January 1, 2001 - AMA: Notes of Peace Corps Physician Robert Davidson in Malawi
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January 1, 2001 - AMA: Notes of Peace Corps Physician Robert Davidson in Malawi
Notes of Peace Corps Physician Robert Davidson in Malawi
Notes of Peace Corps Physician Robert Davidson in Malawi
Notes from a Peace Corps Physician
"Hey Daktari, the Mzungu No Look Good!"
This static-filled telephone call from a park ranger started an incredible chain of events. The mzungu,(roughly translated as European), turned out to be a 27-year-old Peace Corps volunteer who was working in a national park in Malawi. We immediately started planning how to transport him to the medical unit in Lilongwe. The first leg of the trip was in a park ranger truck that met the Peace Corps Land Rover on the highway. When he finally got to the medical unit, his blood pressure was 80/40, his pulse, rapid, and his temperature, 40.1 C. Following re-hydration, he perked up a bit and we awaited lab studies, suspecting malaria. When the results came in we were stunned. Trypanoso-miasis, probably Trypanosoma brucei rhodesiense, was the diagnosis. Following a rapid review of Trypanosomiasis in my tropical medicine book, we quickly decided that we could not handle this in Malawi. We arranged for an air ambulance flight to South Africa where he was admitted to the ICU and started on suramin. His lumbar puncture was negative for CNS involvement that would have indicated adding arsenic, as suramin does not cross the blood brain barrier in adequate amounts. I have never treated anyone with arsenic, but it does not sound like something fun to do. As I write this, the volunteer is out of the hospital and doing well.
Avoiding an Epidemic
The next step in this saga was a phone call to the ministry of health who informed us that Malawi does not have Trypanosomiasis any more because they had undertaken an eradication program two years ago. Well the bugs won again; five more cases were diagnosed in the same park area, all in Malawians. There are known tsetse flies in a number of areas in Malawi and neighboring Tanzania. There is no immunization against the protozoan parasites they carry. So we were faced with what to do with the other volunteers in the area. Thanks to modern communication, we were able to call for advice from the Peace Corps Headquarters and set up a plan for selected removal of some volunteers in known tsetse fly areas. So far, no additional cases in volunteers have occurred. However, we receive daily calls from volunteers who have been bitten by something and are worried they have African Sleeping Sickness.
Reflecting on the Incident
As I look back on this case, several things stand out. First is the issue of emergency transportation. There is no 911 system. It is rare to even find an ambulance outside the major cities. We recently went to see a reported new ambulance in Madagascar that turned out to be a mini-bus with a litter. There was a driver and an attendant with no training. "But daktari, he is real strong." Earlier, I sat with a volunteer with acute appendicitis driving over rutted dirt roads in a vehicle with shocks that had long ago given up. I felt each jolt and knew he was suffering. I had no idea if this jostling was more likely to produce a perforation but sure hoped not. With the financial resources we have as a US agency, we can access air ambulances that are quite good. These are a godsend, as the in-country medical care resources in a place like Malawi are fairly primitive. There are some great doctors, but they just do not have the medicines, facilities or support necessary to care for really sick patients. I do feel a little guilty that we can fly the volunteer to an ICU in Pretoria when this is far beyond the finances of most Africans. However, I also realize that if the finances were available, they would be better spent on basic health supplies and initiatives, not air ambulances and ICUs.
Remembering the Basics
The second reflection was on tropical diseases. I flashed back to my parasitology course at the Indiana University School of Medicine. I remember saying to myself that I just had to memorize this stuff for the exam, since I would never see these bugs in patients. Like so many other things I knew as a medical student, I was wrong. However, I have found that it is not as hard as it sounds to take care of cases like this. The basic principles are the same. You need to deal with things like shock and dehydration. Once the patient is stabilized, you have time to look up these different diseases and read how to treat them. With access to the Internet and telephones, knowledge about tropical illnesses is readily accessible.
Whose Lifestyle Is Unhealthy?
The third reflection concerns my admiration for the Peace Corps volunteers. Most volunteers complete their service with nothing more than an occasional bout of diarrhea. However, they live in remote villages often without electricity. They use pit latrines and rig up outdoor sun heated showers. They boil and filter the water they carry in buckets to their houses. They buy their produce at the village market and soak it in a chlorine bleach solution before cooking, as night soil [human feces] is the standard method of fertilization. They are constantly exposed to all kinds of parasites and viruses. They self-treat as much as possible with a medical kit supplied to them and a copy of "Where There is No Doctor." Yes, they do get diarrhea, URIs, various skin infections, both bacterial and fungal, and lots of anxiety symptoms. However, overall they do remarkably well and almost always return home healthier than when they came. Maybe the real message is the unhealthy life styles too many of us fall into in the United States.
Well, enough for this month. Daktari Bob signing off.
[AKA Robert C. Davidson, MD, MPH Area Peace Corps Medical Officer for Eastern Africa]
Robert Davidson, MD, MPH,
is Professor in the Department of Family and Community Medicine at University of California, Davis, where his interests include both rural health and the organization and financing of health care systems. In the past few years, he has served as both the Director of Rural Health and earlier as the Medical Director of Managed Care for the UC Davis Health System. What follows is an on-line journal of his odyssey in the U.S. Peace Corps as the area Medical Officer in Eastern Africa.
Physician Profiles in Africa
Robert C. Davidson MD, MPH
hen I came to Eastern Africa, I was not sure what to expect regarding my colleague physicians. I have been pleasantly surprised by most of the physicians I have met in Eastern Africa. Since some of you may be contemplating a career or experience in international work, I have decided to profile several of the physicians I have met.
Dr. S., an American, is an important medical consultant to Peace Corps Kenya. He went to medical school in Chicago and completed both his residency in Internal Medicine and a fellowship in Cardiology in Seattle. Now in his fifties, Dr. S. has spent most of his career practicing in Nairobi. He has developed a well-respected group of Kenyan physicians. Dr. S. seems genuinely happy with his practice and his life. Observing him in his consultations, I noted that he uses less confirmatory testing than is customary in the US, which may be a blessing since most people do not have insurance and pay out-of-pocket for their health care. Dr. S. is well known throughout the country as "the President's personal physician," a position that has embroiled him in some messy politics in the country. My impression is that he would enjoy less prestige and demand for his services were he to return to a practice in the US.
Dr. K. is a Kenyan who went to medical school at Nairobi University. He did six years of surgical training at the Medical College of Wisconsin and holds both General and Cardiothoracic Board Certifications in the US. He met his wife during his surgery training when she worked as an ICU nurse at the University hospital. She now manages his office as well as raising their children. He could return to the US to practice but prefers to stay in Kenya. The volunteers who see him are initially taken aback by this obviously Kenyan male who speaks English with a mid-western American accent. He is trying to develop a cardiac surgery program in Nairobi, but is frustrated by the lack of skilled nurses and technicians. Most people here think of South Africa as the place to go for cardiac surgery. He reminds me of some of the well-trained surgeons I met in small communities in rural northern California. They wanted to use the advanced skills they had received in their training and often resented the implication that you get better care for major surgery in the large urban hospitals.
Drs. D. and M. represent the best of the United States contribution to international health through the Centers for Disease Control. I have been surprised by the large CDC presence in Eastern Africa. These two physicians typify the epidemiologist- researcher in international health. Their predominate focus now is on HIV / AIDS. Dr. M is a pediatrician-epidemiologist whose area of interest is maternal-child transmission of HIV. His wife is a social worker, well known for her leadership in several programs in Eastern Africa targeting HIV prevention. They have two children who have been raised around the world and are now in high school in Nairobi. Both have spent their entire careers, except for some obligatory time in Bethesda, in overseas countries, seem very happy with their career choice, and feel a sense of accomplishment from their professional lives.
Dr. H. at 64 heads a major project on reproductive health in Kenya and devotes much effort to marketing his dream to various funding agencies. He envisions an Africa-wide initiative to develop leadership in HIV / AIDS programs based on the US Peace Corps model where African volunteers would be trained, supported in their work for two years in another African country, and then returned to their own country. His enthusiasm when describing his proposal is infectious. I understand his rationale for selecting the Peace Corps model, since I am witness to the tremendous impact the US Peace Corps has had on the development of leadership. Many current employees in the State Dept. and US Agency for International Development are former Peace Corps volunteers, including three of the five US ambassadors in the countries I cover. Dr. H's wife heads a major US program in Pakistan, so the couple maintains a long-distance marriage. He has training in pediatrics, has taught international health in a US medical school, and has worked all over the world in both government positions and with many of the non-governmental agencies (NGOs) involved in health projects. I again sense a happy person who believes he has made a difference through his work, and is still excited about international health projects.
Drs. M, G, and S. are colleagues of mine working for the Peace Corps in Africa. Drs. M. and G. came to Peace Corps from the Indian Health Service. The commitment they have for under-served populations is met by both their previous and current jobs. Dr. S.'s story is a bit different. Following medical school and Internal Medicine and gastroenterology training in the US, she had a private practice for a while and then moved into increasing responsibilities in a managed care company. Becoming disillusioned with this, she came to Africa. She has some wonderful stories about her experience as a black American woman in a position of responsibility in Africa. She is married to an African man whom she met in the US, and they are raising their children in both cultures.
Drs. G. and H. are American physicians working in Kenya as part of religious missions. Dr. G. is an opthalmologist who divides his time between a practice in Oregon and directing an eye institute near Nairobi. He is fascinated by the pathology he treats in Kenya. He plans to return full time to the US sometime in the future. Dr. H. is here on a two-year mission commitment. He is an orthopedic surgeon who acts as Chief of Surgery in a mission hospital that serves a rural, poor population. Both of these physicians receive much personal satisfaction from using their skills in service to humanity.
The conclusion I come to is that all the physicians I have described are happy with their lives and find gratification in what they are doing. In the US, I became tired of belly aching by physicians. I too often heard comments like, "I am just putting in my time until I can get out of practice." Many seemed to look for a villain for their unhappiness and managed care seemed an easy target. They seemed to dwell on their loss of income when they were still in the top five percent of wage earners in the US. Most disturbing to me personally were comments that they did not want their sons or daughters to go into medicine.
Now my advice. If you find yourself sharing that level of frustration, do something about it. There are opportunities throughout the world where your skills are needed. Working overseas may not be the answer for everyone, but it works for the physicians I have profiled.
"Please Help Me. My Baby Is Sick and Needs Medicine!" 
by Robert Davidson, MD, MPH
Before coming to eastern Africa, I was repeatedly warned about "culture shock." We have been fortunate to enjoy a fair amount of international travel and had lived for a time in Central America. I thought I was ready. Most of the transition has gone well. I am even learning a little Swahili. Against the advice of the Regional Security Officer for the US Embassy, we elected to not live in one of the secure compounds of clustered townhomes that house mostly Americans and personnel from other embassies. Instead, we selected a lovely older home on a 2 1/2-acre plot.
Kenyan Asians and African Kenyans
The neighborhood has very nice homes, many of which are owned and occupied by Kenyan Asians. These folks are third or fourth generation Kenyans who culturally continue to relate to India. They are the descendants from the Indian railroad workers brought into Kenya during the British colonial rule. They have prospered in Kenya financially, and "Asians" own many of the larger Kenyan companies. It seems curious that after 3 or 4 generations they still do not identify themselves as Kenyan. We have enjoyed our conversations with our neighbors and have frequently been given advice by them, particularly on how to interact with "Kenyans." It has been more difficult than we thought to relate to "African Kenyans." We have a great relationship with the Kenyan staff at work, both the professional and clerical staff. We have had some wonderful discussions about America. At our Fourth of July party we all toasted our common heritage of rebellion against British rule. However, the rest of the Kenyans with whom we have daily interaction are at such a different income level that it is difficult to be friends or even friendly.
The Most Difficult Cultural Adjustment We Have Faced
The level of poverty and unemployment in Nairobi is so high that we are constantly made aware of the disparity of resources. "Please help me. My baby is sick and needs medicine." This plea came from a woman in rags sitting on the street outside our home with a baby asleep on the dirt. Perhaps the easiest thing to do would be to give her some shillings, which might make me at least feel a little less guilty. However, we are repeatedly warned by other expatriates and our Asian Kenyan neighbors to give nothing to beggars. They will return 10-fold the next day, we are told, if the word gets out that the "daktari" gives money. Perhaps some examples will help portray the dilemma.
We interviewed for a man to help with housework and driving. "Lucas" was selected. He had a pleasant personality and came with good references. However, very soon problems began to arise. Lucas was repeatedly absent for several days at a time due to illness. He came to see me at home on a weekend and asked me to get him some medicine to cure him. I asked if he had seen a doctor. Of course, the answer was that he could not afford it. He then proceeded to take off his shirt to show me a rash that was bothering him. As I gazed at an emaciated body with a typical Herpes Zoster rash, I suspected immediately the problem. This man was in the latter stages of AIDS. The physician part of me began to race through options. How could I help? I knew I could not be his physician. I did not even have a Kenyan medical license. He could never afford retro-viral drugs nor even lab tests and preventive therapy such as Sulfamethoxa-zole/trimethoprim. I began to worry that his cough might be more than a simple problem. Could he be spewing mycobacterium? My mind returned to an incident the previous week when he had presumably fallen asleep while driving and almost went off the road. I knew he could no longer work for us. I was not worried about his infectivity, but rather his capacity to do the job. We sat on the porch and talked for a long time. He seemed to understand that he could not work anymore for me but began bargaining for some money so he could go to the doctor, get cured and find another job. I simply could not say no. I gave him one month's salary as terminal pay and some extra money to go see a doctor. We left on good terms.
The next day he was back with his daughter in her school uniform. "Please, I need some money to pay my daughter’s school tuition or they will kick her out. She wants to be a doctor like you." As hard as it was, I held the line on what I had already given him and assumed this ended the saga. The next day his wife showed up toting a small baby. "Please daktari, Lucas is very sick and will die if you do not give him some money for medicine." My heart went out to this woman. Was she also HIV+? Was the baby? How could I justify sitting on the porch of this beautiful home saying no to her? On the other hand, where would it stop? This is one of the dilemmas of "giving" in Kenya.
Recently, I visited a mission hospital outside of Nairobi, staffed by rotating American physicians under the auspices of their church. The chief surgeon, an orthopod from Atlanta, immediately took hold of me and urged, "Come with me. You have to see something." He led me to the bedside of a precious 10-year-old Kenyan girl. She had been brought to the hospital following snakebite. He had operated to remove necrotic tissue from the area of the bite and relieve the tremendous pressure from swelling. However, she was showing increasing systemic manifestations of the venom. In his opinion, if she did not receive anti-toxin within the next 24 hours, she would probably die. Did the Peace Corps have any? How about the US Embassy? Could I help him? My mind began to race. Yes, I knew that we stocked a shared supply of anti-venom with the US Embassy medical office. It was for use on Embassy personnel or dependants or Peace Corps volunteers. The words from my orientation sessions came ringing back. "Under no circumstances are you to treat or give medicine to any person other than authorized US personnel." This was the General Counsel for the Peace Corps speaking. My boss, the director of clinical services for Peace Corps and a general surgeon, leaned over and whispered, "You better listen to this as you will be tempted." The speaker went on to outline the dire consequences which could ensue if we "misused" US property. OK! I can handle this, I mused. However, standing in a mission hospital a world away from Washington, looking at a little girl that I could probably help from dying, was not part of the bargain. The US spent millions in aid to Kenya. How could I justify not "giving" to this little girl and this caring and dedicated physician?
The harambe is a long-standing cultural custom in Eastern Africa. It has been explained to me that it comes from the tribal custom of helping other members of the tribe in times of need. During my first week in Nairobi, one of the staff said there was a harambe for one of the secretaries and I was invited. Great, I thought. It is nice to be included. It turned out that it was not a gathering at all. Rather, it was a memo to all participants telling them how much they "owed." I have always been supportive of the graduated income tax, but wow, this was a pretty hefty bill. I paid the money, mainly because I was new in country and did not know what else to do. I did not have a very good feeling about it. Sure enough, the next week I was invited to another harambe. Was this the spirit of giving I wanted? Where would it end? Was I being selfish for wanting a bit more personal involvement and control over my gifts? Would I be culturally insensitive if I did not join in this "long standing Kenyan tradition"?
I could cite more examples, but I think these give a good picture of the dilemmas faced by an American physician in Eastern Africa. I purposely did not say how I decided to respond in these situations. The issues are more important than my responses. I do not view my working here as a "gift" to anyone. I am supported well by the US Government through the Peace Corps, and I am gaining much more than I am able to give through my work as a physician. I do feel a desire to "give" in the face of the huge need I see in this country. We are slowly finding what works for us, but if you are faced with the same situation, expect the decisions to be harder than you think.
The views expresse
The Haves and Have-nots
Robert C. Davidson MD, MPH
To understand the health care system of a country, you must first understand its culture. This is so true in reflecting on the theme issue for this month's Virtual Mentor: disparities in health. It is far too simplistic to merely view the disparities as a problem in access to health care services. No, there is something more profound in the way that countries in East Africa approach basic human services. How these services are allocated is driven not only by how much money one has, but by tribal customs that span national boundaries in Africa and by the continent’s history of colonialism. Though I do not claim to be a social scientist, I hope my observations can provide some insight into the complex factors that lead to disparities in health care in Eastern Africa.
First, we will start with the obvious. A walk through the campus of the new Aga Kahn Medical Centers in Nairobi and Dar es Salaam gives the impression of "state of the art" medical care. Most of the consultants have impressive post-graduate training, usually in Great Britain, and have the usual string of initials, confusing to Americans, after their names. The laboratory and radiology units with the latest scientific equipment reside in modern air-conditioned buildings. However, as you look around the campus, you see very few people with the typical dark skin of a native African. Most patients are either East Indian or of European ancestry. Almost all services are provided on a cash basis, paid for at the time of the service. Physicians are much more likely to diagnose by history and physical exam without the usual confirmatory lab or X-ray tests since even the “haves” must pay “out of pocket" for these tests and services.
Contrast this with Central Hospital, a government hospital in Lilongwe, Malawi. Here are the old stucco buildings with concrete floors and open windows without screens. The typical adult ward might house 8 patients with no visual barriers between stark cot-like beds. There is 1 toilet without a shower for each 3 or 4 wards. The nursing care is scant; most patients have 2 or more family members who stay with them and sleep on the floor. Family members prepare meals on small charcoal cookers in the room or hallway. There is an open drain down the middle of the hallway that carries a variety of wastes to the drain at the end of the hall. The odor and smoke combine to make the atmosphere as near to Dante's underworld as I care to see. Physicians routinely lament the lack of medications. Various aid groups supply medications in ample quantities, but most of these wind up on the black market and never reach the hospital and those who have little.
Beyond Health Care Services
It is easy to confirm that there is a wide disparity in health care services in Eastern Africa, but I don’t believe health care differs in this respect from other aspects of life in this society that also have impact on people’s health and quality of life. A fifteen-minute car ride takes one from the worst of the Nairobi slums to palatial mansions with green rolling lawns surrounded by electric security fences and 24-hour guards. The houses in the slums are little more that plyboard or tin sheets held together by whatever is available. There are no toilet facilities, just the occasional water spigot with a line of children carrying "jerry cans” for water.
The public transport system is a combination of old school buses and the notorious Kenyan "matatu." The matatu needs a little explanation for the un-initiated. These are usually Nissan mini-buses decorated with wild colors and slogans. They are meant for 10 passengers. I counted 22 people exiting one at a nearby loading area. There is a driver and a "tout," a combination huckster, money collector, and pusher who crams in as many paying passengers as possible. The drivers are notoriously bad at the job, using horns in lieu of brakes that may or may not work. On the same road will be several Mercedes and other luxury autos with African drivers and Asian or European passengers.
Inequities reign in the utility sector also. When the electricity or telephone goes out in your house, you can expect the requisite 2-week wait for service, or you can ask the dispatcher for special service at an additional cost. Depending on the amount of the "special service" fee, you might get assistance within 15 minutes. Americans often become incensed with the concept of a bribe and rail openly against the system. Their outrage usually causes the waiting period to stretch to 3 weeks. If you have the resources, and are willing to spend them, you can live very well in Eastern Africa. When the drought in Kenya produced staggered electricity blackouts, the generator industry did a land office business. People with money were able to generate power on their own land, although at a major cost to the health of the environment.
The police are not immune to the temptation of providing "extra service" for a fee. I have witnessed a black Kenyan beaten with a police night stick following a minor auto accident while the other driver, a white man, was driven home in the police vehicle. I wonder how much that "special fee" was.
Not Merely a Matter of Money
Even given these glaring examples of the inequities between the haves and have-nots, it is nevertheless too simplistic to attribute all such disparity in service and in treatment to money and class. My "boss" is an African American woman born in South Africa. She is a PhD clinical psychologist whose style of dress puts my California casual to shame. Yet, when we travel together, she is routinely stopped and harassed by customs officials, visa clerks, and so on, while my Anglo face gets me waved through with little hassle. I have viewed more blatant racism at times in Africa than I saw, or, at least, remembered, in the US. The curious thing is that much of the racism is by black Africans against other blacks; other factors in Africa’s history and tribal culture contribute to this.
Many Africans continue to identify with their tribes rather than with their countries. The relatively new and somewhat artificial borders between countries seem strange even to a Western observer. Crossing border checkpoints is laborious, with rampant displays of bureaucratic hurdles to be cleared before one can transit to another country. (Yes, I am sure a special fee would help.) However, not 50 meters away from the checkpoint, is open land with no border fence or even marker. Tribal areas often transcend these country borders, and many view the border as either a colonial invention or a racket to extract visa fees from tourists. In the rural areas, the tribal customs seem to work, and the informal support system of the tribe meets many of the social needs of the group, but not the needs of other “blacks” who are outside the tribe. Perhaps not surprisingly, this tribal identity does not translate well to urban Nairobi, where individual interest, self-gain, and survival dominate the culture. Power and its ability to corrupt rule the political arena; leaders use brutal tactics of oppression to stay in power. The ethics of what people ought to do as an alternative to the ethics of “might makes right” is so foreign as to be almost non-existent.
My initial moral outrage at the disparity of health care services in Eastern Africa seems strangely to have lessened as I have begun to be acculturated to Africa. There will always be "haves” and have-nots." Ethics can help to set a floor or basic level of decency in how we interact with the "have-nots." In Eastern Africa, there is little interest or even recognition of what constitutes this floor. "Ethical" seems to be defined as what one can get away with. Perhaps it is not all that different in the US. With more resources, the “floor” and “ceiling” are less far apart in the US, so the disparity seems more tolerable.
Daktari Bob, [AKA Robert C. Davidson MD, MPH]
by Robert Davidson, MD, MPH
n September 11, 2001, the world changed. The terrorism tragedies at the World Trade Center and the Pentagon have affected every American in some way. I thought you would be interested to hear how it has impacted my work and Americans living in eastern Africa.
I was working in Malawi on September 11. We first heard the news when the information officer at the American Embassy in Lilongwe called over to the Peace Corps to inform them of the terrorist attacks. I am sure most Americans in the US turned to their television and followed the tragedy live. No television was available at the Peace Corps office, but we were able to get the BBC on short wave radio. It seemed surreal to be sitting in a small office listening to a British newscaster describe what was going on in New York and Washington. Rumors began flying. The first was that the US Air Force was going to shoot down commercial airplanes that were veering off course. The US Embassies in eastern Africa were placed on high security alert. Memories of the embassy bombings in Nairobi and Dar es Saalam were still fresh in many peoples’ minds.
Back in my hotel room, I was able to get the BBC television channel and watch the incredible videos of planes flying into the World Trade Center. I sat there with tears in my eyes and a mixture of sadness and anger. I wanted to be with people, so I walked down to the lobby. An obvious African Muslim man looked at me and smiled. He said, "I guess the US is finally getting a taste of what the Palestinians have been getting." In the bar were a group of Americans sitting in a corner. I did not know any of them and usually would have avoided them, thinking we probably had little in common but our citizenship. They were ex-military contractors working on a project at the US Embassy. They were loud, cigar-smoking, beer-drinking Texans who fit the stereotype of the Ugly American. However, they were American, and I needed to be with some countrymen. I could take only about an hour of their increasingly hostile attitude that "we should "bomb the **** out of whomever did it." I could, however, identify with their anger and need for the US to do something.
Over the ensuing 3 months, the aftermath of the attack has continued to affect us on a daily basis. A number of the volunteers were frantic with worry about friends or family in the New York area. The usually unreliable Kenyan telephone system was completely overloaded. All we could get was the recorded message in Kiswahili that "all lines are busy, please try again later." Then we began getting families, and even a couple of congressional offices, calling to find out when we were sending the volunteers home. There was no terrorism in Kenya, and the volunteers were probably safer at their sites than they would be trying to fly back home. This would be impossible for a few days anyway, since all flights to the US were cancelled. Things slowly returned to a relative calm until the 2 follow-up events occurred that affected us more than the initial attack. The first of these was the anthrax mailings, and the second was the US attack on the Taliban in Afghanistan. Because humor is important in these times, I want to relate a few of the anthrax stories in Kenya.
By way of background, anthrax is naturally occurring and quite common in eastern Africa. The Masaii herds of cattle are universally infected with it, and spores are everywhere in the soil. It is not uncommon to get cutaneous anthrax infections that respond nicely to doxycycline. One of the volunteers was diagnosed with cutaneous anthrax by a local physician and started on antibiotics. She happened to mention to her parents in a weekly e-mail that she was being treated for anthrax with no other explanation. That prompted a panic call from the parents to the Peace Corps headquarters in Washington asking what the hell was going on. The headquarters’ staff gave the parents my phone number, and, of course, the inevitable call came at 3:00 a.m. "Was their daughter being flown out in an Air Force medical evacuation plane? Was I a real doctor? CNN should know that Peace Corps volunteers are being attacked by bioterrorists." When I was finally able to explain what was going on, her parents seemed skeptical but at least somewhat reassured. The next day I developed an information sheet on anthrax and sent it to all the volunteers so that we could avoid similar situations with their families.
Several days later, I got a call from an obviously distraught volunteer teacher who said her headmaster was demanding that all the teachers in the school be flown to Nairobi for examination and given prophylactic antibiotics against anthrax. The headmaster’s demand was precipitated by a package my caller had received. She had sent to the Planned Parenthood Association in the US for some brochures on HIV/AIDS prevention that she planned to incorporate in her teachings. The brochures arrived in an envelope. She opened the package while sitting in the teachers’ lounge. As she tore open the envelope, the gray/brown powdery insulation spilled out onto the table causing a panic among the teachers, who ran to the headmaster's office yelling, "Anthrax, anthrax." I was able to assure the headmaster that there was no risk of anthrax. I did ask her to put the package in a plastic bag and send it to me in Nairobi where I would have it tested. I never heard from her again. However, the next day I got a call from a family doctor colleague from the US who was working in Kenya at a mission hospital. There was a group of students from a church school in the US who were in Kenya for a bible study program at a mission school. The bishop in the US called the mission hospital in Kenya to demand that all the students be placed on Ciprofloxin as prophylaxis against anthrax. My colleague had tried unsuccessfully to calm the bishop. He needed, he said, "some muscle from the US Government." I was able to help him by contacting a CDC research physician working in Kenya whose advice, I guess, had enough "muscle."
The War on Terrorism has had a more sinister effect in eastern Africa. Both Kenya and Tanzania have huge Islamic populations, some of whom are fundamentalists very close in ideology to the Taliban brand of Islam. As much as we say that the US attacks are not attacks on the Islamic faith, they are perceived as just that—attacks on Islam. There have been several anti-US demonstrations with the ritualistic US flag burning in major cities. The real effects on volunteers are subtler. Americans who board a matatu, a Nissan bus that is the local mode of public transportation, are told, "Watch out. Bin Laden is sitting in the back seat." Popular beach resort areas have been declared "off limits" because they are predominately Islamic and have sub-groups suspected of being allied with the terrorist network. All in all, America’s War on Terrorism makes an already stressful job that much more difficult.
It is sad that the world must go through this destructive phase. Most eastern Africans, including most members of the Islamic faith, endorse US actions. I understand the need for closing down the terrorist threat to the US and the world. I only hope we will be equally committed to rebuilding and supporting the countries we attack. I also hope the world can understand that we attack terrorism by fostering the development of Third World countries in a more lasting way than bombing them.
My best wishes to all of you for a peaceful 2002.
Daktari, Will You Sign This?"
Robert C. Davidson MD, MPH
y relationship with the Peace Corps volunteers in 5 countries in Eastern Africa is different from any of my previous experiences with patients. For the most part, it is satisfying; its challenges principally clinical. As in any situation, however, occasional difficulties of a more personal type arise. Several aspects unique to working for the US government in Eastern Africa lend themselves to potential problems: the closeness of the community, the level of stress and fear in the volunteers, and the potentially conflicting expectations of the various roles I have as physician to this special community.
The volunteer experience is an intense one. Each country has approximately 150 volunteers who spend 2 to 3 years “in country.” Their dependence on Peace Corps staff leads to very close relationships. Volunteers often stay at my house when they are in Nairobi. Some have difficulty making the transition from this friendship to a patient-physician relationship. For example, although I am very comfortable being called by my first name, as is the norm with other staff, most volunteers prefer to call me "Doc," "Dr. D.," "Daktari," or some variation. When the volunteers get together in the evening, the staff is usually invited. When I attend, I sense that I become a damper on the festivities, especially on the amount of alcohol consumed. This may not be a bad thing. It is likely that my presence reminds them of my in-training exhortations regarding all kinds of health risks, including the use of excess alcohol. It is clear that the volunteers want a certain distance from "their" physician, partially because I will soon be doing their testicular exams or Pap smears, but there is more to it than that. Maintaining a certain professional relationship helps sustain my role as their health advisor and, in many respects, as their "parent in absentia." Most of the volunteers are about the age of my 3 sons, and I am comfortable with this role. I have just never experienced it before in my professional career.
I have often used the analogy of a "stress test" for the Peace Corps volunteer experience. I tell the volunteers that just as we exercise a patient to look for any evidence of cardiac ischemia, they are undergoing a two-year life stress test. It is quite understandable that health or behavioral issues, easily kept at an acceptable level in their previous life, manifest as problems in Africa. I also tell them that the coping skills they develop during this experience will be of tremendous value to them the rest of their lives.
Relatively minor symptoms can become exceedingly frightening when you are living 50 kilometers from the nearest village with a phone and 2 days travel time from competent medical care. When they do come to the medical unit, a thorough exam and use of appropriate diagnostic tools usually allow me to reassure them of the benign nature of their symptoms. However, some are convinced that their symptoms indicate an undiagnosed tropical illnesses. For example, one young man experienced total temporary paralysis while lying in bed at his site. Though the neurologic exam was normal, he was certain that he had some tropical illness and was frightened to return to his remote village. When I cannot find a cause for the volunteer's symptoms and begin talking about how to cope with the problem, I often sense a feeling of skepticism. "Look Doc. This isn't stress. My hair is falling out." "You mean to tell me that I have not had a menstrual period for 6 months because of stress?" "So what if the 10 stool examinations you’ve done show no parasites, Doc, I know this cramping is not related to stress. This is not the irritable bowel syndrome I had in college."
Occasionally, the roles of physician-as-clinician and physician-as-administrator come into conflict of what I call the “company doctor” type. Reimbursement for travel presents one such potential conflict. A volunteer comes to Nairobi for a presumed medical visit. After a normal exam and very little evidence of any problem, I am presented with a form to authorize reimbursement to the volunteer for travel to Nairobi, hotel charges, and per diem. "Hey Daktari. Will you sign this?" Usually we can negotiate this. Occasionally, the request for signature comes after one of the nurse Peace Corps Medical Officers has already seen the volunteer. I suspect that the old shuffle is occurring. If you do not like the response from one person, you go to another hoping for a different, more favorable reply. How well I remember this ploy as our sons were growing up.
The most difficult challenges surround the fundamental ethic of physician confidentiality. The role conflict arises when I learn, as part of a medical interview, that the volunteer is engaging in behavior that puts him or her at too high a health risk in Africa. An example might be repeated episodes of refusing to use safe sex practices with multiple partners. The HIV risk in the Eastern African countries is far too high for me to allow this type of risky behavior to continue. When I become aware of this behavior, it is incumbent upon me to initiate procedures for the volunteer’s separation from the Peace Corps. Another example entails the Peace Corps’ zero-tolerance policy on the use of illicit drugs. The risk to the volunteer from the drugs is made all the greater by stringent in-country laws against illegal drugs: the standard jail term for possession of illegal drugs in Kenya is 10 years. On the one hand, I try to foster a relationship of trust with the volunteer that includes confidentiality regarding information given in the course of a visit. On the other hand, I have a clear moral obligation to do the "right" thing for the volunteer even if he or she is unhappy about it. I also must honor the agreement I made with the US government when I was hired to adhere to the regulations of the agency. Informing volunteers of the limits to confidentiality is part of the Peace Corps orientation process. They are informed that non-disclosure of a significant health problem is grounds for dismissal.
I am glad that we did not title this month's theme the "difficult patient." The patients are not difficult. There are just some difficult issues that arise in the course of providing care to this unique group. Perhaps the issues I am facing are no different from those in any patient-physician population. However, they sure seem different, more common, and more troubling here in Eastern Africa.
Daktari Bob, [AKA Robert C. Davidson MD, MPH]
"Hey Doc.! Something's Crawling Out of My Foot."
Robert C. Davidson MD, MPH
y patient population in Eastern Africa is the Peace Corps volunteers in the five countries I serve. They are a truly remarkable group of individuals. I have great admiration for their fortitude and sense of adventure. Most of them do very well from a health standpoint and return home healthier than they came. In my training activities with new volunteers, I often use the analogy that their two years of overseas service is like a life stress test. I explain the use of stress testing for diagnosis of conditions such as coronary artery disease. I go on to say that if they have medical problems, these will probably get worse during the two years. However, if the volunteers learn to cope with these problems, they will be much stronger and able to adapt to future life stresses when they turn to whatever they do next.
Most of the health problems we see in volunteers are relatively minor and predictable given the environment they live in. Infectious diseases are by far the most common. My son the medical student reminded his mother several times during his microbiology-parasitology course that each lecture usually included the statement that this particular disease is predominately found in sub-Saharan Africa. Even though we spend a lot of training time on water and food purification and preparation, diarrheal diseases are a common and almost expected part of Peace Corps life. The volunteers become quite adept at describing stool quality and frequency. The laboratory gets lots of business from us requesting tests for ova and parasites in stool specimens. While most diarrheal diseases are self-limited and presumed to be viral, we do see Giardia lamblia, Entamoeba histolytica, and a variety of bacterial stool infections. One illness that everyone worries about but we rarely see, or at least rarely diagnose, is cholera. We do not vaccinate against cholera, as the efficacy of the vaccine is not very high. The news media and many concerned parents see cholera as a major threat. There are periodic cries for mandatory cholera vaccination prior to entry in country. Luckily, cooler heads in the Ministry of Health prevail.
Malaria, endemic in many parts of the East Africa countries, kills more people than anything else, more, even, than the HIV/AIDS scourge. Plasmodium falciparum is the species we worry about most because of its potential for cerebral penetration or destruction of blood cells [Blackwater Fever], both of which are potentially fatal complications. All Peace Corps volunteers are required to use anti-malaria prophylaxis, although some try to get by without it because they do not like the side effects of some of the medicines. Diagnosing malaria is a major problem. Laboratories in the smaller rural areas and community clinics seem to report positive malaria smears automatically on any sample we submit. When we have the samples re-examined at the excellent laboratories associated with the major hospitals in Nairobi, often no evidence of parasites is found. Since many of the volunteers are located so remotely that it may take them two to three days to get to an urban area, we supply them with sulfadoxine / pyrimethamine [Fansidar] for interim self-treatment. We teach them to make a thick and thin blood smear at their site, take the Fansidar, and start the trek to their designated urban area. This seems to work well. If the slide is truly positive, then we give a full course of either oral or IV drugs. We do see a few cases of proven malaria in volunteers, but so far they have been easily treated. Several years ago, however, a volunteer in Kenya died from malaria. We maintain a high respect for the disease, work to prevent it, and treat it aggressively when we find it.
Schistosomiasis is endemic in several of the areas I cover. Lake Malawi and Lake Victoria are known reservoirs for both S. haematobium and S. mansoni. It is impossible to keep sweating, itchy volunteers from jumping into or wading in the cool inviting waters of these beautiful lakes. We are almost never able to identify the eggs in either urine or stool. In the absence of symptoms, we postpone drawing blood for schistosome serology until the volunteer has left the endemic area. If the serology is positive, we presume infestation and treat it. Often, the serology results are not available until the volunteer has returned to the US. They are contacted by the Peace Corps and told to go to a local physician for treatment. I got a panic call from a family doctor in a rural town in Colorado who had an anxious volunteer in his office with a positive serology to S. haematobium. They forgot or ignored the time difference, so here I was at 3:00 a.m. trying to wake up and remember the treatment for schistosomiasis. I guess they don’t see a lot of this parasite in rural Colorado.
For sheer numbers, the most common class of health problem in the region is skin disorders. Cellulitis is much more common here than in the States. I don’t know whether it’s the virulence of the bacteria, the difficulty of hygiene without running water in your house, or both. Minor bites or scrapes frequently evolve into cellulitis, requiring drainage and antibiotics. The fungi seem to love our volunteers also. Tinea something seems to show up in almost every volunteer at one time. The common blister beetle known locally as "Nairobi Fly” causes a frequent, though very unsettling, problem. In the usual scenario, a volunteer slaps a bug on his neck with a subsequent large area of second degree burn from the caustic substance secreted by the beetle. We treat the condition symptomatically, but even topical steroids do not seem to offer much relief.
One skin problem that brings revulsion to the hardiest volunteer is the work of the tumbu fly, Cordylobia anthropophaga. This enterprising bug deposits her eggs under the human skin. There they develop into larvae, which crawl out through a breathing hole when mature. "Hey Doc.! Something is crawling out of my foot." I was with a young woman volunteer in Tanzania who was, with my guidance, extracting some larvae from her leg when her parents called from the States. Just as she began to describe to her anxious mother what she was doing, the phone line went dead. I had visions of these two parents sitting up in bed in the middle of the night, wide awake now with fear for their daughter, wondering what the hell was going on. I imagined a call from a congressman to inquire about what we were exposing these young Americans to. Luckily, the parents were able to call back and I allayed their fears. The volunteer found some preservative to keep the larvae in and planned to take them back with her to the States to put in a prominent place on her mantle. I am sure it will be quite a conversation piece; the story surrounding it will growing increasingly outlandish over the years. I also hope she gets a good story ready for the immigration officers who want to know what’s in the bottle.
Sorry Daktari, the Phones are not
Working Today, Maybe Tomorrow
Robert Davidson, MD, MPH
I came to Africa believing that telemedicine technology was going to be a big part of the future of medicine. It seemed like the perfect way to link developing countries with modern medical centers around the world for consultation. I was optimistic that the technology would reduce the need for medical evacuations to countries like South Africa or the United States for sub-specialty consultations not available in country. The reality, however, is quite different. With the exception of the Internet, on which I will comment later, virtual medicine and telemedicine have had limited impact in Eastern Africa.
Hardware Alone Doesn't Do It
When I was asked to contribute to this month's theme topic, I tried to do my homework. I reviewed the two major referral hospitals in Nairobi, a regional medical hub, to find out what kinds of telemedicine technology were being used. The large private hospital is using essentially nothing. The administrator says he gets at least one salesman a week trying to sell him technology, but the unavailability of the bandwidths necessary for transmitting data makes it impractical. The other major hospital has developed more applications. It is part of the Aga Kahn Hospital System with support from the Aga Kahn Foundation and ties to the Aga Kahn Hospital in Saudi Arabia, a major teaching and research institution. The Nairobi affiliate has several direct communication linkages including an MRI scan machine in Nairobi that sends the images to Saudi Arabia for interpretation. The Chief of Radiology was very proud to show me the equipment. When I asked him how often he used the linkage, he chuckled and said he doesn't. The data from the MRI is so massive that it takes hours to transmit via telephone. We both knew how impractical this was as the ability to keep a good long distance connection from Kenya for longer than ten to fifteen minutes is rare. Another great idea but impractical with the current communications infrastructure.
I then talked with the medical unit at the U.S. Embassy in Nairobi. The regional physician also chuckled and said they have a great set up with lots of "neat toys" like derm scopes and naso-pharyngeal scopes and a big two way audio-visual broadcast unit. However, they cannot use them because the telephone system capability renders them useless. So, the reality is that the technology developed in modern countries is fascinating, but useless without a communications infrastructure to support it. I have time this morning to write this segment because the telephones in this section of Nairobi have been out for three days. "Sorry Daktari, the phones are not working today. Maybe tomorrow." This stops any e-mail connection with the medical units of the other countries I support. We have no Internet access without telephones. I can try the cellular phone network but have no confidence it will work. In fairness to other countries in Africa, Kenya seems to have a particularly poor communications system. For instance, in South Africa, the telephone system as well as several cellular networks blanket the country and serve it well. However, South Africa is not an underdeveloped country. It is the classic problem of the haves and have-nots. The South African medical care system is excellent and really does not need telemedicine linkages for consultations but the country has the infrastructure to support it.
The Mixed Blessing of Internet Access
The Internet, however, has had a much more dynamic impact in Eastern Africa. At least when the phones work, I am able to access a tremendous date base of information. The need for reference textbooks is virtually no longer existent. I can get the information including patient information handouts faster from the Internet than paging through outdated reference books. This access is also available to the volunteers, which is a mixed blessing. They often use the information access to self diagnose or at least gather a lot of information. A typical encounter with a volunteer might start with, "Hi Doc. I want to talk to you about X disease." I have learned to start with asking what they already know because often they have several printed information sheets from the Internet and are here to "check out" what I know. Usually this works well and the information is helpful to the volunteer. However, there are some hidden problems with this unlimited access to medical information. For example, medications are readily available from the local chemist without prescription. We have had problems with volunteers self diagnosing, often incorrectly, and starting on an inappropriate or dangerous medication.
Another problem is inaccurate and biased information on the Internet. I recently had an excellent example of this. The Peace Corps follows the World Health Organization recommendations for malaria prophylaxis and uses mefloquine [Larium]. This is a somewhat controversial drug with side effects. I do not want to get into the debate on mefloquine in this article. Maybe we can do a future segment on controversies in medicine. However, recently a volunteer came in with information from the Internet to prove to me that mefloquine was dangerous and the Peace Corps should not use it. I read over his data and found it very different from the known published studies on the side effects of mefloquine. I challenged him on the source of his data and he supplied the Internet address. We logged on together and I was shocked. The Web site was a litigation law firm in the United States which was using the Internet to solicit sign-ups for a class action suit against the makers of Larium. It was a frightening Web site with inaccurate information and lists of anecdotal horror stories about mefloquine. I asked him if he trusted this information, and, after discussing it for awhile, he agreed that it was biased and unreliable. I gave him the data from the few good controlled studies on mefloquine and asked him to review them and then come back to talk with me. He has not returned. I just hope he trusts me enough to continue taking his prophylaxis, as I sure do not want to treat him for malaria.
Access to the Internet is expanding throughout Eastern Africa. Cyber cafes have become quite common and are coming down in price. In Nairobi, a typical charge would be 100 shillings or about $1.25 for the first five minutes and 20 shillings a minute thereafter. Even many rural villages are gaining access to the Internet. The United States and other countries are supporting Internet access in the schools. The Peace Corps volunteers have been in great demand to teach information technology and they report how great it is to see young students really turned on by what the Internet offers. My wife and I keep in touch with family and friends in the States almost entirely by e-mail, and a colleague here at Peace Corps is using the Internet to work on a Masters in Nursing from an American nursing school and finds it excellent. The Internet certainly reduces the feeling of isolation so common in third world countries.
So, the Internet has and will continue to have a tremendous impact in Eastern Africa. Much of this is very positive for the country and its people. But not all. The use of telemedicine technology, however, is more of a dream than a reality until the communication infrastructure catches up. Hopefully, the telephones here start working again in time for me to submit this segment of my journal of experiences in Eastern Africa. Happy surfing.
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Bob - At UCLA for last 3 years but headed to Kenya for a brief teaching thing this summer. If you get this please send a note to get back in touch, Warner Hudson, MD
My e-mail is email@example.com