EMERGENCY NEEDS ASSESSMENT IN WESTERN KENYA

Hello again from Western Kenya. As I conclude my trip, I wanted to update everyone on the status of the project. It's been a wild 6 weeks, full of travel. We were able to visit 27 facilities in total - learning a great deal from all of the wonderful medical providers who gave their time to help in this project.

Not surprisingly, we've discovered there is definite room for improvement for emergency care in Western Kenya. Finding out how we can focus our efforts best will be the greatest challenge. We have found that even basic supplies like X-ray and ECG machines are lacking, the providers (especially specialists) are frequently overworked and spread-thin, referring patient's to a higher level of care poses many challenges and can be dangerous, and many providers are requesting more trainings to be able to take care of their patients better.

I was able to pass the torch to another fellow resident who will continue collecting data. When complete, we will analyze our data and work with local medical officials to raise the standards of emergency care in the region. Fortunately, we've already started a pilot training program to train some providers on emergency anesthesia.

Dave Young, MD

Read More

Flu bad, MERS a diversion?

In an "Infection hot topic" article in Clinical Microbiology and Infection, the Editor, Prof. Didier Raoult writes of the importance of not letting our excessive pride or self-confidence drive our desire to understand a rare and poorly transmissible (slowly-growing epidemic?) virus like the Middle East respiratory syndrome coronavirus (MERS-CoV) and distract us from "real infectious disease epidemics that are well known" at times of mass gatherings like the Hajj.

Because why not?

He notes that the recommendation for influenza vaccination during the recent Hajj probably prevented thousands of influenza cases and that 9% of returning French pilgrims returned an influenza virus positive throat sample. An example of some good communication then.

I wasn't aware that the scientific press, World Health Organization or governments had dropped any other balls in order to give MERS the attention any potentially new human pathogen, with or without pandemic potential, well and truly deserves.

I guess in hindsight, it might look like a lot of wasted effort went into MERS-related reporting. Readers of this blog would be aware of my own opinion on that matter - not nearly enough effort has gone into solving a number of questions about the MERS-CoV and certainly not enough data has been described and reported to make it easy to track and present new cases.

Far from being distracted, the developed nations have continued their fight against flu (so long as their governments aren't shut down), reporting heavily on it and other vaccine preventable diseases that are reappearing in the population (measles and polio for example). Many science communicators of all types in many locations around the world have also been discussing and describing in detail the oncoming wave of antibiotic resistant bacteria and many other viral and bacterial pathogens that can be considered rare depending, on the denominator you choose at the time. SARS-CoV infections were pretty rare (~8,200 confirmed cases) but the social, economic and healthcare impact of that little outbreak was incredibly disproportionate. Or perhaps it was perfectly proportionate? Remembering the SARS outbreak began in the dark without suitable coverage and communication to illuminate the early stages. 

What is the evidence that reporting on MERS has displaced any other efforts to monitor, debate or describe more endemic human infectious diseases?

Thankfully Prof. Raoult didn't call out the scientific community who are working hard to add new knowledge about "rare" human infections; work that will hopefully ensure they stay as rare as possible, for as long as possible if they are not halted at the source forever. 

I'm personally in no rush to read the bazillion Editorials that will follow in the wake of a pandemic due to infection by MERS-CoV, H7N9 or any other viruses with "little known effect on the human population".

Hindsight can be a harsh mistress but communication fosters preparedness.

Read More

New MERS-CoV genome sequence on GenBank...

I'm a little bogged down in my day-job for lots of posts just now (and too busy at nights hanging Christmas lights at home!) but just thought I'd post about the latest Middle East respiratory syndrome coronavirus complete genome sequence that's dropped onto GenBank.

It was submitted in October but came online 7-Dec.

I've added in the likely FluTracker's case number - this is the nearest match to the collection date but it may be from the index case (FT#31); both detected in France, the former form the United Arab Emirates.

Key features...

• Name: Middle East respiratory syndrome coronavirus isolate FRA/UAE, complete genome 
• Date of sample collection: 7-May-2013, France
• Sequence length: 29,901nt
• MERS-CoV case: FT#34; 
• GenBank accession number: KF745068
• Link: http://www.ncbi.nlm.nih.gov/nuccore/KF745068.1
• Authors: Enouf,V., Briand,D. and van der Werf,S.
• Virus sample source: Vero cell culture isolate
• Sequencing type: Sanger

Read More

Zuni IHS Community Experiences

Despite the small size of the population and the Zuni Health Center, I believe they are doing very progressive work through community outreach, population health and the group practice of medicine.  I have shared just short tidbits of some of the amazing opportunities I had the privilege of being part of during my short time in Zuni.

My last morning in Zuni, I had a chance to work with Dr. Chris Piromalli in the group diabetes clinic.  A program truly on the cutting edge of community medicine; what I believe will be the wave of the future.  Moving towards a model of true individual empowerment accomplished through education and the synergy of empathy and understanding that you are not alone in your struggle with chronic disease by engaging with fellow community members facing similar struggles in facilitated group sessions.  For me it was an absolute honor to be welcomed by all involved with open arms and I�ll certainly be a better physician for having had this exposure to this model of care and a chance to hear the stories of struggle and triumphant with a chronic disease that easily becomes routine in the lives of a primary care physician.  I had the opportunity to witness the transformation of a patient taking ownership and responsibility to begin Insulin through the sharing of struggles with his Diabetic peers, a daunting task for this gentleman that had been refused multiple times in the past.  This experience was a wonderful end to an amazing month here in Zuni.  In a similar vein, I had the opportunity to participate in the joyous class of a group of families undergoing group prenatal session.

The opportunity to go with Fred, U.S. Public Health Service Nurse, to the Zuni Prison to meet with patients that were down and out was enlightening and an honor.  This is certainly one of the most disadvantaged patient populations out there and to have Fred seek them out to try to help them in times of need was a powerful demonstration of the need for reaching out to this community to make a difference in a very challenging time in their lives.  Educational and thought provoking�.

I had a chance to spend time with the program leaders of DIPS (Diabetes in Preventive Strategy) a program for pre-diabetics that includes exercise, counseling and personalized guidance to try to prevent people to progressing to diabetes and Healthy Living a program for those with diabetes to help support them with exercise and nutritional support in the community.  Zuni, New Mexico is a trial site for the well-known and published research trial the Diabetes Prevention Program (DPP) - http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/

http://www2.niddk.nih.gov/News/SearchNews/02_06_2002_Diabetes.htm

I especially appreciated this opportunity as it is a goal of mine to one day to work with and perform outcomes research with similar initiatives.

Of all the experiences, perhaps the most poignant was an experience I had during a home visit with the Zuni Home Health Nurse.  She is a truly loving person who cares deeply about her patients.  She and her patients were so amazingly welcoming and friendly; they truly made me feel like an honored guest in their home.  One of her regular patients was a middle-aged woman with depression and advanced diabetes, our major service to her was filling insulin syringes and arranging her medications in a pill box for the week.  As we struggled to fill her pill box with a variety of medications, some weekly, some once a day, some BID/TID, etc. with some obvious confusion about her actual prescribed doses it hit me just how real the threat of poly-pharmacy is for so many of our patients.  It was powerful reinforcement of the need to do a better job of being clear and simplifying prescriptions as much as possible for my patients.  The patient�s functional status and depression was also a major impediment to her ability to care for herself, really a lesson in treating the whole person when formulating a treatment plan for a patient.  This experience made a lasting impact on me and will change my future practice of medicine for the better.

The experiences and opportunity to interact with the community and the variety of healthcare professionals in Zuni have undoubtedly made me a better physician.

Read More

Zuni, New Mexico � A Special Place

I had heard a lot of good things, but really didn�t know what to expect upon arriving to work at the Zuni Comprehensive Community Health Center  � a 2 � hour drive from Albuquerque on the Zuni Indian Reservation in Western New Mexico, near the Arizona border.  I was welcomed with open arms to a beautiful community that is visually stunning, culturally unique and home to proud and amazing people.  The health center and its healthcare professionals were inspirational practitioners of healing.  They had found their calling working in Zuni and it came through in their approach to medicine and living life.  I could not have been made to feel more welcome to be part of a community and a practice of medicine.

Zuni Comprehensive Community Health Center serves approximately 10,000 Zunis and 4,000 Navajo who live on surrounding Navajo Nation reservations lands. The majority of Zunis are bilingual, with Zuni being their first language. Many Navajo over 45 years may not speak English. There are Zuni and Navajo employees who can assist with translation.  Silver-smithing is the main source of cash income and Zunis are renowned for their intricate jewelry work and fetish carving. Employment for others is through government or tribal organizations, the school system or our facility. The median Zuni family income (1999 data) is  approximately $21,000/year and approximately 50% of the population falls below the poverty level. Traditional ceremonies are the center of nearly all social activities and Zunis follow a calendar of night dances and rain dances which take place in the plaza at the center of the old village. Zuni society is divided into six fraternal kiva religious organizations, 10 medicine societies, and 12 matrilineal clans. Traditional medicine is also an important part of Zuni culture and many Zunis incorporate visits to medicine men, bone pressors, or traditional midwives along with seeking care at our facility.  

Dowa Yalanne (DY) A Sacred Mesa, a shelter to the Zuni People during their resistance to the Spanish (my wife and son)

Government Housing across from the hospital provided by the IHS

Looking out from housing to back of Zuni Comprehensive Community Health Center

Each day started with checking on any of my inpatients that I had ad
mitted on previous days and then attending morning rounds with the entire team of physicians, pharmacist, nursing, support staff, etc. to discuss admissions, transfers and a variety of patient updates.  That was followed by a variety of 2 day clinical sessions including an opportunity to participate in a variety of community/public health outreach programs.  The model of care was one in the model of family medicine where the majority of practitioners practiced the full spectrum of care including Pediatrics, Obstetrics/Women�s Health and adult medicine.  There are no ED docs and the catchment area for the Health Center is quite large so when you were the on-call physician you are expected to stabilize, evaluate and treat whatever may come through the door � a very different feeling and expectation than being in a large academic medical center such as MGH.  There is no ICU at Zuni Health Center; on average during my time there they flew out 2 patients a week to Albuquerque for a higher level of care.  In some respects the practice of medicine feels like rural medicine, but the major difference being you are part of a group practice of physicians that provide their support and expertise.  Given the close quarters of colleagues� offices, the health center clinics and the group practice done at the hospital you always feel very supported and it fosters a sense of communication and learning between colleagues.  It certainly doesn�t feel rural or isolated to practice medicine in this environment.  There was a wide breadth of expertise and backgrounds at practicing medicine at the facility including pediatricians, family medicine and internal medicine physicians that had trained all over the country. 

Outside of work, there is an array of things to keep you busy.  There seems to always be a unique cultural event going on in the community � I was lucky enough to be in town for the annual Harvest Festival tribal dancing.  There is an array of amazing outdoor opportunities in the area including multiple national parks/monuments and the local scenery on the Zuni Reservation is also quite breathtaking.  It is the classic west with sunny days and bright blue skies where you can see for miles, filled with beautiful mesas.  During my time there I was lucky enough to make it to Sedona, Arizona (famous for its beautiful Red Rock formation and vortexes), Flagstaff, AZ (mid-size college town and base for trips to Grand Canyon) and the Grand Canyon.  I also visited friends on the Navajo Reservation and hiked Canyon de Chellay National Monument, a beautiful, sacred canyon to the Navajo.  I also made a day trip over to El Morro National Monument, a beautiful mesa with quite a history inscribed in its walls � also home to the highly recommended hang-out �Ancient Way Caf�.   I only scratched the surface of outdoor activities as other co-residents made the way to Moab and many other surrounding parks in Colorado and Utah.

I leave you with an essay about the day in the life of a Zuni physician that I think illustrates the experience well.  It was written some time ago by the clinical director of the Zuni Comprehensive Health Center, Dr. Thomas Faber, a former graduate of the Harvard Med-Peds Program:  https://www.dropbox.com/s/wooa7rfc6uxg76q/Tom%20Faber%20Essay.doc

My family in front of a red rock formation in Sedona

My family and I at the Grand Canyon

Canyon de Chelly - Spider Rock; a sacred canyon and rock formation to the Navajo Indians

Read More