11/24/06

Thoughts \ Developed Thoughts \ Rants \ Raves \ Writing

06/29/2005 18:17 +0200 GMT

Changes, Flexibility, Religion, Medicine, and the Sexes

Now doesn't that title cover a lot of ground? ;-)

What to say...My job description just changed, which is absolutely fine; flexibility was one of the characteristics I packed in my trunks. So now I am being co-opted into the Hercules project.  It's aptly named, because this is a Herculean effort to extract key data points from over 20,000 charts with the aim of getting clear data, and have an accurate picture of where the PEPFAR program stands in Lusaka.

Two interns have been managing this program thus far - they've already extracted data from 19,000+ charts, but they are scheduled to leave next week. The project needs to be completed, so I am tasked with being handed the baton, and with completion of the project.

The hours are going to be long. We're talking 8am to 9pm, Sunday through Monday. Zambia has a four day weekend coming, on account of Monday and Tuesday being government holidays. My holiday has just evaporated. This is not how I wanted to spend the long weekend; I had started forming up plans to chill out, to round at UTH with a surgical resident Tuesday morning, and to catch up on developing a few database tools for the late list, and also to finish my overdue LCME project for the UASOM. Flexibility.

Today I was in familiar territory, at Matero Reference clinic, which is one of the busiest clinics in the Lusaka Urban District Health Management Board (LUDHMB).  I did more evaluation of follow-up for those who have missed appointments. 29 were discontinued from the study, about two thirds of those had passed away. It is a depressing to think of the ones who are lost who, if governments had acted more quickly with different priorities, would have been saved. When I manage to set that aside, there were several interesting issues.

At Matero, patient volume is high, and the Data Associate, named Mobiana, is tasked with entering chart information on all ARV patients that pass through. However, the Patient Tracking System (PTS) has gone through a few iterations over the course of the year, and an unfortunate consequence of this is that 1.0 version charts must be re-entered since the system has developed into 2.0 and up. So all of the data from each chart that arrives on Mobiana's desk since the new version of PTS has been implemented must be re-entered. His work is very important, and in large volume. Add to that the finding of deceased patients, of additional charts being added onto his daily load, and burnout or disinterest could be a problem. I suggested some changes, like the possibility of enlisting help from Data Associates at slower clinics, and the beauty of this whole program is they listen, and are eager to correct possible problem areas.

There were two other interesting problems I noted, more socially oriented. In the course of reviewing charts, I've come across notes that reflect two social phenomena that must be addressed in order to optimally deliver HIV therapy in Lusaka. First is the influence of religion on medicine. Second is the influence of family dynamics and what I'll call the "Second Sex" phenomenon, in honor of Simone DeBeauvoir's oeuvre.

Religion and Medicine. More than one patient has decided to forego treatment of HIV, citing faith in God as their choice for dealing with an HIV diagnosis, in place of medicine. My experience is that these don't have to be mutually exclusive, and seeing the effects of the extraordinary church leaders like the Revs. Christopher Hamlin and Malcolm Marler in Birmingham are testament to that. I think that involving clergy in community outreach for HIV treatment must be an essential component of the social package that is implemented here.

My experience again sounds off in my mind - when I first came here the Trinity Broadcast Network began broadcasting in Lusaka. TBN left a bad taste in my mouth, its figurehead and Zambian lieutenants were urging the poorest of the poor giving away their Kwacha to support their new church efforts. "Even just 20 Kwacha," the pleaded. Shouldn't other currencies be flowing into Lusaka to support the poor, rather than Kwacha being siphoned away to support expansion of a rich church, whose headquarters I have personally visited on prime real estate in Costa Mesa, CA, and whose leadership are driving brand new Mercedes? I digress...but I think you get my point, and I may be wrong.

In some instances, evidently the influence of the Christian church is adversely affecting the health of people, and that hits me the wrong way. Seeing patients whose health and family's health will be adversely affected - let's not sugar-coat it - people will die if some religious ideas in this society are not altered slightly. Religion and medicine need not be exclusive! That's my point.

My second observation was one regarding the power differential seen in the sexes here. A few women have said that if they visit clinic, their husbands will find out they are HIV+, and they will divorce them, and leave them utterly destitute, I assert.

There is plenty of voluntary counseling and testing (VCT) for couples in Lusaka. Plenty now, thanks in large part to Susan Allen's extraordinary work. But I think this phenomenon is more specific, I think. I think a more specifically targeted, tactful intervention must be formulated, so that both the husbands and wives can feel safe and encouraged to undergo VCT and enroll in treatment as necessary.