The ART Clinic Painted with HIV

Last week I spent my time at Lewanika Hospital in the ART (Anit-Retroviral Therapy) Clinic, which is a clinic focused on the treatment of HIV/AIDS.  It's important to remember that the treatment of HIV is not a cure, but only a way to minimize symptoms and delay death for as long as possible.  This of course is the same for HIV positive individuals back home, only the medications in North America are much more developed than they are here.  To put this into perspective the ARV(anti-retroviral) medications that were used in Canada in the early 1990's were first introduced to Zambia in 2005. At first clients were responsible to pay for their medications which were very expensive and created a major barrier for people to receive treatment.  In 2008 the Zambian government made ARV medications available at no cost to clients who met specific criteria.  Since then there has been a steady increase in the number of people requiring the clinic's services.

The ART Clinic supports approximately 1800 HIV positive clients from Mongu and surrounding villages.  This is an insanely large amount of people considering how small and understaffed the clinic is.  Each weekday morning people are lined up outside the hospital waiting for the gates to open so that they can rush to the waiting room in the hope that they will be seen fairly quickly.  One thing I found to be most frustrating was the lack of structure.  Back home we book clinic appointments ahead of time to help ensure everyone is seen in a timely manner and to prevent overwhelming amounts of people showing up at one time.  Here it is first come first serve.  For those clients who remain in the waiting room at the end of the work day they are simply told to come back the next day.  This might not sound so terrible at first, but once you learn how difficult or expensive it is for some people to travel to the clinic you begin to understand some of the challenges they encounter.

Even though I already knew there was a large HIV population in Zambia, it wasn't until I worked in the ART Clinic that it truly hit me.  I was there when people came in for counselling because they were concerned that they may have been exposed to the virus.  I witnessed people being tested and sat there with them for what felt like a lifetime while they waited to see whether or not a stripe appeared on the test strip.  I was there when clients were told they tested positive, and I even delivered the news myself. This is something I never thought about doing when I first went into nursing, and it is something I will never forget.  How do you tell a person that they have HIV, especially someone who is similar in age or a chid for that matter?  I makes it even more difficult when you know that the medications used here are close to 30 years behind the ones used back home, and that the life expectancy for a person with HIV is much shorter here.

I guess my time in the ART Clinic was a big eye opener to the many inequities here.

-Lauren

The Kukoo’s of Zambia:
Filling in for a Lost Generation

This week we (Ali Lake and Savannah Moody) were placed at the Save a Life Center run by an amazing nurse from South Africa named Lihana. Lihana saw a need in Mongu for families of malnourished children and she was determined to establish a feeding center that helps enable those in need.  The Save a Life Center offers feeding programs that provides weekly rations of local food as well as educational presentations on a weekly basis. Once the family is well established in the program they are given information on how to start and maintain a micro business and micro loans are provided.

Save a Life Center also provides follow up home visits by the incredible community health workers that are employed at the Center. We worked mostly with Annie, the eyes and ears of all the surrounding villages. There isn’t much she doesn’t know.

There is also a clinic attached to the center, both of which are apart of The Village of Hope organization. The clinic sees patient’s on a first come first serve basis. Sometimes patient’s walk for over four hours to get to the clinic.

           

Us at save a life centre with Annie, Lihana, and Ivy

We were already aware of the high prevalence of HIV/AIDS in Zambia and knew this disease was responsible for an entire generation lost. It wasn’t until we saw the Kukoo’s (which is Grandmother in Silozi), bring the babies to the clinic and the feeding program that the reality became apparent to us.

Our biggest eye opening moment was when we went on home visits with Annie and we saw many Kukoo’s in the village caring for the young.

There is one particular Kukoo that we will never forget. We met her after walking for a couple of hours through the sandy village of Mbuywana. She was the second home visit of the morning.  The hai (house in Silozi) was made of woven reed from the flood plains, clay walls, and a scrap piece of tin for a roof.  As we walked into her hai, we were both struck with immense sadness. We were taken back by the sight of a woman lying on the dirt floor with only a thin piece of cloth separating her bare skin from the ground. This woman was extremely thin; we could see each individual bone on her body. As we entered the home, her face was hollow and expressionless.

A typical hai  

We asked Annie about the woman, and our suspicions were confirmed; she was the mother of the baby who we were there to see, and she was dying of AIDS. We then learned that the Kukoo was the sole caretaker of the dying mother, the baby, and another young child. When asked how she earned money, Annie told us she goes out into the bush and collects firewood to sell. As there is no one else to care for the baby, this Kukoo has to carry the baby on her back everywhere she goes. It was apparent to us that this Kukoo was extremely overworked and exhausted. A woman of that age, should be relaxing and being a Kukoo; not a mother. The rest of our day was quiet. We both couldn’t get the image of the dying mother out of our heads.

One amazing Kukoo with her 7 month old grandchild

Once back at the clinic, we spoke to Lihana about what we saw and how we felt. We talked about why there is such an epidemic of HIV/AIDS leading to this generation gap. Some of the reasons include: woman relying on trading their bodies for goods and services (survival sex), multiple sexual partners, and a lack of education about how the disease spread. It is unfair that an entire nation must suffer so greatly at the hands of such a devastating disease.

This experience for us has been eye opening and has brought everything we leaned about the generation gap in Zambia to life. We both agree these Kukoos are the hardest working and strongest women we know.

-Ali and Savannah 

Sunset over the Zambezi flood plains 

Nursing in Nomai

We (Caitlin R. & Leah) feel so lucky that we were able to spend the past week at the Nomai Health Clinic as an outreach experience. Geographically speaking, Nomai is only about a 40 minute drive from Mongu. However, the clinic is considered rural as the only access is via 7 km of a sandy/dirt pathway that is wide enough to accommodate a vehicle when necessary (although we only saw one car other than our own throughout the week). The Nomai clinic serves an area that includes about 14 small villages that surround the area and there is no running water, electricity, or even a stethoscope (until we brought one for them last week - thanks donors!) When we arrived on Monday, as our team set up camp, Caitlin & I set to work in the clinic with two of the fabulous volunteers who although not medically trained, have dedicated years of service to the clinic. We helped test for malaria, a required procedure for all those who attend the clinic as there is a high incidence of malaria in the area (we saw a range of 1/4 to 1/2 of presenting patients testing positive for malaria). We also helped out in the assessment, diagnoses, and medication prescription for patients - a challenge for us as we do not diagnose or prescribe medications in Canada, and we were relying on translators for the majority of the assessment. The afternoon was a wonderful way to be introduced to the community as the health care team had organized a health promotion event for International TB Day. They had brought in a local group to drum, sing, and dance to help lure in the village people and then had an informative lesson on TB signs and symptoms, preventative measures, and available treatments. We felt it was a clever and successful way to spread health information, and perhaps a tactic we should use more in Canada. The rest of the week we worked with the nurse who is the only medically educated employee and runs the clinic 7 days a week. We helped assess, diagnose, and prescribe medications to the patients,and although the majority of the visits involved minor treatment we learned a lot about the health care culture in the community. For starters, we found that most patients expected to go home with some sort of medication, the most popular being a week’s worth of aspirin or, more unfortunately, a dose of antibiotics (although we tried to do teaching about antibiotic resistance, and the difference between viruses or bacteria). We faced challenges with this practice as the medication selection consisted of approximately 8 options (until the new shipment arrived mid week), and we had no diagnostic tests or procedures available to guide our clinical decision making. We also had a variety of patients presenting with vague, apparently unrelated symptoms which puzzled us until the nurse informed us that it is common for the villagers (usually younger children) to come in requesting treatment in order to get out of chores at home. Our most acute case was a woman who came in experiencing preterm labour. After assessing and monitoring this woman we soon realized that the woman could not receive appropriate care at the clinic and needed a referral to the nearest hospital. As ambulances only service emergency cases, unfortunately this meant that the woman’s family had to transport her on the clinic’s handmade lifted chair bike to the main road, roughly a 3 hour trek, then find transportation to the hospital from there. This was just one reminder of how the simplest things we take for granted at home are challenges faced daily over here. The highlight of our week was teaching about sexual health to over 150 students consisting of grades 3-9. The community has a high prevalence of teenage pregnancy as well as HIV so we felt it was important to educate the students at a young age. We included teaching of puberty, safe sex, pregnancy, STIs/HIV and respectful relationships; we even had one student volunteer to demonstrate proper condom application at the front of the class. Those who wanted condoms were provided with them at the end of the seminar. We were so thrilled at how involved the students were and the amount of questions we were asked.

Although our clinical experiences were enjoyable, the cultural experience of living in the village was what really made this week unforgettable. The villagers welcomed us into the community and clinic with open arms and we were repeatedly overwhelmed with their generosity and kindness - with gifts of cassava and charcoal, from those who sometimes may not be able to feed their own family. In the evenings, our outreach team members organized a couple campfires and invited the local children to come and sing and dance and we had such a great time listening to their amazing voices. I think we also provided some entertainment for them - they loved our “makua” dance moves. There is something pretty incredible about heading out for a walk only to realize you have a following of about 30 children 5 minutes later. This experience also enabled us to take our friendship to new levels - sharing a one man tent for 5 days and bathing together out of a small basin will do that to people! 

Overall it was an amazing, unforgettable experience and we are so thankful to those who made it incredible. Thanks to Save a Life Centre for organizing this week, to Nasilele & Muyunda for being great company, campmates, and translators, & to the wonderful staff & volunteers at Nomai Health Centre for making us feel at home.  

Caitlin R. & Leah 

‘It’s Cultural’

This week I have chosen to take a more critical reflection on the concept of ‘culture.’ In the little time I have been here in Mongu I have heard several times that certain behaviors and practices that I witness are ‘cultural.’ For example, women are to make little noise during childbirth and if they do cry out they may be reprimanded for making such noise. Also, pain management is not the same priority as it is in the western world, and both of these practices (not allowing a women to show pain in child birth and little pharmaceutical pain management) are often explained to me as a result of the strength and ‘culture’ of the people here. At first I just accepted these realities as ‘cultural’ and neglected to think more critically; however, as I dig deeper I am pushed to question if these experiences for the people in Mongu are in fact ‘cultural’ traditions OR if this is more related to the inequities that the people here have to live with due to the resource challenges present in Zambia’s Western Province?

My colleague has been coming to Mongu since 2008, and she (Jessica) continues to witness significant improvements each year at the Lewanika hospital, as the healthcare providers and community seek quality health care; however the need for improvement in relation to the quality and delivery of healthcare remains. At this hospital Jessica and I attend the morning report. This is a meeting that is attended by all of the heads of the departments as well as the administrative staff. The aim of the meeting is to pass over the night shift report and address any issues or concerns. Due to a language barrier, and the soft-spoken nature of most people in Mongu, I often struggle to understand the report. And yet one morning I heard a man speak very passionately at this meeting about his frustration in regards to the care that was provided for a particular patient. He repeated this statement “we should treat every patient like our brother or sister.” His point was clear- the people deserve quality care.

BUT how does one deliver quality care on a maternity ward where 10 plus babies are delivered within 6 hours with only two nurses/midwives on staff? Or how does one deliver quality care at an anti retroviral clinic that sees over 500 hundred patients per day with similar staffing realities?

The concept of culture remains challenging to define. Many definitions of culture tend to define culture as something that is static; focused primarily on shared values, traditions, beliefs and customs. This narrow view of culture sees certain characteristics of various ethno-cultural groups as ‘cultural traits’ without considering the complex socio-political and economic factors that shape people’s lives. Most people and have been socialized and raised to understand culture primarily through a ‘culturalist lens,’ which can be problematic when it leads to stereotypical thinking in which one assumes that certain behaviors are ‘cultural’ because that is what they have been told, while missing the wider socio-political and economic factors that shape people’s life circumstances. Poverty in this spot of the world is rampant. Children spend their day outside of a grocery store doing any task considerable for 1 Kwacha (1 US dollar is approximately the equivalent of 6 Kwacha). They will wash your car, assist you with groceries- anything! Many men work 2 or more jobs to try and support their family, and the women are working equally as hard. The outcome of colonization is prevalent; however at this point of time I feel the need to look much deeper into the history.

So are these behaviors of healthcare providers that we see ‘cultural’ - women being slapped during childbirth for making noise because they should stay quiet, or little pain management post invasive procedures because the people are strong and taking pain medications is viewed as a weakness to the illness – OR – are these behaviors much more complicated? Is healthcare, and the delivery of healthcare more so shaped by the socio-economic, political and historical factors and less about the ‘culture’ of the people here? As usual I’m left with more questions and less answers…

 Jackie

A Wonderful Week on Maternity and Post-Natal!

      When I was asked to list my top three preferences for clinical placements at the beginning of this trip, maternity was not one of them.  I’ve never found the whole labour and delivery process to be very magical, and I saw newborn babies as screaming bundles of poop and involuntary reflexes rather than bundles of joy.  I preferred pediatrics, where I can enjoy the transformation of these little bundles into real live human beings.  

Lo and behold, as my second clinical rotation of this practicum, I found myself being assigned a split mat-peds week.  But to my surprise, Aryn and I ended up spending the entire week on the maternity ward!  The learning there was so rich that it just didn’t make sense to limit it to only a few days.

There have been many posts about Zambia being a low-resource country; where supplies and resources are replaced by necessity and creativity.  However, my week on the Lewanika maternity ward showed me that you don’t always need supplies to deliver quality care, wherever you are in the world.  As an experienced “baby nurse” once said: “for the most part, these are well women coming into the hospital to do something they’ve been doing for thousands of years.”  In high-resource countries like Canada, laboring mothers are often surrounded by a team of specialized health care professionals, who are monitoring mom and fetus constantly and are ready to intervene at the first sign of trouble or delay.  Based on my experiences in Zambia, I think that some of this close monitoring could improve the maternity care here, but I also think that high-resource countries could also learn something from low-resource areas...     

This week, Aryn and I participated in a C-section of twins!   After the surgery, the mother was returned to the ward with her babies.  They were placed in the “acute bay,” where the sickest patients are usually placed.   Aryn and I returned to the floor about an hour after they had been transfered.  When we arrived, we assessed the mother, and we found her drowsy, weak, and difficult to rouse.  Our nursing-gut alarms went off immediately.  Her blood pressure was less than half of what it should be.  This was a big deal.  Using our best “you need to come NOW”-voices, we rounded up the doctors and anesthesiologists who had been involved in her surgery.  In a flurry of adrenaline and sheets of paper, the patient was somewhat stabilized.  But the situation made me think - how long had she been in that state?  How long until someone would have noticed?  Even without a single supply, an experienced pair of eyes can detect when someone is going downhill.  It’s just a matter of looking.  There’s certainly no shortage of experience on the post-natal/maternity wards, so I think using that experience as a resource to assess patients early and often could be a cost-efficient, sustainable way to improve patient outcomes at Lewanika.

On the other hand, being on a Zambian maternity ward has highlighted how intervention-crazy we are on Canadian L&D wards.  Besides a tool to cut the cord, healthy births really don’t need any medical supplies or interventions at all.  Hormones and muscle power tend to take care of the rest.  One night at Lewanika, there were 10 births between 2 midwives.  It might be out of necessity, but maybe it’s cultural; either way it seems as if the perception is that healthy human mothers are fully capable of delivering babies.  The calm, cool, and collected midwives of Lewanika assist the mothers through the process.  Giving birth is a painful, exhausting process for the mother and I think that health professionals in high-resource countries often take too much credit for it.  Health professionals don’t deliver babies, mothers do.  

- Darien 

This week was my first week in the hospital. Last week I had the privilege of starting my Africa practicum at the Save a Life Center. Transitioning to the hospital was nothing short of terrifying for me. After hearing the experiences of the girls last week, I felt completely unprepared as a nurse. I have never had to resuscitate a neonate and the thought of potentially doing so scared the daylights out of me. Anyone who has worked with babies can understand how fragile and sensitive these little buggers are. This week I realized on the ward how ‘resilient’ they are - or how resilient the professionals on the ward think they are at least...

  I’m not disregarding the care that the physicians show on the ward, but I do think there is room for improvement. During rounds on the ward I found the largest focus of the assessment on the mothers, with minimal focus (in my eyes) on the newborn baby. I guess when I think back to the care that we give in Canada, physicians are doing more of an ‘observation’ assessment than us nurses. Maybe there was some piece that I was missing throughout the day that the babies were receiving more attention than in the morning rounds. Something I have noticed while working in the hospital is that the families of the patients do all of the personal care, bring in all of the food/water/tea and are expected to be there for their family members. Maybe it is expected that your family is supposed to guide you and your newborn baby in the right direction. Maybe I was being paranoid and all of the babies on the ward were actually perfectly fine. Like I said before... to me, babies are fragile, sensitive little buggers! 

One specific story that stood out to me was with a patient who had an incomplete c-section incision. The incision had resulted in two different fistulas for the mother and in turn an infection had festered. The first day I met this woman she was having a cleaning and a dressing change on her wound. They took her into the ‘treatment room’ and put her on the table. They proceeded to pour hydrogen peroxide and iodine into her open, quite deep, wound. I sat there at first and watched her cringe in pain. Without saying a word, or moving her hands from squeezing the bed above her head. I couldn’t take it any more. I went up to the head of the bed, grabbed her hand, and told her to squeeze as hard as she could for as long as she needed. I proceeded to comfort her and tell her how strong she was being for the amount of pain she was pushing through, analgesic free. As I was leaving later that day she waved me over to her and she asked, “Will you be here tomorrow for my treatment?” I assured her that I would be. This moment was the highlight of my week. All of our ‘feelings’ classes that we had gone through in the past four years finally came to use! This is one area that I believe the nurses and health care workers that I met with this week could be stronger at. We have been told over and over that ‘being tough’ and ‘not crying’ is a sign of strength in Mongu - but what strength is anyone gaining from a stone cold nurse or doctor at a patient’s most vulnerable moment. Nobody had expressed to this patient the current procedure or the projected plan. She had expressed to Darien and I her fears in which we then made a point of answering her questions with the best of our knowledge.

This week wasn’t all doom and gloom. For goodness sake, we were a part of a delivery of twins! Darien even caught the second baby! We watched an SVD and were able to experience a smile on a mother’s face that is only had at the sight of a first born child. Rounds with the doctors was a wonderful learning experience. They tested our knowledge and challenged our answers when we were second guessing our confidence. 

I’m grateful for my week on the Maternity and Post Natal ward! And once again, just when you start getting comfortable, change occurs! Looking forward to the Sefula clinic next week with Robyn!

- Aryn 

Shawnel and Caitlan S. – Sefula Health Clinic

            This week we (Shawnel and I) were placed at Sefula Health Clinic (SHC), which is about a 30 minute taxi outside of Mongu. Sefula Village is literally right on the flood plains, very small, and absolutely gorgeous. There is a walkway out onto the flood plains that goes on for over 200 hectares and it is the main way for all of those people living on the plains, to come to SHC when seeking medical attention.

 Sefula Pathway to the Plains

            We definitely noticed two themes present in this clinic, one being Family Centered Care and the other being Low Resources & Staffing.

            Here in Mongu, and Africa in general, everyone has a someone. Every single patient will have a friend or family member with them for all 24hours of every day during their stay at the hospital, and even when they are just coming for an outpatient visit. It is remarkable the care they show their loved ones, doing all personal care, providing food and water, and even retrieving medications. For example, we had many people come in for HIV adherence and medication renewal for themselves, but also for other family members who couldn’t make it to the clinic that day. This was a strange concept to accept because the adherence counselors and clinical officers would be giving medications to and writing reviews on patients who weren’t even there and just going off of what their family member reported about that patient. This was also prevalent in another case we experienced where an older mother (60-70) walked 4 hours to SHC because her pregnant daughter was very ill. We didn’t really know what to do or how to treat a person who we couldn’t physically see or assess. After learning how far away they lived and from listening to the mothers recount of her daughters symptoms, we diagnosed her daughter with probable severe malaria and prescribed medications accordingly. Through this, we truly gained an understanding of the vastness of this under developed country where distance is a HUGE factor in determining life or death of someone needing medical attention.

            A final example we witnessed about the importance of family centered care even presented on our very first day at SHC. A 3 year old child came in with a fever, diareha, and vomiting blood. He was referred to Lewanika Hospital in Mongu but had to wait for the bus which came the next morning. We decided to take the child with us at 1300 that day. In Canada, it would usually only be the child and a parent accompanying during transport. In our one cab, we ended up having the driver, the child, the mother, the grandmother, a sibling, and the two of us! Canada centers and prides its healthcare on patient and family centered care, but we have NOTHING on the African people and the care they show their family members. It is beautiful and inspiring. It may be quite difficult coming back to Canada and seeing so many people in the hospital with little to no family support.

            The other common theme we noticed this week was the total lack of resources and staff at these small clinics! The funding is not present to stock and supply even the most basic resources needed at a health center. Some of the things missing were:

-       - Fetoscope (what is used to listen to a baby’s heart rate in the mothers belly) – it has gone missing

-       - Batteries for the blood pressure machine and NO manual blood pressure cuff for when the batteries die (which they did twice this past week)

-       - Cleaning solution for cleaning some commonly used medical instruments such as the thermometer

-       - Garbages – there was 2 garbages in the entire clinic for general waste….

-       - Sharps containers – needles/lancets are used frequently to test for malaria and HIV and there were only 3 throughout the clinic.  These containers were also made of cardboard

-       - Pain medication – for the first 3 days there was no pain medication at all… no Tylenol, no aspirin, no ibuprofen, nothing! This is a frequently missed stock at SHC. The patients prescribed with pain medications (or any medications the SHC pharmacy did not have) had to go to the local pharmacy and purchase them, which many patients could not afford

-     -  Rehydration fluids – there was only 1 of each 1L bags of fluid (Normal saline, Ringers lactate, Dextrose 5% water)

-      - Strapping (tape) – absolutely no tape was present in the clinic which means that when someone needs an IV, they couldn’t tape it to hold it on, meaning the IV wouldn’t be started

Where we found this most challenging was when we witnessed a male patient in extreme discomfort. When we enquired about his condition, we were simply told he had lumbago, which means back pain (reminder: no pain medications stocked). Both of us knew instinctively that whatever this man was experiencing was not just back pain because he seemed confused, disoriented, and agitated. Further enquiring into his situation, we were told he had been suffering from severe vomiting and diarrhea for the past 24hrs. Immediately we knew he needed IV fluid ASAP as he was likely severely dehydrated and had electrolyte imbalances. When we asked why he had not had an IV started earlier, the nurse said that they had no strapping (tape) to keep the IV in place so it would have just fallen out because of how agitated he was. Thank goodness we had brought tape from home that day and we got an IV started on the man right away! The next day we brought a giant bag full of tape to the clinic so that another patient will not suffer due to a lack of resources.

            In relation to staffing, this issue was most exemplified during the Under 5 Clinic day where over 150 babies and toddlers showed up with their mums for check-ups, weight, and immunizations. ALL of the following duties during this day are normally completed by ONE NURSE for EVERY CHILD.

1.     Weigh and record in the child’s card file.

2.     Find each child in the registrar (a book with written records of each child by number and year).

3.     Enter the weight into the registrar.

4.     Analyze every child’s file to determine what vaccinations are needed at that visit, if any. Enter it into the registrar.

5.     Write in a separate registrar every child’s number who was seen that day and check off the vaccinations they need if any.

6.     Prepare the vaccinations for each child.

7.     Administer the vaccinations.

8.     Educate the mother on the vaccinations given, proper nutrition, and proper hygiene.

We found this day with the amount of tasks to be done and children seen, to be physically impossible for one nurse. We spent 1.5 hours weighing the children and then 2.5 hours completing steps 2-4 and barely got through half of the children’s files! It was so mind boggling that only one nurse usually does all those tasks.

EXTRAS!!

Nawa, our cab driver, was so great! He was very knowledgeable of the Lozi culture and political and historical aspects of Zambia. We learned so much from him.  He even gave us Lozi names! Caitlan is Namakau and Shawnel is Nyambe. Nawa is still searching for the exact meaning of those names in english but is going to let us know very soon :)  

At the end of each day we would hit up the small market right infront of the clinic.  We got samosas, fritters, and fresh veggies after every clinical day! YUM!

The lovely market ladies :)

Us organizing the file room before accepting people into OPD (equivalent to Emerg).

Buried in files!

The first day at the clinic was also World TB (tuberculosis) Day! We had a great time, sipping on sodas, listening to music, and seeing everyone dance.

World TB Day Celebration

Last but not least, Caitlan forgetting to put her runners on.  That was a good laugh – nice socks and sandals!