Small, But Not Simple, Steps

Hi Everyone,

A quick note to flag a recent article from the New York Times yesterday about a tactic that Doctors Without Borders is trying to pioneer in nearby Mozambique to help patients get easier access to their ARVs.

The simple solution devised by Dr. Tom Decroo, a Belgian physician working here in Tete Province for the aid group Doctors Without Borders, was to organize patients into groups of six. They would then take turns making the monthly trip to pick up refills, cutting the number of times each had to go to town — to just two a year, from 12.

It seems so simple.  Create patient groups, organize them so that instead of six people each paying every month to go from their village to the nearest clinic, only one has to.  Except it isn't simple.

The culture of HIV treatment, at least in this region, is that patients must see a clinician every time they pick up their medicine.  In the best scenario, that clinician takes a few measurements (height, weight, etc.), asks a few questions to identify potential side effects or other treatment challenges, dispenses medicine, and the patient goes on their way.  If they are sick, they are referred to a doctor or further examined for potential regimen changes.  Again, simple.  Except it isn't.

We like to think that every patient gets at least that basic level of care each time they go to a clinic, but all it takes is one visit to a busy facility to see how there's not enough time in a day for the staff to provide both the  basic care for all patients and the necessary follow up for patients who are not doing well.  It seems like we can ask for one or the other, but not both.

What Doctors Without Borders and others have recognized is that there is a major difference between a stable patient on ARVs and a new patient, and that many stable patients only need to see a clinician once every six months for updated lab tests and a general checkup.  Doing this significantly reduces the burden on both healthcare workers AND the patients themselves, who often have to scrape together whatever funds they have in order to get from their home to the clinic and back.  By reducing the number of required visits by between 60% and 80%, that's money that can obviously be used for other, better purposes, and the healthcare workers can devote more individual time to patients who are in the clinic that month.

Are there tradeoffs to this approach?  Sure.  Most worryingly, some patients will wait until their turn to go to the clinic even if they are sick or having side effects, and therefore increasing the risk of death in between visits -- though in the "study" mentioned the article no patients died during treatment. This risk, along with a general reluctance to change, makes such changes very difficult to implement at a large scale.*

That said, these kinds of creative, and simple-at-least-on-the-surface solutions are exactly the kind of thing we need to be trying to get and keep more patients on treatment.  I believe strongly that the easier we make it for patients to get medicine, the more patients are going to get it.  In Swaziland, we just recently crossed the 70,000 mark for patients on treatment.  We'd like to have 90,000+ patients on treatment soon, but the next 20,000 will be a lot harder to reach than the first 20,000.  Without innovations like this, practices that reduce patient and healthcare worker burden and improve the overall experience at clinics,  I don't see how we'll ever get there.

G

*In Swaziland, unfortunately, we're going the opposite way right now.  As I wrote in August, the financing challenges facing the government have limited our ability to purchase ARVs at a national level.  And while fortunately we again have plenty of medicine in the country, patients are now being asked to come to the clinic every month to collect their medicines.  Previously, we had been dispensing two- or three-months' worth of medicines to stable patients, again in an effort to reduce the burden on patients and healthcare workers.  The argument for giving one-month refills only is that at least all patients will receive some medicine, instead of some patients getting "too much" while others get none.  In an acute crisis, this makes sense to me, but as I look at the next six months and the fact that we have enough ARVs to last at least until then, it just seems like we'll be asking more from the healthcare staff (70,000 vists/month instead of 35,000) and requiring two or three- times as many visits from patients.  Fingers crossed we'll change that policy soon.

What We Don't Need

Headlines and stories like this in the national newspaper:

The solution to HIV/AIDS crisis?

by Mduduzi Magagula

EZULWINI – A woman who was bedridden for over a year says she has been healed by a mixture of water and oxygen.
Sibongile (last name withheld to protect her) (37) said she has been suffering from a rare illness that caused sores all over her body. She preferred not to discuss her HIV status.
The disease also caused her to lose weight and confined her to bed for a whole year.
During that time, she was also not able to do anything by herself. She said she was turned away from many clinics she visited for her sickness.
"Health officers at the Mbabane Government Hospital told me that I should stay at home without offering any medication to help my situation," she said.
Her health condition continued to deteriorate until her niece introduced some foreigners to her who offered her a bottle of medication called Oxysilver. She said a week after taking the mixture the sores on her body started to heal and she was able to eat without assistance.

The story, which ran in the Sunday edition of the national newspaper and was advertised with just the above headline written on signposts throughout all the towns (one of 5 or six stories advertised), shouldn't surprise me, I guess.  A story about some AIDS cure or other like this runs every few months or so.  This time, apparently it's driven by an American "businessman" named John Kreitzer who does at least successfully run a website listing about 10 companies in different industries and pictures of himself with Barry Goldwater and other American luminaries.  He  has, according to a companion story, written to the king to say he'll bring "investment worth over US$2 billion (about E14 billion) to the Swazi economy" by starting a factory for his Oxysilver product here.  


I'm sure he will.


I'm also sure that another set of people who are already scared and confused by HIV will be even less sure about what works as this new week begins.  I guess it highlights what an important part continuing to try to educate journalists should play in the strategy to combat HIV.  For all I know Ms. Sibongile really did get better after drinking their magic water, but I'm also sure it didn't cure her HIV, if she is infected.

Back on the Horse

I guess it's been 6 months since I've written anything.  That seems like too long a break, but with every passing day/week, it gets harder to write. So here goes.  Wish me luck, and keep up the not-so-subtle reminders that I need to write more.

The view north into Pine Valley toward Mbuluzi from our house in Mbabane

This is the view from our front lawn in Mbabane this afternoon, taken at about 5:15 p.m. or 55 minutes before the sun went down.  Strangely, the last two days here have been rainy and gray, which isn't really supposed to happen in the winter here.  Earlier this week we had near-freezing temperatures at night, but it does seem like it is starting to warm up as the days get longer.

It's been an interesting time to be in Swaziland the last few months.  The country is experiencing what the government calls a "cash-flow problem," but more and more appears to be a failure of budgeting accompanied by (or perhaps the cause of) an inability to get a loan from anywhere.*  Accurate figures are few and far between, but the government employs about 35,000 people, which the International Monetary Fund and others say is far too many for a country with just over a million people.  The government has introduced potential austerity measures, and each month threatens to implement a 10% reduction in civil servant salaries, but so far protests or threat of protests have prevented that from materializing.

Recent months have seen significant delays in payments of nearly everything.  Salaries have been routinely late, though so far have been paid.  Government vehicles that break down are unable to be fixed.  Non-essential government ministries have been prohibited from refueling cars.  Health and education spending are theoretically "ring-fenced" from the austerity measures, but it seems to be an all-out brawl to get funds each month when the revenue comes in, and civil-servant salaries have been at or near the front of the line, followed by other things including health and education.

That last piece, of course, impacts what we are trying to do on a daily basis with HIV treatment and Anti Retroviral medicine.  The Minister of Health and others have said publicly that we are currently drawing down our buffer stock for ARVs and that we need to buy more, but so far it's been difficult to ensure the financing is there to do it.  It's something we've been paying close attention to and trying to rectify, and it's an ongoing effort.  We haven't been successful yet, but we will keep trying.  In many ways it's admirable and fairly unique that the government wants to fund its own ARV procurement, so we all hope that funds will come available soon/immediately.

So that's the update for now, I still have a long list of things I'd like to write about from my request several months ago, and I'm hopeful that now that I've written something, the writers block will come to an end and I'll be a more regular correspondent

More to come...

G

*Just this week apparently South Africa has offered the government a E2.4 billion loan (~350 million USD), so it's possible that things aren't quite as bleak as they seem.  However, the IMF is here this month to review things, and by most accounts, that review isn't going to be pretty.

Kilimanjaro's Uhuru Peak -- 19,345 Feet Above Sea Level

Courtesy of Lani and Val's Flip Camera Christmas present, I present my first video entry (in HD!) on this blog.  Apologies for the out-of-breath narration and not-so-good camera work.  19,000+ feet and 8 hours of hiking will do that to a person.

More pictures and full(er) stories to come, but in short: Hiking Kilimanjaro was difficult.  We did the last day in a blizzard (see video below, click here for larger) and were at the summit at "sunrise" though in practice that only meant the sky changed from black to gray.  Of our group of 14, all of us made it to the summit at Gilman's point, and another 10 of us went on to Uhuru Peak, Africa's highest point.  We're all back in our respective homes now, 10 of us back in Swaziland, and the other four, including my high-school friends Nick Potter and Matt Flanders, are back in the US.

I do think this video gives a sense of what it was like up there, maybe hold your breath while you're watching it to bring your oxygen levels down to further simulate the experience.

February Pictures 9: Unusual Signs

The sign on a a men's room door at a restaurant in Johannesburg.  Sadly, it was the only thing memorable about the restaurant.

**P.S.  I had planned to put up ten pictures in advance while I'm away for the next week in Tanzania, but work and other things have conspired against me.  I will make up for it when I return.  In the meantime, wish us luck as we climb Kilimanjaro.  Wish us luck as we try to summit on Tuesday morning!

G

February Pictures 8: Our House

Not much to say about this picture, except to say that it's where I live.  It more than does the trick for Joe and I, with three bedrooms and two bathrooms.  We do seem to have a lot of ants these days, but otherwise no complaints.  And you already saw the view.

February Pictures 7: Malolotja Reserve

Expats in Swaziland travel in packs (there are 11 of us hiking Kilimanjaro next week).  This picture is from a day hike in Malolotja Reserve.  We hiked from the top of the hills to the bottom of the valley where this photo was taken. I think about half of the group is visible in this photo.

Malolotja is about 30 minutes from Mbabane, and all the hikes begin at the top of a ridge and then go down into the valley.  The park has several waterfalls, and some of the best views I've seen in Swaziland.