Saturday, January 28, 2012

Uganda. Our first week in Gombe

Monday, 20 patients 

Tuesday, 25 patients

Wednesday, 26 patients           

Thursday, 25 patients

Friday, 15 patients


Our first week at work in Uganda and we are in Gombe, a small rural village about 2 hours west of Kampala, 45 minutes of the journey on a bumpy dirt road.  It is small community, with a hospital, but with only intermittent power and untreated water from the well.  It is a one road, agricultural community (banana and ginger) that appears to be out in the middle of nowhere.  PINCC was found by it's incredible administrator, Dr. Lule Haruna, a very savvy man who is finding any way he can to fulfill the needs in his community.


We are staying with Janet, a retired social worker who lives in both Gombe and Kampala.  She is around 60 years of age and has been married to her husband for 40 years.  She has five children, the last of which just graduated from college.  She is an open, loving woman who has been a champion for women's rights all of her life.  During Idi Amin's reign, she and her family were refugees in Kenya but upon their return, they were able to repossess their banana plantation and she lives here now, part time, and employees several people to work it.  A week of bucket baths and power when it came on, possibly twice the entire week for only a few hours at best, breakfast by candlelight, incredible sunrises and sunsets, evening spent sitting on the steps of the veranda, living with Janet, her best friend and sister-in-law Mary, and Hope has been a joy.  Our days were filled.  In the week we were in Gombe, the doctors saw 111 patients, performed 22 Pap smears, eleven biopsies and five cervical cancers were diagnosed. 


We worked with eight trainees, all but one of who had been trained on one of the two previous visits PINCC has made to this community.  All of the trainee's skills were sharp and efficient, and Melissa concluded that they have all completed their classroom training, including Josephine, the one trainee who had not yet met with PINCC.   We were able to set up the cyrotherapy lab and the trainees were able to practice; we were able to start the community outreach education program and we began working with the community health educators for the district of Gombe; we successfully facilitated a training for trainers workshop on women's health; we were very busy, and we had a wonderful time. 


As for Arlayne and I, we followed our job descriptions and got it done!  We inputted our findings in the computer, having to charge the computer batteries off of the jenny the hospital has for the OR, cleaned speculums, facilitated patient registration and made sure every patient was interviewed, kept record of every woman's name and contact who stated they had been in an abusive relationship for the community social worker to contact later, made sure the treatment rooms were stocked and ready to go, and got the things for the medical staff asked for.  And I?  I saw my first cervix, a prolapsed uterus, am fairly confident I can now perform a successful VIA on a cervix for cancer, although I have yet to do one, performed two HIV tests, two pregnancy tests, trained women waiting to be seen by the doctors on women's health, and began the facilitation of the Training of Trainers Workshop.  It was a full week, and one where I for one learned more that I ever thought I would.  It has been amazing. 


The team is fantastic and we are working as though we have done so for years.  The three clinicians are such good teachers that the trainees are learning anything and everything they want to.  Arlayne keeps us all laughing and Carol makes sure everything is where it is supposed to be.  Everyone has commented as to how well it is going and we are all thankful.  Again, it is a privilege to be on this team.


We are in Jinja now, our one day off (kind of, I am doing the blog…) awaiting Mike, our Kenyan driver to arrive so that we may be on our way to Kenya.  A successful week complete; our next week before us.  On to Kenya…


Amelia T. Hambrecht

On to Gombe...


January 21, 2012

Have you ever heard a lion purr? At the reserve, there are three lions, one male and two female. One of the females is in heat. I am watching the lions in their enclosure. One female laying on a platform, and the male is sleeping under a tree. The female in heat is pacing around in the enclosure, a large space I would guess to be around the size of a small city block. I would be unable to see the loins if they were in most of the other areas of the enclosure. After she tires of pacing, she walks up to the male and snuggles up to him, rubs her face into his mane and purrs. The purr is the purr of a cat, however it is as loud as an engine, and vibrates to my bones. It is pure music.

Our team has congregated and we are preparing to leave. We are lead by an obstetrician, Dr. Melissa Miskell from Texas. She has been a volunteer on PINCC trips, twice a year for the last six or seven years, and just loves what she does. A straight shooter with a wonderful Texas twang, she is the perfect leader for the team. Our second doc is Dr. Sharry Kreitlow, an OBGYN from Wisconsin who is also fantastic. She has done similar work in Haiti and is scheduled for a trip in Guatemala this summer. This is her first trip with PINCC. Our third medical staff is Eva Bryer, is a nurse midwife who, when not on PINCC trips, volunteers in a free clinic in the South Bay. Arlayne Mandell, a friend of Melissa's who is living in Holland when not with PINCC and myself are the support staff whose job description is basically: get it done! And lastly Carol, our coordinator, our MC who rounds out our team, a random mix of six people, six backgrounds with six personalities, all coming together because we all share one thing in common: a need to balance the abundance in our lives with the realities in our world; a need to share our talents and knowledge with those that do not have access to them; a need to make a difference. It is an honor to be a part of this team.

Tomorrow we leave to our first site, Gombe. We will spend a week in very rural Uganda. We are excited, and looking forward to the days that come. Gombe, here we come!

Amelia T. Hambrecht

Friday, January 27, 2012

Thanjavur Report – PINCC Consults to a sister organization for Quality Improvement

Dr. Aarti and Dr. Rhoda reviewing the ICTPH Screening Program

On Monday, January 16, 2012 we were driven after breakfast from READ, in Andimadam, down to Thanjavur for our consulting visit to the IKP Centre for Technologies in Public Health (ICTPH). The drive was a pleasant roll through countryside and small villages – to the extent that any drive can be pleasant in India! After two hours we arrived at our hotel in Thanjavur, and had the rest of the day for site seeing.


When we got settled into our rooms, we went for lunch and then some of our team got massages at the hotel spa. (In spite of having a spa, this hotel is NOT a nice place to stay, and the next morning we moved across the street to a slightly less not nice place to stay.)


After the spa visit we all five piled into an auto-rickshaw and went to the Chola Palace (built about 1200 CE) to see ancient bronze statues of deities and to climb up the eight level breeze tower to look out over the city. The Palace itself is a bit the worse for wear, but is still owned and operated by descendants of the original ruling family. The various museum rooms contained incredible old statues, jewelry, artifacts and artwork.


From the Palace, we hired another "auto" to take us to the "Big Temple" – also a 1200 CE period Chola dynasty Hindu temple. The Temple is in excellent condition and is protected as a world heritage site. January 16 was at the end of Pongal, so there was much celebrating and exchanging of best wishes with strangers! After dark, we sat on the ground and watched a recital of young girls playing traditional Indian stringed instruments and troupes of young girls doing traditional Indian Nataraj dances.


After breakfast on Tuesday morning, we hauled our gear across the road to the PL.A Residency Hotel – a small cut above the one we left, but right on the RR tracks and next to the station, so very little real advantage – we traded darkness and dinginess for immense noise pollution. At least there was hot water!


At 11:00, a driver from ICTPH picked us up and we spent a few hours with Dr. Aarti Sahasranaman, VP for Interventions (which means health programs like vision, dentistry, cardiovascular and women's health), and the ICTPH Research Analyst Ms. Vani Priya. We learned about the history of ICTPH (4 years) and the women's health program, where their screening work is located (about 3 months). VIA and VILI screenings are presently carried out opportunistically at two of their first four Regional Micro Health Centres.


After a nice lunch at a really good hotel restaurant nearby, we went out to visit one of the RMHCs, about an hour's ride out of town, where VIA and VILI are being carried out whenever women who come in for other reasons agree to be screened. We were all exceptionally impressed with the quality of the physical space and also the supplies and equipment – for all their programs, including VIA and VILI. For example, the have locally designed and built gyne tables with built-in lighting and foot rests that are very innovative. When we got back to the hotel, all were pretty tired, so Joy, Liz and Janis went to eat snacks in their rooms while Rhoda and John went to the hotel restaurant for soup and "Chicken 65" – a new to us menu item that presents chunks of deep fried boneless chicken marinated in a similar manner to Chicken Tikka – garnished with red onion rings and cut limes.


Wednesday morning, we got picked up at 9:30 and spent the whole day at ICTPH. Joy and John interviewed Vani, Dr. Aarti, Kartik (AVP for Finance and newly appointed ICTPH COO), and Zeena Johar, President of ICTPH. The focus of these explorations was on the organization and administration. All of these folks are young and full of energy and passion for their project – which is to ultimately build a Kaiser Permanente-like prepaid health network of 10 RMHCs that each offer comprehensive care. Most impressive!


Rhoda, Janis and Liz went to the second clinic that is currently offering screening and met with the people trained to carry out the screening at that clinic. In the afternoon, they returned to town along with some of the clinic staff and met further in the ICTPH conference room.


Wednesday evening was Joy's last night with the team, so we went back to the nice hotel dining room for an exquisite celebration dinner. As we were tucking in to appetizers, Zeena, Kartik and a few other ICTPH senior staff came in for their own dinner party. Not really a surprise, according to Kartik, since there are so few acceptable restaurants in Thanjavur!


Thursday morning we saw Joy off to Chennai and Delhi for her holiday tour, and then went to ICTPH at about 11:00 for a feedback session to the entire ICTPH staff about what we had learned from our meetings and interviews. They were most eager to learn, since most are new to ICTPH, and especially since the VIA & VILI screening program, the focus of our visit, is just getting off the ground.


Both the organizational and the clinical interviews and observations converged on the same four areas for improvement recommendations:

1.     Community engagement and public education

2.     Training and continuous learning of screeners

3.     Documentation

4.     Referral system


We felt that little cervical cancer reduction can take place in the region under the current model, which again is just getting started. Relatively few orientation sessions have been held with community women's self help groups. These sessions to date stay away from mentioning cancer, so there is little compelling reason for an asymptomatic woman to choose to come to the clinic for such an invasive procedure for no reason that she understands as urgent. Also, the screenings do not account for inadequate screenings and when they see lesions, the do not do Paps or biopsies, but refer the women to the city cancer hospital for having these procedures done – another invasive process for reasons still not clearly understood by the women.


Not surprisingly only a couple of women have actually gone for Paps and biopsies. So we made several recommendations about how they could engage the community more realistically, how they need to move towards doing their own Paps and biopsies (and ultimately to single visit see and treat).


We also recommended creating a system for proctoring and supporting the continuous learning of the existing screeners and, as they scale up to 10 RMHCs, new screeners. Certain shortcomings were pointed out in their documentation system, which is an in-house created software program that is over-all very impressive! We also recommended that when the bugs are worked out, their record keeping system would be a commercial success that could generate more income for the ICTPH.


Finally we attempted to show how their present referral system would not ever be viable and that with the implementation of the above recommendations (plus a few more referral-specific ones) their overall operation could be built into a successful and important contribution to local women's well-being.


Our team went out to a final night dinner at another of the "acceptable" restaurants in Thanjavur for a veritable vegetarian south Indian feast – one of the best meals of the entire trip! On Friday morning, we went to the train station to go to Chennai, on our way home!!!

After a lovely evening in Chennai, we took off on time and landed at SFO a few minutes early.

Saturday, January 21, 2012


Amelia T. Hambrecht

Monkeys and Malaria

SFO to Dubai  15 + hours.  12 hour layover in Dubai.  Dubai to Addis Ababa 3 ½ hours.  I hour layover in Addis.  Addis Ababa to Kampala 2 hours and we are finally here.  Carol and I left San Francisco at 3:30 Tuesday afternoon and arrived in Entebbe around 4pm Thursday.  Uganda takes some serious effort to get to.


We arrive at our accommodations and they are fantastic.  They are funky, very funky, but entirely magical.  We are staying at the Uganda Wildlife Education Center, a nature preserve where animals that cannot return to wild for whatever reason are cared for. They have rhinos, and lions, giraffes and water buffalo, zebras and crocodiles, beautiful birds and monkeys.  Do they have monkeys… 


Monkeys, we have decided, must be an indigenous species for this area.  They are everywhere.  A cute grey little thing with black faces, they scamper around in packs.  It also appears that, what ever their natural predator was, no longer resides in the area.  I would estimate there are a thousand monkeys here, and do they have a mind of their own!


The café where we go for meals is a circular cinderblock open air building overlooking Lake Victoria.   Funky and magical.  We meet some visitors, a pilot from Ohio via Turkey, a tour guide from Iran, have a beer and collect some things for the room, namely, a few bananas and some mantaz, also known as half-cake, a fried bread donut type thing that looks really good.  On our walk back to the room, we travel through a path that is canopied by trees where out of nowhere, a monkey runs up and leaps to grab our bag of goodies.  Unsuccessful, he runs off but another attacks from different angle.  Carol and I are trying to get though this gauntlet with our bounty but these monkeys know what they are doing.  The second monkey got a hold of the plastic and tore the bag.  Donuts and bananas cascade to the ground and monkeys are immediately on deck to pick up their loot. We carry on down the path schooled in the behavior of Ugandan Monkeys.


We return to the café the following morning for breakfast.  It is a spectacular morning.  The blue mist rising on the flat still lake, a few scattered boats fish for their daily catch, it is a lovely place to sit and read while waiting for the café to open.   Carol forgot some things so she returned to our room while I stayed to enjoy the moment; she left her malaria meds on the table with me, sealed in their child protected pill bottle.  The café opens and I go to order some tea and unbeknownst to me, a monkey scampers by and grabs Carol's malaria meds.  I return to the table, pick up my kindle, and start to read but out of the corner of my eye, I see something.  I look up and there is a monkey, looking straight at me, holding Carol's pill bottle, chewing the label.  I yell and go after the little thief, hoping he would just drop them but he scampers up to the roof, pills and all.  One of the young gentlemen who work at the cafe came to help and we walked around the building, trying to find the offending monkey to see if we could get the meds back.  We find him, chewing the label happily, and the child protective top no longer on the bottle. 


With the pills no longer in the bottle, I left the monkey to enjoy his prize and I looked around the grass, hoping to find at least a few pills.  I personally only travel with the amount of pills I need and I didn't know if Carol did the same.  This could be a problem.  We had already learned that we were on two different medications so I could not share.  I did do a quick calculation and we could have someone call in a new script and have them picked up by Eva before she got on her flight that afternoon but what to do for today?  I found some, a few pills lying on the grass.  I picked them up.  One looked completely untouched.  It will be up to Carol…


I return to my kindle and this blissful morning scene where out of the corner of my eye, I see the pill bottle flying from the roof on to the ground.  At least I now have some evidence as to the happenings of Carol's medication and the monkey.


Carol returns and we have a laugh.  Fortunately, she has some extras in another bottle so there is no concern.  Breakfast is delivered and we are given plates of beautiful fresh fruit and hard-boiled eggs.  We are just ready to begin eating when another monkey comes racing towards Carol and attacks her fruit!  What is it about Carol's monkey Karma?  She was holding the bag the evening before, so she was the one who was attacked.  It is her Malaria medication, and now her plate of fruit!  The wait staff did have a quick solution. The young waiter who assisted me earlier sat with us as we ate, a long wooden stick in his hand that he waived it at any monkey who considered coming near.


As we left the café to go out for our day, Carol to do her thousand's of errands before we go and I to explore Kampala, I heard a drop and looked.  The child protective top had landed on the path just behind us.  Apparently, the monkey thought we should take it with us…


Our first 12 hours in Uganda, funky and magical.


Amelia T. Hambrecht

Tuesday, January 17, 2012

Rural Education and Action Development, Andimadam, Tamil Nadu

Dr. Rhoda speaking to the local medical association group in Jayagondam in the Ariyala district of Tamil Nadu.


John Adams

16 January 2012


We took an overnight train from Mysore to Kumbanakom on 10-11 January, 2012 to visit the Rural Education and Action Development (READ) NGO that is a sister NGO to our Mysore hosts, PHRII.  D. Selvam has created a wonderful set of institutions in the town of Andimadam, including an HIV+ women's program, school, disabled school, and craft programs. READ also coordinates over 900 women's self help groups.


We arrived just a the start of Pongal, the biggest festival of the year in Tamil Nadu – a merry-making harvest festival that brings Tamil natives home each year from all over the world. The first morning (Wednesday) of our visit, we observed the making of Pongal Rice and visited the school. We also visited a beautiful old Chola Dynasty temple that dates back nearly 1000 years.


On Thursday, there were more READ institution visits and then Dr. Rhoda spoke to the local Indian Medical Association chapter about PINCC, HPV, and VIA. The group greatly appreciated the talk and spoke eagerly about getting the training brought here. See the picture above.


We spent Friday morning at the local Public Health Center in Andimadam, where some of the doctors from Thursday's talk work. The PHC doctors spoke of training they received in the now defunct VIA program instituted by the state a few years ago and proudly proclaimed that they have a Cryo gun from that program – however they don't use it! One of the nurses stated that she does 3-4 VIAs a month, but was unclear what happens when a positive case is found. We are just a tad skeptical about what is going on here, but they invited us to bring our PINCC training to the PHC if they can get approvals up the state bureaucracy line. It would be a perfect venue, and the 100 or so HIV+ women in the READ program would be an ideal group to start the trainings with. We gave Selvam the PINCC commitment letter and he will be working with the PHC to get the needed approvals.


On Friday afternoon, we went to a Tamil "Backwater" area and took rowboats through a mangrove area that eventually led to a gorgeous and totally deserted ocean beach! It was an incredibly wonderful experience.


Saturday was a day of further meetings around READ and many hours of finalizing the Tata proposal with Mr. Selvam to fund our envisioned Centre of Excellence for Cancer Prevention in Women in Mysore, that intends to train 320 doctors, nurses and midwives a year in the PINCC methods by the fifth year of its operation. On Sunday, the PINCC team's three Christians went to a catholic mass in Andimadam, and afterwards, in conversation with the priest, learned of his social and community missions in eco-developments. He is sponsoring a number of "green" local programs for tree planting, organic gardening, and so on. Very impressive service and we really were excited by the community focus. We spent Sunday afternoon visiting Selvam's home and meeting his family.


Monday morning we traveled by car to Thanjavur, the last stop on this trip, for three days of Quality Improvement consultations with an NGO that sponsors a clinic where three staff have received VIA training at Adyar Cancer Hospital  in Chennai. 

Monday, January 9, 2012

Mysore activities January 02-10, 2012

John Adams


MYSORE --  02 – 10 2012



























St. Josephs




































(1 as co-teacher)

























St. Josephs














(Broken Cryo gun)





































We completed our fourth four-day VIA screening and training clinic in Mysore on 07 January. Once again, we were highly impressed with the organizational support provided by all the staff at the Public Health Research Institute of India. They provided a total of 21 staff for patient education, registration, informed consent, record keeping, nursing and patient flow management. We had to make a late switch from JSS Hospital to St. Josephs Hospital due to a government mandated polio vaccination program that was announce just before we departed for India.


During the camp, we saw a total of 198 women. 58 of the screenings were inadequate and Pap smears were sent to JSS Medical College Pathology Department. 53 patients were judged positive and 50 biopsies of the possibly affected areas of these women were also sent to JSS. Eight Cryotherapy treatments were performed for moderate lesions and seven LEEPs were performed for more severe lesions. We saw one "definite" case of cervical cancer and one possible case.


The original intention on day four was to bring in a large cohort of HIV+ women. Unfortunately there was a late glitch and so we only got to see a handful of HIV+ cases. As a result, Day four was shortened and we saw about half as many patients as on the other three days.


At the end of the camp, we certified five of the trainee doctors as qualified to perform and to teach VIA and Cryotherapy. We concluded that a fifth camp is necessary in order to certify any of the doctors in LEEP.


In our follow up meetings at PHRII after the camp, they reaffirmed their intention to continue to develop the VIA screening camps on a monthly basis in the Mysore area. We also held a "pluses and deltas" review of the camp with all staff at PHRII and identified several areas for clarifications and improvements. In another meeting of the PHRII management and clinical group (nurses, trainee doctors, administration), we focused on planning for the development of a longer-term cervical cancer screening and prevention program – with the vision of making Mysore the "capital" of cervical cancer prevention in all of India.


On 09 January, Dr. Rhoda Nussbaum, PINCC-India Medical Director, gave an excellent CME presentation on cervical cancer, which included an actual colposcopy demonstration on three patients back stage, with video coverage into the auditorium. A first for PINCC-India to be sure!