Closing Ceremony

We concluded our health training of trainers yesterday. We held one last teaching session at the Schweitzer Hospital outpatient clinic. Nurses from the General Hospital led sessions on HIV/AIDS and family planning. Both topics created some excellent discussions and an informative question and answer session. I know I said this before, but I am really proud of their work and their commitment to this training.

Following the last teaching session we held a closing ceremony (photo included of all the trainees) in which I thanked them for their hard work, discussed future plans, and distributed certificates of participation for each of the trainees. Regarding future plans, I have spoken with the current moderators, Mme. Nze and Mme. M'Badinga (aka Mamma SIDA) and they have agreed to continue to serve as moderators for future health training sessions. The nurses and midwives would like to continue with this training and they recognize that we have just scratched the surface as far as covering important health education topic are concerned.

The best news of the day came when I ran into the Director of Care. She informed me that subsequent to the closing ceremony, she was in the hospital and overheard some of the trainees discussing their plan of action for training the remaining nurses on their respective hospital service and strategies for conducting health education sessions with the patient population. I truly believe that we had an excellent group of trainees that will follow through with their work and our initial objectives.

So that wraps up my public health work in Gabon. I have written a final report summarizing the steps taken to organize this training, the different contacts made, the results of the pre- and post-test questionnaires and my thoughts /reflections on my experience here. I have also left copies of all of my presentations and teaching materials. I will work with the PMI (Protection Maternal et Infantile...a.k.a. the community health clinic) on Wednesday and Thursday and then I will leave Lambarene early Friday morning. My flight for Ethiopia departs at 2:30PM on Saturday.

I will spend the following 9 days in Ethiopia seeing the sights and enjoying the people and some of the best food around.

Final Health Education Training Session

We concluded our training of trainers teaching sessions this past Friday with a presentation on Buruli ulcers. The last session went very well and I feel that the nurses are well prepared to train the remaining staff throughout the hospital. In the end the trainees participated in over 24 hours of training on 6 different subjects (Malnutrition, Family Planning, Tuberculosis, Malaria, AIDS and Buruli ulcers). Their enthusiasm for learning and creativity in the numerous activity sessions that complemented the teaching sessions was encouraging.

We conducted our first teaching session in the hospital yesterday. We held the teaching sessions in the community health clinic and ended up presenting two health topics (malaria and tuberculosis). Both sessions went extremely well. We projected the illustrations created by the artists on to a screen and the nurses gave commentary and reviewed the main teaching points for the patients. Approximately 50 women and children were in attendence. We are going to hold two more teaching sessions before my departure at the end of next week.

Here are some other examples of the illustrations the artists created for the health education program.

Tuberculosis illustrations:

HIV/AIDS Illustration:

Other photos from the last couple weeks:

View of the sunrise from my front porch:

Flurina and Adriana (the two Swiss medical students working at the hospital):

Bamboo grove in Belle Vue (one of the villages we visit with the community health team):

Here is a photo of a baby elephant found alone in the forest near Lambarene (subsequently she was sold to one of the National Parks in Gabon) :

Mr. Taranchula:

Women and children listening to the health education session at one of the community health centers (in N'Goumou)

Children in N'Goumou

Lambarene's central market:

Health Education Illustrations

The artists have completed 3 of the 6 sets of health education illustrations. It has been a lot of fun working with them as it has provided for an excellent opportunity to teach them about disease etiology, disease transmission, preventative techniques, and different therapies available. I sit down with the artists and review the pertinent information for each health topic and then we brainstorm different ways in which we can convey the important information using illustrations. I try to provide the artists with as much creative freedom as possible. I have been very impressed with their work and am pleased with how the project has worked out. Here are a few example of the illustrations they created for the malaria prevention flip chart.

And here are a couple from the HIV/AIDS series:

Time really passes fast here. It is hard to believe that I only have 4 weeks left! I feel lucky that I have had the opportunity to do both clinical and public health work as this work has kept me very busy and has provided for some very different experiences. Things have been extremely busy and I just took a long overdue day off yesterday. I spent most of the day in Lambarene, walking around the market and just watching (African) life go by. I think it was just what I needed.

There have been some bumps in the road regarding the health education training program. Last week, the director / moderator of the training decided that she would no longer participate. The real unfortunate thing is that she didn’t tell me until the night before she was to give the presentation on family planning. I ended up working through the night and put together the presentation myself and then gave the presentation. I broke the talk up into two 50 min long presentations and I learned that it is exhausting to speak in French for 2 hours straight. For some reason I had difficulty pronouncing one of the technical words in French. I tried about 5-6 times to get the correct pronunciation much to the amusement of the group. When I finally got it right, I got a standing ovation. It really made me smile.

In the end I think everything went well and we have had some excellent discussions. So far we have covered malnutrition and family planning. I think the highlight of the training sessions are the case studies/ role playing exercises. The nurses and midwives that I am working with are quite talented. They are so incredibly animated and I have been impressed with their creativity.

There is some concern in my eyes about the sustainability of this program now that our leader has stepped down. I am in the process of talking to an epidemiologist that works with the Ministry of Health in Lambarene. She has expressed interest in helping out with the training so I am hopeful that she can replace our previous moderator. In addition, I am working with "Mamma SIDA" a local woman who organizes community health education session on HIV prevention. She has a strong presence, is knowledgeable and has a booming voice. She is scheduled to present the HIV talk next Monday and I am hopeful that she will continue to assist with future health sessions.

Ultimately the goal is to have someone continue to lead these health education sessions on a monthly basis. We can eventually expand the training to include the nursing assistants that work in the rural health posts throughout the region.

In other news, the health illustrations that the artists have created are incredible. I am extremely pleased with their work. The two artists that I am working with are very motivated and talented. The illustrations really capture the important points concerning the selected health topics. We are hoping to have the illustrations for 4 of the 6 subjects completed by the end of next week.

We will be able to use the Malaria education illustrations for this week's presentation. I will eventually scan all of the images onto my computer before my departure on March 14th. I then plan to have the illustrations enlarged and printed in a flip chart format. After looking into prices here in Gabon, I think it will be less expensive to do the printing in the US. Future Schweitzer Fellows and other staff can hand deliver the charts once they are completed.

The pediatric work continues to be a highlight of my time here. I really look forward to the trips out to the villages. Not only is the clinical work exciting and challenging but traveling out to the villages provides for a rich cultural experience. Recently there seems to be an increase in malaria cases. After speaking with the malaria research center here I think that can mainly be attributed to the seasonal rains. It really can be challenging working in
the rural villages without any lab/ diagnostic tests to support a diagnosis. On one hand, it is challenging to make the diagnoses without the myriad of tests that we have at our finger tips back at home but on the other I truly feel that my clinical skills have been tested and as a result have improved significantly. You really only have the patient history, a stethoscope, otoscope / opthalmoscope and your brain to rely on. I have medical reference books that have also provided some useful information.

Over the past few weeks, some of the cases I have seen include malaria, upper and lower respiratory infections, shingles, buruli ulcers, gastrointestinal infections, fungal skin infections, malnutrition, dehydration and conjunctivitis. Some of the children are very sick when they arrive at the health clinics. The health team can help transport the very sick to the hospital with their truck and over the past 2 weeks we have brought back 5 children (2 with cerebral malaria and the other 3 extremely dehydrated and malnourished/ failure to thrive).

Thanks again for following the blog. I will continue to post photos as often as possible.

Here are a few more random photos I thought I would share......a cobra, killed about 20 yards from my house.

Dinner out on the town:

Additional Photos

Here are some more photos from my time here. I will continue to do my best to provide updates. Thank you for taking the time to follow my work here.


Just joking around:










Community Health Team:
Marie Benoite, Mamma Sophie, and
Hortance











Vaccinations:

Overlooking Zile:

Rainy day:

Pet monkey:

Mamma Sophie at Albert Schweitzer Hospital:

Peds consultations:

X-ray of pediatric patient with miliary tuberculosis:

ER equipment










With Veronique during rainstorm:

In the OR at the Albert Schweitzer Hospital:

Hospital in Fougamou:

Community Health Visits:

The following is a list of some of the villages the community health team visited over the past couple weeks:

1/15: Massika , 1/16: Oulianga , 1/21: Issinga and Nambakele , 1/22: Paris- Bifoun , 1/23: Noumbakele , 1/28: Oyenano , 1/29: Fougamou .

I have enjoyed this aspect of my experience here in Gabon. It is during these days that I gain experience in clinical pediatrics. On a typical day do approximately 10-15 pediatric consultations and will assist with the vaccination of approximately 40-60 children. For the consultations, I have two pediatricians at the Albert Schweitzer Hospital and a nurse practitioner with whom I can consult for complicated cases. A majority of the cases have been respiratory infections, gastro-intestinal infections, malaria, skin rashes and abscesses. As I mentioned previously, we have a limited supply of medication with which to treat but most of the antibiotics we do have access to have a broad spectrum of therapy.

It is saddening and frustrating at times to witness the poor healthcare infrastructure here. These people basically have limited access to medical care. The only time they can be seen by trained professionals is when the community health team visits. The remainder of the month the only option would be to go to the hospital (which transportation itself makes it cost-prohibitive) or visit one of the traditional medicine men located in the village. The Schweitzer Hospital serves as a model for the country in serving remote villages. There is only so much they can do though. Our team visits approximately 15 of the 31 health posts located throughout the region. In theory the health posts are to be manned by nursing assistants but my experience is that these health professionals either leave their posts or do not work.

Marchella, the girlfriend of the German physician working at the hospital, joined the health team on one of our visits a couple weeks ago. She was working for the hospital taking photos to be used on their new website (still under construction) and she was nice enough to share some of her photos with me.

Public Health Work

It is hard to believe that a month and a half has already passed. My experience thus far has truly been rewarding. I am thoroughly enjoying both the clinical and public health work. I have run into a few challenges along the way but most are related to logistical problems (nothing a little persistence can’t fix). One of my Schweitzer mentors sent me the following quote:

"Anyone who proposes to do good must not expect people to roll stones out of his way, but must accept his lot calmly if they even roll a few more upon it. A strength which becomes clearer and stronger through its experience of such obstacles is the only strength that can conquer them." ~Albert Schweitzer

It has been challenging to attempt to create this extensive health education program but I appreciate the process of planning and implementing this project. I have met some extremely motivated individuals with altruistic commitments. In addition I have learned a tremendous amount about how the Albert Schweitzer Hospital and the General Hospital in Lambarene are run and have come to understand some of the needs of the community.

One of the greatest challenges that I face though is the brevity of my stay and the possibility of implementing such a large project in this timeframe. It would be naïve to think that I could fully understand the intricacies of the health system and the numerous barriers that exist to implementing different programs. I do have the advantage of accessing a needs assessment that has been conducted at the hospital prior to my arrival. This assessment had identified health education as one of the major areas that needed improvement, hence the development of this training program.

I have proposed the idea of implementing a health education program to the administration at the Schweitzer Hospital, General Hospital and Ministry of Health and all are in complete support of our program. We will begin by conducting a training of trainers. We have identified health care workers at the two hospitals and will begin health education teaching sessions next week. Our goal is to address 6 health related topics (malaria, tuberculosis, malnutrition, buruli ulcers, HIV/AIDS and family planning) and provide the staff with basic information on the etiology and epidemiology of these illnesses, propose preventative measures, and treatment options. Those trained will in turn be able to hold teaching sessions for other health staff and patients in their respective services.

We are in the process of developing questionnaires which will be used to assess the quality and content of our health education sessions. As part of this program, I am also working with 2 local artists in developing illustrations that will be used in the patient education sessions. I have secured funding for the artist’s work and am currently looking into options for printing the illustrations in a flip-chart format. The long term goal is to provide a training conference for all health care workers in the region. Each health post located within the region will then be provided with a copy of the health illustration flip charts to be used in the teaching sessions.

We are planning on beginning the training on Monday February 9th. Teaching sessions will be held every Monday and Friday afternoon for the following 4 weeks. Teaching sessions will be conducted by hospital staff and public health professionals working in Gabon.

Leatherback Turtles at Pongara National Park- Pointe Denis, Gabon- January 23-25

I had an opportunity to travel to the beach last weekend. I went with four co-workers from the Schweitzer Hospital with the intention of doing some sightseeing along the coast. We arrived in Libreville Friday afternoon and took a short boat ride to Pointe Denis, approximately 3 miles off the coast of Libreville. Pointe Denis is part of Pongara National Park and the location of a sea turtle research station (Centre d’Information sur les Tourtues Marines de Pongara) and the nesting ground for approximately 5 different sea turtle species.
After arriving Saturday morning and hiking a short distance to the turtle research station we relaxed and enjoyed a day at the beach. It was great to have a break from the hospital and to enjoy the cool breeze. We set up our tents along the shore and after eating dinner set out with a team of park rangers.
We left the turtle station at approximately 10pm and hiked about 30 minutes up the beach where we found encountered the first turtle of the night. It was a female leatherback (Luthe) turtle making her way back to the water after having just laid her eggs. I was completely astonished by the size of the turtle. It was enormous. I was also surprised with how fast it made it to the waters edge. The park rangers were very informative and were open to answering all of our questions.
Leatherback turtles are the largest sea turtles alive. They have a leathery shell instead of a bony exoskeleton like other sea turtles. They return approximately every two years to lay eggs (roughly 100) on the same beach in which they were born. They travel throughout the deep waters of the Atlantic for most of their life. They live almost solely off of a jellyfish diet and we were told that they may actually be responsible for controlling the world’s jellyfish population.
We continued hiking up the coast for another 3-4 hours into the early morning hours. We encountered 2 more females both of whom were in the process of laying their eggs. We used red lights, which apparently do not disturb the turtles and were actually able to go up one by one and touch the turtles as they were laying their eggs. It really was a fascinating experience. One of the females had a fishing net caught on her shell. Usually people are discouraged from using flash photography as it can easily disorient the turtles (which rely upon the horizon to orient themselves). One of the park rangers had asked if one of us would take a photo of the turtle from behind to document the fishing net caught on the turtles shell. Fortunately I had my camera and was able to capture this amazing turtle on film. The rangers were able to free the turtle of the fishing net before she re-entered the water.
After spending Sunday on the beach we headed back to Lambarene and learned a lesson: never take a taxi ride from Libreville to Lambarene in a torrential downpour…in the night. It was a harrowing experience but we finally arrived early Monday morning safe and sound.

Public Health Project

After meeting with hospital and public health officials in Lambarene, I now have the support to begin a health education program. The ultimate goal is to provide comprehensive health education/ disease prevention for patients in the Lambarene region (Middle Ooguee Region). This will be done by training nurses and community health care workers posted in their designated villages. In addition, we intend to use local artists to create health education materials such as poster animations.

The first step in this process is identifying key members of the health care community who are going to be the major players in the implementation of this project. It is extremely important that these individuals have ownership of the program as my time here is limited to 3 months. I am also in the process of developing a survey/ questionnaire which will be used to assess the level of knowledge of the nursing staff at the hospital. This will aid us in addressing appropriate health education topics and will also serve as an evaluation tool when the training is complete. Once the nurses have been trained, they will be responsible for conducting health education sessions with their patients.

Weekend boat trip up the Ooguee River

We spent last Saturday on a boat ride up the Ooguee rive. We traveled for approximately 3 hours up the river. It was a beautiful ride winding through the jungle. We were searching for hippos or any signs of wildlife along the river bank but had no such luck. Our guide, Ya-ya , informed us that the river level was still too high to spot any hippos. Maybe in another month or two. One of the islands we stopped at had a monastery. Here are some photos from the trip:

Surgery/ Internal Medicine Service

I have included some photos of my time here and wanted to provide a warning before you proceed: Some of the photos may be quite graphic.

In addition to the public health and community health clinic work, I spent a few days working in the surgery and internal medicine wards. The chest x-rays shown are actually a success story. The patient was a 35 year old female diagnosed with tuberculosis. The x-ray on the L is the one taken on her first visit approximately 6 months ago. Notice the L side of her chest (your R) is completely white. This infection has spread throughout her L lung field. The patient initially presented with the typical symptoms…weight loss, anorexia, fever, and night sweats. The patient was placed on multi-drug therapy for 6 months. Upon return to the clinic for her 6 month check-up the patient had the x-ray on the R taken. The infection had completely resolved and the patient had a healthy recovery.

Working on the surgery ward was one of the most eye opening experiences I have had in medicine. The patients were of various ages but almost all had severely debilitating diseases. What was most unsettling was the fact that many of the patients had come to the hospital long after their disease process began. One of the most impressive diseases commonly found in tropical hospitals is the buruli ulcer. Buruli ulcers are chronic necrotizing skin infections caused by the bacteria Mycobacterium ulcerans. The ulcers usually begin as painless nodules that can sometimes itch. Some spontaneously resolve but many times the ulcers will grow in size and begin to spread rapidly. They can become quite large and disfiguring. The best way to treat these ulcers is by early detection and surgical excision of the ulcer. Without treatment or with a late diagnosis the lesion may slowly heal after a few years.

Community Health Visits to Chad and Belle Vue

I had an opportunity to join the community health group twice last week. On Wednesday we went to Chad, a village approximately 40 km away from Lambarene, along the road to Libreville. The ride out was beautiful as they are cut right out of the jungle. The roads in Gabon are fairly well maintained and are some of the safest I have traveled on in Africa.

As we pulled into the village, Mamma Sophie began her ritual yelling out the window of the pick-up. I have to wonder if there is an easier way to inform the people that the health team has arrived but this system seems to work, plus it has provided for some amusing moments. Mamma Sophie will call out to any mother she sees with an infant and insist that the mother bring her child to the health clinic for vaccinations. The two usually have a friendly shouting match; defending their own position and going back and forth, as we slowly drive by.

Chad is a relatively large village and we had roughly 50 children show up, of which approximately 15 were sick visits. I assisted with the meticulous vaccination process. As we immunize the children, records are kept of all new children seen and of all updated vaccinations. Well child checks are simultaneously conducted, which include weighing the children (which has to be one of my favorite photo opportunities), plotting their weight on growth charts, and conducting brief physicals on every child. Added on top of this patient load are the 15 other pediatric consultations making for a busy day.

There have been a relatively wide variety of cases that I have seen in the community health visits. A majority of the cases are similar to pediatric outpatient clinics in the US…upper respiratory and lower respiratory infections, gastrointestinal problems, skin rashes, etc. Out of the remaining cases, we get a relatively high number of malnourished children, and then a mix of tropical and sometimes bizarre cases…malaria, buruli ulcers, and a woman presenting with a fishhook in her finger(which she somehow managed to endure for 5 days).

On Thursday we traveled by boat to Belle Vue, a small village of approximately 200 people. The village reminded me of villages I encountered as a Peace Corps volunteer. It was remote in location, about 30 miles down the Ooguee River. The village has no electricity, no running water and the people support themselves by fishing and farming. There is something completely calming about working and living in this type of village. While the landscape differed from the village where I lived in Mauritania, it still had a similar ambiance. Just walking around the village and talking to the people gave me a sense of the strong community ties and family bonds that exist in such a tight knit community. The air smells of firewood cooking today’s lunch and sandy paths bisect the thick jungle, connecting one family compound to another. It was a wonderful experience to work here and I am enjoying getting to know the different members of the community health team.

Weekend Activities

Arts and Crafts day, designing masks that will be displayed throughout the hospital:

Meeting the neighbor's pet chimp:

At the entrance to the hospital:

Public Health Project

I spent most of last week orienting myself to the daily operations of the pediatric ward and the hospital in general. As mentioned in a previous posting I also spent some time with the community health group doing pediatric consultations. After observing patient care and working with the hospital staff for approximately 1 and 1/2 weeks there appears to be an opportunity to improve the health education/ disease prevention conducted at the hospital.

Schweitzer pediatric ward:

Currently, the community health clinic is the sole source of health education on the hospital's campus. The visual aides they use are a bit outdated and weathered to say the least. On Friday I met with the regional public health director (Dr. Diallo) at Lambarene's General Hospital. Dr. Diallo appears to be an extremely motivated individual and identified disease prevention education as the region's primary health care concern. Subsequent to our meeting I met with a young artist who lives on the Albert Schweitzer Hospital campus and spoke with him about possible collaboration in creating health animations. I intend to meet with the hospital director this week to discuss the possibility of developing a health education program.

Lambarene General Hospital:

New Year Celebration

W/ Caroline (a French Pharmacy PhD student):

Aude (a French Pediatric Nursing Student) w/ Henry (Hospital technician):

Natalie (a French Pharmacist), Caroline and Aude:

Paul (a Pediatrician from Germany) and his girlfriend Marchella (a Graphic Designer taking photos of the hospital during her month vacation here):

Community Health Visits- 12/31/08

Today was my first day heading out to the rural villages surrounding Lambarene. I went as a member of the community health team which consisted of 4 nurses and myself. Our first and only stop of the day was to Kongolou, a small village approximately 40 km from Lambarene. We first drove through the village as Mamma Sophie, the Director of the Community Health Clinic, yelled out the window informing people that the health team has arrived. The people then knew to bring any sick children or any children due for vaccinations or a well child check-up to the community's health clinic.

I was a bit nervous knowing that I was the only one that was going to be doing the pediatric sick visits for the day. Everyone knew that I have yet to graduate from medical school (and I made a point to remind them). I think they were happy though to have another helping hand and someone with medical knowledge was a definite bonus. There were only 3 sick visits today; one fungal skin infection and 2 upper respiratory infections. Fortunately, I felt prepared to handle these cases and truly enjoyed being part of the health team.

After the sick consultations we mainly dealt with vaccinations and well child check-ups.

I am meeting with the former director of the community health program on Friday to discuss potential public health projects during my time here.

Here are some other photos from my first week:

Lambarene's market: Kongolou's market:

Making charcoal:



Self-portrait at the hospital: Vaccination calendar:
Thank goodness for screening: Infant feeding schedule:

Passing out Christmas gifts in the internal medicine ward Christmas morning.

Today, Monday 12/29, was my first day of work in the pediatric ward. I spent most of my time working with Dr. Bonito (a pediatrician from Burundi) and Paul (a pediatrician from Germany). We saw an incredibly broad range of cases throughout the day....inguinal hernia, multiple children with sickle cell disease, tuberculosis, diarrhea, snake bite, malaria, fever of unknown origin...to name a few. I will start doing pediatric consultations and immunization tours in remote villages starting Wednesday.

Scenes from around the hospital

I arrived in Lambarene safe and sound on December 24th. It was a bit strange arriving on Christmas Eve but after 20+ hrs of flying and accepting that I may never see my luggage again after it failed to arrive on my flight, I was more than happy to be here. Things have been surreal since my arrival in Gabon. It always seems to take time to fully adjust to life abroad.

I was welcomed by the hospital staff, who were gearing up for a holiday party. Everyone was extremely welcoming and made me feel right at home. I was able to move my belongings into my house, pictured below, but have yet to unpack. My days have been fairly busy since arriving; spending most of my time orienting myself to the hospital grounds and introducing myself to the staff.

Friday, December 26th was my first day of work. I spent most of the day in the maternity/pediatric ward where I helped with vaccinations and weighing babies. It is with these staff members that I will work twice a week, traveling out to villages in the greater Lambarene area. These visits will consist of pediatric consultations, vaccinations and well child checks. The remainder of the week will be spent developing long term public health projects. Some potential projects include investigating infant mortality rates and associated risk factors, family planning, pediatric HIV, and establishing and centralizing vaccination records for children in the Lambarene area.

View from my front porch: Home sweet home:

Overlooking the old Albert Schweitzer Hospital:

Ooguee River:

Gabon

The postings on this site are my own and do not necessarily represent the positions, strategies or opinions of The Albert Schweitzer Fellowship, the Albert Schweitzer Hospital, or the Brody School of Medicine at East Carolina University.