Thursday, February 27, 2014

Bungoma and Kibera, February 2 - 15, 2014

By Maureen McSherri, RN

I knew that I wanted to go back to East Africa. And I knew that I would want to spend time with the friends that I had made in both Uganda and Kenya the last time 1 ½ years ago. But I also knew, that as before, I wanted something to do that was more than just being a tourist. Previously I had volunteered as a nurse with Hospice Africa Uganda. A hospice started by a woman physician, Anne Merriman, 20 years ago when she was 58. She is still going strong and with assistance from USAID and private donors HAU continues to thrive. I had a wonderful experience with them. Learned a tremendous amount about the Ugandan people and probably even more about myself.

When I had returned from my last trip a mutual friend of Carol Cruickshank and mine gave me a card. It had PINCC in large letters and had Carol’s name and contact information. I had not seen Carol for many years and had only heard about her briefly through our friend so I had no idea what she was up to and certainly had never heard of PINCC before. So I did what we all do these days and got on line to investigate.

I was intrigued by the idea of working with an organization supported and coordinated by someone like Carol. I had always known her to be a compassionate and unselfish person who had spent much of her life in the service of others. I was also excited about the idea of working specifically with African women. As amazing and beautiful as East Africa is it is the people that draw me. My internet search lead me to a U tube video of women singing out their gratitude to PINCC as they stood waiting in line to be screened. That was the all it took and I decided that I would contact Carol right away to investigate becoming a volunteer.

Approximately 1 year later I met with my first PINCC group in Bungoma, Kenya. I had already been traveling for several weeks in Uganda visiting Hospice and seeing friends. I arrived a couple days early so had a chance to check out the town. Like many East African towns Bungoma was bustling with street life. Cars, matatus, boda bodas and what I call boda bikes (transport of people on a padded seat on the back of a bicycle). Window shopping is easy in East Africa because the clothing shops display their cloths on wire hangers that express the cultural appreciation for women being well rounded from the waste down.

Our hotel was peaceful with a friendly staff. I was touched when it was time to go that they genuinely seemed sorry to see us leave. And despite a few kinks in the plumbing, a few holes in the mosquito netting and that toilet paper was hard to come by, it was a pleasant place to stay.

But of course the highlight was what we all came for, saving women’s lives with cervical cancer screening. One of the things that attracted me to PINCC in particular was the fact that it isn't just a group that comes in, rescues Africans and then departs leaving them with a vague memory of the experience and no ongoing skills. PINCC teaches the screening itself, even providing supplies and sometimes expensive equipment such as cryotherapy and LEEP machines. I was also so impressed with the other volunteers. Doctors, nurses and support people who have not only spent the time and money to be here but do their work with grace and compassion. I watched the doctors patiently and gently teaching the many different personalities that made up the doctors, nurses and medical officers from each site who are all so eager to learn how to make cervical cancer screening available to the women in their country.

Our second site was Kibera, one of the largest slums in East Africa. Each morning we would trade our shoes for rubber boots to make the 20 minute or so walk to the clinic. It had been raining (and a downpour in Kenya is very impressive) which made the narrow passageways through the slum more difficult, as the last thing anyone wanted to do was slip and fall into the mud here. We also had to be mindful of our heads as low metal roof overhangs were abundant. But the walk and the emotional experience of Kibera itself were all worth it when we encountered the enthusiastic group of healthcare providers waiting for us.

I have to say, that as I had thought, it was the women themselves who impressed me the most. Many of them had never seen a health care provider before and certainly most of them had never undergone a pelvic exam. Many of them were truly frightened but they overcame their fears and came in numbers. My favorite job while volunteering was when I had the opportunity to teach about cervical cancer. Generally this was done with an interpreter. Often a woman herself waiting to be screened who spoke English. I also found it very rewarding to explain to a woman what to expect from the process of screening itself in hope of easing her fear. But despite everyone’s best effort at preparation there was still some fear and in this case a hand to hold and a soothing voice became the necessity of the moment.

Gently, firmly with humility and much grace, Carol, our fearless leader kept us all on track. It was such a great experience getting to work with this amazing woman. She was truly the conductor of the orchestra and there would have been no music without her.

Volunteering with PINCC will always be a highlight, not only in my career as a nurse, but my life in general. It was a profound and rewarding experience and I am forever grateful to all the courageous, compassionate PINCC volunteers that I worked with. It was a true honor to be counted among you. AND I will see you again!

Saturday, February 22, 2014

World Cancer Day in Nyabondo

It is appropriate that on National Cancer Day we are able to provide cervical cancer screening and training to the women of Nyabondo, in the region of the Luo tribe.  The overall rate of HIV in Kenya is 4%, but here the rate is 15%.  This is due to early age of intercourse (13-15 for girls), polygamy and poor nutrition.  5/6 women we interviewed yesterday were HIV positive, all of them on meds and appeared healthy.  Being HIV positive makes a woman much more likely to have cervical cancer, as her immune system is weaker and unable to protect her from the HPV virus that causes cervical cancer.  The program we are providing to teach medical personall how to perform the screening will be immensely helpful to the area woman as intervention can be provided early on in the disease process.  The 8 nurses/physicians that attended the lecture yesterday were very enthusiastic about the program and eager to learn.  They return today as we screen 15 more women and teach as we do the screenings.  

Getting here by car from Bogamo yesterday was an adventure - as are most trips in Kenya.  Part of the road was under construction and we were driving on a bumpy sideroad next to the very smooth, partially completed paved road.  Although we were not allowed to drive on the road, it was a perfect smooth pathway for the area cows, goats and motorcycles.  Our driver stopped in the middle of the congested, dusty road - or so I thought!  The car had just quit and couldn't be restarted.  A passing motorcyclist called his friend, a car mechanic , and brought him back to our car within 5 mins.  After taking apart the steering column, glove box and under the hood, he determined that we needed a new fuse. We found this in town, replaced the old fuse and were on our way in under an hour. During our delay I was able to get some great pictures of the passing traffic, both animal and human.  Not a wasted time at all.  

The woman that I have been working with this week are all incredibly interesting and well traveled.  Talking with them in the 4 hour car trip yesterday was much better than reading a book on public health and more informative.  I will miss them immensely by the end of the week, but hope to travel with them again in the future.  This program, PINCC, is so necessary both from the standpoint of the actual screening but also due to the education that we are providing to both the students and the patients.  

Friday, February 21, 2014

Tabitha pictures, February 2014

PINCC volunteers, Tabitha Staff and patient, Classroom teaching session.

Lauren Ayres, RN-BS-N, CCRN.

Kibera, Tabitha Clinic, February 10-14, 2014

By Lauren Ayres, RN


            PINCC volunteers arrived on the outskirts of Kibera at the offices of Carolina for Kibera on Monday morning, albeit later than expected because of the ever-unpredictable Nairobi traffic, ready to get to work. For some volunteers this was to be their first experience entering the slum they had only heard about in the various forms of popular media. Apprehension, excitement, curiosity, determination and many shades of emotions in between were apparent on the faces of the volunteers as we prepared to make our way through the narrow paths that would lead us to Tabitha Clinic. Along with donning our rubber boots we carefully forced straight and stoic faces while mentally preparing for what we had only heard about. The residents of Kibera were already in the midst of their day, easily traversing the somewhat treacherous terrain which we nervously (and very slowly) tread. I am happy to report there were no slips during our week of walking in and back out from the clinic despite the heavy rains that made this trek all the more daunting.

            Upon arrival to Tabitha Clinic, most of us were struck by the large concrete structure. How they managed to construct this massive building in the midst of small tin-roofed homes, open ditch sewage, millions of residents and muddy streets is a feat I will not even begin to contemplate. We were, as per usual, greeted with enthusiasm and hospitality that far exceeded our expectations. All the staff went well out of their way to be accommodating for the duration of the week, and yet every day I was amazed that this seemed effortlessly to be the case. We walk in and disrupt their routines and their staff roles, and they couldn’t be more welcoming to this ordered chaos. After a brief introduction of the team we would be working with throughout the week, we realized how much assistance we would have available. Community and peer health workers were in abundance and more than prepared to encourage the residents of Kibera to come in and be screened by the PINCC trainees. As we took a tour of this clinic it was a bit jarring to look around and see how well supplied it was. Tabitha Clinic is a CDC site and is also made possible by Carolina for Kibera. Therefore, it is resourced fairly adequately, particularly in comparison to some of the other sites PINCC visits. Since this was the second visit to Tabitha, we were going to try to use the supplies provided by the clinic as they were available. The clinic had their own cryotherapy equipment, but PINCC supplied the LEEP equipment in order to have this service available to clients throughout the week.

            For the majority of the trainees this was their first experience working with PINCC. We were all impressed by how quickly they learned and the enthusiasm in which they undertook the training. Many had never performed a speculum exam, and I can personally attest to the fact that by the middle of the second day they were patiently and competently teaching me. The learning that took place within this group was exceptional. Dually noted was the warmth and kindness that radiated from everyone in the clinic. From the clinical officer to the maintenance staff, every person I encountered was contentedly working towards helping this startlingly underserved community. The energy of that goal was palpable from the time we stepped foot in the clinic to the time we took our last steps out. I have not a shadow of a doubt that this is the attitude even when there are no witnesses. What a humbling and honorable experience to have the opportunity to work alongside this dedicated group of men and women.

            I couldn’t help but compare the experience at Tabitha Clinic with the experience from the previous week at Bungoma District Hospital. When first walking in Tabitha, it feels a bit closed off compared to the open and spread out layout we experienced in Bungoma. Our “nursing station” was a desk in the middle of the crowded waiting room. Among large numbers of waiting clients and screaming children getting their vaccinations, we began. Despite the lack of personal space and the crowded nature of this room, the volunteers and health workers tried to provide as much privacy as possible while interviewing clients. It was a difficult realization that the simple concept of privacy in these situations is somewhat futile. Asking personal questions and performing cervical examinations are usually tasks that are kept as dignified and as private as possible. However, our idea of patient privacy and confidentiality does not quite align with realistic possibility in Kenyan clinics. Still, we worked with what was available and tried to preserve patient privacy as much as was feasible. It’s just one aspect of the great learning curve we had the privilege of experiencing every day. We had five exam rooms; one of which served as a cryotherapy room and one that was used for LEEPs as needed. The rooms inside the clinic are about the size of a closet and have no source of light except for the natural light peeking through the windows. Conditions were tight, but everyone made the best of it and worked past the small discomforts with ease. Even when, on the first day, the skies opened up and the clinic was under several inches of water, everyone simply slipped on their boots without complaint and carried on with the tasks that needed to be completed before we were able to leave for the day.

            The patients we saw during the week spoke a variety of languages, primarily Kiswahili, Luo and English. We had printed materials in all three languages and the community health workers were able to assist with patients that had limited English. Despite the language barrier, the gratitude emanating from every client and staff member was palpable. I suppose some things traverse language, and spoken words become inadequate. Again, such an incredibly humbling and honorable week from start to finish. The patient population coming in for screening tended to be younger than I personally had anticipated. Typically, PINCC recommends screening only for women older than age 25. However, during our week at Tabitha we amended this standard. Because the majority of women are sexually active at an earlier age and a high percentage are HIV positive, the risk of cervical cancer is significant even for women in their late teens or early twenties. Education for these clients was vital and it was encouraging to see such proactive young women coming in to be screened. Despite the fact that the average life expectancy in Kibera is only mid-30’s, alongside the younger population there were also middle-aged women coming in to be screened for the first time. We detected varying degrees of dysplasia and were able to successfully treat many women of all ages.

            We had several cases throughout the week where we would have to turn women away for one heartbreaking reason or another. Once cervical cancer is detected, the services PINCC has the ability to provide become insufficient and the woman is encouraged to seek medical attention elsewhere. Sadly, the waiting lists are endless, resources few and financial assistance unavailable. Many women also come to the clinic in the hopes of finding an answer for their breast cancer or their neighbor’s progressing cervical cancer. Not looking for money, but simply for an answer. A pleading look, a desperate grasping of hands and the inevitable walk back out the door into the harsh reality. There is nothing. That is something I hope to never become accustomed to.

Throughout the week we saw anywhere from 30-55 patients a day, and performed several cryotherapies and LEEPs. As the trainees grew in their knowledge base and experience, our confidence in them increased exponentially. By the end of the week we were able to certify two trainees and both were present at PINCC’s first visit. The small number of certifications awarded is due to the fact that PINCC likes to have each learner perform a large number of exams in order to confidently certify someone in VIA. Needless to say this usually does not happen during the trainee’s first experience with PINCC. We encouraged all the trainees present during this visit to return upon PINCC’s third, and perhaps final, visit in September. Based on the skill level and educational development of the trainees, there is sure to be many more certifications earned upon PINCC’s next visit. As we prepared to leave, we were surprised by an impromptu performance by both the Kenyan Boys Choir and the Kenyan Girls Choir. They were incredible and it seemed a very fitting way to end our last day. As we put on our rubber boots to make our way out of Kibera slum for the last time, the energy among PINCC volunteers, Tabitha employees and Kibera residents was tangible. The Friday afternoon activities were in full swing: children out of school, food being prepared along the narrow streets, people going about their business as we inconspicuously left Tabitha, and Kibera, behind. It almost seemed as though nothing had changed since our arrival, and yet, for me, everything had.

Lauren Ayres, RN-BS-N, CCRN. 

Thursday, February 20, 2014

Kiambu 2014

Thursday is now behind us. Today we saw 46 people. The cryo gun was fixed on Wednesday and we have done a number of cryosurgeries and LEEPs. The electricity was out for a short time this morning but it didn't slow us down at all. Mike our driver helps to locate things(vinegar for tests, meat to practice LEEPs , unwitting papayas for us to practice biopsies on) and we have additional help from George a young man from Kibera with support work. The team has gelled really well and like my trips before with PINCC I always feel like I get more than I give. Carol and Sheila( the nurse guiding the program at the hospital ) help to keep the wheels on the bus and things running smoothly. Both answer our questions with a smile and search out what we and our patients need.

Tuesday, February 18, 2014

Kiambu February 2014

Hello All,
This is my first venture into the world of blogging so be patient. Things here in Kiambu are off to a great start! We have a interested group of learners which are mix of people from PINCCs first and second trips here. 
The team consists of Dr. Art Levit, Dr. Sharry Kreitlow, Dr. Harmony Schuttler, Dr. Sara Cochrane, Caitlyn Husar, and the glue holding us together Carol Cruikshank.
We have a number of patients who are HIV positive and we are working on teaching LEEP and are struggling a bit with the Cryotherapy machine but hope to have it up and running soon. This is not uncommon and if I were skilled at engineering I would design a hearty cryo machine that never broke down.
We are staying at the HeartLodge which is cozy and has internet when the electricity is up. This allows us to keep in touch with friends and family. Three of us are from Wisconsin and our families share how much snow and cold is back home. We may just stay here until April or May.
More to come as the week goes on.
Sharry Kreitlow

Saturday, February 8, 2014

Community Health Workers and PINCC Volunteers

The PINCC Team on the last day at Bungoma District Hospital (photo taken by Mike Muthama) and three wonderful Community Health Workers who came to help teach about prevention of cervical cancer as patients waited to be screened (and eventually to be screened themselves).

Bungoma Photos

Bungoma Photos and Blog by Dr. Monica Hahn and Lauren Ayres, RN, PINCC volunteers, February 2014.

Bungoma Photo, February 2014

Bungoma PINCC visit February 1 - 8, 2014

PINCC volunteers arrived in Bungoma and immediately fell in love with this beautiful city.  On our first day we were welcomed at the District Hospital with smiles and genuine Kenyan hospitality.  Everyone was very enthusiastic and eager to learn, or in some cases improve upon, the skills necessary to provide the community with cervical cancer screening, a great need in this community.

It was immediately apparent that Bungoma and the surrounding area is in desperate need of these services, as we found that the overwhelming majority of women screened during our visit had never been screened before. We were struck by how many middle aged and older women came to get screened for the very first time with us this week.  On the contrary, the large number of young women who wanted to be screened impressed us.  The program outreach and awareness the community had regarding the importance of cervical cancer prevention was encouraging. Many women from the vulnerable population clinic (CCC), including many HIV+ patients, were screened this week as well, which was a great opportunity to educate women about HPV and risk factors for cervical cancer. We also received referrals from surrounding towns for positive or questionable cervical exams. In addition to all of these patients, we were happy to screen all of our trainees as well as the community health workers who provided health education to patients as they waited to be screened. It truly was remarkable to see the volume and wide range of women who wanted to be screened with us this week.
In general, we were able to screen between 35-55 patients per day, perform approximately 5-7 cryotherapies per day and between 1-3 LEEPs per day.

By the end of our week of training, which included morning and afternoon didactics as well as in-clinic precepting, PINCC was able to certify 8 trainees in VIA and 2  trainees in cryotherapy. We were also very proud to certify Dr. Kubuasu, the only OB/GYN in Bungoma, in performing VIA, Cryo and LEEP.  As this was PINCC’s third and final visit to Bungoma, the focus was to encourage sustainability and assignment of roles within the healthcare team. We supported efficiency in the regulation of patient flow, promoted the utilization of their own equipment and resources, encouraged troubleshooting and overall management of the screening program independently.   PINCC volunteers were excited to take a step back and watch this site grow into self-sufficiency day by day.

We were also able to donate a LEEP machine to this site, as well as other essential equipment.  Bungoma District Hospital (BDH)  will now be able to provide cervical cancer screening along with treatment on-site and on the same visit if a lesion is identified. This will also enable BDH to accept referrals from outside hospitals and clinics that do not have the resources to provide cervical cancer screening or treatment options for their community. The nursing staff were very excited about their current plan to have the hospital serve as a main training hub in order to continue expanding these vital services to other outlying clinics and dispensaries.

            With new certifications and skilled staff, Bungoma District Hospital will now be able to provide these services every day of the week at their family planning clinic. We were pleased to educate all the women who came for screening about the new availability of this service. Cervical cancer screening services were in such high demand this week, that as we were finishing up our last exams the clinic was already accumulating a long waiting list for women who wanted screening. Therefore, the women we did not have time to see will be screened in the coming weeks by our newly certified and competent participants.

In the past week the trainees blew us all away with their dedication, effort and enthusiasm for learning about cervical cancer screening and treatment. It was so rewarding to watch as their confidence and skills improved each day.  From trainees who were learning VIA for the first time to the veteran nurses who have been practicing VIA for some time, everyone showed amazing progress in their abilities and made our whole team very proud. 

Outside of our time in the hospital, we volunteers had a blast taking walks around town, getting caught in the occasional rainstorm or power outage, chasing aggressive chickens away from our dinner table almost nightly, and treating ourselves to excessive amounts of pizza and chocolate to reward our hard work. 

We are very grateful to the PINCC volunteers who came before us and fostered such strong relationships with the trainees in Bungoma. All of our work combined has led us to complete what was started a year ago and we couldn’t have done it were it not for the strong foundation the groups before us had built. We have every confidence that the people of Bungoma will be well served by the dedicated and skilled staff we have trained over the past year. We also thank our amazing driver Mike and our lovely lodging host Dennis for their assistance throughout the week.  Every member of our team plays a vital role in PINCC’s mission to prevent cervical cancer.

Although this was the final visit, Bungoma will always hold a special place in our hearts.  As we leave for home or for our next PINCC training site, we leave with an overwhelming appreciation for all the trainees, patients, hospital staff and the wonderful people in Bungoma for what they have accomplished within their community.  Undoubtedly we learned as much from everyone as they learned from us. It was an irreplaceable trip for all of those involved and we couldn’t be more proud of the result.

Dr. Monica Hahn and Lauren Ayres, RN