Tune in, turn on…

Back in the 1980s “appropriate technology” for the developing world was usually ‘lower tech.’  But cheap electronics – phones, computers and the Internet – have really changed a lot of things.  Now, things like phones are everywhere – especially remarkable in in countries that never had land-line phone networks because of lack of infrastructure. Now, nurses in rural clinics perform continuing education exercises using DVDs and laptops ,  community health workers in rural communities send images of what they’re seeing to doctors in the central city, and docs in developing countries beam x-rays to specialists for consultation.

Duke EWH Chapter Students are in the EWH equipment warehouse testing pulse oximeter probes. Photo courtesy of EWH

One thing that doesn’t get mentioned, however, is how much load those electronic devices place on power grids that aren’t that competent.  More load on the grid means more probability of fluctuations in power and blackouts.  It’s indicative of a phenomenon called “energy poverty” that’s starting to get attention.

Research shows energy poverty is a growing problem worldwide.  The US Energy Information Administration estimates energy consumption in South America, Africa, and the Middle East will grow 60 percent above existing levels by 2030.

That’s some of what the kids from Engineering World Health learn when they travel to other countries.

You can listen to today’s story here:

James Molini and Adam Kurzrok hold the Cell Saver

James Molini and Adam Kurzrok both talked about being ‘shocked’ (they weren’t being pun-ny either) when they arrived in Tanzanian hospitals to find almost daily power outages.  They say that’s a big reason much of the equipment they encountered was broken – essentially circuits or components had been fried by bad power supply.  And although all the hospitals had generators, fuel was often too expensive. So they came up with the idea for the Cell Saver – and they got help from Chris Hamman and Pat Caputo.

So, their idea for creating back up power is pretty simple, and not particularly novel.  My electrical engineer husband – who’s also a ham radio operator – tells me that hams rig up back up power supplies for their radios all the time (especially when they want to go broadcast from obscure places ).

So, what’s so different about this device that isn’t already out there on the market in the form of a commercial UPS – an uninterruptible power supply?

UPS’s tend to be pricey – about $75.  Molini and Kurzrok, et al, intend to sell their device for about $12-15

UPS’s tend to be for short term power outages, or would be used to successfully close down your computers, etc, and then be turned off within a few minutes – the intention of the Cell Saver is to power machines for an hour or more, so that surgeries can be completed, for example.

Use of recyclables

The Cell Saver

That recycled thing is key. A 12 V lead-acid batteries can be recycled if they’re not completely depleted and the lead plates inside are not completely eaten by the acid.  Plus, you hook them up together and you can get extra power (just the say way you use more than one AA battery to power a hand-held radio).  If you’re in a place with plenty of lead-acid batteries in the waste stream – you’re in business.

The idea was cool enough to win the guys second place in the Dell Social Innovation Competition. Here’s the website for the competition.

Comments? Drop a line to NCVoices@wunc.org

Anyone who’s read this blog knows I have a soft spot for lab workers (see this spread on lab workers in Zambia).  They toil away in artificially lit rooms making the work of docs and nurses possible (they actually do the tests that confirm the diagnoses) – meanwhile they get none of the credit.  So… another homage to lab workers!  But this time, it got onto the radio. 

Take a listen to today’s story:

A local condom brand from Malawi

So… I got wind of the condom testing lab at FHI and my interest was aroused. On top of my labworker geekery, I admit there was a bit of adolescent curiosity… you know… the giggle factor.  I needed to go see, hear and record the popping condoms.

In good reporter’s fashion, I pestered the poor press officer at FHI for months to let me come see it.  Finally, word came, just in time for this series.

I went there prepared giggle all the way through the tour, and to write lots of bad puns about the lab.  But lab director Eli Carter and FHI VP Gary West were professionalism all the way.

That's a BIG hole.

It seems that Carter is the man when it comes to condoms.  He’s helped write the international standards for condom safety and testing.  If you turn a box of condoms over, you’ll see something like : “This product meets international ISO 4074 standards.”    ISO is the International Standards Organization, and Carter leads the US delegation to the ISO.  He can recite the condom standards in part because he wrote most of them.

As we went through the tour, my desire to write bad puns about the condoms also shrank (OK… so I have had some puns in this blog post – all intended).  But seriously, what they do there is very serious stuff.  A faulty condom can put the user at risk for unwanted pregnancy and/ or a deadly disease.

And we’re talking billions of condoms, millions of people. FHI is the testing lab for US AID, and US AID administers all of the programs for PEPFAR (the President’s Emergency Program for AIDS Relief). Click here for distribution numbers.

It seems the humor around condoms is saved for advertising instead – sex sells, sure, but humor PLUS sex sells better.  A quick perusal of YouTube finds a plethora of commercials from all over the world.  But several of them illustrate points made in today’s story.

In this ad from Central America, taste is touted as one of the selling points of this brand of condom:

And in this ad from Kenya, people cheer when the man ‘uses’ the condom.  It’s a great selling point – use a condom and everyone is happy:

What I didn’t get to in the story is the other stuff they do at the FHI lab – for instance, they test for efficacy of anti-retroviral drugs and oral contraceptives.  Injectable contraceptives too – in particular, Depo Provera, one of the world’s most widely used injectable contraceptives.  Depo prevents pregnancy for about 3 months, and many women like it because it’s not a daily pill to be remembered… or noticed by a partner who might want more children than she wants.

Carter and industrial chemist David Jenkins also tell a story about how a rumor got started in Zambia that the Depo was contaminated with HIV.  Overnight, usage of the drug plummeted.  US AID asked the FHI lab to test batches of the Depo to see what was up. Eli Carter tells the story:

David Jenkins shows off a field-testing lab.

Our chemist and our virologist who works in another part of FHI, teamed up and they were able to simulate a false positive to show that they could replicate what had happened and prove that there was no contamination of the Depo-Provera.

And I think it also points out how much faith and trust the US AID puts in this lab… that they can call on us and we are able to respond here from North Carolina out to Zambia. We have a country office in Zambia and we worked with the Zambian authorities and facilitated all the preparations for this and monitor the situation…

One contraption David Jenkins showed for me was a portable lab they’ve acquired to field test for counterfeit drugs.  Counterfeits are a huge problem, especially for anti-malarial drugs.

The testing kit has everything needed to test pharmaceuticals in almost any location - even a rural area.

Use of a counterfeit anti-malarial drugs can 1) increase the risk you don’t get better and die and 2) increase the probability that malaria parasites become resistant to the disease.  That’s happening right now in SE Asia, and there’s a real need to nip it in the bud.  FHI is looking for money for a project that would send – yes, lab workers – out into rural areas to test the drugs people are using and make sure they actually contain active ingredient.

Comments? Drop a line to NCVoices@wunc.org

… to fight HIV.  It’s not as easy as you might think.

Writing about a process can be difficult… precisely because it’s a process .  There’s not a lot of action per se.  That’s unfortunate, though.  Because processes are important.   And Durham needs this process of figuring out the best ways to arrest the spread of HIV. What’s more, a surprising number of people really aren’t sure of the best ways to prevent HIV. A survey done in POZ magazine – a publication aimed at people living with HIV – found 34% of readers cited the lack of HIV education as the main reason they contracted HIV.

You can listen to today’s story here:

NC HIV Disease Rates, 2008

As of the end of 2008, Durham ranked number 3 in the state for HIV acquisition (figure right) with about 36 out of every 100,000 residents coming up positive for the virus. The statewide rate is 22 people per 100,000.

What’s more, the rate for black males is 113.6 new cases per 100,000 people, for black females, it’s 50.7 cases (PDF). So, the black community in Durham should be clambering for someone to study how to prevent HIV transmission, right?

Maybe not.

I remember once hearing a presentation at the American Public Health Association conference about researchers from the Texas Department of Health trying to study kids who lived downwind from a lead smelter. A lead smelter for  Pete’s sake… spewing lead-filled smoke into a poor Latino neighborhood!! Shoulda been a no-brainer, right?

Yet, the families of these kids didn’t want to participate in the study.  Why? They’d been studied to death, they hadn’t gotten feedback, they felt used and felt like they’d been poked and prodded … and for what?

For the black community, there are also the echoes of Tuskegee.  I don’t think whites appreciate how much the Tuskegee study echoes throughout the African American community.

I certainly didn’t until a few years ago, when I did a story on end of life care in the black community, and interviewed Tonya Armstrong, a clinical psychologist.  She talked about doing focus groups with UNC students to ask about their attitudes to research:

By and large, the African American students were much less likely to participate [in medical research] and they  named Tuskegee – as young as they were – as the reason. Meanwhile, the white students at UNC were generally  unaware of Tuskegee.

So these young people who had not even been born yet, when Tuskegee was going on, they pick up these vibes from their communities and we  still have ongoing difficulty in [the research] community for people to recognize that building trust is not something you can do in an in-and-out maneuver, you have to be there, and show your self in a predictable, consistent behavior and it doesn’t matter what you look like.

That distrust continues today and is exacerbated by, our… inability to really demonstrate those long-term relationships with members of our community.

It seems like it’d be obvious to researchers: involve the folks you’re studying into the research process. But it’s surprisingly common that researchers don’t do that. .  Part of that could well be the pressures of research on a timeline – you have a 3-year grant, say, and getting nuanced information across to people takes time that often feels like a luxury. Part of that is certainly a level of academic arrogance. But part of it is definitely the cultural divide between the PhDs in academia, who’ve spent their lives with their noses in a book… and the rest of us folk.

That’s something that makes LinCS 2 Durham somewhat unique.  They’ve got a grant that allows them to engage in this process.  Essentially, the process is the research.  And they have 5 years to do it.

I had an opportunity to go to one of the meetings of the working group – the Collaborative Council (through a consensus process, they asked me not to tape the proceedings.  Instead, I took notes).

At that meeting, they were combing through the language of the community survey they’ll be debuting later this summer.  Comments came up about how perhaps language about HIV was negative: “why not frame an HIV+ neighbor in a more positive light?”  They also worked on how to get at the stigma that surrounds sex, talking about sex, men who have sex with men, and the stigma of having HIV.  It was a lively – and sometimes loud discussion – and insightful.

That’s because the room was populated by lots of academic-types, but there was also a hospital social worker there, Rev. Rhonda Royal Hatton (quoted in today’s story), her friend Wisdom Pharaoh (a spoken word artist/ poet who’s also the head of the residents’ council at MacDougal Terrace), an HIV-positive gentleman who identified himself as ‘no one special’, a couple of students… in short, a mix of folks to give input on how to get the word out on HIV prevention.

Comments? Drop a line to NCVoices@wunc.org

How do you solve a problem like orphans?

International orphans have been in the news a lot lately – a group of Idahoans take 30 Haitian children across the border after the earthquake; a mother in Tennessee puts her adopted child on a plane alone back to Russia; fewer countries are offering children for adoption by western parents as stories of baby-selling and coercion reach the ears of officials both here and in ‘sending countries.’

Images of destitute orphans endure throughout literature.

But the world holds many children who desire a place to call home. To be ‘orphaned’ in many countries means losing one parent. In a 2004 study, UNICEF put the number of orphaned children anywhere up to 143 million worldwide. Many of those are ‘double-orphaned’, meaning they’ve lost both parents. Although many of those children have been orphaned by AIDS, even without AIDS, the numbers of orphaned children would be staggering.

Duke’s Dr. Kate Whetten has a personal connection to what happens to kids orphaned in other countries. She was a Peace Corps volunteer in the Democratic Republic of Congo in the 80s where she saw kids orphaned by malaria and other easily treatable diseases. Later, her work took her to many countries where she met more kids orphaned by AIDS.  So, when it came time, she chose to adopt from abroad. She has three children.

When Whetten published her paper last year in the online journal PLoS, she expected it to add to the literature about what happens to all those kids in other countries – she never expected the results to have an impact here in the U S.

You can listen to today’s story about her research here:

Whetten says that when she first wrote her proposal what she was most interested in was examining which caregiving characteristics make sense for the kids in terms of promoting good outcomes over time – she really didn’t go looking to enter the debate over institutions vs families. Ironically, she originally included in her study 550 orphaned and abandoned kids in North Carolina, Texas, New York and Chicago. But the committee that reviewed her study proposal said it wasn’t necessary to study kids in the U S – the attitude was that ‘we know what we’re doing.’

But Whetten was amazed when she got the first phone call from a residential care provider in this country after her paper was published. In the U S, it turns out there’s a whole world of opinions and ideas about what’s ‘best’ for kids. There’s little agreement on the answers and no one is dispassionate about their opinions.

For example:

CORE – the Coalition for Residential Education represents programs which house kids congregately. They believe kids can do just fine in high-quality residential programs, even living away from family. CORE asked Whetten to speak about her research at their annual meeting earlier this year. Many of the residential care providers volunteered to be one of Whetten’s study sites when she does another round of research.

Many researchers at Chapin Hall  at the University of Chicago tend towards favoring foster care over institutional care. In recent years, ‘kinship’ care, where kids are placed with someone with a connection to the family – whether it be blood relative or a close friends – has become the favored placement for kids. But there’s room for debate. And – importantly, as Fred Wulczyn said (in an hour-long interview), resources are limited, kids’ are wired to live with stable caregivers and there’s a need to maximize the benefit to the child. He argued that family care does this better than institutional care. He also said the quality of the care makes a big difference – we just don’t always know what that is.

Observers such as UC Irvine economist Richard McKenzie argue that kids who’ve grown up in well-run residences do better over the long run economically. He also found ‘graduates’ of these orphanages had more stable relationships. McKenzie does have a bias, however… he grew up in such a residence, and he’s studied self-selected ‘alumni’ of several programs.

The kids are alright.

The view of North Carolina's mountains near Crossnore

Drive through the North Carolina mountains, through the trees, past the trailers and abandoned stores and then past the new-ish condominium communities for retirees and vacationers.

A sign appears on the side of the road a the green street sign that reads, “Crossnore School – Miracle in the Mountains”. Turn there.

Suddenly the bracken and the forest gives way to manicured lawns, stone retaining walls and tidy buildings. Two teenaged boys with weed whackers, earphones and hats are working on the side of the road . One wears a red shirt proclaiming saying, “sober.” He gives me a nod, as if to say welcome.

You’re at Crossnore.

Dr Phyllis Crain leads the place. As she tells it, she was on the career ladder as teacher, then principal, then superintendent of the Avery County schools. She planned to stay there a few years, then move onto a larger, urban district. “I really think I envisioned being the head of the public schools in North Carolina at some point,” she says.

But the Crossnore opportunity opened up, and she took a visit. She says she’d been looking for ‘purity of purpose’ in her life and found it in this job.

Crain is a woman on fire. During her tenure, she’s presided over the building of a beautiful, light-filled school building, that has therapy spaces integrated into the facility. As she walked me through the school’s library, she said, “When we opened the place up, one of the kids who was here came up to me and grabbed my hand and asked me, ‘isn’t it too good for us?’”

The light-filled library at Crossnore.

Crain says that comment has stayed with her – that many of these kids believe that something good would be ‘too good’ for them. She says that’s driven her to seek out quality in the buildings and staff.

By all appearances, she’s accomplished creating a quality program. The day I visited, I met more than a dozen kids who looked happy and healthy. What was even more remarkable was that all these kids – even the teenagers – stood straight and looked me in the eye as they spoke. They talked. They expressed themselves – sometimes hesitatingly, but nonetheless they expressed themselves. As each of the kids walked away, Crain would quickly sketch for me a history – sexual abuse, neglect, drugs, alcohol, prison. Each story was filled with sadness – but you’d never know it to talk to these kids.

For example, Amy,14, calmly talks about her two stints at Crossnore. “I was here for about two years and then I went with my grandma. Then, I came back here after she OD’d.”

She talks about calling the ambulance to take her grandma away and ending up at Crossnore that same evening. I have to keep myself from visibly starting. Did I hear that right? Her grandmother overdosed…?

I heard her correctly. Her mom lives in Charlotte, she’s not allowed to have contact with her and she didn’t mention a father. She did say she hopes residential advisor (house father), Mr. Todd, walks her down the aisle when she marries someday.

She hopes to be adopted. “I want someone who loves me and cares about me and supports me and doesn’t put me down, and believes what I believe in,” Amy says.

What constitutes quality?

Crossnore director Dr Phyllis Crain talks with one of the boys and a residential counselor

I asked Crain about scandals, such as sexual abuse and neglect that have taken place at some of these facilities. She admitted that it’s an issue. “We have to screen our people very carefully and I’m always holding my breath, wondering, ‘did we miss something?’” She’s asked people to leave. But Crain also talks about how kids are abused in foster homes all the time, and they’re simply moved from the foster home. She argues, institutions like hers receive more public scrutiny, so a single scandal at a residential care facility can end up tainting all other such enterprises, even when there are no problems.

However, she makes the point that there’s considerable regulation on residential care facilities, and so problems get reported and addressed vigorously. And there are more ‘adults’ around to notice things. But she says it’s often harder for child welfare officials to know what happens in foster homes.

The one commonality I noticed through all the interviews and visits was one word – ‘quality.’ There seems to be common ground that ‘quality’ programs, and ‘quality’ care, are key for kids’ success. The question is, what is quality, and are we, as a society, willing to pay for it?

Questions? Comments? Contact us at NCVoices@wunc.org

Welcome back for another series on global health! This year, I’m examining how global health knowledge affects North Carolina.

One of the enduring ideas about global health work is the one that knowledge all flows one way – from ‘here’ to ‘there.’

Indeed, money tends to flow from the developed world to the developing world – the billions spent by the US and others on combating AIDS, TB, malaria and other diseases is a testament to that reality.

But knowledge and skill are a much more fluid commodities. U S hospitals and doctors’ offices are filled with practitioners from many countries – some of the greatest minds in this country were born, raised and educated in another place. The U S pharmacopoeia is filled with drugs which were first noticed by practitioners from other places – aspirin is an example, while a new case in point is artemisinin, a compound noted by Chinese practitioners as effective against malaria, and now is the cornerstone of treatment for the disease. And we’ll see in this series how studying the sociology of other cultures can inform the process of doing research in this country.

“Global Health Comes Home” is an attempt to see how knowledge and ideas flow in all directions, and eventually make us better for it. I hope you enjoy the series.

So what’s UNC doing in Malawi anyway? And what does it get in return?

Throughout my trip to the UNC Project, I kept asking the same question, why should Malawi matter to North Carolina?

When I posed the question to Irving Hoffman, he mentioned the humanitarian aspect of what UNC does in Malawi… clinicians employed by UNC all spend part of their time providing patient care, and that to be in Malawi is the ‘right thing to do.’

However, I know that people in North Carolina might be saying, “Why aren’t they doing this stuff at home?” And… “why aren’t these people spending time and money back in the US?”  I put these questions to both Irving Hoffman and to Francis Martinson. Here is the synopsis of what they said:

Girls pump water at a well in Dzama Village donated by UNC staff members

Essential research

All the practitioners at the UNC Project are quick to point out one basic fact – if you want to research malaria, you have to be where people have malaria, if you want to study HIV, you have to be where lot of people have HIV. I haven’t even touched on diseases such as leishmaniasis or schistosomiasis or sleeping sickness.

For the past four or five decades research into diseases that effect tropical countries, or poor countries has been slim at best. Once colonial powers left places like Asia and Africa, they stopped studying them. Why bother? Their people were no longer being affected.

Add to that the market model of pharmaceutical research: most drug executives believe (rightly) that there’s no lucrative market for drugs they might make to fight these diseases, so they didn’t do it. To whit, not one new medication for tuberculosis has been brought to market since the early 1960s. Only one drug for sleeping sickness has been created, but it’s only available because it’s also quite good at removing unwanted hair. Yet pharmaceutical manufacturers spend hundreds of millions of dollars to create drugs for… what, erectile dysfunction???

For years, we neglected these diseases – at our peril. Tropical countries are great places for microbes to evolve – for any number of reasons, from weather, to close contact with animals, to poverty. Now that we’ve ignored ‘poor people’s diseases’ such as tuberculosis, we find that they’ve evolved into ever more deadly forms, such as extensively-drug-resistant TB.

UNC Lab worker Creto Kanyemba holds up a bacteria sample

UNC researchers are doing work on essential problems – malaria, HIV, tuberculosis, nutrition. Their results get used both here and in the rest of the world. That’s a win.

Training

Working in Malawi provides a place for training health care professionals from both Malawi and the US. American researchers get opportunities to do basic research on problems that matter to millions of people. Researchers in Malawi learn to become better researchers, so they can partner with others to answer some of those pressing problems. And the opportunity to do research at home means they’re more likely to stay there.

On the clinical side, the world is getting increasingly small and diseases are getting better at getting around. It’s only 20-some hours to fly from Malawi to the US. And lots of travelers come back to the US after having acquired a disease in another country even before they feel sick. It’s a good thing that some of the practitioners at area hospitals can recognize something such as malaria, or schistosomiasis if they walk into a clinic with symptoms. In 2006 (the last year for complete data), 1500 people in the US were diagnosed with malaria. And just this past week, the CDC reported on a patient who acquired a form of simian malaria while traveling in the Philippines.

My co-worker Leoneda Inge can tell you something about that. A few years ago she was asked to mentor a young woman at the annual meeting of the National Association of Black Journalists. When she arrived, the girl complained of flu-like symptoms. Leoneda accompanied her to an emergency room where they sent her back to her hotel, telling her she had the flu. No one took a basic history to discover that the girl had recently returned from a summer working in Namibia.

Two days later, Leoneda took her back to the hospital. The girl was admitted and never went home. She died of multi-organ failure, resulting from of case of malaria that was recognized too late.

Self-interest

People in North Carolina who might wonder why their tax dollars go to Malawi, might surprised when they hear this next fact. UNC actually comes out ahead from running these projects.

Huh?

Entrance to the STI clinic at Kamuzu Central Hospital

It turns out almost all the money for research and patient care at the UNC Project comes from research grants, not from UNC, or North Carolina tax dollars. According to project director Francis Martinson, as money makes its way to Malawi from the Gates Foundation, or the Elizabeth Glaser Pediatric AIDS Foundation, or the National Institutes of Health, between 30-40 percent of it stays in Chapel Hill in the form of administrative overhead paid to the University (that’s standard for grants handled by the university). So, in effect, UNC makes money by running the project in Lilongwe.

And the whole operation in Lilongwe costs a whopping $8 million a year – to provide tens of thousands of patient encounters, train dozens of health care workers, prevent thousands of cases of HIV, treat tens of thousands of patients with malaria, TB, HIV and other diseases and employ more than 300 people.

So, between the money, the training opportunities and the research opportunities, UNC does pretty well from being in Lilongwe.

Diplomacy

Finally, this wasn’t something Hoffman or Martinson said, but something I observed, during this trip and during all of my other tenures abroad. People in other countries really want to get to know Americans, and are actually rather surprised when they do.

While I was in Malawi, I took several hours out to visit with the family of one of Hoffman’s employees. He and I sat in the couple’s house, had lunch and chatted (Hoffman, the man and I, the wife spoke no English).

I had brought some balloons with me. I took out a bag, and blew several up. Then the man’s wife, their daughter, son and I batted the balloon around and giggled for about 45 minutes as Hoffman talked to the father. When we left, the kids wrapped themselves around me for hugs. I got a big hug from the wife too.

UNC Project health educator Chimwemwe Buwalo with children at Dzama village

Tell me those kids won’t grow up with a good impression of Americans, even if they never meet another. Take my one afternoon and multiply that by all the encounters UNC researchers living in Lilongwe have with Malawians.

Way back at the beginning of this blog, I cited an article that posits the thesis that controlling neglected tropical diseases is key to US foreign policy. One can argue that it also serves us for countries not to be as grindingly poor as Malawi. People become less desperate, less sick. Their region becomes more stable. They become better trading partners. They don’t try to emigrate illegally. And they support us when we need it. It’s a win in every direction.

A VW bug made of beads at the market in Lilongwe

And a final thought…

One of the enduring impressions I’ve taken away from Malawi and Zambia is of all the clever people I met there.

In the markets, I met clever local people making wonderful art and utilitarian crafts out of virtually nothing. At the UNC Project researchers and local staff were ingenious at making due with limited resources, and at writing research grants that would also provide for tens of thousands of episodes of patient care. The leaders at the UNC Project, or at Malawi Children’s Village have been patient and careful in their planning, eventually scraping a few dollars here and a few there to build an enduring infrastructure for care.

In Zambia: A wheelchair assembled from spare parts

So much unrealized potential exists in places like Malawi and Zambia, but it gets mired down because of the overwhelming poverty. If only people there could turn their creativity to something more than the day-to-day scraping by to survive, how much better off the whole world might be.

Thoughts?  We’d like to hear them.  Contact us at ncvoices@wunc.org.

STI Clinic

Clement Mapanje

On the Sunday I was in Lilongwe, I swung by to interview Clement Mapanje, one of the clinic’s senior staff.  He was there to do some work, and do some studying (he’s working on a masters in public health from the London School of Tropical Hygiene and Medicine).  The clinic was strangely quiet.

But Monday through Saturday, it fairly bustles with activity. There are always people sitting on the benches outside, waiting to be seen, and at least 60-70 patients get seen and treated daily.  Many patients come before sunrise to get in the queue to be seen.  Because if they arrive later than 8 am, they often have to return another day.

UNC researchers working at the STI Clinic have done seminal research into HIV.   In today’s story, Irving Hoffman mentions one – the study finding that having a sexually transmitted infection makes it easier to give and get HIV.  That study was a groundbreaker in the 1990s. Since then, people at the STI clinic have done studies on nutrition and HIV, on improving detection of HIV in patients, they’ve helped the Malawian government get a better handle on how many people in Lilongwe have HIV… the list of studies literally stretches for pages and pages.

Today’s story focuses on the STI clinic and research being done there.

Patients wait to be seen at the STI clinic in the morning

Training the next generation of Malawi’s health leaders.

While in Malawi, I met a number of people who had trained at UNC or who had received further training because of UNC. You’ll meet some of them in this  story.

In the past, many countries have depended on expatriate medical professionals who come for several years and then go – with little continuity of management or projects. But what countries need is local expertise.  And the key to insuring a successful future for health care in Africa is training the next generation of health care leaders – doctors, nurses, public health experts – who will stay and build health systems.

One of the ways that UNC has worked to build that kind of capacity in Malawi is by training people, getting them involved in research and exposing them to their American peers.  Currently there are several Malawian students at the Gillings School of Global Public Health, and several more have graduated and returned to Malawi.  Others have been recommended by UNC for fellowships through the Fogarty International Center – part of the US National Institutes of Health.

Linda Kalilani in front of her office in Blantyre

One of those is Linda Kalilani who’s now an associate professor at the College of Medicine in the southern Malawian city of Blantyre after receiving her doctorate in epidemiology from UNC.  The school is in the process of building a school of public health – literally and figuratively.  Buildings are going up, personnel are being hired, students are being accepted for study. Right now, public health students are distance learners who spend several weeks a year on campus, and spend the rest of their time in their jobs around the country.  About 30 young people from Malawi are entering the program annually.  Every summer, professors from UNC travel to Blantyre to teach classes in epidemiology and grant writing.  Students from UNC go too – it’s a way for them to get exposed to public health issues in the region, come up with proposals for future research, and develop relationship with their peers in Malawi.

The future School of Public Health in Blantyre

Kalilani and others say that continued engagement from UNC gives them an incentive to stay at home in Malawi –, because they can continue doing research, stay intellectually engaged, and continue to build academic careers.  In turn, they’ll be in Malawi to train the next generation, and build the intellectual caliber of the entire health care workforce.

This billboard is a common sight. It encourages people to treat nurses and midwives with respect... so they won't emigrate.

Continued association with UNC also helps someone like Kalilani, or Dr Dan Namelika at Kamuzu Central Hospital, or Dr Sam Phiri at the Lighthouse materially.  Getting involved in research projects means that they get written into grant proposals – and that means they receive a stipend to supplement meager government salaries at home. It’s enough of a financial incentive so that skilled medical and public health personnel are less tempted to leave the country.

And after returning home to Malawi with a doctorate from UNC someone like Kalilani almost instantly becomes one the country’s public health leaders. That’s an incentive too.

Thoughts?  We’d like to hear them.  Contact us at ncvoices@wunc.org.

The lab

In order to do good care for patients with HIV, a practitioner needs access to certain information – CD4 counts, viral testing, blood work to find other problems (such as malaria, which I haven’t talked about at all… but is a huge problem, and the UNC Project is doing lots about malaria… but I only had 6 days there!!!).

Of course, you need the lab if you’re doing research so you can collect and store samples for examination now and in the future.

I got a tour of the lab with the lab’s managers, Debbie Kamwendo and Rob Krysiak.

Debbie’s interesting.  She came to Malawi as a Peace Corps volunteer, met a Malawian man, married and stayed.  She did return to the States to get a graduate degree, but she’s in Malawi for good.  They have children and she’s accepted as part of her husband’s large, extended family.  And… her husband is a regional politician, so she knows everyone.  She’s also a creative problem solver… as you’ll hear during this slide show tour of the lab, here.

Microbiology

You’ll have to forgive my including a slide show on the lab.  Lab teching isn’t a glam job. You’ll never see a TV show about medical lab techs, the way you will about doctors.  Those techs are always peripheral characters in House or CSI.  But without thorough and precise work in the lab, Dr. House would get those diagnoses wrong, and the CSI people would never solve a case.

And the lab is also fascinating for the way the UNC Project has found to build this lab… and all the infrastructure in Lilongwe.  According to Irving Hoffman, who’s the international director of the project, they’ve asked for a little money here, a little money there in all of the research proposals that they’ve written.  He says the money for all this infrastructure development happened over years, with an eye to long term planning.  It’s a building task that’s required a lot of patience from him and from the director on the ground, Francis Martinson.  (4:00 audio) 

Profile

Francis Martinson, Irving Hoffman and Mina Hosseinipour boogie down at the UNC Project holiday party

While I’m at it, I want to write a little bit about Irving.

Irving Hoffman is a physician assistant specializing in infectious disease who’s on the faculty of the school of public health at UNC.  He’s been working in Malawi on and off since 1992. Now, he serves as the international head of the project.

I’m going to give some attention to Irving precisely because he’s someone who doesn’t seek it out, and is so self-effacing.  He was my main liaison to the project.  He continually pointed me away from himself, and towards the Malawians doing good work, to the other UNC researchers doing the original work…  But in order for many of these people to do that good work, they need an infrastructure to function within.   In many ways, Irving is the quiet, steady guy with the wrench behind the workings of the project.

And he’s a true believer – he and his entire family.  They spent several years living in Malawi while his kids were in high school, and from the way he tells it, all of them are as invested in Malawi and the success of the UNC Project as he is.

One evening over dinner (and without a microphone), I asked him why he does what he does.   He said (and I paraphrase), “At first it appealed to my sense of adventure.  Then I began to see how much needed to be done and that we could make a difference here.  Eventually, these people became my friends, and I knew I was in it with them for the long run.”

Later, on tape, he changed his answer to something more politically correct (I hate it when people do that).  But Irving, I told you, nothing was off the record!  Here’s what he said (:53):

Infrastructure for a party

The Saturday night that I spent in Lilongwe, also happened also to be the night of the UNC Project’s annual party.  It was similar to an office party in the U S.  Free food and drink.  Speeches from company officers (Irving and Francis) that few people listened to.  Dancing. Celebrating their good work.  People enjoyed the opportunity to watch their bosses make fools of themselves on the dance floor.  And did I mention free food and drink?

What I found extraordinary was the cheering people did for the project.  They could easily pass for fans at the Dean Dome.  The popping you hear is firecrackers (:38)…

The other extraordinary thing was how proud of what they’re doing everyone is.  And they do have something to be proud of.

Thoughts?  We’d like to hear them.  Contact us at ncvoices@wunc.org.

I’m just trying to get my head around this place. Every time I turn around, I get an earful about a completely different activity that UNC people are engaged in.

Surgery and trauma

Jon Samuel and his wife Lillian Brown (we'll hear about her work on Monday's broadcast)

Doctor Jon Samuel took me on a tour of Kamuzu Central Hospital. Samuel is a third year surgical resident who’s spending a year as a research fellow in Malawi. He’s also working as a surgeon there, seeing more and more varied problems than he would have back in the States. Here he describes some differences in the kinds of problems he sees and how they get treated here, versus in the States.

In this minute-long interview, Samuel talks about treating conditions he’d never see in the U S.

And in this piece (:49), Samuel talks about working in the pediatric surgical ward.

Samuel’s work here has been to compile a registry of all the trauma cases that come into the hospital. The aim is to help get hard data on the kinds of trauma that kill Malawians and what are the best treatments for them. His work is basic epidemiology – counting and compiling data in order to determine what’s the best thing to do about a problem.

Bad drivers ?

Malawi has THE world’s highest rates of motor vehicle death per kilometer driven. Here’s a smattering of the data:

Number of accidents per 100 million vehicle-kilometers:
1) Malawi 2730
2) Rwanda 1764
3) South Korea 510
10) Portugal 194
33) United States 74

In short, Malawi’s accident rate is 37 times higher than the US. The death rate per 100 million vehicle-kilometers is 1117. That’s four times higher than the next country, and many times higher than that of the US. Only 2.3 people out of every thousand actually have cars in Malawi, compared to 481 people per thousand in the US. So that means there aren’t that many drivers Malawi, but they’re really, really bad, or, what’ s more likely is that more people die per accident than in other places.

That’s why everyone, and I mean EVERYONE I talked to about the country said the same thing: “Don’t travel at night!!!” No overnight buses, no car trips after dark, except for driving a mile or two to go out and eat. And then, only with great caution.

Why so many accidents?

One of the reasons behind those trauma numbers is Malawi’s physical infrastructure… it’s part and parcel of the poverty that marks the country. The roads in Malawi are awful. There are few paved roads and what roads are paved are often a thin layer of tar and crushed rock pressed into compacted earth underneath. There are no shoulders to the road, which becomes a problem because traffic consists of not only motor vehicles, but bicycles, ox carts and pedestrians. When it rains, what little shoulder there is to the roads crumbles as the compacted earth at the road’s perimeter washes away. Potholes form easily during rainy season too.

Photo credit: Eve Vitaglione

Roads in Malawi are few, and only half are paved. For comparison, the Malawi’s about the same size as Arizona. But the National Forest Service in Arizona has 28,000 miles of roads, compared to 9,600 of roads in Malawi.

When roads exist, they’re not well built. I had the opportunity to watch to road building – it was taking place so that we could drive on it. The road consists of a long ribbon of dirt that’s raised about 6-8 feet above the ground around it. The dirt is graded, then a thin layer of tar gets sprayed onto the dirt, followed by a layer of crushed rock that’s shoveled onto the tar. Then, rollers push the crushed rock into the dirt and tar.

Just a thin layer of gravel is applied over packed dirt to create a 'paved' road

It’s a recipe for potholes, abrupt and crumbling shoulders and motor vehicle accidents. Once off the main road, it’s just dirt paths… or mud, depending on the season.

Poverty works to make roads unsafe in other ways too. Cars are held together with crude welding, they often lack one or both headlights, tires are often bald, maybe underinflated and people pack themselves into dangerously overcrowded minivans and pickups to get around. I think every car I saw in Malawi had a cracked windshield. Minivans intended for 7 or 8 passengers look like something from a silent film– there’s seemingly no end to the number of people who climb out when vans stop.

And, of course, roads have, at most, one lane in either direction. And everyone uses the roads, cars, buses, trucks, people, shepherds, cow herders, pedestrians, children, bicyclists, bicyclists hauling pounds of goods in the backs of the bicycles, dogs. You name them, they’re in the road, sometimes all at once. So, reckless passing often becomes an occasion for motor vehicle accidents.

Take a listen as Samuel describes what happens when there’s a mass trauma (1:02):

Cars in Malawi take a regular beating

Often accidents involve crowded minivans that collide or overturn as they run off the road. Ambulances are few and Samuel has determined through his research that it takes patients on average 4 hours to get the hospital in a public ambulance. Patients arrive more quickly if they’re in a private vehicle – that takes on average two and a half hours. But… years of research shows that patients do best if they arrive in the first hour post-trauma. After that, mortality rises dramatically.

Samuel says he sees all kinds of traumas from vehicular accidents… drivers, passengers, bicyclists and pedestrians. No one’s immune.

Here’s a short video (1:33) I shot out of the window of a car (so it’s a little noisy). It shows the conditions of a typical road in Malawi.

Samuel is finding that next in the numbers are assault victims, frequently young men who arrive in greater numbers around the time they receive their paychecks. Samuel says alcohol is frequently a factor.

He says there are some women who admit to being victims of domestic violence. And finally, Samuel says, there are people who come in and are victims of ‘mob justice.’ Take a listen (:31):

Comments? Send them to ncvoices@wunc.org

Today’s story focuses on the care for AIDS patients provided by UNC. Take a listen here or here:

“… so high you can’t get over it,
So low, you can’t get under it,
So wide, you can’t get around it…”

When I started researching this project, I was determined that I wouldn’t be yet another reporter parachuting into Africa to do stories about the tragedies of HIV/AIDS. I’ve worked in the developing world, I know that there are other problems – the issue of health worker out-migration, malaria, tuberculosis, substance abuse, you name it.

But when you arrive in Africa, you find all pales compared to HIV. So in the end, I find myself doing stories about care for people with HIV or AIDS because the problem is just so big, I can’t get around it… just like in the old song.

What I found refreshing here at the UNC Project, is that in addition to providing care for patients with AIDS, researchers from UNC are intently looking for ways to solve the problem of AIDS. It’s not just a band-aid approach.

Hundreds of women wait outside the Bwaila prenatal clinic every morning to be seen

And this isn’t just research. The reality is that you can’t just study people without doing something for them in return. That’s one of the driving forces behind a concept called “community-based participatory research,”  a process whereby the ‘experts’ actually listen to the community they’re studying… and the community acts as a full partner in and beneficiary of the research.  In other words, research isn’t done just to advance the career of an academic.  It’s done in conjunction with priorities identified by the community.

The UNC researchers seem to have taken that seriously by trying to provide some of the best quality care they can. They are certainly not taking short cuts and self-justifying it by saying, “Well, these people are getting something… it’s more than what they’d get otherwise.”

Bwaila head nurse, Gertrude Mwale

Nope. No thinking like that here.

But taking the research approach is also a brilliant move. It means that instead of constantly begging charitable donors for money, most of the patient care is paid for as part of research dollars. And in Malawi, those dollars buy more bang for the buck… a LOT more bang for the buck.

I’ll talk about these numbers later next week in a little more detail, but according to the project director, Francis Martinson, UNC Project spends about $8 million annually to care for patients – that money comes from research grants. And here are some of the numbers:

Patients being followed at the Lighthouse: 8000/ year
Women being followed at the prenatal clinic: 32,000/ year
Patients being seen at the STI clinic: 12,000/ year

For someone who knows the health care system in the US, to be able to see all these patients for so little boggles the mind. AND on top of that, UPC Project provides opportunities for faculty and students to do research and learn.

UNC isn’t the only US university functioning in this fashion in Africa. Researchers from Harvard, Johns Hopkins, Duke and many others have established similar relationships all over Africa. But the UNC Project is large, produces consistently good research and provides care for tens of thousands of people. And that’s saying something.

Bwaila Clinic

One of the more uplifting places I’ve visited during this whole trip is the clinic at Bwaila. There, they see pregnant women – 2000 of them a month! Every time I write that number, I have to look up the transcript of the interview again, to be sure I’ve gotten the number correct. Along with another satellite clinic, UNC Project workers see more than 3000 women monthly.

Women wait to be seen at Bwaila Clinic. An outreach workers hands out medical record booklets to the expectant mothers.

Keep in mind, in a country such as Malawi, most women only go for prenatal care once, twice, maybe three times. So the antenatal clinic is providing the prenatal care for many thousands of babies. Perhaps that’s why prevalence of HIV has begun to drop in Lilongwe and the Central Province of Malawi. For women attending this clinic, the rate of babies being born with HIV has dropped to below 10 percent. It used to be more than 30 percent.

In this first video, the women sing before the clinic opens in the morning:

In this second video, mothers bring their babies to get weighed. I’ve never seen anyone as efficient as getting a baby on and off of the spring scale. I still have a spring scale at home from my days as a home health nurse! They’re a great, low-tech instrument!

Comments? Send them to ncvoices@wunc.org