team. Our team benefits greatly from having the long term national staff. Just briefly, Athanasius is involved in programs serving the deaf community, Gopar does peace work, and Matthew runs the office as well as being involved in programs like the EPRT (see below), and the Hartman-Souders are the country representatives (overall MCC Nigeria program planning and connecting with partners). The MCC Nigeria program/staff is fairly small and its major mode of operation is to work through local partners. The balance then comes in being more than just an external funder- We can see that MCC works very hard at the relationship to these organizations. MCC currently has multiple partners with HIV/AIDS programs and has asked me to use a portion of my time to add a public health perspective to our connection with these organizations.

Char and I look forward (with a bit of anxiety) to starting our health work assignment this week at Vom Christian Hospital (on whose extensive compound we live, a 35 minute drive from Jos where the kids go to school). My position particularly is vaguely defined now, which is fine at this point. Clarity would be nice, but I am often tempted to try to impose clarity when it isn’t really there. I remember a communications professor at seminary once saying that it is a gift to be able to wait for clarity- So that is what I will strive for.

My goal is to connect with people in a meaningful way as I work at public health (which is the basis for our family’s being here with MCC, reflecting the “transformative” aspect of MCC’s mission). There are pre-existing givens and needs of the hospital that I will try to meet as much as possible, while also hoping to utilize basic public health precepts in shaping my work (e.g. looking at what information is available on illness and death in the region and what are the existing public health efforts to address them; what has program evaluation shown; what issues have the attention of the community, its leaders, and potential funders; what evidence based interventions are there for these issues). One of the expatriate physicians will be leaving in 6 months, and it is likely that I will try to fill in for some of the administrative/program planning HIV/AIDS clinic (PEPFAR funded) work that she currently does. They are also hoping to tie in to more home-based care and perhaps work with the existing extensive church networks in some way. Their Tuberculosis clinic also is in need of strengthening.

Hopefully that work will still allow for me to spend some time looking at some other public health issues- things like basic sanitation (e.g. latrine use, water quality, and other environmental health issues which are readily apparent) or malaria prevention. Injury impacts people heavily (particularly traffic related- the risk of driving here feels about ten-fold greater than in North America- it would be interesting to see the stats), and the recent hundreds of deaths in the Jos crisis of late November is a reminder that violence in its many forms takes a heavy toll. (Mennonite Central Committee was instrumental in the formation of an Emergency Preparedness and Response Team for the Plateau State a few years ago. This diverse, government connected network has played an important role in the response to the recent crisis and has likely helped to prevent other violence in the past. Peace work is a major focus of MCC and is considered a unique lens we have to offer in our service here.) Polio survivors are often seen on the streets, although it is further north in Nigeria where they are still experiencing outbreaks. Tobacco use seems very low, although I am told substance abuse is common and increasing. (The Vom Christian Hospital has actually formed a partnership with the Jos University Teaching Hospital in the last year to run a couple of wards for inpatient substance abuse rehab here- an important service as well as generating much needed income for the hospital.)

A 2000 WHO report ranked the Nigerian health care system 187 out of 191 countries. Nationally, the fertility, infant and maternal mortality rates are very high, with immunization rates and life expectancy very low.

On the positive side, I see amazing examples of community networks and support systems for community capacity. I have read that historically, the western medical model brought by missionaries was not always readily accepted/utilized by local cultures. Although western influences are readily seen today, particularly in urban settings, I have to think that such considerations will still guide my involvement in community health. The balance and tension are always challenging between sharing knowledge and listening, taking direction from communities and also being rigorous in the application of established public health principles. I look forward to learning a lot.

So the New Year has started and we hope to settle into some new routines. The Jos crisis still hangs heavily over life for everyone here. Military checkpoints and curfews will likely be maintained for months yet. Figuring out how to get the children to and from school when they start back the 14th is another major decision. We will likely rely on drivers, but due to the high risk of travel here, we are quite anxious about how this will work out. The 3 ½ months we have been here in some ways seems so short, in others so long. Living day by day is always a good idea- I’m not sure if that’s harder or easier to do here.

Thanks for your thoughts and prayers.

Randy