Community Health Workers and expanding primary care in rural Uganda, Paul J. Krezanoski, MD

Another discovery on my recent trip to Uganda is the growing use of technology to augment the ability of lower skilled health workers to improve care delivery. The Healthy Child Uganda cell phone project, funded by an aid organization from Canada, is a perfect example.

They have piggy-backed a cell-phone based technology project onto a Uganda national government initiative to utilize communty based health workers. These health workers are designated by their communities as respected leaders at the village level. Depending on the size of the village, there is usually 1-3 CHWs identified. Their typical job is to help with training and mobilization for vaccine campaigns and other national priorities.

Healthy Child Uganda has rolled out a full scale point-of-care treatment program using cell phone technologies. They have programmed phones with interactive algorithms that CHWs use to treat the patients they see in the villages. Using the age of the child, the symptoms and a checklist of red flag symptoms, teh algorithm designates intital treatment options (amoxicillin for fast breathing (?pneumonia) or artersunate for fever (?malaria)). Then, based on the symptoms, the phone will recommend referral to a local clinic and automatically update that clinic of what to expect via a web application.

They are using this platform for stock delivery of medications at the CHW and clinic level and have a sophisticated web application which provides real-time data about what cases the CHWs are seeing in the field categorized by age, symptom and geographic location.

The hope is that these sorts of low-end technological solutions are gonig to allow the health systems in poor countries to overcome logistical challenges to provide higher quality primary care in remote locations. I thought this was a great example of that concept.

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Trauma and Critical Care at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa

I joined the Trauma Unit at the University of Witwatersrand Medical School, Charlotte Maxeke Johannesberg Academic Hospital at a volunteer faculty surgeon for a few weeks last month.  It was my first time in South Africa although I had worked and travelled in Uganda and Mozambique before. 

I chose to spend some time at this particular hospital for several reasons.  This hospital and it's sister facility (Baragwanath Hospital) are world renown as high volume trauma centers and have produced many international leaders in trauma care such as Dr. Demetriades (Chief of Trauma at LA County/USC Hospitals) and Dr. Velmahos (Chief of Trauma at MGH), among others.  As such, these two facilities draw visiting faculty, trainees and medical students from around the world.  As a Trauma and Acute Care Surgery Fellow at the Brigham, I was drawn to visit, observe and participate in these settings which trained some of the most remarkable surgeons in my field.

Furthermore, I am particularly interested in how systems of trauma and emergency services are developed, both locally in the United States and globally.  Through a collaboration between UCSF and Mulago Hospital in Kampala, Uganda, I was able to work on injury-related research during my residency and plan to continue work along those lines in Rwanda in the upcoming years through BWH/PIH.  Thus I have wanted to learn about how the South African health system is set up to address trauma and emergency services and determine what lessons I can gather for my upcoming work in Rwanda.

Here are a few photos from my first day at Joberg General.  It was a fantastic institution to visit and a great group of faculty and residents to work with during my three weeks there. 

More postings to come about the details of my time there....

Sudha Jayaraman MD MSc

Fellow, Trauma Burns and Surgical Critical Care

Brigham and Women's Hospital

Univ of Witwatersrand Medical School

Charlotte Maxeke Johannesberg Academic Hospital (Joberg General)

Trauma Resuscitation Bay




Bedside in the Trauma ICU

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Use of bednets in rural Ugandan households, Paul J. Krezanoski, MD

My work in Uganda is related to understanding the determinants of the use of bednets. These insecticide-treated nets have the potential to dramatically improve the lives of pregnant women and their children. Mere ownership in a household has been correlated with a 20% decrease in mortality among children under 5 years of age.

Uganda and especially western Uganda, has a very high level of malaria. It is a significant burden on the health system and leads to lives lost and time away from work. Bednets are often too expensive for households and even when they own them, they don't always use them as they are meant to be used.

I spent multiple afternoons visiting households in rural villages trying to understand the barriers to bednet use. This usually involved trekking into the banana trees with a local health worker and showing up at households. The first thing they would always do is invite us in to their homes. No matter how poor, they always invited us in, asked us to sit and thanked us for coming.
In many of the households, the walls were made of crumbling mud caked onto wooden frames. The ground was packed dirt and there were only a few small (small) rooms. The bednets I saw typically took up the whole space of the bedroom. Challenges included keeping them clean, finding creative ways to mount them in such small spaces, and finding ways to put them up adequately over sleeping areas.

I spent a lot of time asking people about their perceptions of bednets and their understanding of why they are used. We also discussed local programs for bednet distribution and ways that the people thought these programs could be improved. Often I would talk with the village health worker after I'd left the houeshold to get the "real scoop" about that household's malaria behaviors. I heard about husbands who refuse to sleep under the nets for fear of reducing their sperm count. I heard about how nets make people too hot so they aren't used in the humid rainy season (the time they are most needed). I heard about bednets made into wedding veils for local celebrations.

There is much to learn about how this technology makes it way into the real lives of local people. And that is where I am focusing my work.

Paul J. Krezanoski, MD

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