Today is an oddity. Weekends included, the water shuts off here in Blantyre almost precisely at seven every morning, returning at its evening counterpart for some hours, giving us just enough time for some showers and a quick restock of our supply in 50 gallons containers. Yet today it wasn't the liquid but the usually reliable power that cut out, leaving us dark but delighted to take afternoon showers after another dusty morning in the dry season. Today, Monday, brought us to our every week sites of nkhate market and makwila in chickwawa district--one district and 3000 feet below blantyre. Though I may prefer two-wheeled man-powered transportation, I'll be the first to admit that its quite a spectacular drive. 10 minutes south of blantyre the road begins to drop precipitously, switchbacks included, as the mts of blantyre give way to the tschire valley below carrying its namesake for hundreds of miles through the lowlands of subsaharan africa, connecting with the zambezi in mozambique before spilling into the indian ocean. They say that on a clear day you can see mozambique from one of the turns--the third of three distant mountain ranges.
On reaching the bottom we quickly take a sharp left back to the west, leaving the lone malawian highway in the south, bisecting the country east and west. In fact its referred to as the 'tarmack' for its actually concrete, unlike the rest of the dirt roads in the south. Even I have been surprised at how undeveloped the basic infrastructure of the country actually is. The road is often packed with traffic not of the motor kind, but those on foot or fortunate enough to have purchased a chinese bike carrying sugar cane, pvc pipe, grasses, even bricks are transported. As we barrel down this one lane dirt path at 40kms an hour these transporters ditch right and left into the fields to avoid our machine. A bridge over the tshire is as good as it gets--thereafter are a series of smaller rivers to be forded, rutted roads left over from washed out rainy seasons past, and boulder obstacle courses. What I'm trying to convey is how far removed a place like nkhate is from the world of globally traded goods. Just to get to the tarmak is a days walk, and blantyre and nsanje from there is a minibus ride costing you your monthly wage. And it means that you live off of what you and your neighbors produce and what you can sell or trade at the market. Being strapped brings a whole new meaning... Are the children going to be able to eat this year? (In Chichewa they describe the two seasons as the current 'masika' (harvest) and the coming 'njala' (hunger).)
As you might imagine, nkhate has no medical facilities. The binder with charts we keep is labeled 'nkhate market,' for we literally hold clinic next to the basket and mat weavers every monday on the side of the market. Its the most logical place in a 10km radius to hold clinic, where all can meet in a central location. Most mothers are there to do business or buy food anyways, so we often pull interested passer-byers. But the bulk of our population at clinic are referred by governmental 'health surveillance assistants,' or HSAs as they are known. Assigned to 2-3 villages each and armed with a MUAC tape and a bike, they refer kids under 12.5 cm to our clinic on monday morning. By disseminating through their communities the info in chiponde clinic and performing initial screenings, these HSAs are positively the fuel that powers our whole project, and for this they are thanked copiously and fairly compensated.
Today we had 30-40 women with their 6month - 5 year olds that came to be screened, of which we treated about 10. I understand this number could as much as triple or quadruple in the hungry season--which I also understand is approaching by as much as 3 to 4 months earlier than normal this year, due to a variety of factors I should write on later. But suffice to say, there is a general feeling of unease regarding the time at which the family's surplus begins to run low this year. So we are now getting the hang of things around here before they get completely crazy...
I'm off to Namindanje tomorrow for the weekly overnight. We are way up in the northeast part of central region--too far to return to blantyre. I realize now that I haven't written at all about what I had planned, but for next time I'll write about the study--yeah I am doing research here I promise:> mugano bwino to you all--sleep well. I know I shall myself.
Jay
Monday 28 July 2008
Saturday 19 July 2008
PPB: from a bird's view
Matzuka bwanji! Its a gorgeous bright sunny morning here in Blantyre, temperatures hovering near the low 70s. Winter really can't get much better than this. A jacket for the cool before the sun rises is about all you may need now, for by early afternoon its rising to the low 80s with the sun beating down. I'm coming to appreciate greatly those clinic sites with a bit of shade.
I've returned now from two weeks worth of clinic visits, which, as we rotate on a week A week B schedule, means that I've fully seen all of my current sites. It feels a little like finishing the border of a puzzle--I've at least got a foothold now on what things are going to look like for the year, but I've still no clue on how its all going to fit together. Names like Mbiza, Ndaja, Chikweo, Mposa, Nkhate are running through my head as I'm struggling to connect health assistant faces with sites, roads with districts. Last week we covered close to 500km of distance as we leave the 'comfort' of blantyre and drive deep into the countryside daily.
I've much to say on these experiences but this morning its seems more permanent for me to share and reflect on the history of this project a bit. I may not get all the facts and details just right as the story has unfolded in pieces to me over the last two weeks from a plethora of sources, but I'll do my best here to summarize what has developed from Dr. Manary and his family over the course of the last 15 years (and hopefully as briefly as summarizing 15 years permits)... Graduating from wash u med school and after a stint with the National Health Service Corps as a doc on a reservation, Dr. Manary and his wife Mardi took a trip to Tanzania for a brief rotation in a district hospital there. This was to be the first of many trips to Africa, for from Tanzania the 'professor' was invited for a brief time to the neighboring country of Malawi in the early 90s to work in the Queen Elizabeth Hospital in Blantyre. As a pediatrician by training, the story goes that while touring the maternity and child health services departments at this dismal national hospital (which I can attest remains just that today), the professor asked from a distance of a ward that was set away a bit from the hospital and overflowing with people: "Thats our NRU, you don't want to go there" came the answer, and so started what is now almost 15 years of malnutrition work in Malawi for the Manary family.
What the professor found inside the NRU (nutrition rehabilitation unit) was shocking: two, three, or more mothers and their children sharing one bed, thirty beds jammed shoulder to shoulder in a small room, sanitary conditions less than unsatisfactory, one doctor with spotty treatment available, and all of this creating the environment of care for children so severely malnourished that they are 3 standard deviations below their proposed developmental weight, facial bones protruding through tought skin and mid upper arm circumferences easily encompassed by one's thumb and forefinger. As imagined, these little ones were not getting much better in those conditions, with dismal recovery rates of 25%, and mortality rates equally high. So began musings on PPB, though what was exactly to be done was yet unknown.
At that time the standard of treatment for malnutrition of all kinds and in all regions of the world was something called 'F100,' which is a therapeutic milk-based product fortified with vitamins and minerals produced in France. The benefits were its calorie and nutrient capacity as well as its consumability (word?)--kids love milk. However, the benefits were equally its curses as milk is not a local commidity in much of the world, certainly not in the developing world. And in addition, we all know milk must be refrigerated (or does it Sellers?), and these two strikes against F100 meant its availability was limited by 1) its cost, and 2)its necessary upkeep (refrigerators are hard to come by in places that have no electricity). Does F100 work when administered? Sure, but to say the least, F100 was not a practical solution to the causation of 58% of world mortality: malnutrition. So began the search for a calorie and nutrient rich product both cheap and accessible. To make a long story encompassing several key figures, sleepless nights in back-room kitchens, and lots and lots of taste testing--to make this long story short (in the interest of doing something else today), meet 'RUTF.'
When I tried it, something came out along the lines of "This is medicine?" Up there with the childhood greatness of amoxicillin. So good in fact I'm worried about potential project losses given my initial rates of consumption:> Ready to Use Therapeutic Food (RUTF) is something like sweet peanut butter, composed of the following : 1/4 peanut paste, 1/4 milk powder, 1/4 oil, 1/4 sugar, all with a blend of vitamins and minerals specially prepared for malnutrition in subsaharan africa mixed in. This is 'Chiponde' as its called: non-refrigerated, locally produced (we have a small factory here in blantyre), with a shelf life nearing a year. And the kids love it. So do I.
I mentioned before that the site of origin for the project was the Queen Elizabeth hospital here in Blantyre, which is the main hospital to which all surrounding district hospitals refer patients if unable to manage a particular patient. As an expensive and refrigerated treatment, F100, the original milk therapy for malnutrition, was in the 90s only being used at Queen Elizabeth. This meant that malnourished children at the district hospitals were being treated with porridge and maize products--which for some were the only foods the children were able to eat at home, and the subsequent lack of non-carbohydrate nutrients (vitamins and proteins) was leading to their further malnourished status. RUTF was quickly instituted in Malawian hospitals in the early 2000s, but it quickly became evident that a better approach to the gigantic problem of malnutrition (later blog entry...) involved village screenings to catch children hopefully before they progress to a complicated severely malnourished status seen in the hospitals. And thus was born project peanut butter (thereabout in so many words), and now it may be clear why it is that we as team chiponde drive to these remote sites everyday to host chiponde clinic, as its affectionately called here.
Since its development, RUTF has now been chosen as the standard of treatment for malnutrition worldwide by the WHO. Yet, PPB has continued, together with a French company called Nutriset (who were the original manufacturers of RUTF, or plumpy nut as you may know it), to work toward better products. Last year students in the project ran a study to establish a soy blend of RUTF as the standard treatment for moderate malnutrition. This year we are working on a slightly different blend of RUTF with less milk powder content (the most expensive ingredient) to establish its equal efficacy in comparison to the standard RUTF as described above. More on this later surely... And in the pipeline is a line of chiponde for HIV wasting. So, much happening around this place on the topic of childhood malnutrition. For now I'm attempting to get my address and phone number memorized, but soon enough I'll be working to improve my kwash and maras diagnoses, and looking at preliminary data on our results for this research project. Chao for now, I hope this finds you well!!
I've returned now from two weeks worth of clinic visits, which, as we rotate on a week A week B schedule, means that I've fully seen all of my current sites. It feels a little like finishing the border of a puzzle--I've at least got a foothold now on what things are going to look like for the year, but I've still no clue on how its all going to fit together. Names like Mbiza, Ndaja, Chikweo, Mposa, Nkhate are running through my head as I'm struggling to connect health assistant faces with sites, roads with districts. Last week we covered close to 500km of distance as we leave the 'comfort' of blantyre and drive deep into the countryside daily.
I've much to say on these experiences but this morning its seems more permanent for me to share and reflect on the history of this project a bit. I may not get all the facts and details just right as the story has unfolded in pieces to me over the last two weeks from a plethora of sources, but I'll do my best here to summarize what has developed from Dr. Manary and his family over the course of the last 15 years (and hopefully as briefly as summarizing 15 years permits)... Graduating from wash u med school and after a stint with the National Health Service Corps as a doc on a reservation, Dr. Manary and his wife Mardi took a trip to Tanzania for a brief rotation in a district hospital there. This was to be the first of many trips to Africa, for from Tanzania the 'professor' was invited for a brief time to the neighboring country of Malawi in the early 90s to work in the Queen Elizabeth Hospital in Blantyre. As a pediatrician by training, the story goes that while touring the maternity and child health services departments at this dismal national hospital (which I can attest remains just that today), the professor asked from a distance of a ward that was set away a bit from the hospital and overflowing with people: "Thats our NRU, you don't want to go there" came the answer, and so started what is now almost 15 years of malnutrition work in Malawi for the Manary family.
What the professor found inside the NRU (nutrition rehabilitation unit) was shocking: two, three, or more mothers and their children sharing one bed, thirty beds jammed shoulder to shoulder in a small room, sanitary conditions less than unsatisfactory, one doctor with spotty treatment available, and all of this creating the environment of care for children so severely malnourished that they are 3 standard deviations below their proposed developmental weight, facial bones protruding through tought skin and mid upper arm circumferences easily encompassed by one's thumb and forefinger. As imagined, these little ones were not getting much better in those conditions, with dismal recovery rates of 25%, and mortality rates equally high. So began musings on PPB, though what was exactly to be done was yet unknown.
At that time the standard of treatment for malnutrition of all kinds and in all regions of the world was something called 'F100,' which is a therapeutic milk-based product fortified with vitamins and minerals produced in France. The benefits were its calorie and nutrient capacity as well as its consumability (word?)--kids love milk. However, the benefits were equally its curses as milk is not a local commidity in much of the world, certainly not in the developing world. And in addition, we all know milk must be refrigerated (or does it Sellers?), and these two strikes against F100 meant its availability was limited by 1) its cost, and 2)its necessary upkeep (refrigerators are hard to come by in places that have no electricity). Does F100 work when administered? Sure, but to say the least, F100 was not a practical solution to the causation of 58% of world mortality: malnutrition. So began the search for a calorie and nutrient rich product both cheap and accessible. To make a long story encompassing several key figures, sleepless nights in back-room kitchens, and lots and lots of taste testing--to make this long story short (in the interest of doing something else today), meet 'RUTF.'
When I tried it, something came out along the lines of "This is medicine?" Up there with the childhood greatness of amoxicillin. So good in fact I'm worried about potential project losses given my initial rates of consumption:> Ready to Use Therapeutic Food (RUTF) is something like sweet peanut butter, composed of the following : 1/4 peanut paste, 1/4 milk powder, 1/4 oil, 1/4 sugar, all with a blend of vitamins and minerals specially prepared for malnutrition in subsaharan africa mixed in. This is 'Chiponde' as its called: non-refrigerated, locally produced (we have a small factory here in blantyre), with a shelf life nearing a year. And the kids love it. So do I.
I mentioned before that the site of origin for the project was the Queen Elizabeth hospital here in Blantyre, which is the main hospital to which all surrounding district hospitals refer patients if unable to manage a particular patient. As an expensive and refrigerated treatment, F100, the original milk therapy for malnutrition, was in the 90s only being used at Queen Elizabeth. This meant that malnourished children at the district hospitals were being treated with porridge and maize products--which for some were the only foods the children were able to eat at home, and the subsequent lack of non-carbohydrate nutrients (vitamins and proteins) was leading to their further malnourished status. RUTF was quickly instituted in Malawian hospitals in the early 2000s, but it quickly became evident that a better approach to the gigantic problem of malnutrition (later blog entry...) involved village screenings to catch children hopefully before they progress to a complicated severely malnourished status seen in the hospitals. And thus was born project peanut butter (thereabout in so many words), and now it may be clear why it is that we as team chiponde drive to these remote sites everyday to host chiponde clinic, as its affectionately called here.
Since its development, RUTF has now been chosen as the standard of treatment for malnutrition worldwide by the WHO. Yet, PPB has continued, together with a French company called Nutriset (who were the original manufacturers of RUTF, or plumpy nut as you may know it), to work toward better products. Last year students in the project ran a study to establish a soy blend of RUTF as the standard treatment for moderate malnutrition. This year we are working on a slightly different blend of RUTF with less milk powder content (the most expensive ingredient) to establish its equal efficacy in comparison to the standard RUTF as described above. More on this later surely... And in the pipeline is a line of chiponde for HIV wasting. So, much happening around this place on the topic of childhood malnutrition. For now I'm attempting to get my address and phone number memorized, but soon enough I'll be working to improve my kwash and maras diagnoses, and looking at preliminary data on our results for this research project. Chao for now, I hope this finds you well!!
Sunday 13 July 2008
The Shedoolay and other backdrop items...
The Hilux truck broke down yesterday on the doctor's drive to Namindaje for the zinc study. So early this morning I got up and drove one of the project's nine vehicles to pick up Ramsey and Vegas, one a Malawian and one a Mozambiq(an?), so they could tag team drive the vehicles back from the Catholic outpost near the Mozambique border. These guys have been driving trucks on the shabby back "roads" of Malawi for quite some time, and a couple jugs of water ought to keep the Hilux's temp down for the ride back tonight before some much needed service. So the zinc study pushes on, as the project continues the search for the elusive causation of kwashiorkor (no stritchers, turns out its not as easy as robbins wishes--studies on protein replacement have not corrected kwash...)
But the early of this morning doesn't compare to my Mon-Fri schedule. I wake everyday at 4:30, to be out the door by 5, to get the drivers by 5:30, to pick up the nurses by 6:15, to be at the sites by 7:30 or 8ish for the clinics. We run clinic--distributing therapeutic food and making referrals--til all mother's and children have been seen, usually somewhere between 10 and 2 PM. The long drive back to Blantyre, dropping all at their respective places of rest, and home by 6 or 7 (hopefully!!). And early to bed, early to rise, and we start it over... 15 sites in two weeks and the cycle begins again.
Yah-like surg rotation for a whole year! Except I don't get pimped every day on the location of tissue and structure madness, just peed on a whole lot holding kids scared out of their minds by the crazy 'muzungu.' You decide whats better: feeling dumb or looking dumb? I'm pretty sure you can't lose either way:>
Coming soon: Some background on project peanut butter would probably be helpful eh? Just as soon as I can!!
But the early of this morning doesn't compare to my Mon-Fri schedule. I wake everyday at 4:30, to be out the door by 5, to get the drivers by 5:30, to pick up the nurses by 6:15, to be at the sites by 7:30 or 8ish for the clinics. We run clinic--distributing therapeutic food and making referrals--til all mother's and children have been seen, usually somewhere between 10 and 2 PM. The long drive back to Blantyre, dropping all at their respective places of rest, and home by 6 or 7 (hopefully!!). And early to bed, early to rise, and we start it over... 15 sites in two weeks and the cycle begins again.
Yah-like surg rotation for a whole year! Except I don't get pimped every day on the location of tissue and structure madness, just peed on a whole lot holding kids scared out of their minds by the crazy 'muzungu.' You decide whats better: feeling dumb or looking dumb? I'm pretty sure you can't lose either way:>
Coming soon: Some background on project peanut butter would probably be helpful eh? Just as soon as I can!!
Friday 11 July 2008
Chiponde' = Peanut Butter
Muli Bwanji... Hello to all from Blantyre, Malawi. I'm 8 days old now in my new home of sorts, adjusting daily to new sights, smells, tastes, sounds, allergies, languages... I'm here with project peanut butter (projectpeanutbutter.org), also known here as st. louis nutrition project, TEAM CHIPONDE, ect... based on who you're talking to. Chiponde means peanut butter in Chichewa, the first of two official languages here in Malawi, the second being that business language we all know and love which spins the world round everyday for better or worse... English. Now, Chichewa is one of the many Bantu languages which literally means the language of the Chewa, a people who once upon a time ruled a magnificent kingdom here in the highlands above Lake Malawi in central subsaharan africa. These were times before documentation, before inter-global economies, before colonialism. Anyhow, before I get carried away, I wanted to briefly say that I, with a team of nurses, give out fortified chiponde to the children of this economy-less landlocked desititute country, where the average salary reaches an astonishing $3.25 a week. And a 10 kilo bag on maize now costs $12, and we are just post-harvest. I'm not a math person (as some of you well know), but its really shocking what many live on here. But warm smiles abound nonetheless here, and so--through me--the warmest of greetings from malawi: muli bwanji...
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