Last day at Kibera

Kibera continues...

Today was day 4 of our time at the JJJ Clinic in Kibera. The trainees continue to make progress, and we continue to catch early lesions (so far have only found one case of invasive cervical cancer) that can be treated with cryotherapy or LEEP. Today we learned that the hearty lunches they have fed us every day are prepared by the families of the girls in the attached girls school. The school is free - including uniforms, shoes and two meals a day - but someone from each student's family has to commit five weeks of work to the school. So the mothers, or sisters, or aunties of the girls have been cooking us lunch. Yesterday they had to prepare food for the 100 girls in the school, the 80 clinic staff members, the 6 of us and the 20 community health workers at our training. Quite a feat! It's inspiring to see how committed the girls' families are to their education and how integrated the community is to the work of the school and the clinic.

Kibera

We are in Nairobi traffic ("the jam") on our way back to the Johanna Justin-Jenich clinic in Kibera for our second day of training. The first day was wonderful. Kibera is a large (1.5 million people live there) slum filling a depression by the railroad tracks out of Nairobi. The government of Nairobi apparently does not want it to exist and does not provide services to the area. As a result of the conditions of the slum the life expectancy there is 30, compared to 50 for the rest of Kenya. We were bracing ourselves for a hard first day there, expecting to have to troubleshoot a multitude of difficulties over the day, but it ran very smoothly. The clinic has been set up by an organization (the Shining Hope for Communities) founded by a man named Kennedy from Kibera who is now studying at Wesleyan University (in Connecticut). It's a really good story and you can read about it more on their website. At this point they have a two-story bright blue school decorated w children's hand prints, a clinic with three exam rooms, electricity provided by a generator, the largest clean water supply in Kibera, a clean latrine, and an enthusiastic and dedicated staff. We had 6 clinical trainees, consisting of nurses, clinical officers (equivalent to mid-level practitioners in the US like physician assistants) and one doctor. I was lucky to be in a room with the two clinical officers, Purity and Diana, who already had some experience w cervical cancer screening and were clearly competent in their clinical judgement, quick to learn more and caring towards the patients.

We have now pulled through the jam and are at the gates of Kibera. More later.

by Merritt Evans

Kisii to Nairobi

Habari gani, rafiki ya PINCC? (Which may or may not mean "How are you
doing, friends of PINCC?")

I am with PINCC for the first time, in Kenya for the first time,
blogging for the first time. Lots of firsts! We have just arrived at
the Mennonite Guest House in Nairobi, which is a beautiful garden
sanctuary. Our time in Kisii was very satisfying. It was PINCC's final
trip there and it appears that cervical screening in Kisii Level 5
Hospital (<kisiihospital.org>) has great momentum going forward. The
midwives are excited about the project and are diligently screening
women every day in two different clinics. Dr Ondari, their new
gynecologist, has already led a training for other midwives and
clinicians in the region. And the medical director of the hospital
clearly has ambitions for the hospital to be a model of cervical
cancer screening for the region. It is very exciting, and a very
inspiring introduction to PINCC for me, which appears to be a model of
how international efforts can help train local providers to
independently provide the services that they themselves feel are
essential to provide.

Tomorrow we go to Kibera in Nairobi, a brand new site, which promises
to be an entirely different, but also exciting, experience. I'm
looking forward to it. And I'm also loving Kenya - the beauty, the
warmth of the people, the way that everyone who greets you takes the
time to inquire how you're doing, the gingeriness of Stoney Tangawizi,
the English Premier League football on every bar TV, the chapatis, the
chaos of the boda-bodas, the sweet burnt smell, the odd cow in the
road, the deliciously ripe pineapple, the whole package. I feel very
lucky that we are so welcomed to do this work here.

Endebess, Kenya

Weekly tally for Endebess:

Patients seen: 358

Biopsies: 24

PAPs: 39

Cryo's: 35

LEEPs: 5

16 Trainees and 10 Supervisors were trained in VIA, VILI, Cryo and LEEP. We expect to certify all during our next visit in August.

60 Community Health Educators were trained in the importance of screening for cervical cancer and education materials were distributed for the CHE's to use in their communities.

These last two weeks with PINCC have been absolutely extraordinary. It is always a pleasure to go into a community and share talents but to train others so that your talents can continue after you depart is truly the way to go. PINCC's combination of classroom sessions plus 1-on-1, hands-on transfer of skills is effective; the growth and empowerment seen in all of the trainees has been remarkable. It was a real pleasure to work with such motivated, enthusiastic people. Every one of them has stated they will continue after we leave and they look forward to follow up training when we return in six months. If these 16 trainees see only 3 patients a week, there will be 1248 women screened before we return. If the numbers remain at the roughly 29% needing further treatment or tests as it has this last week, that will mean approximately 362 women will have been treated for conditions which generally result in cervical cancer before we even return… and this is only for Endebess!

Working with PINCC has been a privilege and I hope you have enjoyed my sharing the experience with you. This is, however, the last blog entry I shall be writing for PINCC. I am now in Kisumu, visiting with a Peace Corps Volunteer friend to see a bit of Kenya before I return to the states but I am sure Carol will find someone in the new team to continue. They are in Kisii now, until Wednesday, when they move on to the Johanna Justin-Jinich Community Clinic, a project of Shining Hope for Communities (SHOFCO) in Kibera , a vast Nairobi slum. I imagine them now, the end of the day, arriving at their accommodations, tired and dirty, yet fully energized by the work and appreciating the simple pleasures: electricity, hot running water, paved roads, thread count sheets. They have cleaned up and are sitting around a table or a cluster of sofas, discussing the trainees and the difficult cases of the day. They are thoughtful, and dedicated, and all working hard to make a difference. I am truly proud to be a part of this team. Talk to you on the next trip…

Amelia T. Hambrecht

Endebess

Where Gombe was a small rural hospital, seeing an average of 22 women a day, Endebess is a larger hospital that is vying for district status. Here, during our first two days, we saw more women than we did the entire week in Gombe. Monday, Carol and I did the cervical cancer training to 60 community health workers. The pace is faster; there are more women with severe cases, yet the facilities are more reliable so the work seems more fluid. Small town Kenya is worlds away from rural Uganda. We have consistent power so we are now able to use our equipment. We even have hot water and showers where we are staying, so we can now feel more like ourselves. As much as we all loved Gombe, Endebess is a big step up.

Our replacements are starting to arrive. Art Levit and Carol Savio flew in last night from the states. Art is a piano playing OBGYN, most recently from Kaiser East Bay, who has been Medical Director on numerous PINCC trips since his retirement three years ago. Carol is a retired RN who moonlights at the Women's clinic in San Francisco when she is not on PINCC trips. Melissa leaves us tomorrow for the states and Art will take over as Medical Director for the remainder of the trip. Eva and Arlayne leave on Saturday and I will be dropped off on Sunday in Kisumu to visit a friend while the rest of the new team meets in Kisii. This has been a wonderful adventure; it is hard to believe our two weeks are nearly over.

And how is it, you ask, that I have time to blog on a Wednesday afternoon? I, the one who has eaten street food all over the world and never gets sick, got sick. And even more unsettling is that I cannot figure out what got me there. Yesterday was excruciatingly difficult, trying to shoulder my responsibilities while also trying to keep from being sick in front of everyone; I managed but do I owe Arlayne! She was a huge trouper and did nearly everything while I just organized paperwork and inputted in the computer. She most defiantly earned the golden speculum award yesterday! And I must say, if you have to get sick on a trip, do it on a trip with Doctors. My meds, of course, were deemed inferior once reviewed yet any meds I needed, someone had. And when your body rejects said meds faster than you can get out of bed, your doctor roomie is not fazed at all and gives you hers while she goes to another room. The complete injustice of it all is that I feel fine today. Hungry even, as I sit, quietly relaxing, writing this blog as I know everyone is working hard 45 minutes away but fortunately Carol and Art are there to help and all will go well. I see my future though. Tomorrow will be speculum city for me!

Amelia T. Hambrecht

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...

Endebee

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

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.

 

Amelia T. Hambrecht