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

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. 

Mysore activities January 02-10, 2012

John Adams

 

MYSORE --  02 – 10 2012

SUMMARY OF FOUR SCREENING TRAINING CLINICS IN MYSORE

 

DATE	HOSPITAL	DAYS	VIA	PAP	BIOPSY	CRYO	LEEP	CANCER		MD / RN TRAINEES
08/2010	St. Josephs	4	159	43	15	5	2	1		8
12/2010	Cheluvamba	4	202	47	31	2	2	2		7 (1 as co-teacher)
07/2011	JSS	4	263	46	50	14	5	7		5
01/2012	St. Josephs	4	198	57	50	8  (Broken Cryo gun)	7	1		8
TOTAL		16	822	193	146	29	16	11

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!

9 days and counting! Readying for Africa

The bags are (almost) packed! Shots and meds on Wednesday, first aide kit replenished, camera batteries and kindle charged, mosquito repellent and skin so soft purchased… got to pick up a mosquito net.

My name is Amelia, and this is my first trip with PINCC. I became acquainted with the organization last May, helped in the fundraiser in June, and waited until there was a trip that fit in my schedule. I will be going to Uganda and Kenya in two weeks. I am not a nurse or a doctor, I am a former teacher now nursing school candidate who will act as a community educator and all around support for the team while they train the host country medical staff on the identification and treatment of cervical cancer.

Today the team met in Oakland to prepare for the trip. At least 8 suitcases bigger than I have ever owned were packed with gauze, small cotton swabs, large cotton swabs, gloves, gloves and more gloves, pregnancy tests, LEEP machines and materials, exam kits that we put together, headlamps, alcohol solution, cytobrushes, pap sticks, syringes, loops, silver nitrate, lidocaine, and all kinds of instruments that I am only fairly familiar. Each suitcase had a packing list, each carefully thought out so that everything that was needed would be with us yet none would be over 50lbs, so no one would have to pay over sized luggage fees.

And what fun the day was! These are some terrific people going on this trip. Our fearless leader, Carol, has a Zen like quality that, regardless as to what is going on around her, keeps everyone calm and unfretted. Art, a retired OBGYN who plays drums and is studying Jazz piano has an elfish sparkle in his eyes, a joy of life seen in many people who are readying to embark on an adventure. Another Carol and Eva, two lively and cheerful nurses who have been to South America with PINCC, round out our team to Africa. The day went fast as we filled the suitcases, smiled and giggled at the stories and perused a book Barbara and John made of the last trip to Africa.

Many thanks to Kay, Pat, Carol, Art, Carol, Eva, Mitra, John, Barbara, Cheryl, Renee, Sujata and Karen for giving of their time in helping us prepare for this trip.

The bags are nearly packed. We are just about ready to go. For me, nine days and counting…

Amelia T. Hambrecht

Arrival of PINCC INDIA

John Adams

ARRIVAL IN INDIA: 02-03 January 2012

 

Our PINCC-India team of five departed from SFO new year's eve on time on an Emirates flight that is the longest non-stop flight coming out of San Francisco – nearly 16 hours! With suitable drug therapy we all got enough sleep to get off the plane in Dubai, walk around for an hour, and then board another three-hour flight to Bengaluru. For once, we actually arrived at our destination in India a few minutes early – unheard of in the annals of modern flight!

In the picture, from left to right, Janis Luft, Liz Armstrong, Joy Carlson and Rhoda Nussbaum, waiting for our car at Bengaluru Airport at 4:00 am Monday morning 02 January.

 

Our team consists of Dr. Rhoda Nussbaum, Medical Director, PINCC-India; Janis Luft, NP; Joy Carlson, and Liz Armstrong; and your trusty blogger and Administrative Director for PINCC-India, John Adams.

 

Our regular driver, Mr. Khan, met us at the airport and drove us safely to Mysore, where we arrived at 7:00 am on 02 January, and checked into our regular hotel. For Rhoda and me it is always like coming home! We spent the morning going to the bank to exchange money, shopping for room necessities, and getting our telephone SIM card charged up. We spent the afternoon at PHRII coordinating the week.

 

On Tuesday we had a wonderful meeting at the government hospital, where we worked during our second visit to Mysore, with the Radiation Oncology doctors, who are most interested in learning VIA and setting up clinics to screen for and prevent cervical cancer in the villages. They both declared they'd come to see our clinic set up on Wednesday to get an idea of what it takes. We may well be doing further PINCC camps in Mysore with new populations of doctors!

 

Next we went to the JSS Medical College and got a tour. During our July 2012 visit, the JSS Swamiji (Holy Man) blessed our project and invited us to make JSS hospital our home. When we were introduced to the JSS Medical College Principal, he told us that the Swamiji had spoken highly of our project. He invited us to submit a proposal for incorporating VIA, Cryo and LEEP training into their medical school curriculum. If it is successful, they would advocate to the National Medical Council, which controls all medical school curricula, to add VIA, Cryo and LEEP to all gynecology programs across the country. We continue to dream big and find progress!

 

Tomorrow we stat our fourth PINCC clinic hosted by The Public Health Research Institute of India and held at St. Joseph's Hospital (JSS not being available at the last second due to a government mandated national polio program – if only they'd take HPV as seriously as polio!).

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